Psychological tools may help patients with chronic pain successfully taper opioid use, control pain

In patients with chronic postsurgical pain (CPSP) at highest risk for developing chronic pain and persistent high-dose opioid use, acceptance and commitment therapy (ACT) may effectively reduce opioid use, as well as improve pain interference and mood, according to preliminary results of a study published in the Canadian Journal of Pain.

"If we lower how many opioids patients are taking, but leave them disabled and not able to live their lives, that is not helpful," said study co-author Aliza Weinrib, PhD, a clinical psychologist who developed this innovative psychology program and teaches it to surgical patients at Toronto General Hospital (TGH) in Toronto, Ontario, Canada. "Patients can learn to respond to their pain in a different way, making it less overwhelming. They don't have to be so tied to their medications."

Dr. Weinrib and colleagues conducted this clinical practice-based study to assess outcomes of the psychology program at the Toronto General Hospital Transitional Pain Service (TPS), which is a multidisciplinary, hospital-integrated program developed to prevent and manage CPSP and support opioid tapering. The TPS psychology program provides acceptance and commitment therapy (ACT) to patients at risk for CPSP and persistent opioid use.

They included 91 patients who received ACT, and 252 patients who did not, and compared patient outcomes at the first and last TPS visits. Patients were those at highest risk for developing chronic pain and persistent opioid use after major surgeries.

Using two-way ANOVA testing, they analyzed pain, pain interference, sensitivity to pain traumatization, pain catastrophizing, anxiety, depression, and opioid use.

As part of the TPS treatment, patients receiving high-dose opioids who were willing to consider tapering their medication to improve their pain management were referred to a clinical psychologist. Patients were taught coping skills, and to focus on engaging in meaningful life activities rather than focusing only on reducing their pain intensity. ACT promotes mindfulness and acceptance of difficult experiences like pain.

These skills are taught during three or four sessions, with patients setting personally meaningful goals, and learning to observe and describe their pain and the thoughts and feelings that accompany it, as well as identify avoidance behaviors and track how these can increase pain, distress, and interfere with living life fully.

At both time points in patients referred for ACT, they found the following to be true compared with those who did not receive ACT:

• More likely to report a mental health condition preoperatively (P < 0001);
• Higher opioid use at first postsurgical visit (P < 0.001);
• Higher sensitivity to pain traumatization (P < 0.05); and
• Higher sensitivity to anxiety (P < 0.05).

At the last TPS visit, both groups demonstrated reduction in pain, pain interference, pain catastrophizing, anxiety, and opioid use (P < 0.05). In patients in the ACT group, they observed greater reductions in opioid use and pain interference, as well as reductions in depressed mood (P=0.001) compared with the no ACT group.

"There's the pain in your body, and there's the pain in your heart about not being able to do the things that you love," concluded Dr. Weinrib. "We can help people move towards what is important to them, even through their pain. We can help people reduce their pain of not living." 

Recent guidelines written in both the United States and Canada for the management of non-cancer pain stress that alternative treatments should be tried before considering opioid use, in order to avoid dependence and/or addiction, according to senior author Hance Clarke, MSc, MD, PhD, FRCPC, assistant professor, department of anesthesia, University of Toronto, and medical director, Pain Research Unit, Toronto General Hospital, Toronto, Ontario, Canada.

Yet data on post-surgical patients who receive psychological support and the effects of this support in their management of pain, opioid use, psychological distress, and disability, are sparse.

"This study and our clinical work in TPS suggest that there is a powerful role for interventions other than the prescription pad in helping patients manage their pain and suffering, taper their opioids, and lead rewarding lives," said Dr. Clarke. 

Funding for the Transitional Pain Service was provided by the Ontario Ministry of Health and Long-Term Care. Other funding for the authors include support from the Canadian Institutes of Health Research and the Department of Anesthesia, University of Toronto.