Telehealth Therapy for Chronic Pain

Chronic pain affects at least 15% of the veteran population and represents a high priority
for the VA. In addition to primary pain conditions, chronic pain is a common secondary
condition resulting from battlefield injuries, traumatic accidents, and congenital and
acquired disorders. Unlike most forms of acute pain, treatment options available for
patients suffering from chronic pain frequently offer only short-term or partial relief from
symptoms. The focus of rehabilitative intervention thus becomes the reduction of disability
and emotional distress and improvement in quality of life and activity levels.

Chronic pain rehabilitation has evolved from a primarily one dimensional, medically oriented
approach to a multidisciplinary approach that incorporates a biopsychosocial formulation to
pain management with physiological, cognitive, behavioral, and emotional components. This
conceptualization of pain recognizes that multiple intervention modalities, including
psychosocial approaches, are required when providing treatment to chronic pain patients.

A relatively new psychosocial approach to chronic pain management and rehabilitation
involves acceptance of pain-related experiences. The Acceptance and Commitment Therapy (ACT)
model is based on the theory that attempts to escape, avoid, or control negative experiences
that cannot be changed, such as chronic pain, may paradoxically contribute to the increased
experience of them. Instead of seeking to control the negative experience, ACT teaches
individuals to use mindfulness strategies to enlarge the scope of experience beyond pain and
to engage in behaviors that are consistent with personal values and goals when total
elimination of pain or other negative experiences is not possible. Empirical support for
acceptance-based approaches to chronic pain management is growing. Data from one of the
first comparisons of ACT to a well-established psychosocial intervention,
Cognitive-Behavioral Therapy (CBT), performed at VASDHS by the PI, suggests that ACT may be
superior to CBT as an adjunctive treatment for chronic pain.

The proposed study assembles a multidisciplinary team with extensive experience in chronic
pain interventions research to evaluate the benefits of a brief, individual psychosocial
in-person or telehealth intervention which could be easily integrated into multidisciplinary
pain rehabilitation programs throughout the VA system to reduce disability in veterans with
chronic pain secondary to other conditions. Specifically, we propose to examine the effects
of a promising new chronic pain intervention based on ACT principles on the primary outcome
of pain interference and secondary outcomes of emotional distress, quality of life, physical
activity, pain intensity, and treatment satisfaction among 196 veterans with chronic benign
pain as a secondary condition. The participants are randomized to between-subjects design
where in-person ACT intervention will be compared with telehealth ACT intervention. Outcomes
include an objective measure of physical activity, actigraphy, as well as self-reported
measures and will be evaluated at baseline, 4 weeks, 8 weeks (end of treatment), 3-month
follow-up and at a 6-month follow-up period to investigate maintenance of gains. Telehealth
sessions are conducted using secure video-conferencing equipment at the most convenient
clinic for the participant. Thus, the proposed project has the potential to enhance the
current VA standard of care as well as to add to the scientific literature on psychological
models and rehabilitation of chronic pain.

Inclusion Criteria:

- Chronic non-terminal pain condition;

- Pain severity and interference rated > 4/10; and

- Pain most days (> 3/week) for at least 6 months.

Exclusion Criteria:

- Current participation in group psychotherapy for pain or any type of individual
psychotherapy;

- Previous treatment with ACT;

- Active suicide ideation or history of suicide attempt within 5 years;

- Serious or unstable medical or psychiatric illness or psychosocial instability that
could compromise study participation; and

- The following DSM-IV diagnoses or active problems within the past 6 months noted in
the patient's CPRS medical record or diagnosed during a structured psychiatric
interview:

1. schizophrenia;

2. other psychotic disorder;

3. bipolar disorder;

4. organic mental disorder;

5. borderline or antisocial personality disorder; or

6. alcohol or substance abuse or dependence.