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Psychological tools help high-risk chronic pain patients to taper opioid use

From News Medical - June 29, 2017

Psychological support and new coping skills are helping patients at high risk of developing chronic pain and long-term, high-dose opioid use taper their opioids and rebuild their lives with activities that are meaningful and joyful to them.

A study of 343 post-surgical patients treated by an innovative, multidisciplinary hospital-integrated pain program at Toronto General Hospital (TGH), University Health Network (UHN) found that all patients showed reductions in pain and anxiety in the two-year study, but those who also received psychological services had greater reductions in opioid use, and their mood improved.

The study, "Acceptance and Commitment Therapy to Manage Pain and Opioid Use after Major Surgery: Preliminary Outcomes from the Toronto General Hospital Transitional Pain Service," is published today in the Canadian Journal of Pain, by first author Muhammad Azam, Ph.D. candidate at York University and senior authors Dr. Joel Katz, Affiliate Scientist, Toronto General Hospital Research Institute (TGHRI) and Dr. Hance Clarke, Director of the Transitional Pain Service at TGH, UHN and Clinical Researcher, TGHRI.

Although psychological approaches to help patients cope with pain have been used previously, what is novel in this study is the combined use of a specific psychological approach with mindfulness meditation training to help patients wean off high-doses of opioids and reduce their pain-related distress and disability.

"If we lower how many opioids patients are taking, but leave them disabled and not able to live their lives, that is not helpful," says Dr. Aliza Weinrib, one of the authors of the paper and a clinical psychologist who developed this innovative psychology program and teaches it to surgical patients at TGH. "Patients can learn to respond to their pain in a different way, making it less overwhelming. They do not have to be so tied to their medications."

Patients in the study were those at highest risk for developing chronic pain and persistent high-dose opioid use after major surgery. All attended the Transitional Pain Service (TPS) at TGH between 2014 and 2016. TPS is the first hospital-integrated, comprehensive, long-term post-surgical pain management program of its kind.

Patients on high-dose opioids willing to consider tapering to improve their pain management were referred to a clinical psychologist, as part of their treatment in the TPS. They had chronic post-surgical pain, pre-existing chronic pain, clinical depression, problematic or higher than expected opioid use, and difficulty in coping with pain.

These patients were taught coping skills grounded in Acceptance and Commitment Therapy (ACT). Instead of focusing solely on reducing pain intensity, this psychological treatment encourages patients to engage in meaningful life activities, while promoting mindfulness and acceptance of difficult experiences such as pain.

Patients can be taught these skills in three or four sessions, by setting personally meaningful goals, observing and describing pain and the thoughts and feelings that come with pain, identifying avoidance behaviours and tracking how they can increase pain, distress and interfere with the ability to live life fully.

Study results between the two groups showed that both decreased their pain intensity, anxiety symptoms and opioid use. But the patients who participated in the psychology programwho initially reported higher opioid use, anxiety, depression, and higher sensitivity to painshowed significantly greater reductions in opioid use, depression and less disruptions in their daily living as a result of their pain than those patients who received TPS physician-guided treatment alone.

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