Healthy Ways to Deal with Chronic Pain: An Acceptance and Commitment Therapy Perspective

1. Healthy Ways to Deal with Chronic Pain: An Acceptance and Commitment Therapy Perspective Steven C. Hayes University of Nevada

2. My Goal • To explore briefly our view of chronic pain • To provide an alternative, evidence based approach that applies not just to pain but to behavioral health treatment generally • To show some data • To work with a very small set of methods • To interest you in exploring the area

3. Is Pain the Issue or is itOur Relationship to Pain • In the case of acute pain, pain is clearly a focal issue • But chronic pain may be a very different issue

4. Immersion in Struggle • For many of those with chronic pain, pain intensity has been the focus of years of struggle … and yet it seems virtually untreatable.

5. The data are hardly reassuring. . .

6. Chronic Pain • is extremely common e.g., Breivik et al., 2006; Gureje et al., 1998 • remits in only a minority of cases e.g., Andersson, 2004; Elliott et al., 2002 • does not reliably respond to our clinical arsenal over the longer term e.g., Eccleston et al., 2009; Hoffman et al., 2007; Martell et al., 2007; Chou et al., 2007; Armon et al., 2007; Kemler et al., 2000; 2008

7. Opioids – No evidence of long-term pain reduction (i.e., > 15 weeks). Martell et al., 2007 – Ann. of Internal Medicine – Systematic Review Chou et al., 2007 - Ann. of Internal Medicine – Clinical Guidelines • Surgery - Continued pain and disability are the norm following spinal surgery (i.e., discectomies & fusions). Franklin et al., 1994; Hoffman et al., 1993; Turk, 2002; Turner et al., 1992; 1995 • Spinal Cord Stimulators - Pain reduction is relatively transient (absent @ 3, 4, & 5 year f/u). No evidence of improvement in functioning or quality of life. Kemler et al., 2000 NEJM; 2002 J Neurosurgery; 2006 NEJM; 2008 J Neurosurgery • Epidural Steroid Injections – • Lumbar - “Probably not” effective for long-term pain relief, for improving functioning, or decreasing rates of surgery. • Cervical – Not enough evidence yet available upon which to base a conclusion. Armon et al., 2007., Neurology – Systematic Review & Clinical Guidelines commissioned by the Amer. Acad. of Neurology

8. Pain and Functioning • Studies find very limited evidence for a relationship between reported pain intensity and direct measures of • daily activity • medication use • health care use, or • observed behavior.

9. E.g., Physical Ability Vowles & Gross, 2003, Pain

10. Future Work Status • Following treatment (6 months later): • Degree of pain was a nonsignificant predictor (post-treatment depression level predicted 28% of the variability) • Vowles, Gross, & Sorrell, 2004, Euro J Pain • In the absence of treatment (4 months later): • Pain accounted for 0.3% of variance (nonsignificant), while pain related acceptance accounted for 14.0% (p < .001). • McCracken & Eccleston, 2005, Pain

11. Data Like These Raise a Question . . . • What are we treating?

12. Treatment Options • There seem to be few evidence-based reasons to focus on pain per se • We should focus on meaningful functioning in the context of the person’s total life situation, including pain when there is pain • That is the ACT approach

13. The Problem is That We All Normally Think Pain Suffering

14. Therefore, for pain patients … • “Its important to keep fighting this pain.” Is endorsed by 92% of patients! McCracken, Vowles, & Eccleston, 2004, Pain

15. That is Shocking Because Persistent Struggling With Pain is … • Single best predictor of, now and over several months prospectively: • Worse Pain • Lower Levels of Activity • Greater Disability • Worse Depression • Greater Avoidance McCracken, Eccleston & Bell, 2005, Eur J Pain McCracken, Vowles, & Gauntlett-Gilbert, 2007, J Behavioral Med Vowles & McCracken, 2010, Beh Res & Therapy

16. Willingnessand Acceptance • My tinnitus as an example

17. A Larger System Supports This Link Pain Suffering

18. The System Creating Suffering Pain Struggling with Pain Suffering Multiplied Lost Freedom & Opportunity Failure

19. The Cycle of Suffering Pain Struggling with Pain Suffering Multiplied Lost Freedom & Opportunity Failure

20. The Cycle of Suffering More Struggling with Pain Pain Suffering Multiplied Increase Pain Focus & Lost Freedom & Opportunity Failure

21. Breaking the Cycle of Suffering Self- Compassion And Life Direction Pain Suffering Multiplied Lost Freedom & Opportunity Failure

22. Breaking the Cycle of Suffering Maintained Life Direction Pain Suffering Multiplied Freedom & Opportunity Failure

23. Breaking the Cycle of Suffering Maintained Life Direction Pain Suffering Multiplied Freedom & Opportunity Success

24. Breaking the Cycle of Suffering Maintained Life Direction Pain Suffering Reduced Freedom & Opportunity Success

25. Breaking the Cycle of Suffering Maintained Life Direction Pain? Suffering Reduced Freedom & Opportunity Success

26. The Impact of That Approach • Listed by APA as having “strong research support” as a evidence-based approach • The only approach listed by APA as generally applicable to all kinds of pain • 7 RCTs (~ 360 patients) and 7 open trials (~950 patients, up to 3 yr follow up)

27. Chronic PainDahl, Nilsson & Wilson, Behavior Therapy, 2004 • 20 public health caretakers at risk for developing long-term pain/stress symptoms • 10 TAU, 10 ACT protocol, 4 sessions at work-site/home • Baseline=60 days, intervention: 4 1-hr sessions over 30 days, FU 60 days • 2 therapists: 1 experienced CBT, 1 nurse

28. Cohen’s d at follow-up = 1.00

29. Pediatric PainWicksell et al, 2009 • 32 patients w/ longstanding pediatric pain • 25 female; ~ 15 y o, 32 mo pain duration • Randomly assigned to ACT or multidiscipinary Rx & amitriptyline (MDT). 2 drop outs. • Pre / post / 3.5mo f-up / 6.5 mo f-up

30. Content of Treatment • ACT = 10 individual, 1-2 parental over 4 mo; on average 13 sessions thru f-up • MDT = About 10 individual + parents sessions; medication titrated and continued for 10 mo, with addition meetings with team throughout; on average 22.8 sessions through follow up

31. Between Effect Sizes (p eta sq) Post F-Up • Fight with pain .29*** .23*** • Pain intensity .13** .13** • Pain interference .16** .09 • Physical health .03 .05 • Mental health .15** .11* • Depression .12* .10* • Fear of movement .21*** .12* • Pain related worry .34***.15** * p < .1; **p < .05; *** p < .01; medium = .09; large = .25

32. 4 6 2 Pain Interference MDT Pain Interference (1-10) ACT Pre Post 3.5 mo 6.5 mo

33. WhiplashWicksell et al, 2008 • 21 patients with whiplash associated disorder. • 11 female; ~ 42 y o, 83 mo pain duration • Randomly assigned to ACT or wait list. One wait list drop out. • Pre / post / 4mo f-up / 7 mo f-up in Rx arm

34. Between Effect Sizes (p eta sq)Post through F-U • Pain disability .44 • Life satisfaction .40 • Fear of movement .40 • Depression .60 • Pain intensity .01 n.s. • Pain interference .31 All p < .01 except as indicated; medium = .09, large = .25

35. For Example, Life Satisfaction 25 ACT 20 Satisfaction w Life Scale TAU 15 Pre Post 4 Month Follow Up

36. Chronic PainMcCracken, Vowles, & Eccleston, BRAT, 2005 • Effectiveness trial: 108 chronic pain patients • Average of 132 months of Chronic pain • 6.3 treatment programs • Multidisciplinary in-patient program • Within subject analysis: Preassessment; 3.9 months later (on average) pretreatment assessment; 3-4 week residential program; 3 month follow-up

38. Three Year Follow UpVowles, McCracken & O’Brien, BRAT, 2011 • 108 chronic pain patients treated with ACT • Follow up data at three month and 3 years

39. Effect Sizes at 3-36 Mo. Follow Up Small Medium Large 3 Month Follow Up Acceptance 36 Month Follow Up Values Success Values Discrepancy Pain Depression Pain-Related Anxiety Physical Disability Psychosocial Disability Medical Visits .2 .5 .8 1.1 1.5

40. A Quick Note Before We Leave Data • One reason nurses may want to consider learning ACT: • There are good effects from very short ACT interventions in the management of diabetes, exercise, weight, epilepsy, MS, cancer treatment and many other areas in addition to mental health

41. And by The Way • We have local projects coming together right now in post partum depression and hypertension (if you might be able to help email me: hayes@unr.edu)

42. Randomized controlled trial with poor, mostly minority clients 40 / group: ACT plus diabetes education (one six-hour workshop) or diabetes education (also a six hour workshop) Pre, post, 3-month follow-up ACT for Diabetes ManagementGregg, Callaghan, Hayes, & Glenn-Lawson, 2008, JCCP

43. Level 3 Process Evidence Change (Pre to Follow up) % in Diabetic Control AAQ (Diabetes) Self- Management 10 50% 50% 5 25% 25% 0 0% 0% Ed’n ACT Ed’n ACT Ed’n ACT AAQD and Self-Management mediate blood glucose outcomes

44. Psychological Adjustment Among Cancer Patients: ACT and CBT • Stage 4 cancer patients randomly assigned either to ACT or to a form of traditional CBT (cognitive restructuring plus relaxation): 30 / group • 12 sessions with each participant during chemotherapy visits: pre and sessions 4, 8, and 12. • No follow up, in part due to the relatively high likelihood of death (12 died during the study) Rost, Wilson, Hildebrandt, & Mutch, in press

45. Impact on Distress (POMS)(change scores) Session 12 d = .9 Wilks’ Lambda=.722, F(3,29)=3.722, p=.022

46. I will give to a link to a society that will help you do just that if you are interested Indeed, a nursing SIG is forming in that society My Point: It is Worth Learning

47. Psychological Flexibility The ACT Model An ACT Model of Treatment/Health

48. The two-minute Persuasion Exercise

49. Speaker • Think of something you want to change, but still have some ambivalence about. • Perhaps something related to a health area (smoking, diet, exercise), recreation (TV watching, hobby), or work (study more, change jobs). • If none of this applies personally, role play someone you know but don’t say which is which

50. Clinician: • Put yourself in the mental state in which you have a good understanding of the speaker’s problem, and you know what he/she needs to do to address the problem. • Even if this is not your style, play this out