Acceptance- and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review

The INternet ThERapy for deprESsion Trial (INTEREST): protocol for a patient-preference, randomised controlled feasibility trial comparing iACT, iCBT and attention control among individuals with comorbid chronic pain and depression

INTRODUCTION

Approximately one-third of adults with chronic pain also report clinically relevant levels of depression. Internet-delivered psychological therapies such as Cognitive Behavioural Therapy (iCBT) and Acceptance and Commitment Therapy (iACT) have been developed to overcome barriers of access to services and ensure the timely delivery of care. The objective of this trial is to collect data on feasibility, acceptability and range of probable effect sizes for iCBT and iACT interventions tailored towards the treatment of depression and chronic pain using a randomised controlled patient-preference design.

METHODS AND ANALYSIS

Community dwelling adults with chronic non-cancer pain (CNCP) and major depression will be recruited from pain clinics and primary care providers in Newfoundland and Labrador, Canada. The study is a randomised controlled patient-preference trial. Eligible patients will be randomly assigned to a 'preference' or 'no-preference' arm during the first step of randomisation and to intervention or control in the second step of randomisation. Two interventions (ie, iCBT or iACT) will be evaluated relative to attention control. iCBT and iACT involve the completion of 7-weekly online modules augmented with one session of motivational enhancement and weekly therapy sessions. Primary outcomes include (1) feasibility and acceptability parameters and (2) change in symptoms of depression. Secondary outcomes include pain, physical function, emotional function and quality of life. We will recruit 60 participants and examine the range of effect sizes obtained from the trial but will not conduct significance testing as per recommendations for behavioural trial development.

ETHICS AND DISSEMINATION

Ethics was approved by the provincial Health Research Ethics Board. Dissemination of results will be published in a peer-reviewed academic journal and presented at scientific conferences.

TRIAL REGISTRATION NUMBER

NCT04009135.

Brief cognitive analytic therapy for adults with chronic pain: a preliminary evaluation of treatment outcome

BACKGROUND

Cognitive analytic therapy (CAT) has diversified in its application to a broad range of presenting difficulties and formats and there has been growing interest in its use in clinical health settings including Pain Management Services. Despite its growing popularity, to date, no studies have examined the application of CAT for chronic pain.

AIMS

The purpose of this study was to examine the effectiveness of time-limited, individual CAT for adults with chronic pain as delivered in a publicly funded Community Pain Management Service.

METHODS

This was an observational service evaluation of treatment practice within a routine clinical setting. Participants were 53 adults with chronic pain who completed eight sessions of individual therapy. Individual and group-level outcomes on self-reported distress, pain-related self-efficacy, as well as changes in healthcare utilisation pre- and post-intervention were examined.

RESULTS

Large pre-post effects on wellbeing (d = 1.50) and self-efficacy (d = 1.13) were observed, while effects on healthcare utilisation were medium to large (d = 0.67). Moreover, reliable change and clinical significance analyses demonstrated that results were clinically meaningful. The majority of clients (67.9%) showed reliable improvement following the CAT intervention and 28% achieved both reliable and clinically significant improvements in psychological distress. Approximately 4 of 10 clients (43.5%) showed reliably higher perceived self-efficacy at the end of therapy.

CONCLUSION

The results of this evaluation suggest that brief CAT is an encouraging intervention for adults with persistent pain. While preliminary, our findings provide support for a brief approach to persistent pain that focuses not on controlling or eliminating pain but on elucidating and revising unhelpful relational patterns that may impinge upon one's pain management. Directions for future research are suggested.

A User-Centered Approach to an Evidence-Based Electronic Health Pain Management Intervention for People With Chronic Pain: Design and Development of EPIO

Background

Chronic pain conditions are complicated and challenging to live with. Electronic health (eHealth) interventions show promise in helping people cope with chronic illness, including pain. The success of these interventions depends not only on the technology and intervention content but also on the users’ acceptance and adherence. Involving all stakeholders (eg, patients, spouses, health care providers, designers, software developers, and researchers) and exploring their input and preferences in the design and development process is an important step toward developing meaningful interventions and possibly strengthening treatment outcomes.

Objective

The aim of this study was to design and develop a user-centered, evidence-based eHealth self-management intervention for people with chronic pain.

Methods

The study employed a multidisciplinary and user-centered design approach. Overall, 20 stakeholders from the project team (ie, 7 researchers, 5 editors, 7 software developers, and 1 user representative), together with 33 external stakeholders (ie, 12 health care providers, 1 health care manger, 1 eHealth research psychologist, and 17 patients with chronic pain and 2 of their spouses) participated in a user-centered development process that included workshops, intervention content development, and usability testing. Intervention content was developed and finalized based on existing evidence, stakeholder input, and user testing. Stakeholder input was examined through qualitative analyses with rapid and in-depth analysis approaches.

Results

Analyses from stakeholder input identified themes including a need for reliable, trustworthy, and evidence-based content, personalization, options for feedback, behavioral tracking, and self-assessment/registration as factors to include in the intervention. Evidence-based intervention content development resulted in one face-to-face introduction session and 9 app-based educational and exercise-based modules. Usability testing provided further insight into how to optimize the design of the intervention to the user group, identifying accessibility and a simple design to be essential.

Conclusions

The design and development process of eHealth interventions should strive to combine well-known evidence-based concepts with stakeholder input. This study, designing and developing the pain management intervention EPIO, illustrates how a stakeholder-centered design approach can provide essential input in the development of an eHealth self-management intervention for people with chronic pain.

Trial Registration

ClinicalTrials.gov NCT03705104; https://clinicaltrials.gov/ct2/show/NCT03705104

Are Processes in Acceptance & Commitment Therapy (ACT) Related to Chronic Pain Outcomes Within Individuals Over Time? An Exploratory Study Using n-of-1 Designs

Introduction

Acceptance & Commitment Therapy (ACT) explicitly postulates experiential avoidance (EA) and values-based living (VBL) as essential treatment processes. As outcomes from between-subject studies cannot readily be generalized to within-subject processes in individuals, we explored the unfolding of, and relationship between, EA and VBL and levels of pain interference in daily life and emotional well-being within individuals experiencing chronic pain.

Methods

Using n-of-1 designs, three participants following a multidisciplinary treatment program filled out a 12-item daily questionnaire (87-110 days). After multiple imputation of missing data, McKnight Time-series analysis procedures were performed for each participant separately. The interrelationships of EA, VBL and pain intensity, and the relationship of EA and VBL beyond pain intensity with both chronic pain outcomes were assessed both concurrently (same day) and prospectively (consecutive days).

Results

Both EA and VBL were associated with at least one of five outcome variables (four domains of pain interference and emotional well-being) beyond pain intensity in two participants, but not in the third participant. These associations primarily existed for concurrent, but not consecutive, days. In contrast to VBL, EA was not associated with emotional well-being for any of the three participants.

Conclusions

Although the finding that ACT-processes were associated with pain outcomes on concurrent days is consistent with ACT theory, the absence of such associations on consecutive days means that alternative explanations cannot be rule out. One possibility is that pain interference fluctuates within days at a higher variability rate than was currently assessed. Future research should consider using a higher measurement frequency to be able to grasp time-lagged effects.

Pediatric pain treatment and prevention for hospitalized children

Introduction:

Prevention and treatment of pain in pediatric patients compared with adults is often not only inadequate but also less often implemented the younger the children are. Children 0 to 17 years are a vulnerable population.

Objectives:

To address the prevention and treatment of acute and chronic pain in children, including pain caused by needles, with recommended analgesic starting doses.

Methods:

This Clinical Update elaborates on the 2019 IASP Global Year Against Pain in the Vulnerable “Factsheet Pain in Children: Management” and reviews best evidence and practice.

Results:

Multimodal analgesia may include pharmacology (eg, basic analgesics, opioids, and adjuvant analgesia), regional anesthesia, rehabilitation, psychological approaches, spirituality, and integrative modalities, which act synergistically for more effective acute pediatric pain control with fewer side effects than any single analgesic or modality. For chronic pain, an interdisciplinary rehabilitative approach, including physical therapy, psychological treatment, integrative mind–body techniques, and normalizing life, has been shown most effective. For elective needle procedures, such as blood draws, intravenous access, injections, or vaccination, overwhelming evidence now mandates that a bundle of 4 modalities to eliminate or decrease pain should be offered to every child every time: (1) topical anesthesia, eg, lidocaine 4% cream, (2) comfort positioning, eg, skin-to-skin contact for infants, not restraining children, (3) sucrose or breastfeeding for infants, and (4) age-appropriate distraction. A deferral process (Plan B) may include nitrous gas analgesia and sedation.

Conclusion:

Failure to implement evidence-based pain prevention and treatment for children in medical facilities is now considered inadmissible and poor standard of care.

Treatment of Vulvodynia: Pharmacological and Non-Pharmacological Approaches

Vulvodynia is a common, recurrent, vulvar pain condition with debilitating consequences for affected women's health and quality of life. The heterogeneity of women suffering from vulvodynia as well as its uncertain and likely multifactorial etiology pose a significant challenge to identifying any kind of "gold standard" treatment. Thus, treatment providers must be well versed in the various options and the evidence for each. In this review, we begin with pharmacological treatments, followed by non-pharmacological treatments, surgery, and finally multimodal treatments. For each approach, we briefly discuss the method, mechanism of action, and empirical support for the treatment. In sum, pharmacological treatments that may be beneficial but require further research include antinociceptive agents (lidocaine, capsaicin), anti-inflammatory agents (corticosteroids, interferon), neuromodulating medications (anticonvulsants and antidepressants), hormonal agents, and muscle relaxants (e.g., botulinum toxin). There is strong evidence to support and recommend non-pharmacological interventions including psychological therapy, pelvic floor physical therapy, as well as surgery (i.e., vestibulectomy for provoked vestibulodynia) for the treatment of vulvodynia. We conclude this review with a discussion of issues that may have hindered progress of treatment efficacy and effectiveness, and recommendations for moving the field forward.

Integrated Behavioral Treatment for Veterans With Co-Morbid Chronic Pain and Hazardous Opioid Use: A Randomized Controlled Pilot Trial

Opioid prescription in the treatment of chronic pain is frequent and carries a risk of increased morbidity and mortality in a clinically significant number of patients, particularly those who are using opioids in a hazardous manner. Few treatment options are available that target both pain-related interference and hazardous opioid use among patients with chronic pain. In military Veterans, this issue is of particular importance as numerous reports indicate continued high rates of opioid prescription for chronic pain, as well as significant opioid-related problems. The overall aim of the present study was to determine the feasibility of an integrated psychosocial treatment in Veterans with chronic pain, who also have evidence of hazardous opioid use. To examine this aim, a random design was used to assess the feasibility and initial efficacy of integrating 2 empirically supported interventions: Acceptance and Commitment Therapy for chronic pain and Mindfulness Based Relapse Prevention for opioid misuse. Half of participants were randomized to the integrated treatment group and all participants received usual care through a Veteran's Administration co-occurring disorders medical clinic to treat chronic pain and opioid misuse. In total, 37 participants were randomized and included in intent-to-treat analyses and 32 individuals were included in per protocol analyses with 6-month follow-up serving as the primary study endpoint. Feasibility indicators included recruitment, retention, and treatment completion rates. Recruitment fell short of targeted enrollment, although retention and completion were excellent. Primary outcome measures were opioid misuse, pain interference, and pain behavior. Simultaneous multiple regression analyses controlled for pain duration, baseline opioid dose, and baseline value for outcome measures. Results of both the intent-to-treat and per protocol indicated a significant effect in favor of the integrated intervention for opioid misuse, pain interference, and pain behavior. Results support the feasibility of providing an integrated treatment for both opioid risk and pain interference. PERSPECTIVE: Opioid misuse occurs in some opioid-prescribed individuals with chronic pain. Few treatment options exist that target both pain interference and opioid misuse. This study examined feasibility and initial efficacy of an integrated behavioral treatment for Veterans. Feasibility was supported, except recruitment. Efficacy was supported compared to usual care.

Beyond Adaptive Mental Functioning With Pain as the Absence of Psychopathology: Prevalence and Correlates of Flourishing in Two Chronic Pain Samples

Chronic pain outcomes are traditionally defined in terms of disability and illness. A definition of adaptive functioning in the context of chronic pain beyond the mere absence of negative outcomes, is the ability to flourish (i.e., experience emotional, psychological and social well-being; Keyes, 2002). We explored in two chronic pain samples the prevalence and sociodemographic, physical and psychological correlates of flourishing, and complemented this exploration with a similar examination of (being at risk for) psychopathology to help contextualize findings. Sample 1 (n = 1498) was a nationally representative sample. Subgroups included people with regular joint pain (1), regular joint pain and rheumatoid arthritis (2) and without chronic pain (3). Using chi-square tests we calculated the prevalence of both mental health outcomes and examined if people with or without chronic pain were more/less likely to flourish/at risk for psychopathology. Sample 2 (n = 238) concerned baseline data of a Randomized Controlled Trial on the effectiveness of Acceptance and Commitment Therapy for chronic pain (Trompetter et al., 2015b). We performed logistic regression analysis to identify flourishers/those at risk for depression. The Mental Health Continuum-Short Form was used to measure flourishing. The prevalence of flourishing was 34% (recurrent joint pain) and 38% (recurrent joint pain and arthritis) in sample 1, and 23% in sample 2. Compared to those without chronic pain, people with chronic pain were as likely to flourish, but more likely to be at risk for psychopathology. In sample 2, both flourishing and being at risk for depression were related foremost to psychological correlates. While engaged living was the most important correlate of flourishing, pain catastrophizing and psychological inflexibility were most important correlates of being at risk for depression. In conclusion, people with chronic pain are able to flourish. Findings suggest that positive and negative chronic pain outcomes function on two different continua, with potentially unique protective and risk factors. The Psychological Flexibility model provides pathways to explain both poor and optimal functioning in the presence of chronic pain. A better understanding of people with chronic pain who are able to flourish can be a fruitful endeavor to improve chronic pain models and interventions.

Does Mindfulness-Based Cognitive Therapy for Migraine Reduce Migraine-Related Disability in People with Episodic and Chronic Migraine? A Phase 2b Pilot Randomized Clinical Trial

OBJECTIVE

The current Phase 2b study aimed to evaluate the efficacy of mindfulness-based cognitive therapy for migraine (MBCT-M) to reduce migraine-related disability in people with migraine.

BACKGROUND

Mindfulness-based interventions represent a promising avenue to investigate effects in people with migraine. MBCT teaches mindfulness meditation and cognitive-behavioral skills and directly applies these skills to address disease-related cognitions.

METHODS

Participants with migraine (6-30 headache days/month) were recruited from neurology office referrals and local and online advertisements in the broader New York City area. During the 30-day baseline period, all participants completed a daily headache diary. Participants who met inclusion and exclusion criteria were randomized in a parallel design, stratified by chronic migraine status, to receive either 8 weekly individual MBCT-M sessions or 8 weeks of waitlist/treatment as usual (WL/TAU). All participants completed surveys including primary outcome evaluations at Months 0, 1, 2, and 4. All participants completed a headache diary during the 30-day posttreatment evaluation period. Primary outcomes were the change from Month 0 to Month 4 in the headache disability inventory (HDI) and the Migraine Disability Assessment (MIDAS) (total score ≥ 21 indicating severe disability); secondary outcomes (headache days/30 days, average headache attack pain intensity, and attack-level migraine-related disability [Migraine Disability Index (MIDI)]) were derived from the daily headache diary.

RESULTS

Sixty participants were randomized to receive MBCT-M (n = 31) or WL/TAU (n = 29). Participants (M age = 40.1, SD = 11.7) were predominantly White (n = 49/60; 81.7%) and Non-Hispanic (N = 50/60; 83.3%) women (n = 55/60; 91.7%) with a graduate degree (n = 35/60; 55.0%) who were working full-time (n = 38/60; 63.3%). At baseline, the average HDI score (51.4, SD = 19.0) indicated a moderate level of disability and the majority of participants (50/60, 83.3%) fell in the "Severe Disability" range in the MIDAS. Participants recorded an average of 16.0 (SD = 5.9) headache days/30 days, with an average headache attack pain intensity of 1.7 on a 4-point scale (SD = 0.3), indicating moderate intensity. Average levels of daily disability reported on the MIDI were 3.1/10 (SD = 1.8). For the HDI, mean scores decreased more from Month 0 to Month 4 in the MBCT-M group (-14.3) than the waitlist/treatment as an usual group (-0.2; P < .001). For the MIDAS, the group*month interaction was not significant when accounting for the divided alpha, P = .027; across all participants in both groups, the estimated proportion of participants falling in the "Severe Disability" category fell significantly from 88.3% at Month 0 to 66.7% at Month 4, P < .001. For diary-reported headache days/30 days an average headache attack pain intensity, neither the group*month interaction (Ps = .773 and .888, respectively) nor the time effect (Ps = .059 and .428, respectively) was significant. Mean MIDI scores decreased in the MBCT-M group (-0.6/10), whereas they increased in the waitlist/treatment as an usual group (+0.3/10), P = .007.

CONCLUSIONS

MBCT-M demonstrated efficacy to reduce headache-related disability and attack-level migraine-related disability. MBCT-M is a promising emerging treatment for addressing migraine-related disability.

Mindfulness- and acceptance-based interventions for patients with fibromyalgia - A systematic review and meta-analyses

Objectives

To analyze health effects of mindfulness- and acceptance-based interventions, including mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT) and acceptance and commitment therapy (ACT). Additionally, we aimed to explore content and delivery components in terms of procedure, instructors, mode, length, fidelity and adherence in the included interventions.

Methods

We performed a systematic literature search in the databases MEDLINE, PsychINFO, CINAHL, EMBASE, Cochrane Central and AMED from 1990 to January 2019. We included randomized and quasi-randomized controlled trials analyzing health effects of mindfulness- and acceptance-based interventions for patients with fibromyalgia compared to no intervention, wait-list control, treatment as usual, or active interventions. MBSR combined with other treatments were included. Predefined outcomes were pain, fatigue, sleep quality, psychological distress, depression, anxiety, mindfulness, health-related quality of life and work ability. The Template for Intervention Description and Replication (TIDieR) checklist and guide was used to explore content and delivery components in the interventions. Meta-analyses were performed, and GRADE was used to assess the certainty in the evidence.

Results

The search identified 4430 records, of which nine original trials were included. The vast majority of the participants were women. The analyses showed small to moderate effects in favor of mindfulness- and acceptance-based interventions compared to controls in pain (SMD -0.46 [95% CI -0.75, -0.17]), depression (SMD -0.49 [95% CI -0.85, -0.12]), anxiety (SMD -0.37 [95% CI -0.71, -0.02]), mindfulness (SMD -0.40 [-0.69, -0.11]), sleep quality (SMD -0.33 [-0.70, 0.04]) and health-related quality of life (SMD -0.74 [95% CI -2.02, 0.54]) at end of treatment. The effects are uncertain due to individual study limitations, inconsistent results and imprecision.

Conclusion

Health effects of mindfulness- and acceptance-based interventions for patients with fibromyalgia are promising but uncertain. Future trials should consider investigating whether strategies to improve adherence and fidelity of mindfulness- and acceptance-based interventions can improve health outcomes.

Early Changes in Pain Acceptance Predict Pain Outcomes in Interdisciplinary Treatment for Chronic Pain

Studies have shown that pain acceptance is associated with a better pain outcome. The current study explored whether changes in pain acceptance in the very early treatment phase of an interdisciplinary cognitive-behavioral therapy (CBT)-based treatment program for chronic pain predict pain outcomes. A total of 69 patients with chronic, non-malignant pain (at least 6 months) were treated in a day-clinic for four-weeks. Pain acceptance was measured with the Chronic Pain Acceptance Questionnaire (CPAQ), pain outcomes included pain intensity (Numeric Rating Scale, NRS) as well as affective and sensory pain perception (Pain Perception Scale, SES-A and SES-S). Regression analyses controlling for the pre-treatment values of the pain outcomes, age, and gender were performed. Early changes in pain acceptance predicted pain intensity at post-treatment measured with the NRS (B = −0.04 (SE = 0.02); T = −2.28; p = 0.026), affective pain perception at post-treatment assessed with the SES-A (B = −0.26 (SE = 0.10); T = −2.79; p = 0.007), and sensory pain perception at post-treatment measured with the SES-S (B = −0.19 (SE = 0.08); T = −2.44; p = 0.017). Yet, a binary logistic regression analysis revealed that early changes in pain acceptance did not predict clinically relevant pre-post changes in pain intensity (at least 2 points on the NRS). Early changes in pain acceptance were associated with pain outcomes, however, the impact was beneath the threshold defined as clinically relevant.

Complementary and Integrative Health Treatments for Migraine

BACKGROUND

Migraine is a chronic disabling neurologic condition that can be treated with a combination of both pharmacologic and complementary and integrative health options.

EVIDENCE ACQUISITION

With the growing interest in the US population in the use of nonpharmacologic treatments, we reviewed the evidence for supplements and behavioral interventions used for migraine prevention.

RESULTS

Supplements reviewed included vitamins, minerals, and certain herbal preparations. Behavioral interventions reviewed included cognitive behavioral therapy, biofeedback, relaxation, the third-wave therapies, acupuncture, hypnosis, and aerobic exercise.

CONCLUSIONS

This article should provide an appreciation for the wide range of nonpharmacologic therapies that might be offered to patients in place of or in addition to migraine-preventive medications.

Neuroimaging of Pain: Human Evidence and Clinical Relevance of Central Nervous System Processes and Modulation

Neuroimaging research has demonstrated definitive involvement of the central nervous system in the development, maintenance, and experience of chronic pain. Structural and functional neuroimaging has helped elucidate central nervous system contributors to chronic pain in humans. Neuroimaging of pain has provided a tool for increasing our understanding of how pharmacologic and psychologic therapies improve chronic pain. To date, findings from neuroimaging pain research have benefitted clinical practice by providing clinicians with an educational framework to discuss the biopsychosocial nature of pain with patients. Future advances in neuroimaging-based therapeutics (e.g., transcranial magnetic stimulation, real-time functional magnetic resonance imaging neurofeedback) may provide additional benefits for clinical practice. In the future, with standardization and validation, brain imaging could provide objective biomarkers of chronic pain, and guide treatment for personalized pain management. Similarly, brain-based biomarkers may provide an additional predictor of perioperative prognoses.

Building a Collaborative Model of Sacroiliac Joint Dysfunction and Pelvic Girdle Pain to Understand the Diverse Perspectives of Experts

BACKGROUND

Pelvic girdle pain (PGP) and sacroiliac joint (SIJ) dysfunction/pain are considered frequent contributors to low back pain (LBP). Like other persistent pain conditions, PGP is increasingly recognized as a multifactorial problem involving biological, psychological, and social factors. Perspectives differ between experts and a diversity of treatments (with variable degrees of evidence) have been utilized.

OBJECTIVE

To develop a collaborative model of PGP that represents the collective view of a group of experts. Specific goals were to analyze structure and composition of conceptual models contributed by participants, to aggregate them into a metamodel, to analyze the metamodel's composition, and to consider predicted efficacy of treatments.

DESIGN

To develop a collaborative model of PGP, models were generated by invited individuals to represent their understanding of PGP using fuzzy cognitive mapping (FCM). FCMs involved proposal of components related to causes, outcomes, and treatments for pain, disability, and quality of life, and their connections. Components were classified into thematic categories. Weighting of connections was summed for components to judge their relative importance. FCMs were aggregated into a metamodel for analysis of the collective opinion it represented and to evaluate expected efficacy of treatments.

RESULTS

From 21 potential contributors, 14 (67%) agreed to participate (representing six disciplines and seven countries). Participants' models included a mean (SD) of 22 (5) components each. FCMs were refined to combine similar terms, leaving 89 components in 10 categories. Biomechanical factors were the most important in individual FCMs. The collective opinion from the metamodel predicted greatest efficacy for injection, exercise therapy, and surgery for pain relief.

CONCLUSIONS

The collaborative model of PGP showed a bias toward biomechanical factors. Most efficacious treatments predicted by the model have modest to no evidence from clinical trials, suggesting a mismatch between opinion and evidence. The model enables integration and communication of the collection of opinions on PGP.

Mediators and moderators of change in mindfulness-based stress reduction for painful diabetic peripheral neuropathy

Painful diabetic peripheral neuropathy (PDPN) is a chronic pain condition with modest response to pharmacotherapy. Participation in mindfulness-based stress reduction (MBSR) leads to improvements in pain-related outcomes but the mechanisms of change are unknown. The present study examined the mediators and moderators of change in 62 patients with PDPN who participated in a randomized controlled trial comparing MBSR to waitlist. Changes in mindfulness and pain catastrophizing were tested simultaneously as mediators. Increased mindfulness mediated the association between participation in MBSR and improved pain severity, pain interference, and the physical component of health-related quality of life (HRQoL) 3 months later. The mediation effect of pain catastrophizing was not significant. Linear moderated trends were also found. Post-hoc moderated mediation analyses suggested that MBSR patients with longer histories of diabetes might increase their mindfulness levels more, which in turn leads to improved pain severity and physical HRQoL. These results allow for a deeper understanding of pathways by which MBSR benefits patients with PDPN.

Relationship between Future Orientation and Pain Severity in Fibromyalgia Patients: Self-Compassion as a Coping Mechanism

The present study examined the relationship between future orientation and fibromyalgia-related pain severity in a sample of 287 adults with fibromyalgia. Specifically, authors examined dimensions of self-compassion (for example, self-kindness, isolation, mindfulness) as possible mechanisms through which future orientation might be associated with pain severity. Results of conducting a multiple mediator test with 10,000 bootstraps indicated that the significant negative association between future orientation and pain severity was mediated through one specific self-compassion dimension, namely, isolation. The article concludes with a discussion of the implications of the present findings for working with fibromyalgia patients, specifically the potential value of social workers working with fibromyalgia patients to build future orientation as a resilience factor to combat pain severity. Also discussed is the value of working with patients to develop a sustainable social support system that can disrupt experiences of social isolation and disconnectedness from others, and which appear to contribute to greater pain severity.

Prescription Opioid Misuse After a Recent Sexual Assault: A Randomized Clinical Trial of a Video Intervention

BACKGROUND AND OBJECTIVES

Prescription opioid (PO) misuse is increasing and is associated with overdose. Individuals who experienced a recent sexual assault are at risk for increased substance use, yet limited interventions target PO misuse after sexual assault. The current study examined the efficacy of video interventions on PO misuse after sexual assault.

METHODS

Adolescent girls and women (n = 154) were recruited in the context of a sexual assault medical forensic exam in the emergency department. Effects of a prevention of post-rape stress (PPRS) video and a pleasant imagery and relaxation instruction (PIRI) video were compared with treatment as usual (TAU) during a sexual assault medical forensic exam on PO misuse. Participants reported if they had used POs for non-medical purposes since the sexual assault at 1.5 month follow-up.

RESULTS

Results from a logistic regression analysis indicated that participants with a prior sexual assault were less likely to misuse prescription opioids 1.5 months after the assault in the PIRI condition compared with TAU. There were no main effects for video condition and no interactions for the PPRS condition on PO misuse.

DISCUSSION AND CONCLUSIONS

Providing the PIRI video, or teaching other types of mindfulness or relaxation exercises, may be warranted as a secondary prevention for individuals during the sexual assault medical forensic exam for those with a prior sexual assault history.

SCIENTIFIC SIGNIFICANCE

This research provides an initial examination of the impact of mindfulness skills recently after traumatic event exposure on PO misuse. (Am J Addict 2019;28:376-381).

Psychological pain responses in athletes and non-athletes with low back pain: Avoidance and endurance matter

BACKGROUND

Dysfunctional psychological pain responses, namely fear-avoidance (FAR), including catastrophizing and helplessness, as well as endurance-related responses (ER), including thought suppression and overactivity, have been shown to be risk factors for persistent low back pain (LBP). Literature suggests that athletes may differ from non-athletes regarding psychological responses to pain.

OBJECTIVES

This study set out to compare FAR and ER between athletes and non-athletes with LBP. It was hypothesized that athletes would report less frequent FAR and more frequent ER, and that both FAR and ER are associated with LBP intensity and disability.

METHODS

The 173 athletes and 93 non-athletes cross-sectionally reported how frequently they employ FAR and ER on the Avoidance-Endurance Questionnaire (AEQ), as well as LBP intensity and disability on the Chronic Pain Grade Questionnaire (CPGS). MANOVA was applied to compare FAR and ER between athletes and non-athletes. Hierarchical multiple linear regression models were used to determine the unique associations between FAR and ER with LBP intensity and disability.

RESULTS

Athletes reported lower frequencies of behavioural avoidance than non-athletes, but no other FAR variables differed between the groups. Frequencies of ER did not differ between athletes and non-athletes. Regression analysis indicated substantial associations of FAR with LBP intensity, as well as of FAR and ER with disability in athletes and non-athletes.

CONCLUSIONS

The results of the present study suggest that athletes and non-athletes with LBP differ regarding behavioural avoidance, but overall, differences regarding pain responses are marginal. FAR and ER are both reported in athletes and non-athletes and contribute to disability in both groups.

SIGNIFICANCE

Athletes train to endure pain in the course of athletic socialization, at least in the context of exercise. However, there is sparsity of knowledge about psychological pain responses in athletes with low back pain and whether they differ from those in non-athletes. The results of this comparative study suggest that endurance responses are more frequent than avoidance responses among athletes and non-athletes alike. However, both types of responses seem relevant to clinical pain management in athletes as well as non-athletes.

Acceptance and commitment therapy for chronic pain: protocol of a systematic review and individual participant data meta-analysis

BACKGROUND

Acceptance and commitment therapy (ACT) can be effective in treating chronic pain. Despite evidence supporting the effectiveness of ACT, uncertainties remain regarding which subgroups in the chronic pain population are likely to benefit most and least. This protocol describes the application for two meta-analytic approaches, one at the level of individual participant data and the other at the level of aggregated data, from randomized controlled trials of ACT for chronic pain (ACT-CP-MA).

METHODS

We will systematically conduct literature searches in CENTRAL, MEDLINE, EMBASE, PsycINFO, and trial registers. Two reviewers will independently select studies for inclusion and data extraction. ACT-CP-MA will include randomized controlled trials with ACT for chronic pain compared to control conditions for adults (≥ 18 years) with chronic pain (> 3 months). We will invite the authors of all eligible trials to share individual participant data. Outcomes will include standardized measures of pain interference, pain intensity, depression, anxiety, health-related quality of life, participants' rating of overall improvement, and ACT-related process variables. Using the Cochrane Collaboration's tool and GRADE, reviewers will independently check for risk of bias, quality of evidence, and strength of recommendations. In the individual participant data meta-analysis, we will use a one-step approach where participants are clustered with studies and data from all studies are modeled simultaneously. For analyses, we will use mixed-effects models. Additionally, we will employ a meta-analysis with aggregate data and compare the results of both meta-analyses.

DISCUSSION

This collaborative meta-analysis of individual participant data from randomized controlled trials of ACT for chronic pain versus control conditions will demonstrate how the known benefits of ACT for chronic pain vary across different subtypes of the chronic pain population. The results of the meta-analyses will be based on a comprehensive search of multiple databases and will help to inform future clinical trials and decision-making on the use of ACT in chronic pain and improve the quality, design, and reporting of future trials in this field.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019120901.

Treating chronic pain and opioid misuse disorder among underserved populations in Colorado

The increased use of prescription opioids has resulted in widespread misuse. As a result, more than 40,000 Americans lost their lives to opiate overdose in 2016 alone. These data have led to a national movement focused on appropriate opioid prescribing practices. The Centers for Disease Control and Prevention (CDC) developed its Guidelines for Prescribing Opioids for Chronic Pain (2017), a template for pain management and substance assessment in primary care. These CDC guidelines aim to prevent misuse/deaths and early identification of substance use disorders. Although the guidelines are appropriate for initiation of opioid therapy, they are not sufficient to manage patients who have already developed misuse disorders. Other modalities such as medication-assisted treatment (MAT) have been described as beneficial for patients with high risk for or who have an opioid misuse disorder. This article builds on the CDC's 2017 advisory document by applying it in praxis: first, non-opioid medication therapy options and nonmedication therapy options are explored; next, a case study is presented of an integrated primary care-managed patient who presented with both chronic pain and established opioid use disorder. Although the CDC guidelines were not followed in the patient's initial prescription opioid treatment regimen, those guidelines were used as a starting point for follow-up treatment, helping both to assess the patient's risk for opioid misuse disorder and to determine that MAT was an appropriate method of treatment.

An experimental investigation of the relationships among race, prayer, and pain

Background and aims Compared to White individuals, Black individuals demonstrate a lower pain tolerance. Research suggests that differences in pain coping strategies, such as prayer, may mediate this race difference. However, previous research has been cross-sectional and has not determined whether prayer in and of itself or rather the passive nature of prayer is driving the effects on pain tolerance. The aim of this study was to clarify the relationships among race, prayer (both active and passive), and pain tolerance. Methods We randomly assigned 208 pain-free participants (47% Black, 53% White) to one of three groups: active prayer ("God, help me endure the pain"), passive prayer ("God, take the pain away"), or no prayer ("The sky is blue"). Participants first completed a series of questionnaires including the Duke University Religion Index, the Coping Strategies Questionnaire-Revised (CSQ-R), and the Pain Catastrophizing Scale. Participants were then instructed to repeat a specified prayer or distractor coping statement while undergoing a cold pressor task. Cold pain tolerance was measured by the number of seconds that had elapsed while the participant's hand remained in the cold water bath (maximum 180 s). Results Results of independent samples t-tests indicated that Black participants scored higher on the CSQ-R prayer/hoping subscale. However, there were no race differences among other coping strategies, religiosity, or catastrophizing. Results of a 2 (Race: White vs. Black)×3 (Prayer: active vs. passive vs. no prayer) ANCOVA controlling for a general tendency to pray and catastrophizing in response to prayer indicated a main effect of prayer that approached significance (p=0.06). Pairwise comparisons indicated that those in the active prayer condition demonstrated greater pain tolerance than those in the passive (p=0.06) and no prayer (p=0.03) conditions. Those in the passive and no prayer distractor conditions did not significantly differ (p=0.70). There was also a trending main effect of race [p=0.08], with White participants demonstrating greater pain tolerance than Black participants. Conclusions Taken together, these results indicate that Black participants demonstrated a lower pain tolerance than White participants, and those in the active prayer condition demonstrated greater tolerance than those in the passive and no prayer conditions. Furthermore, Black participants in the passive prayer group demonstrated the lowest pain tolerance, while White participants in the active prayer group exhibited the greatest tolerance. Results of this study suggest that passive prayer, like other passive coping strategies, may be related to lower pain tolerance and thus poorer pain outcomes, perhaps especially for Black individuals. On the other hand, results suggest active prayer is associated with greater pain tolerance, especially for White individuals. Implications These results suggest that understanding the influence of prayer on pain may require differentiation between active versus passive prayer strategies. Like other active coping strategies for pain, active prayer may facilitate self-management of pain and thus enhance pain outcomes independent of race. Psychosocial interventions may help religiously-oriented individuals, regardless of race, cultivate a more active style of prayer to improve their quality of life.

Are acceptance and mindfulness-based interventions 'value for money'? Evidence from a systematic literature review

OBJECTIVES

Acceptance and mindfulness-based interventions (A/MBIs) are recommended for people with mental health conditions. Although there is a growing evidence base supporting the effectiveness of different A/MBIs for mental health conditions, the economic case for these interventions has not been fully explored. The aim of this systematic review was to identify and appraise all available economic evidence of A/MBIs for the management of mental health conditions.

METHODS

Eight electronic bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Web of Science, NHS Economic Evaluation Database (EED), Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment (HTA) database, and EconLit) were searched for relevant economic evaluations published from each database's inception date until November 2017. Study selection, quality assessment, and data extraction were carried out according to published guidelines.

RESULTS

Ten relevant economic evaluations presented in 11 papers were identified. Seven of the included studies were full economic evaluations (i.e., costs and effects assessed), and three studies were partial economic evaluations (i.e., only costs were considered in the analysis). The A/MBIs that had been subjected to economic evaluation were acceptance and commitment therapy (ACT), dialectical behaviour therapy (DBT), mindfulness-based cognitive therapy (MBCT), and mindfulness-based stress reduction (MBSR). In terms of clinical presentations, the evaluation of cost-effectiveness of A/MBIs has been more focused on depression and emotional unstable personality disorder with three and four economic evaluations, respectively. Three out of seven full economic evaluations observed that A/MBIs were cost-effective for the management of mental health conditions. Nevertheless, the heterogeneity of included populations, interventions, and economic evaluation study types limits the extent to which firm conclusions can currently be made.

CONCLUSION

This first substantive review of economic evaluations of A/MBIs indicates that more research is needed before firm conclusions can be reached on the cost-effectiveness of A/MBIs for mental health conditions.

PRACTITIONER POINTS

The findings of the review provide information that may be relevant to mental health service commissioners and decision-makers as all economic evidence available on acceptance and mindfulness-based interventions for mental health conditions is summarized. Evidence relating to the cost-effectiveness and cost-saving potential of acceptance and mindfulness-based interventions is focused mainly on depression and emotional unstable personality disorder to date. Heterogeneity in the specific forms of acceptance and mindfulness-based interventions may limit generalizability of the findings. The number of health economic evaluations relating to acceptance and mindfulness-based interventions remains relatively small. Further research in this area is required.

The relationship between mindfulness facets, depression, pain severity and pain interference

The high prevalence of depression among chronic pain populations is well-established: however, treatments for both depression and chronic pain remain only moderately effective. Previous research has indicated that mindfulness is a promising treatment pathway for both depression and chronic pain, however, the mechanisms of change underlying mindfulness are unclear. The purpose of this study was to examine the effects of the mindfulness facets on depression and pain, using two pain measures; severity and interference. One hundred and fifty-eight Australian females and 32 males with chronic pain participated in the study. Higher levels of mindfulness were associated with lower depression as well as lower pain. Path models using depression as a mediator, found that the mindfulness facets observing and describing had a direct effect on pain, while non-judgement, non-reactivity and describing showed indirect effects on pain through depression. Greater effects were seen for pain interference compared to pain severity, highlighting its importance as a potential treatment outcome. Future research should continue to analyse the effects of the mindfulness facets and consider using pain interference as a core treatment outcome.

Understanding the Impact of Chronic Pain in the Emergency Department: Prevalence and Characteristics of Patients Visiting the Emergency Department for Chronic Pain at an Urban Academic Health Sciences Centre

Background: Canadians make approximately 16 million visits to the emergency department (ED) each year. ED visits for non-urgent reasons contribute to suboptimal patient care and ineffective resource use. Aims: To estimate the proportion of ED visits related to chronic pain at our institution. Methods. We conducted a retrospective review of 1000 randomly selected ED visits at TOH during the 2012-2013 fiscal year (April 1, 2012 to March 31, 2013). Visits for chronic pain were identified using pre-defined criteria. Demographic and medical data were extracted from medical charts. Results: 104 visits during this time period were related to chronic pain (10.4%; 95% CI: 8.2-12.6). All visits were from unique patients (i.e., no patients contributed more than 1 visit). Patients were predominantly women (71%), with a mean age of 45.9 years. Seventy-eight percent of patients had a primary care provider. The most common location of pain included the abdomen (24%), the head or face (21%), and the low back (21%). Only 5% of patients had consultation with a pain medicine specialist while 78% were awaiting a consultation. More than 2/3 of patients (71%) reported using opioids for their pain. Conclusion: Presenting to the ED for chronic pain was found to occur among a sample of ED visits reviewed. This can result in ineffective care for patients with chronic pain. Cost-effective solutions to improve clinical outcomes and reduce ED use for chronic pain may yield significant improvements in health outcomes of patients and benefits for the health care system.

Assessing Beliefs Underlying Rumination About Pain: Development and Validation of the Pain Metacognitions Questionnaire

Metacognitions, which are beliefs about our own thinking processes, can modulate worry and rumination and thereby influence emotional distress. This study aimed to develop a self-report measure of unhelpful pain-related metacognitions which might serve as a clinical and research tool to better understand pain catastrophizing, a significant risk factor for adverse pain outcomes. Two phases of validation are presented. Phase 1 reports on how the Pain Metacognitions Questionnaire (PMQ) was empirically developed through a qualitative study of 20 people with chronic back (n = 15) or knee (n = 5) pain in secondary or tertiary care and then validated in a large internet sample of people experiencing pain (N = 864). Rasch analysis yielded a 21-item scale with two dimensions (positive and negative metacognition) assessing how useful and problematic people believe rumination about pain to be, respectively. In Phase 2, further validation using a new sample (N = 510) replicated initial findings. Both PMQ subscales have good retest reliability (r = 0.76, r = 0.72) and internal consistency (0.86, 0.87). They correlate negatively with mindfulness and positively with pain intensity, disability, anxiety, depression, catastrophizing, rumination, and metacognition. The PMQ also predicts unique variance in catastrophizing when other variables are controlled and predicts 'patient' status for pain catastrophizing. Sensitivity analysis yielded preliminary suggestions for clinically meaningful cut-offs. Unhelpful pain metacognitions can be validly and reliably measured using a self-report instrument. Future studies using the PMQ might shed new light on pain-related thinking processes to develop better interventions for people prone to worry and rumination about their pain.

Medicate or Meditate? Greater Pain Acceptance is Related to Lower Pain Medication Use in Persons With Chronic Pain and Spinal Cord Injury

OBJECTIVES

There is little information about whether use of pain self-management skills that are common targets of psychosocial interventions for pain are associated with reduced reliance on pain medications. The aim of this study was to test whether higher chronic pain acceptance, which is a readily modified pain self-management approach, is related to lower use of pain medications (eg, opioid medications, and gabapentinoids) in a sample with chronic pain and spinal cord injury (SCI).

MATERIALS AND METHODS

This is a cross-sectional survey study of pain medication use, pain severity and distribution (Brief Pain Inventory [BPI]), depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]), and chronic pain acceptance (Chronic Pain Acceptance Questionnaire [CPAQ]) administered to a sample of 120 adults with chronic pain and SCI.

RESULTS

Regression results indicated that, above and beyond the effects of pain intensity, pain distribution, and depressive symptoms, higher pain acceptance was related to lower use of all types of pain medications, and lower odds of using opioid medications or gabapentinoids. Pain intensity was not related to pain medication use, but greater pain distribution was related to using more pain medications in general and to greater odds of using gabapentinoids.

DISCUSSION

Findings from this study indicate that those with chronic pain and SCI who have a more accepting orientation to pain are less reliant on pain medications, and thereby experience lower risks associated with medication consumption. Longitudinal, daily process, and clinical trial studies are needed to better understand the association between pain acceptance and pain medication consumption.

Psychological flexibility mediates the effect of an online-based acceptance and commitment therapy for chronic pain: an investigation of change processes

One way to improve treatment effects of chronic pain is to identify and improve control over mechanisms of therapeutic change. One treatment approach that includes a specific proposed mechanism is acceptance and commitment therapy (ACT) with its focus on increasing psychological flexibility (PF). The aim of the present study was to examine the role of PF as a mechanism of change in ACT. This is based on mediation analyses of data from a previously reported randomized controlled trial, evaluating the effectiveness of an ACT-based online intervention for chronic pain (ACTonPain). We performed secondary analyses on pretreatment, posttreatment, and follow-up data from 302 adults, receiving a guided (n = 100) or unguided (n = 101) version of ACTonPain, or allocated to the waitlist control group (n = 101). Structural equation modelling and a bias-corrected bootstrap approach were applied to examine the indirect effects of the treatment through pretreatment and posttreatment changes in the latent construct reflecting PF. The latent construct consisted of data from the Chronic Pain Acceptance Questionnaire and the Acceptance and Action Questionnaire. The outcomes were pretreatment to follow-up changes in pain interference, anxiety, depression, pain, and mental and physical health. Structural equation modelling analyses revealed that changes in PF significantly mediated pretreatment to follow-up changes in all outcomes in the intervention groups compared with waitlist (standardized estimates ranged from I0.16I to I0.69I). Global model fit yielded modest but acceptable results. Findings are consistent with the theoretical framework behind ACT and contribute to growing evidence, supporting a focus on PF to optimize treatment effects.

Acceptance and Commitment group Therapy for patients with multiple functional somatic syndromes: a three-armed trial comparing ACT in a brief and extended version with enhanced care

BACKGROUND

Psychological treatment for functional somatic syndromes (FSS) has been found moderately effective. Information on how much treatment is needed to obtain improvement is sparse. We assessed the efficacy of a brief and extended version of group-based Acceptance and Commitment Therapy (ACT) v. enhanced care (EC) for patients with multiple FSS operationalised as Bodily Distress Syndrome multi-organ type.

METHODS

In a randomised controlled three-armed trial, consecutively referred patients aged 20-50 with multiple FSS were randomly assigned to either (1) EC; (2) Brief ACT: EC plus 1-day workshop and one individual consultation; or (3) Extended ACT: EC plus nine 3-h group-based sessions. Primary outcome was patient-rated overall health improvement on the five-point clinical global improvement scale 14 months after randomisation. A proportional odds model was used for the analyses.

RESULTS

A total of 180 patients were randomised; 60 to EC, 61 to Brief ACT, and 59 to Extended ACT. Improvement on the primary outcome after Extended ACT was significantly greater than after EC with an unadjusted OR of 2.9 [95% CI (1.4-6.2), p = 0.006]. No significant differences were found between Brief ACT and EC. Of the 18 secondary outcomes, the only significant difference found was for physical functioning in the comparison of Extended ACT with EC.

CONCLUSIONS

Patients rated their overall health status as more improved after Extensive ACT than after EC; however, clinically relevant secondary outcome measures did not support this finding. Discrepancies between primary and secondary outcomes in this trial are discussed.

Third Wave Treatments for Functional Somatic Syndromes and Health Anxiety Across the Age Span: A Narrative Review

Functional disorders (FD) are present across the age span and are commonly encountered in somatic health care. Psychological therapies have proven effective, but mostly the effects are slight to moderate. The advent of third wave cognitive behavioural therapies launched an opportunity to potentially improve treatments for FD.

A narrative review of the literature on the application of mindfulness-based therapies (MBT) and Acceptance &amp; Commitment Therapy (ACT) in children and adult populations with FD.

There were very few and mainly preliminary feasibility studies in children and adolescents. For adults there were relatively few trials of moderate to high methodological quality. Ten MBT randomised trials and 15 ACT randomised trials of which 8 were internet-delivered were identified for more detailed descriptive analysis. There was no evidence to suggest higher effects of third wave treatments as compared to CBT. For MBT, there seemed to be minor effects comparable to active control conditions. A few interventions combining second and third wave techniques found larger effects, but differences in outcomes, formats and dosage hamper comparability.

Third wave treatments are getting established in treatment delivery and may contribute to existing treatments for FD. Future developments could further integrate second and third wave treatments across the age span. Elements unambiguously targeting specific illness beliefs and exposure should be included. The benefit of actively engaging close relatives in the treatment not only among younger age groups but also in adults, as well as the effect of more multimodal treatment programmes including active rehabilitation, needs to be further explored.

The methodological quality of third wave interventions for FD should be improved, especially in younger age groups.

The effect of ACT interventions may be comparable to CBT in adults with FD.

The evidence for third wave interventions in young people with FD is still very limited.

Newer studies combining second and third wave treatments show some promise.

Agreement on, and for child populations further development of, core outcomes, could help determine effect across studies.

Acceptance and Commitment Therapy for the Treatment of Chronic Pain and Coexisting Depression: A Single-Case Study

Pain resulting from chronic medical conditions (CMCs) can create debilitating effects globally across domains of functioning in the lives of those it impacts. There currently remain no treatment options to eliminate associated pain entirely, leaving care efforts often to manage the disabling effects and consequential depression. Acceptance and commitment therapy (ACT) has recently been introduced as an alternative treatment approach, emphasizing the commitment to engage in actions that contribute to a fulfilling life even in the face of disability through the fostering of psychological flexibility. For patients who do not respond to traditional psychological approaches, ACT may offer a sensible substitute. This single-case study delineates ACT for chronic pain and comorbid depression using standardized and patient-centered outcome measures across areas of general symptom functioning, therapeutic processes, and flexibility surrounding pain associated with CMCs. Clinical significance and reliable change were calculated using the reliable change index, in conjunction with patient-reported behavioral engagement and subjective assessment. Results indicate significant improvement across areas of depression, psychological flexibility, and flexibility in relating to pain endured from CMCs. The patient reported perceived improvement in quality of life and no longer viewed herself as a “professional patient.” This case study illustrates the potential of shifting from restraining and extinguishing symptoms to fostering a stance of willingness to reengage in a valued life while continuing to live with CMCs.

A Replicable and Sustainable Whole Person Care Model for Chronic Pain

Background: Integrative health is an expanding field that is increasingly called upon by conventional medicine to provide care for patients with chronic pain and disease. Although evidence has mounted for delivering integrative therapies individually, there is little consensus on how best to deliver these therapies in tandem as part of whole person care. While many models exist, few are financially sustainable.

Methods and results: This article describes a conceptual and logistical model for providing integrative outpatient health care within an academic medical center or hospital system to patients with chronic pain and disease. In hopes that the model will be replicated, administrative details are provided to explain how the model operates and has been maintained over nine years. The details include the intentional building of a particular work culture.

Conclusion: This whole person care model that addresses chronic pain and disease in an outpatient integrative clinic has been successful, sustainable and can be replicated in other academic medical centers or hospital clinics.

Age, Pain Intensity, Values-Discrepancy, and Mindfulness as Predictors for Mental Health and Cognitive Fusion: Hierarchical Regressions With Mediation Analysis

Background: Several studies have confirmed that higher levels of psychological flexibility predict better functioning for those suffering with chronic pain. However, few studies have investigated the role of the individual components of psychological flexibility within a chronic pain population in relation to aging specifically and the related indirect mediational processes.

Aim: The present study aimed to compare how age, pain intensity, mindfulness, and values-discrepancy predicted mental health and cognitive fusion separately. It also explored the indirect process relations through the use of a mediated analysis.

Methods: Two hundred and thirty three participants completed an online survey which included demographical questions as well as the following questionnaires; Short Form McGill Pain Questionnaire (SF-MPQ); General Health Questionnaire 12; Cognitive Fusion 7-Item Questionnaire (CFQ-7); Mindfulness Attention Awareness Scale (MAAS); and the Chronic Pain Values Inventory (CPVI). The relationships from the responses of the questionnaires and demographics were then analyzed through two hierarchical regression models followed by further mediation analysis.

Results: In the first model, values-discrepancy, pain intensity, and mindfulness all predicted mental health, but age did not. However, age did account for a significant portion of the variance in the second model when cognitive fusion was used as the dependent measure. It was also found that cognitive fusion mediated the relationship between age and mental health.

Conclusion: These results are discussed within the context of using indirect process relations of psychological flexibility and third wave therapies such as acceptance and commitment therapy for a chronic pain population.

Update and future perspective of behavioral medicine in the treatment for chronic pain

Chronic pain is a biopsychosocial condition, and behavioral medicine has made significant contributions to the understanding of the phenomenon and optimization of therapeutic outcomes. The objective of this article is to provide future perspectives of behavioral medicine in pain management based upon recent development in the field. We will briefly review the mainstream approach of cognitive-behavioral therapy, its variations and new and innovative approaches that are on the horizon. We also review strategies that address potential barriers to pain management. Behavioral medicine is a promising field in pain medicine. The future growth is likely to come from addressing how we incorporate the patient heterogeneity into our treatment approaches and a better understanding of its role in a multimodal treatment.

Psychotherapeutic interventions for chronic pain: Evidence, rationale, and advantages

BACKGROUND

Long-term use of opioids to treat chronic pain incurs serious risks for the individual-including misuse, abuse, addiction, overdose and death-as well as creating economic, social, and cultural impacts on society as a whole. Chronic pain and substance use disorders are often co-morbid with other medical problems and at the present time, primary care clinicians serve most of this population. Primary care clinicians would benefit from having alternatives to opioids to employ in treating such patients.

METHOD

We electronically searched different medical databases for studies evaluating the effect of nonpharmacological treatments for chronic pain. We describe alternative approaches for the treatment of chronic pain and cite studies that provide substantial evidence in favor of the use of these treatments.

RESULTS

Cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness-based programs have well-documented effectiveness for the treatment of chronic nonmalignant pain. Integration of such behavioral health therapies into primary care settings may optimize health resources and improve treatment outcomes.

CONCLUSION

Evidence-based psychotherapy for chronic pain has established efficacy and safety and improves quality of life and physical and emotional functioning. Such interventions may be used as an alternative or adjunct to pharmacological management. Chronic opioid use should be reserved for individuals undergoing active cancer treatment, palliative care, or end-of-life care.

Multidisciplinary Pain Management for Pediatric Patients with Acute and Chronic Pain: A Foundational Treatment Approach When Prescribing Opioids

Opioid therapy is the cornerstone of treatment for acute procedural and postoperative pain and is regularly prescribed for severe and debilitating chronic pain conditions. Although beneficial for many patients, opioid therapy may have side effects, limited efficacy, and potential negative outcomes. Multidisciplinary pain management treatments incorporating pharmacological and integrative non-pharmacological therapies have been shown to be effective in acute and chronic pain management for pediatric populations. A multidisciplinary approach can also benefit psychological functioning and quality of life, and may have the potential to reduce reliance on opioids. The aims of this paper are to: (1) provide a brief overview of a multidisciplinary pain management approach for pediatric patients with acute and chronic pain, (2) highlight the mechanisms of action and evidence base of commonly utilized integrative non-pharmacological therapies in pediatric multidisciplinary pain management, and (3) explore the opioid sparing effects of multidisciplinary treatment for pediatric pain.

Development and pilot testing of the treatment and education approach for childhood-onset lupus (TEACH): a cognitive behavioral treatment

BACKGROUND

To develop and test the feasibility and initial effectiveness of the Treatment and Education Approach for Childhood-onset Lupus (TEACH) protocol, a 6-session cognitive behavioral therapy (CBT) intervention for adolescents and young adults (AYA) with childhood-onset systemic lupus erythematosus (cSLE).

METHODS

Females with cSLE (n = 14; ages 13-19 years, M = 16.21 years) presenting to a pediatric rheumatology clinic subsequently completed the protocol, which was iteratively modified based on participant/interventionist feedback. Upon intervention completion, participants provided qualitative data on feasibility, acceptability, potential modifications, and perceived effectiveness of the program via a semi-structured interview, which was analyzed for shared themes. Participants also completed measures of fatigue, psychological distress, and pain intensity before and after the intervention. Nonparametric statistics were conducted to examine changes in outcome measures following the intervention.

RESULTS

During the study, several protocol modifications were employed to better address the unique needs of individuals with cSLE (e.g., separate content for adolescents versus young adults). Results suggest that TEACH is feasible, acceptable, and potentially effective in the management of cSLE symptoms. Following the intervention, there was a statistically significant reduction in fatigue (Z = - 2.81, p < .01) and depressive symptoms (Z = - 2.69, p < .01). Reductions in pain and anxiety symptoms were marginal.

CONCLUSIONS

TEACH, a tailored CBT protocol for AYA with cSLE, is a feasible and potentially effective intervention for the management of fatigue and depressive symptoms. Future directions include testing the protocol in a larger controlled study.

Evaluation of Self-Management Support Functions in Apps for People With Persistent Pain: Systematic Review

Background

Smartphone apps are a potential mechanism for development of self-management skills in people with persistent pain. However, the inclusion of best-practice content items in available pain management apps fostering core self-management skills for self-management support is not known.

Objective

The aim of the study was to evaluate the contents of smartphone apps providing information on pain management strategies for people with persistent pain facilitating self-management support and to appraise the app quality.

Methods

A systematic search was performed in the New Zealand App Store and Google Play Store. Apps were included if they were designed for people with persistent pain, provided information on pain self-management strategies, and were available in English. App contents were evaluated using an a priori 14-item self-management support (SMS-14) checklist. App quality was assessed using the 23-item Mobile Apps Rating Scale.

Results

Of the 939 apps screened, 19 apps met the inclusion criteria. Meditation and guided relaxation were the most frequently included self-management strategies. Overall, the included apps met a median of 4 (range 1-8) of the SMS-14 checklist. A total of 3 apps (Curable, PainScale-Pain Diary and Coach, and SuperBetter) met the largest number of items (8 out of 14) to foster self-management of pain. Self-monitoring of symptoms (n=11) and self-tailoring of strategies (n=9) were frequently featured functions, whereas a few apps had features facilitating social support and enabling communicating with clinicians. No apps provided information tailored to the cultural needs of the user. The app quality mean scores using Mobile Apps Rating Scale ranged from 2.7 to 4.5 (out of 5.0). Although use of 2 apps (Headspace and SuperBetter) has been shown to improve health outcomes, none of the included apps have been evaluated in people with persistent pain.

Conclusions

Of the 3 apps (Curable, PainScale-Pain Diary and Coach, and SuperBetter) that met the largest number of items to support skills in self-management of pain, 2 apps (PainScale-Pain Diary and Coach and SuperBetter) were free, suggesting the potential for using apps as a scalable, wide-reaching intervention to complement face-to-face care. However, none provided culturally tailored information. Although 2 apps (Headspace and SuperBetter) were validated to show improved health outcomes, none were tested in people with persistent pain. Both users and clinicians should be aware of such limitations and make informed choices in using or recommending apps as a self-management tool. For better integration of apps in clinical practice, concerted efforts are required among app developers, clinicians, and people with persistent pain in developing apps and evaluating for clinical efficacy.