Nancy A. Melville

June 01, 2016

AUSTIN, Texas — As researchers strive to find the right psychotherapeutic approaches to best help patients break destructive thought patterns that perpetuate chronic pain, acceptance and commitment therapy (ACT) and psychological flexibility are gaining favor — and evidence.

In one of several papers looking at the issue presented here at the American Pain Society (APS) 35th Annual Scientific Meeting, researchers showed the importance of acceptance in offsetting patient perceptions of injustice, which are known to be strongly associated with pain-related outcomes.

"When pain becomes chronic, patients can experience many losses: loss of function, loss of employment, and loss of independence. It's very intuitive to not feel responsible for it and develop a sense of injustice," first author Junie Carriere, a PhD candidate in experimental psychology at the Center for Research on Pain, Disability and Social Integration at McGill University, Montreal, Quebec, Canada, told Medscape Medical News.

"The sense of injustice can further set the wheels in motion for a vicious cycle of negative outcomes, such as decreased function and perceived disability."

Conversely, an acceptance of pain has been associated with fewer pain-related difficulties and better quality of life.

"Overall, people with high acceptance push forward, mentally and physically. As a result, they experience better health and pain outcomes," Carriere said.

To study the role of ACT in potentially mediating those perceptions, Carriere and her colleagues from McGill University and Stanford Medical School, Palo Alto, California, evaluated 344 adult patients with chronic pain who presented at the Stanford Outpatient Pain Management Center.

In analyses using multiple mediation analysis, they found a negative correlation between perceived injustice and pain acceptance, which is consistent with previous research.

The acceptance of pain, however, mediated the relation between perceived injustice and pain interference (P < .001). Acceptance did not fully offset the relation between perceived injustice and pain intensity.

"These findings suggest that perceived injustice and acceptance have significant roles in the degree to which pain interferes with the lives of individuals with chronic pain," the authors write.

"Although the study design limits our ability to establish causal relationships, it provides a theoretical framework for the use of interventions that target pain acceptance in order to improve physical, mental and social adjustment to chronic pain, particularly in patients who perceive their pain as unjust."

Carriere added that "clinicians should be made aware of the detrimental impacts of feelings of injustice on pain outcomes."

"They may want to identify patients who express high feelings of injustice and consider including acceptance-based therapy as part of their pain management treatment plan," she said.

Numerous other studies have underscored the role of pain acceptance in chronic pain, and one recent study published in the Journal of Pain in 2015, showed that pain-related acceptance, part of a 5-week outpatient multidisciplinary program of cognitive-behavioral therapy, was the strongest mediator across several different indices of outcome.

In a plenary talk on psychological flexibility and functional contextualism presented at the APS meeting, Lance M. McCracken, PhD, a coauthor on that study, speculated on the additional role of flexibility in shifting the patterns of thought that perpetuate chronic pain.

"Instead of shifting what we think and feel, maybe we can shift whether what we think and feel is in charge of what we do," said Dr McCracken, a professor in the Institute of Psychiatry, Psychology and Neuroscience at King's College London, United Kingdom.

"I would call that a shift in looking at verbal regulation over behavior. And the question should be, can we decrease verbal regulation in some situations and increase it in others?"

The broader focus of such efforts is to turn patients away from pain catastrophizing, known to be a critical driver of poor outcomes and continued pain.

"When you catastrophize, it's like living in a catastrophe — of course it affects you," Dr McCracken said. "Thoughts and words, given the right context, carry the influence of the experience of the things is they describe."

"The question is how can we undermine it, and should we do battle with catastrophizing, or make peace with it? I think what we're learning is that making peace is an option, and I think we know how."

ACT and Telehealth

ACT has been shown to be particularly beneficial for veterans with chronic pain, helping to reduce pain interference and improve quality of life. However, restricted access is a common limitation in preventing patients from getting the help they need.

In another study presented at the meeting, researchers sought to determine whether telemedicine could offer an equally effective option for ACT.

For the study, the researchers randomly assigned 129 veterans with chronic pain in the Veterans Affairs San Diego Healthcare System to receive 8 weeks of ACT therapy through video conferencing or in-person.

On the study's primary outcome of pain interference on the Brief Pain Inventory, results showed noninferiority of the telehealth approach, with participants in both groups having lower pain inference scores compared with baseline (P < .05), and no significant differences between groups in time-by-treatment interaction.

There were also no significant differences between groups in terms of reductions in depressive symptoms and pain-related anxiety, and improvements in quality of life.

Despite no significant improvements in sleep or post-traumatic stress disorder between groups, attrition rates were higher in the telehealth group, underscoring one of the key challenges with telemedicine.

"The findings of the present study suggest that ACT for chronic pain delivered [by] telehealth or in-person are comparable, though attrition rates may differ based on delivery type," the authors concluded.

Ms Carriere and Dr McCracken have disclose no relevant financial relationships. The research at Veterans Affairs San Diego was supported by a Veterans Affairs Rehabilitation Research and Development grant.

American Pain Society (APS) 35th Annual Scientific Meeting. Presented May 13, 2016.

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