Chronic post-surgical pain (CPSP) is a common and debilitating problem that occurs in a significant number of patients following surgery. Orthopedic surgeries are consistently associated with high postoperative pain, with the prevalence of chronic pain at 3–24 months to be 20% or more after Total Knee Arthroplasty (TKA) and 8% or more after Total Hip Arthroplasty (e.g., Wylde et al., 2011). Patients undergoing surgery are also at increased risk of becoming chronic users of opioids. For example, patients who have knee surgery are roughly five times more likely than nonsurgical patients to end up using opioids chronically (Sun et al, 2016). Risk factors for poor outcomes include pre-operative anxiety, depression, and regular pain. Veterans are at particularly high risk of CPSP and prolonged opioid use after surgery because 80% experience some level of psychological distress prior to surgery and 50% experience pain on a regular basis (e.g., Sareen et al. 2007). Providing a preventive intervention for the substantial number of Veterans who experience significant distress or pain prior to surgery may prevent deleterious outcomes, including CPSP and prolonged opioid use.
Drs Dindo and Rakel and their team evaluated the preliminary effectiveness of a brief 1-day Acceptance and Commitment Training (ACT) workshop as a pre-surgical, preventive intervention. Veterans scheduled for orthopedic surgery and identified to be “at risk” for chronic postsurgical pain and prolonged opioid use were randomly assigned to 1-day ACT (N=44) or to Usual Care (N=44). The Veterans ranged in age from 25 to 83 years (average of 62.6), were primarily male, married, Caucasian, had completed a vocational degree or some college (52.5%), had been in a combat zone (57%), were scheduled for total knee arthroplasty (68%), had at least one other chronic pain condition (71.5%) and were not taking opioids for their pain (68%).
After surgery, Veterans completed the Daily Log of Pain and Pain Medication (DLPM) to record their maximum pain intensity each day and the total amount of each pain medication taken each day until pain and opioid cessation was achieved. Pain acceptance was measured using the Chronic Pain Acceptance Questionnaire (CPAQ). Engagement in values-based behavior was measured using the Chronic Pain Values Inventory (CPVI). The study found that patients who received ACT reached post-operative pain and opioid cessation sooner than those who received Usual Care and the effect of ACT was greater in patients without surgical complications. For example, the (median) days to pain cessation for the ACT group 61 compared to 74 for the Usual Care group. Seven weeks post-surgery, 29% of the patients in ACT and 52% of those in Usual Care were still taking opioids. Increases in pain acceptance and engagement in values-based behavior, which are coping processed addressed in ACT, were related to better outcomes.
What is ACT?
ACT is a behavioral intervention that combines acceptance and mindfulness-based strategies with behavior change strategies. ACT is listed by the American Psychological Association as an empirically supported treatment for chronic pain, depression, and mixed anxiety.
People living with chronic pain often avoid meaningful life activities and relationships as an attempt to cope with pain and distress (e.g., I am in too much pain to go out; if I engage in physical activities, the pain will worsen). When that happens, people may begin to define their life based on their illness, rather than on what is important to them. Their focus is narrowed in to the pain which paradoxically increases the experience of pain and also leads to depression and anxiety symptoms. ACT emphasizes active acceptance of what cannot be fully changed, including physical changes and limitations as well as uncomfortable internal states such as anxiety or chronic pain, and a reorientation towards what can be changed or influenced, namely our behaviors and the choices we make. Patients are encouraged to clarify their life values and to (re)-engage in meaningful life activities in spite of obstacles that arise.
How is ACT delivered?
ACT has been delivered in many formats including 1-day workshops; and in many settings, including primary care settings and businesses. Short, yet powerful interventions from ACT can be incorporated into clinic visits to motivate patients to re-engage in their life in important and meaningful ways. For example, values-based questions include: “What do you want your life to be about?” or “If you didn’t have this pain (anxiety, depression, etc), what would you be doing more of?” or “What has this pain (anxiety, depression, etc) gotten in the way of you doing?” Questions that get at the ineffectiveness and cost of using maladaptive coping strategies (e.g., opioids, alcohol, drugs, staying home, distraction, avoiding activity) include: “What strategies have you used to address this pain (or anxiety, depression, etc) ? How has that worked in the short term? How has it worked in the long term?” Many avoidance strategies we use work very well in the short term but do not work well in the long term and also have a significant cost to quality of life. Gently guiding the patient to an appreciation of the futility of chronic avoidance strategies, along with a discussion of values, can help motivate change and reduce suffering.
Summary
First, several pre-surgical risk factors, such as depression and anxiety, have been consistently associated with the development of chronic pain post-surgery. Addressing these factors prior to surgery may reduce the incidence of chronic pain and opioid abuse. Second, it is critical to identify a psychotherapy treatment that can be completed within a limited time frame by patients who are undergoing surgery; these patients have limited flexibility for regular appointments. Third, enhancing pain acceptance and values-based behaviors, key skills taught in ACT, may be particularly important for this patient population.
About Lilian Dindo
Dr Dindo is an Assistant Professor in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine and a Research Health Scientist at the Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center. The focus of Dr. Dindo’s career has been on developing pragmatic and innovative ways to improve the mental health and functioning of patients suffering from psychiatric and chronic medical conditions. In addition to developing 1-day interventions, she also examines the use of electronic technology to assess various psychiatric measures and to deliver treatment (e.g. Aburizk et al. 2013; Turvey et al., 2012).
References
Wylde V, Hewlett S, Learmonth ID, Dieppe P. Persistent pain after joint replacement: prevalence, sensory qualities, and postoperative determinants. Pain. 152:566-572, 2011
Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients in the Postoperative Period. JAMA Intern Med. 2016;176(9):1286–1293. doi:10.1001/jamainternmed.2016.3298
Sareen J, Cox BJ, Afifi TO, Stein MB, Belik SL, Meadows G, Asmundson GJ. Combat and peacekeeping operations in relation to prevalence of mental disorders and perceived need for mental health care: findings from a large representative sample of military personnel. Archives of general psychiatry. 64:843-852, 2007
Dindo, Lilian et al. (2018) Acceptance and Commitment Therapy for Prevention of Chronic Post-surgical Pain and Opioid Use in At-Risk Veterans: A Pilot Randomized Controlled Study. J Pain. Epub ahead of print
Aburizik, A., Dindo, L., Kaboli, P., Charlton, M., Klein, D., Turvey, C. (2013). A Pilot Randomized Controlled Trial of a Depression and Disease Management Program Delivered by Phone. Journal of Affective Disorders, 151 (2), 769-774. PMID: 23871127.
Turvey, C., Sheeran, T., Dindo, L., Wakefield, B., Klein, D. (2012). Validity of the PHQ-9 Administered Through Interactive-Voice-Response Technology. Journal of Telemedicine and Telecare, 18 (6), 348-351. PMID: 22933480.