Kevin E. Vowles

Acceptance and commitment therapy and mindfulness for chronic pain: model, process, and progress.

Over 30 years ago, treatments based broadly within cognitive behavioral therapy (CBT) began a rise in prominence that eventually culminated in their widespread adoption in chronic pain treatment settings. Research into CBT has proliferated and continues today, addressing questions very similar to those addressed at the start of this enterprise. However, just as it is designed to do, the process of conducting research and analyzing evidence reveals gaps in our understanding of and shortcomings within this treatment approach. A need for development seems clear. This article reviews the progress of CBT in the treatment of chronic pain and the challenges now faced by researchers and clinicians interested in meeting this need for development. It then focuses in greater detail on areas of development within CBT, namely acceptance and commitment therapy (ACT) and mindfulness-based approaches, areas that may hold potential for future progress. Three specific recommendations are offered here to achieve this progress.

Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis.

Abstract Opioid use in chronic pain treatment is complex, as patients may derive both benefit and harm. Identification of individuals currently using opioids in a problematic way is important given the substantial recent increases in prescription rates and consequent increases in morbidity and mortality. The present review provides updated and expanded information regarding rates of problematic opioid use in chronic pain. Because previous reviews have indicated substantial variability in this literature, several steps were taken to enhance precision and utility. First, problematic use was coded using explicitly defined terms, referring to different patterns of use (ie, misuse, abuse, and addiction). Second, average prevalence rates were calculated and weighted by sample size and study quality. Third, the influence of differences in study methodology was examined. In total, data from 38 studies were included. Rates of problematic use were quite broad, ranging from <1% to 81% across studies. Across most calculations, rates of misuse averaged between 21% and 29% (range, 95% confidence interval [CI]: 13%-38%). Rates of addiction averaged between 8% and 12% (range, 95% CI: 3%-17%). Abuse was reported in only a single study. Only 1 difference emerged when study methods were examined, where rates of addiction were lower in studies that identified prevalence assessment as a primary, rather than secondary, objective. Although significant variability remains in this literature, this review provides guidance regarding possible average rates of opioid misuse and addiction and also highlights areas in need of further clarification.

Acceptance and Commitment Therapy for Chronic Pain: Evidence of Mediation and Clinically Significant Change Following an Abbreviated Interdisciplinary Program of Rehabilitation

UNLABELLEDnThere is an emerging body of evidence regarding interdisciplinary acceptance and commitment therapy in the rehabilitative treatment of chronic pain. This study evaluated the reliability and clinical significance of change following an open trial that was briefer than that examined in previous work. In addition, the possible mediating effect of psychological flexibility, which is theorized to underlie the acceptance and commitment therapy model, was examined. Participants included 117 completers of an interdisciplinary program of rehabilitation for chronic pain. Assessment took place at treatment onset and conclusion, and at a 3-month follow-up when 78 patients (66.7%) provided data. At the 3-month follow-up, 46.2% of patients achieved clinically significant change, and 58.9% achieved reliable change, in at least 1 key measure of functioning (depression, pain anxiety, and disability). Changes in measures of psychological flexibility significantly mediated changes in disability, depression, pain-related anxiety, number of medical visits, and the number of classes of prescribed analgesics. These results add to the growing body of evidence supporting interdisciplinary acceptance and commitment therapy for chronic pain, particularly with regard to the clinical significance of an abbreviated course of treatment. Further, improvements appear to be mediated by changes in the processes specified within the theoretical model.nnnPERSPECTIVEnOutcomes of an abbreviated interdisciplinary treatment for chronic pain based on a particular theoretical model are presented. Analyses indicated that improvements at follow-up mediated change in the theorized treatment process. Clinically significant change was indicated in just under half of participants. These data may be helpful to clinicians and researchers interested in intervention approaches and mechanisms of change.

A comprehensive examination of the model underlying acceptance and commitment therapy for chronic pain.

The therapeutic model underlying Acceptance and Commitment Therapy (ACT) is reasonably well-established as it applies to chronic pain. Several studies have examined measures of single ACT processes, or subsets of processes, and have almost uniformly indicated reliable relations with patient functioning. To date, however, no study has performed a comprehensive examination of the entire ACT model, including all of its component processes, as it relates to functioning. The present study performed this examination in 274 individuals with chronic pain presenting for an assessment appointment. Participants completed a battery of self-report questionnaires, assessing multiple aspects of the ACT model, as well as pain intensity, disability, and emotional distress. Initial exploratory factor analyses examined measures of the ACT model and measures of patient functioning separately with each analysis identifying three factors. Next, the fit of a model including ACT processes on the one hand and patient functioning on the other was examined using Structural Equation Modeling. Overall model fit was acceptable and indicated moderate correlations among the ACT processes themselves, as well as significant relations with pain intensity, emotional distress, and disability. These analyses build on the existing literature by providing, to our knowledge, the most comprehensive evaluation of the ACT theoretical model in chronic pain to date.

Single-Case Research Design in Pediatric Psychology: Considerations Regarding Data Analysis

OBJECTIVEnSingle-case research allows for an examination of behavior and can demonstrate the functional relation between intervention and outcome in pediatric psychology. This review highlights key assumptions, methodological and design considerations, and options for data analysis.nnnMETHODSnSingle-case methodology and guidelines are reviewed with an in-depth focus on visual and statistical analyses.nnnRESULTSnGuidelines allow for the careful evaluation of design quality and visual analysis. A number of statistical techniques have been introduced to supplement visual analysis, but to date, there is no consensus on their recommended use in single-case research design.nnnCONCLUSIONSnSingle-case methodology is invaluable for advancing pediatric psychology science and practice, and guidelines have been introduced to enhance the consistency, validity, and reliability of these studies. Experts generally agree that visual inspection is the optimal method of analysis in single-case design; however, statistical approaches are becoming increasingly evaluated and used to augment data interpretation.

Pain as a predictor of heavy drinking and any drinking lapses in the COMBINE study and the UK Alcohol Treatment Trial

AIMSnTo test the association between pain and heavy drinking lapses during and following treatment for alcohol use disorders (AUD).nnnDESIGNnSecondary data analysis of data from two clinical trials for AUD.nnnSETTING AND PARTICIPANTSnParticipants included 1383 individuals from the Combined Pharmacotherapies and Behavioral Interventions (COMBINE) Study in the United States [69.0% male, 76.8% non-Hispanic White average age=44.4, standard deviation (SD)u2009=u200910.2] and 742 individuals from the UK Alcohol Treatment Trial (UKATT) in the United Kingdom [74.1% male, 95.6% White, average age=41.6 (SD=10.1)].nnnMEASUREMENTSnForm-90 (a structured assessment interview) was used to assess the primary outcome: time to first heavy drinking day. The Short Form Health Survey and Quality of Life measures were used to assess pain interference and pain intensity.nnnFINDINGSnPain was a significant predictor of heavy drinking lapses during treatment in UKATT [odds ratio (OR)=1.19, 95% confidence interval (CI)=1.08, 1.32, P=0.0003] and COMBINE (OR=1.12, 95% CI=1.03, 1.21, P=0.009), and was a significant predictor of heavy drinking lapses following treatment in COMBINE (OR=1.163, 95% CI=1.15, 1.17, P<0.00001). After controlling for other relapse risk factors (e.g. dependence severity, self-efficacy, temptation, psychiatric distress), pain remained a significant predictor of heavy drinking lapses during treatment in UKATT (OR=1.19, 95% CI=1.06, 1.34, P=0.004) and following treatment in COMBINE (OR=1.44, 95% CI=1.07, 1.92, P=0.01).nnnCONCLUSIONSnAmong people treated for alcohol use disorder, being in physical pain appears to predict heavy drinking lapses during or after treatment.

Acceptance and Commitment Therapy for Pediatric Chronic Pain: Theory and Application

Acceptance and Commitment Therapy (ACT) is a third wave behavior therapy approach which aims to increase engagement in activities that bring meaning, vitality, and value to the lives of individuals experiencing persistent pain, discomfort, or distress. This goal is particularly relevant when these aversive experiences cannot be effectively avoided or when avoidance efforts risk their exacerbation, all of which may be common experiences in children and adolescents with chronic pain conditions. The primary aim of the present paper is to review and summarize the extant literature on the application, utility, and evidence for using ACT with pediatric chronic pain populations by: (1) defining the theoretical assumptions of the ACT model; (2) summarizing research study findings and relevant measures from the published literature; and (3) critically discussing the strengths, limitations and areas in need of further development.

Living Well with Pain: Development and Preliminary Evaluation of the Valued Living Scale

OBJECTIVESnEncouraging individuals with chronic pain to focus on nonpain-related goals that are consistent with personal values is a goal of most psychosocial pain interventions. A valid and reliable measure of goal-related variables would be useful to evaluate the importance of these to patient quality of life and as factors that may explain treatment outcome.nnnDESIGNnWe developed items for a measure (the Valued Living Scale, VLS) to assess goal importance, success, and confidence with respect to eight value domains and 26 specific values-related goals, and administered these items to individuals with three chronic pain conditions (low back pain, Nu2009=u200958; fibromyalgia, Nu2009=u200955; headache, Nu2009=u200961).nnnRESULTSnAnalyses supported: 1) a two-factor model of the VLS items assessing goal-related variables associated with a) health and productivity and b) social relations; 2) VLS scale score reliability, with Cronbachs alphas greater than 0.70; and 3) VLS scale score validity, as indicated by significant associations with pain intensity, depression, and pain interference in the expected directions.nnnCONCLUSIONSnThe VLS items can be administered and scored to assess: 1) the importance of as well as 2) confidence in and 3) success in achieving values-consistent goals. The measure can be used by clinicians to monitor and track changes in patients perceptions about their goals with treatment. Researchers can use the VLS to test theoretical models of the roles that patient perceptions about goal importance, confidence, and success play in chronic pain treatment outcome.

Psychological flexibility in coping with chronic pain: further examination of the brief pain coping inventory-2.

Objective:The role of coping in chronic pain management is well established. One challenge to the coping approach, however, is in identifying forms of coping that reliably lead to better functioning. An emerging approach to coping is based on the notion of psychological flexibility, a response pattern entailing openness to experience, awareness of specific behavioral options in a given situation, and persistence or alteration of activity according to personally held values and goals. A primary measure of psychological flexibility has been the Brief Pain Coping Inventory-2 (BPCI-2), and initial analyses have provided support for its utility in chronic pain treatment settings. The present study aimed to extend the previous work by examining relations of the BPCI-2 with measures of patient functioning, as well as with measures related to psychological flexibility, pain acceptance and valued activity in this case. Method:A total of 324 individuals with chronic pain who completed a series of measures at an initial assessment appointment were included in the study. Results:In correlation and regression analyses, the Psychological Flexibility subscale of the BPCI-2 achieved consistently significant relations with measures of disability, emotional functioning, pain acceptance, and valued activity, even after controlling for pain intensity and traditional coping methods. Discussion:These results lend support to the adoption of psychological flexibility as a framework in future studies of coping with chronic pain.

Alcohol and opioid use, co-use, and chronic pain in the context of the opioid epidemic: a critical review

The dramatic increase in opioid misuse, opioid use disorder (OUD), and opioid-related overdose deaths in the United States has led to public outcry, policy statements, and funding initiatives. Meanwhile, alcohol misuse and alcohol use disorder (AUD) are a highly prevalent public health problem associated with considerable individual and societal costs. This study provides a critical review of alcohol and opioid misuse, including issues of prevalence, morbidity, and societal costs. We also review research on interactions between alcohol and opioid use, the influence of opioids and alcohol on AUD and OUD treatment outcomes, respectively, the role of pain in the co-use of alcohol and opioids, and treatment of comorbid OUD and AUD. Heavy drinking, opioid misuse, and chronic pain individually represent significant public health problems. Few studies have examined co-use of alcohol and opioids, but available data suggest that co-use is common and likely contributes to opioid overdose-related morbidity and mortality. Co-use of opioids and alcohol is related to worse outcomes in treatment for either substance. Finally, chronic pain frequently co-occurs with use (and co-use) of alcohol and opioids. Opioid use and alcohol use are also likely to complicate the treatment of chronic pain. Research on the interactions between alcohol and opioids, as well as treatment of the comorbid disorders is lacking. Currently, most alcohol research excludes patients with OUD and there is lack of measurement in both AUD and OUD research in relation to pain-related functioning. Research in those with chronic pain often assesses opioid use, but rarely assesses alcohol use or AUD. New research to examine the nexus of alcohol, opioids, and pain, as well as their treatment, is critically needed.