Acceptance and Commitment Therapy for Prevention of Chronic Postsurgical Pain and Opioid Use in At-Risk Veterans: A Pilot Randomized Controlled Study

Abstract

High levels of pain, significant anxiety, or depressive symptoms before surgery put patients at elevated risk for chronic pain and prolonged opioid use following surgery. The purpose of this preliminary study was to assess the efficacy of a 1-day Acceptance and Commitment Therapy (ACT) workshop in "at-risk" veterans for the prevention of chronic pain and opioid use following orthopedic surgery. In a randomized controlled trial, 88 at-risk veterans undergoing orthopedic surgery were assigned to treatment as usual (TAU; n = 44) or TAU plus a 1-day ACT workshop (n = 44). Pain levels and opioid use were assessed up to 3 months following surgery. Pain acceptance and values-based behavior were assessed at baseline and 3-month follow-up. Participants who completed the ACT workshop reached pain and opioid cessation sooner than those in TAU. Postoperative complications exhibited a moderating effect on these outcomes, such that the effects of ACT were greater in patients without complications. Increases in pain acceptance and values-based behavior, processes targeted in ACT, were related to better outcomes. These promising results merit further investigation in a larger clinical trial. Providing an intervention before surgery for at-risk veterans has the potential to change clinical practice from a focus on management of postoperative pain to prevention of chronic pain in at-risk individuals.

Perspective: This pilot study compared the effects of a 1-day preventive behavioral intervention (ACT) to TAU in at-risk veterans undergoing orthopedic surgery. Three months following the intervention, veterans receiving ACT exhibited quicker cessation of pain and opioid use. Focusing on preoperative pain management may help prevent chronic postsurgical pain.

Trial registration: ClinicalTrials.gov NCT01364870.

Keywords: Acceptance and Commitment Therapy; Chronic pain; anxiety; depression; prolonged opioid use.

Conflict of interest statement

The authors do not have any conflicts of interest.

Copyright © 2018 the American Pain Society. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1

Consort Diagram. Consort diagram depicting participant enrollment, randomization to groups, and follow-up visits. Note. TAU=Treatment as usual; ACT=Acceptance and Commitment Therapy; AE = Adverse event.

Figure 2

Kaplan-Meier curve for the outcome of pain cessation showing the product-limit estimate of the cumulative probability with pain>3 at post-surgery follow-up for a) intent to treat, b) per protocol, and c) per protocol without complication. This shows the effect of adherence to protocol and complication status in assessing the efficacy of ACT on pain cessation.

Figure 3

Kaplan-Meier curve for the outcome of opioid cessation showing the product-limit estimate of the cumulative probability of opioid use at post-surgery follow-up for a) intent to treat, b) per protocol, and c) per protocol without complication. This shows the effect of adherence to protocol and complication status in assessing the efficacy of ACT on opioid cessation.

Figure 4

Predicted probability distribution for post-operative pain>3 from Cox proportional hazard regression for specific values of a) change in CPAQ active engagement, b) change in CPAQ Total, and c) change in CPVI mean success. The figure illustrates the effect of 5 points difference in CPAQ active engagement change or CPAQ Total change, or a 0.5 difference in CPVI mean success change on the probability distribution for post-operative pain>3.

Figure 5

Predicted probability distribution for post-operative opioid use from Cox proportional hazard regression for specific values of a) change in CPVI mean success and b) change in CPVI discrepancy score. The figure illustrates the effect of a 0.5 difference in CPVI mean success change, or CPVI discrepancy score change on the probability distribution for postoperative opioid use.