Researchers out of York University have found evidence that psychological support and coping skills help to reduce the risk of long-term, high-dose opioid use in patients with post-surgical pain.
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, but those who also received psychological services had greater reductions in opioid use, as well as their depressive symptoms.
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," was published June 28 in the Canadian Journal of Pain.
Aliza Weinrib
Muhammad Abid Azam
The first author, Muhammad Abid Azam, is a PhD candidate at York University, studying under the supervision of Prof. Joel Katz, Canada Research Chair in Health Psychology and Dr. Aliza Weinrib, an adjunct faculty member in the York graduate program in psychology. Weinrib is also the lead clinical psychologist at the Toronto General Hospital, Transitional Pain Service where she is responsible for developing and administering the psychology intervention in one-on-one and group-based formats.
Senior authors of the study include Katz, affiliate scientist, Toronto General Hospital Research Institute (TGHRI) and Hance Clarke, director of the Transitional Pain Service at TGH, UHN and Clinical Researcher, TGHRI.
Weinrib and her York U clinical psychology student trainees worked along with medical specialists at the clinic using psychological approaches such as mindfulness meditation to help patients wean off of high doses of opioids and reduce pain-related distress and disability.
“There’s a lot of attention on opioid use and how to prescribe and regulate it,” said Azam. “It creates a stigma for those who are using opioids to manage pain and I think it’s very important to validate patients after major surgeries who are suffering with pain, and to recognize that their pain can be very hard to manage without support.”
Dr. Aliza Weinrib, clinical psychologist who developed the innovative psychology program in the Transitional Pain Service (TPS) at TGH and Dr. Hance Clarke, medical director, TPS, look over a psychological tool which helped patient Paul Ross wean off opioids and manage his chronic pain
Patients in the study presented with chronic post-surgical pain, pre-existing chronic pain, clinical depression, difficulty coping with pain, and problematic or higher than expected opioid use. These patients were referred to a clinical psychologist as part of their treatment, and 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.
"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 Weinrib. "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."
Study results between the patients seeing a psychologist and those electing not to show that both groups decreased their pain intensity, anxiety symptoms and opioid use. However, patients in the psychology program – who initially reported higher opioid use, anxiety, depression, and higher sensitivity to pain – showed significantly greater reductions in opioid use, depression and fewer disruptions to daily life activities.
An estimated 15 per cent to 19 per cent of all Canadians suffer from chronic, non-cancer pain, which is pain that lasts for more than three months and interferes with their daily activities. It is the leading cause of health resource use and disability among working-age adults.
In Ontario, admissions to publicly funded treatment programs for opioid-related problems doubled from 2004 to 2013, from 8,799 to 18,232.
"This study and our clinical work in the TPS suggest that 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 Clarke.
Katz said the findings are important and timely given the current "opioid crisis" and the new 2017 Canadian Opioid Guideline to manage chronic non-cancer pain.
The Transitional Pain Service’s research will continue with randomized controlled trials to determine more precisely the efficacy of the psychological services, and to see how the intervention can be standardized and made widely accessible.
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, the Department of Anesthesia, University of Toronto, and York University through the Canada Research Chair in Health Psychology.