Psychological Flexibility, Pain Characteristics and Risk of Opioid Misuse in Noncancerous Chronic Pain Patients

Experiential Avoidance, Pain, and Suicide Risk in a National Sample of Gulf War Veterans

OBJECTIVE

Pain confers risk for suicidal thoughts and behaviors. Experiential avoidance (EA), which is relevant to both pain and suicide risk, has not been studied as a potential mechanism for this relationship. The present study tested the hypothesis that pain indirectly impacts suicide risk through EA in a national sample of Gulf War veterans.

METHODS

Participants included a stratified random sample of United States veterans (N = 1,012, 78% male) who had served in the Gulf War region between August 1990 and July 1991. Validated scales were used to quantify levels of pain, EA, and suicide risk.

RESULTS

Regression analyses indicated independent associations between pain, EA, and suicide risk; moreover, the association between pain and suicide risk was no longer significant once EA was included in model. Bootstrapping analyses confirmed that EA partially accounted for the cross-sectional association between pain and suicide risk, independent of common co-occurring problems, such as depression, PTSD, and alcohol use disorder symptoms.

CONCLUSIONS

EA could be a key modifiable risk factor to target in people experiencing pain.

Which outcome variables are associated with psychological inflexibility/flexibility for chronic pain patients? A three level meta-analysis

The psychological flexibility model can be seen as a basis for an integrated and progressive psychological approach to chronic pain management. Some researchers suggest that psychological flexibility and inflexibility represent distinct processes and constructs. This meta-analysis is the first to provide a summary estimate of the overall effect size for the relationship between psychological (in)flexibility and common outcomes among chronic pain patients. The research protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO, https://www.crd.york.ac.uk/PROSPERO/), registration number CRD42021285705. Four databases were searched (PsycINFO; PubMed; Web of Science, CINAHL) along with reference lists. Thirty-six cross-sectional studies were included (7,779 participants). Meta-analyses (random effects model) indicated a significant medium negative association between psychological flexibility and pain intensity or functional impairment. The present study also indicated a significant small to medium association between psychological inflexibility and pain intensity, a nearly large association between psychological inflexibility and functional impairment as well as the quality of life, and a large association between psychological inflexibility and anxiety/depression. Due to the limited number of included studies, the relationship between risk behavior and psychological inflexibility may not be significant. Types of countries and instruments measuring psychological inflexibility may explain part of the heterogeneity. These findings may carry significant implications for chronic pain patients regarding the potential relationship between psychological inflexibility or flexibility and these outcomes. It may consequently form the basis for more robust testing of causal and manipulable relationships.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42021285705.

Associations Between Six Core Processes of Psychological Flexibility and Functioning for Chronic Pain Patients: A Three-Level Meta-Analysis

The previous research showed contradictions in the relationships between psychological flexibility processes and functioning. This meta-analysis is the first to provide a comprehensive meta-analysis of the associations between six core processes of psychological flexibility and functioning among chronic pain patients. Four databases were searched (PsycINFO; PubMed; CINAHL; Web of Science) along with reference lists. Thirty-six cross-sectional studies were included (7,812 chronic pain patients). A three-level meta-analytic model was used to examine the associations. The publication bias was assessed with the Egger test, funnel plot, and p-curve analysis. Significant associations were found between functioning and six processes of psychological flexibility (i.e., acceptance, defusion, present moment, committed action, self as context, and values). Except for the relationship between defusion and functioning, the relationships between the other five psychological flexibility processes and functioning were all moderated by domains of functioning. No moderators were found regarding age, percentage of females, country, or type of instrument used to measure functioning. These findings may carry significant implications for chronic pain patients and clinical workers. It might be more effective to focus on functioning-related psychological flexibility processes rather than all therapy packages if the relationships between functioning and specific processes of psychological flexibility were better informed. Limitations were also discussed.

Pain Acceptance Creates an Emotional Context That Protects against the Misuse of Prescription Opioids: A Study in a Sample of Patients with Chronic Noncancer Pain

There is solid evidence of an association between several psychological flexibility processes, particularly pain acceptance, and adaptation to chronic pain. However, there are relatively few studies on the relationship between pain acceptance and opioid misuse in chronic pain patients. Thus, the aim of the present study was to test a hypothetical model in which pain acceptance would regulate pain sensations and pain-related thoughts and emotions, which would be related to opioid misuse. The sample comprised 140 chronic pain patients attending two hospitals. All patients were receiving pharmacological treatment, including opioid analgesics. Structural equation modelling analyses showed a significant association between higher pain acceptance and lower pain intensity and catastrophizing, and lower levels of anxiety and depression. Only higher anxiety and depression were significantly associated with increased opioid misuse. The results suggest that levels of anxiety, depression, and pain acceptance must be assessed before opioids are prescribed. Pain acceptance implies a relationship with internal events that protects against anxiety and depression and thus against opioid misuse. Acceptance and Commitment Therapy appears to be particularly appropriate for these patients.

Opioid Pain Medication Prescription for Chronic Pain in Primary Care Centers: The Roles of Pain Acceptance, Pain Intensity, Depressive Symptoms, Pain Catastrophizing, Sex, and Age

Background: Psychological factors of patients may influence physicians’ decisions on prescribing opioid analgesics. However, few studies have sought to identify these factors. The present study had a double objective: (1) To identify the individual factors that differentiate patients who had been prescribed opioids for the management of chronic back pain from those who had not been prescribed opioids and (2) to determine which factors make significant and independent contributions to the prediction of opioid prescribing. Methods: A total of 675 patients from four primary care centers were included in the sample. Variables included sex, age, pain intensity, depressive symptoms, pain catastrophizing, and pain acceptance. Results: Although no differences were found between men and women, participants with chronic noncancer pain who were prescribed opioids were older, reported higher levels of pain intensity and depressive symptoms, and reported lower levels of pain-acceptance. An independent association was found between pain intensity and depressive symptoms and opioid prescribing. Conclusions: The findings suggest that patient factors influence physicians’ decisions on prescribing opioids. It may be useful for primary care physicians to be aware of the potential of these factors to bias their treatment decisions.