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Cited by 121Mindfulness and Compassion InterventionsAnesthesia and Pain ManagementOpioid Use Disorder Treatment

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

Open access
Dindo, Lilian, Zimmerman, M. Bridget, Hadlandsmyth, Katherine, StMarie, Barbara, Embree, Jennie, Marchman, James, Tripp-Reimer, Toni, Rakel, Barbara·2018·The Journal of Pain
DOI 10.1016/j.jpain.2018.04.016PMC PMC6163061
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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.

Integrity signals

Registry

Crossref · 10.1016/j.jpain.2018.04.016

Cites

42 of 42 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

20 of 38 cited sources checked · 10 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    Before this study, only one non-randomized study and one case report had described ACT effects on chronic post-surgical pain and opioid use.

    “To date, there has only been one non-randomized study1 and a detailed case report42 describing the effects of ACT on CPSP and opioid use.”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites [1] Azam, 2017, Acceptance and Commitment Therapy to manage pain and opioid use after major surgery: preliminary outcomes from the Toronto General Hospital Transitional Pain Service, Can J Pain source
    • cites [42] Weinrib, 2017, A case report on the treatment of complex chronic pain and opioid dependence by a multidisciplinary transitional pain service using the ACT Matrix and buprenorphine/naloxone, J Pain Res source
  • Premisecitation

    Patients with significant preoperative anxiety or depression are at elevated risk that their pain will persist after surgery.

    “Additionally, patients with significant psychological distress (anxiety and/or depression) prior to surgery are at high risk of having their pain persist after surgery103731.”
    Quote in the paperSubstantial claim3 of 3 sources checked
    • cites [10] Edwards, 2009, Catastrophizing and depressive symptoms as prospective predictors of outcomes following total knee replacement, Pain Res Manag source

      In “Predicting global pain ratings” (page unavailable), higher depressive-symptom scores predicted greater pain at the next assessment after total knee replacement. The paper does not report a separate anxiety measure or establish that significant preoperative anxiety or depression puts patients at high risk of persistent pain; its analysis used symptom scores measured at successive time points. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
    • cites [37] Singh, 2012, Predictors of use of pain medications for persistent knee pain after primary Total Knee Arthroplasty: a cohort study using an institutional joint registry, Arthritis Res Ther source

      The Discussion (page unavailable) reports that preoperative depression predicted NSAID use and anxiety predicted opioid use for knee pain two and five years after total knee arthroplasty. It describes medication use as a surrogate for poorer pain outcomes, rather than directly measuring whether pain persisted. The paper also identifies anxiety and depression from diagnostic codes, not a measure of significant psychological distress. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [31] Noiseux, 2014, Preoperative predictors of pain following total knee arthroplasty, J Arthroplasty source
  • Premisecitation

    High pre-surgical pain, depression, and anxiety are risk factors for chronic post-surgical pain and prolonged opioid use.

    “particular risk factors (high pre-surgical pain, depression, and anxiety) that put patients at risk for chronic post-surgical pain and prolonged opioid use31”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [31] Noiseux, 2014, Preoperative predictors of pain following total knee arthroplasty, J Arthroplasty source

      The Discussion reports that severe preoperative pain, depression, and anxiety were associated with pain six months after total knee arthroplasty, though depression was significant only in the univariate analysis. The paper does not establish that these factors predict prolonged opioid use; its Introduction mentions only an earlier report on immediate postoperative analgesic intake. (LLM, conf=0.90)

      Experimental — accuracy not yet measured
  • Premisecitation

    A brief treatment format is more accessible to surgical patients who have competing demands on their time.

    “The brief format is also more accessible to surgical patients who have conflicting demands on their time9.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [9] Dindo, 2017, Acceptance and Commitment Therapy: A Transdiagnostic Behavioral Intervention for Mental Health and Medical Conditions, Neurotherapeutics source

      The “ACT Meets Implementation Needs” section says one-day workshops have been offered to patients undergoing surgery and are more accessible than weekly treatment. It does not specifically say that competing demands on surgical patients’ time account for that accessibility; the barriers it identifies are rural location and functional limitations. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
  • Premisecitation

    Using ACT as a preventive intervention for chronic post-surgical pain and prolonged opioid use is still novel.

    “However, the use of ACT as a preventive intervention for chronic post-surgical pain and prolonged opioid use is still novel.”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites [1] Azam, 2017, Acceptance and Commitment Therapy to manage pain and opioid use after major surgery: preliminary outcomes from the Toronto General Hospital Transitional Pain Service, Can J Pain source
    • cites [42] Weinrib, 2017, A case report on the treatment of complex chronic pain and opioid dependence by a multidisciplinary transitional pain service using the ACT Matrix and buprenorphine/naloxone, J Pain Res source

      The Introduction (page unavailable) calls the transitional pain service novel and describes its aim of supporting opioid weaning after surgery for patients at risk of chronic postsurgical pain. The Behavioral intervention section shows that ACT was used within that service, but the paper does not say that ACT itself is still novel as a preventive intervention for chronic postsurgical pain and prolonged opioid use. (LLM, conf=0.78)

      Experimental — accuracy not yet measured
  • Classified as probably not a substantial claim. 27
  • May combine two claims. 27

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The chosen cut-offs for anxiety and depression indicate significant levels of those conditions.

    “The cuts-offs for anxiety and depression indicate significant levels of anxiety and depression3629.”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [36] Shear, 2001, Reliability and validity of a structured interview guide for the Hamilton Anxiety Rating Scale (SIGH-A), Depress Anxiety source

      The Methods describe administering anxiety rating scales, and the Discussion describes their use in assessing anxiety severity. Neither section identifies cut-offs indicating significant anxiety or depression; searches for severity thresholds and depression cut-offs found no such passage in our copy. (LLM, conf=0.72)

      Experimental — accuracy not yet measured
    • cites [29] Moberg, 2001, Comparison of the standard and 1220 The Journal of Pain Acceptance and Commitment Therapy for Prevention of Chronic Postsurgical Pain structured interview guide for the Hamilton Depression Rating Scale in depressed geriatric inpatients, Am J Geriatr Psychiatry source

  • May combine two claims.

    Premisecitation

    The ACT treatment model is transdiagnostic and applicable to the range of difficulties in the recruited population, including depression, anxiety, and/or chronic pain.

    “we utilized the ACT treatment model because it is transdiagnostic14 and applicable to the range of difficulties experienced by the patient population recruited, including depression, anxiety, and/or chronic pain7.”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [14] Hayes, 2013, Acceptance and commitment therapy and contextual behavioral science: examining the progress of a distinctive model of behavioral and cognitive therapy, Behav Ther source
    • cites [7] Dimidjian, 2016, Considering Meta-Analysis, Meaning, and Metaphor: A Systematic Review and Critical Examination of "Third Wave" Cognitive and Behavioral Therapies, Behav Ther source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Behavioral interventions have a long history of success in treating chronic pain.

    “Behavioral interventions have a long history of success for the treatment of chronic pain26.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [26] McCracken, 2014, Acceptance and commitment therapy and mindfulness for chronic pain: Model, process, and progress, Am Psychol source

  • May combine two claims.

    Premisecitation

    Repeated opioid use produces opioid-induced hyperalgesia, which is increased pain sensitivity caused by opioid exposure.

    “Growing evidence shows that repeated opioid use causes “opioid-induced hyperalgesia” (i.e. increased pain sensitivity caused by opioid exposure), making pain control even more difficult2021.”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [20] Koppert, 2007, The impact of opioid-induced hyperalgesia for postoperative pain, Best Pract Res Clin Anaesthesiol source
    • cites [21] Liang, 2008, Chronic morphine administration enhances nociceptive sensitivity and local cytokine production after incision, Mol Pain source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    ACT has been delivered effectively in several formats, including one-day workshops.

    “Importantly, ACT has been effectively implemented in various treatment-delivery formats, including one-day workshops8.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [8] Dindo, 2015, One-Day Acceptance and Commitment Training Workshops in Medical Populations, Curr Opin Psychol source

  • Probably not a substantial claim: may not pass S2 (checkable).

    Premisecitation

    Greater recognition of risk factors for chronic pain and prolonged opioid use after surgery creates an opportunity for preventive and comprehensive care.

    “Increased recognition of the risk factors that put patients at risk for chronic pain and prolonged opioid use following surgery allows opportunity for preventive and comprehensive care41.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [41] Weinrib, 2017, The psychology of chronic post-surgical pain: new frontiers in risk factor identification, prevention and management, Br J Pain source

      The discussion on p. 170 says identifying modifiable risk factors for chronic postsurgical pain is a first step toward addressing it, and the Transitional Pain Service section (p. 172) describes comprehensive care for high-risk patients. The paper also discusses long-term opioid use and opioid weaning, but the cited passages do not establish risk factors that predict prolonged opioid use specifically. (LLM, conf=0.78)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingown data

    At 7 weeks after surgery, 29% of ACT+TAU participants and 52% of TAU participants were still taking opioids, with an odds ratio of 0.39 (95% CI 0.14 to 1.08).

    “Among Veterans in the ACT+TAU group, 29% were still taking opioids at 7 weeks follow-up vs. 52% in the TAU group (Odds ratio 0.39; 95% CI 0.14-1.08).”
    • Also stated in: § Discussion · plain
      “Seven weeks post-surgery, 29% and 52% of the patients in ACT+TAU and TAU, respectively, were taking opioids.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Twenty Veterans attended the ACT workshop before surgery (median 44 days preoperatively) and 11 attended it after surgery (median 35 days postoperatively).

    “Twenty Veterans attended the workshop before surgery (median: 44 days preoperatively) and 11 attended it after surgery (median: 35 days postoperatively).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    For both pain and opioid cessation, the hazard ratio estimate and upper confidence limit were larger for post-surgery ACT, but the lower confidence limits were similar and the confidence intervals overlapped.

    “For both endpoints, although hazard ratio estimate and CI upper limit of CI was larger for post-surgery, the CI lower limits were similar, resulting in overlapping Cis.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In both intention-to-treat and per-protocol analyses, postoperative complications moderated the treatment effect, with ACT+TAU showing a larger effect on pain cessation among participants who had no complications.

    “Of note, in both the ITT and per protocol analyses, postoperative complications exhibited a moderating effect on treatment outcome such that ACT+TAU exhibited a greater treatment effect in those with no complications”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In the per-protocol analysis, the median time to pain cessation was 61 days for ACT+TAU and 74 days for TAU.

    “Similar, but stronger results were obtained in the per protocol analysis, with median days to pain cessation for the ACT+TAU group of 61 compared to 74 for the TAU group (IQR: 28 days to > 3 months)”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Among participants without complications, the pain cessation hazard ratio for ACT+TAU versus TAU was 1.58 (95% CI 0.74 to 3.37) in the intention-to-treat analysis and 1.64 (95% CI 0.76 to 3.52) in the per-protocol analysis.

    “with a hazard ratio of 1.58 (95% CI: 0.74, 3.37) for ITT, and 1.64 (95% CI: 0.76, 3.52) for per protocol”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In the per-protocol three-group analysis, the pain cessation hazard ratio for ACT versus TAU was 1.42 (95% CI 0.66 to 3.08) for pre-surgery ACT and 1.91 (95% CI 0.62 to 5.94) for post-surgery ACT.

    “The hazard ratio estimate of pain cessation from this analysis for ACT relative to TAU was 1.42 (95% CI: 0.66, 3.08) for ACT pre-surgery, and 1.91 (95% CI: 0.62, 5.94) for ACT post-surgery.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    More TAU participants than ACT+TAU participants had been in a combat zone (p=0.04), and the TAU group had significantly better baseline CPVI scores (p=0.004-0.005).

    “Significantly more participants randomized to TAU had been in a combat zone (p=0.04) and this group also had significantly better baseline CPVI scores (p=0.004-0.005).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In the per-protocol three-group analysis, the opioid cessation hazard ratio for ACT versus TAU was 1.45 (95% CI 0.72 to 2.94) for pre-surgery ACT and 1.96 (95% CI 0.74 to 5.24) for post-surgery ACT.

    “The opioid cessation hazard ratio was 1.45 (95% CI: 0.72, 2.94) for ACT pre-surgery, and 1.96 (95% CI: 0.74, 5.24) for ACT post-surgery.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    All 5 female Veteran participants were randomized to the ACT+TAU group (p=0.06).

    “Surprisingly, all 5 female Veteran participants were randomized to the ACT+TAU group (p=0.06).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Veterans who had surgery did not differ significantly from those who did not have surgery, except that those who had surgery were more likely to have been in a combat zone (p=0.03).

    “Veterans who had surgery (and were, therefore, included in the Intent-To-Treat analyses) were not significantly different from Veterans who did not have surgery (and were, therefore, excluded from the ITT analyses), except that Veterans who had surgery were significantly more likely to have been in a combat zone (p=0.03).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    In this pilot study, substance use was assessed with a screening measure and rates were generally low.

    “In this pilot study, substance use was assessed with a screening measure and the rates were generally low.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In this pilot study, patients who had postoperative complications reported descriptively worse outcomes in pain severity and increased opioid use.

    “For example, in this pilot study patients who experienced complications following the surgery reported descriptively worse outcomes, both in pain severity and increased opioid use.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Before enrollment, the study statistician generated the randomization sequence in SAS v9.2 PROC PLAN using permuted blocks of 4 and 6, stratified by orthopedic surgery type.

    “Prior to enrollment of participants, a randomization sequence was generated by the study statistician (author M.B.Z.) using SAS v9.2 PROC PLAN with randomization occurring in permuted blocks of 4 and 6, stratified by type of orthopedic surgery (TKA, THA, shoulder, spine, other).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Baseline variables that differed between groups were included as covariates in the efficacy analysis.

    “Baseline variables that were found to differ between groups were used as covariates in assessing the efficacy of ACT+TAU compared to TAU.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning

    The project director and the recruiter were not blinded to group assignment.

    “The project director and the recruiter were not blinded so they could be available throughout the study to ask and answer questions regarding the participants’ treatment.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    In this study, CPVI Cronbach's alpha exceeded .80 for both scales.

    “In this study, Cronbach’s alpha were greater than .80 for both scales.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Treatment allocation was concealed through background programming until consent and eligibility were established.

    “Allocation to treatment group remained concealed via background programming until consent and inclusion/exclusion criteria were determined.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    ACT is an evidence-based, trans-diagnostic treatment for depression, chronic pain, and mixed anxiety.

    “Acceptance and Commitment Therapy (ACT) is a trans-diagnostic (applicable to a variety of conditions) and evidence-based treatment for depression, chronic pain, and mixed anxiety7.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [7] Dimidjian, 2016, Considering Meta-Analysis, Meaning, and Metaphor: A Systematic Review and Critical Examination of "Third Wave" Cognitive and Behavioral Therapies, Behav Ther source

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    At follow-up, the medical record was checked to confirm that opioid cessation by non-renewal of prescription matched self-report.

    “The medical record was reviewed again at follow-up visits to confirm that opioid cessation by non-renewal of prescription was consistent with self-report.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    A per-protocol analysis excluded nine ACT+TAU participants who did not complete the treatment protocol.

    “The efficacy of ACT+TAU compared to TAU was also examined in a per-protocol analyses that excluded 9 participants randomized to ACT+TAU; these 9 participants did not complete the treatment protocol (8 did not attend a workshop and 1 did not meet the study protocol requirements).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductcitation

    The CPAQ has shown good reliability and validity and supports valid inferences about pain acceptance.

    “The CPAQ has been used in treatments of chronic pain patients, is related to improvements in emotional functioning, and has demonstrated good reliability and validity. It yields valid inferences regarding acceptance of pain, based on significant negative correlations with measures of avoidance and emotional distress and positive correlations with measures of patient functioning27.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [27] McCracken, 2004, Acceptance of chronic pain: component analysis and a revised assessment method, Pain source

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductown data

    The study was a single-blinded, prospective, randomized controlled trial comparing treatment as usual with ACT plus treatment as usual.

    “This was a single-blinded, prospective, randomized controlled study with assignment to one of two groups: treatment as usual (TAU) or ACT plus TAU (ACT + TAU).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In a registry study of total joint replacement from 2008 to 2011, 41% of patients who had total knee arthroplasty were still taking opioids for knee pain 90 days later.

    “For example, an examination of the Total Joint Replacement Registry between 2008 and 2011 found that 41% of patients who underwent TKA were still using opioids for their knee pain after 90 days.30”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [30] Namba, 2018, Persistent Opioid Use Following Total Knee Arthroplasty: A Signal for Close Surveillance, J Arthroplasty source

  • May combine two claims.

    Interpretationown data

    The treatment results were stronger in per-protocol analyses and especially among participants who did not have postoperative complications.

    “Importantly, these results were strengthened when the analyses were restricted to patients who attended the workshop and particularly to those who did not experience complications following surgery.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Among participants who had surgery and completed the workshop, 91% completed the booster session.

    “Of those who had surgery and completed the workshop, 91% completed the booster session.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Intent-to-treat analyses included all randomized participants who had surgery, regardless of adherence.

    “Intent-to-treat (ITT) analyses were performed including all participants randomized to treatment groups that had surgery, regardless of adherence to treatment protocols.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Among Veterans Affairs patients, post-traumatic stress disorder, other anxiety disorders, and depression are common, especially in those exposed to atrocities or massacres during deployment.

    “In this population, distress-based conditions, including post-traumatic stress disorder, other anxiety disorders, and depression, are common, particularly for those who have experienced atrocities or massacres during deployment3435.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [34] Sareen, 2007, Combat and peacekeeping operations in relation to prevalence of mental disorders and perceived need for mental health care: findings from a large representative sample of military personnel, Arch Gen Psychiatry source
    • cites [35] Seal, 2007, Bringing the war back home: mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities, Arch Intern Med source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    In this study, CPAQ reliability was 0.89 at enrollment and 0.87 at follow-up.

    “In this study, reliability values ranged from 0.89 at enrollment to 0.87 at follow-up.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductnone given

    The principal investigator and the research assistants who assessed outcomes did not know group assignment.

    “The principal investigator and research assistants assessing outcomes were blinded to group assignment.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    All Veterans who attended the ACT workshop completed it.

    “Of note, all Veterans who attended the ACT workshop completed it.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductcitation

    Studies support the internal consistency and construct validity of the CPVI as a measure of values-based engagement and activation.

    “Studies support the internal consistency and construct validity of this measure as a reflection of values-based engagement and activation2423.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [24] McCracken, 2009, Acceptance, mindfulness, and values-based action may counteract fear and avoidance of emotions in chronic pain: an analysis of anxiety sensitivity, J Pain source
    • cites [23] McCracken, 2011, Processes of change in psychological flexibility in an interdisciplinary group-based treatment for chronic pain based on Acceptance and Commitment Therapy, Behav Res Ther source

  • May combine two claims.

    Study design and conductown data

    The 3-month follow-up visit was completed by 90% of ACT+TAU participants and 91% of TAU participants.

    “Furthermore, the follow-up rates were excellent with 90% of the participants in ACT+TAU and 91% of those in TAU completing the 3-month follow-up visit.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductreasoning

    All postoperative assessments were done by a blinded assessor, and participants were told not to reveal whether they attended a workshop.

    “All post-operative assessments were conducted by a blinded assessor and participants were instructed not to discuss whether they attended a workshop or not so the assessor would remain blinded.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Timing of opioid cessation was obtained by Veteran self-report and then checked against the medical record for consistency.

    “In this study, timing of opioid cessation was obtained by Veteran self-report followed by a review of the medical record to confirm consistency between the two.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Study design and conductnone given

    The 3-month follow-up period in this study is relatively short.

    “For example, the 3-month follow-up period in this study is relatively short.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Chronic pain is associated with decreased quality of life and productivity and with long-term opioid use.

    “Chronic pain is not only associated with significantly decreased quality of life and productivity, but also with long term opioid use25.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [25] McCracken, 2011, Psychological advances in chronic pain: a concise selective review of research from 2010, Curr Opin Support Palliat Care source

  • May combine two claims.

    Premisecitation

    Prolonged opioid use can cause significant tolerance and can paradoxically increase pain sensitivity, or hyperalgesia.

    “Prolonged opioid use can result in significant tolerance and can paradoxically increase pain sensitivity (i.e., hyperalgesia)20”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [20] Koppert, 2007, The impact of opioid-induced hyperalgesia for postoperative pain, Best Pract Res Clin Anaesthesiol source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationown data

    Patients who have postoperative complications may be a subgroup that could benefit from more attention and therapeutic guidance after surgery.

    “Thus, this subset of patients may represent a particular group of patients who could benefit from increased attention and therapeutic guidance postoperatively.”
    Quote in the paperNot a substantial claim
45 of 45

  • The paper relies on this without support.

    The at-risk Veterans recruited at one Veterans Affairs medical center are representative of at-risk Veterans having orthopedic surgery more generally.

    “veterans scheduled for an orthopedic surgery were recruited from the Iowa City Veterans Affairs Medical Center (VAMC).”

  • The paper relies on this without support.

    The daily self-report log accurately measures pain intensity and opioid intake.

    “After surgery, participants used the Daily Log of Pain and Pain Medication (DLPM) to record their maximum pain intensity each day and the total amount of each pain medication taken each day until pain and opioid cessation was achieved (pain < 3 for 5 consecutive days; zero doses of opioids recorded for 5 consecutive days).”

  • The paper relies on this without support.

    The standardized questionnaires used for other variables are reliable and valid in Veteran and pain samples.

    “These are all standardized questionnaires with established reliability and validity in Veteran and pain populations.”

  • The paper relies on this without support.

    Veterans who are undergoing surgery have limited functional capacity and flexibility to participate in weekly treatments.

    “These Veterans have limited functional capacity and flexibility to engage in weekly treatments.”

  • The paper relies on this without support.

    Less research has focused on preventing chronic pain than on treating it.

    “Less work, however, has focused on the prevention of chronic pain.”

  • The paper relies on this without support.

    The opioid crisis in the United States is connected to opioid use among patients who have surgery.

    “the opioid crisis in the United States is related to the use of opioids among surgical patients.”

  • The paper relies on this without support.

    Surgery is a critical event in which patients receive opioids to manage acute pain.

    “Surgery serves as a “critical event” where patients are exposed to opioids for the management of acute pain.”

  • The paper relies on this without support.

    This is the first study to use an ACT approach to prevent chronic post-surgical pain and prolonged opioid use in at-risk Veterans having orthopedic surgery.

    “This is the first study utilizing an ACT approach to prevent the development of chronic post-surgical pain and prolonged opioid use in at-risk Veterans undergoing orthopedic surgery.”

  • The paper relies on this without support.

    Traditional weekly in-person psychotherapy has problems with treatment adherence and completion.

    “a growing body of literature that highlights problems with treatment adherence and completion of the traditional weekly, in-person, psychotherapy.”

  • The paper relies on this without support.

    Several pre-surgical risk factors have been consistently linked to the development of chronic pain after surgery.

    “In recent years, several pre-surgical risk factors have been consistently associated with the development of chronic pain post-surgery.”
10 of 10

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Single-session ACT interventions are gaining empirical support.

    “Single session ACT interventions are gaining empirical support [23–26]”

    From A single-session acceptance and commitment therapy intervention among women undergoing surgery for breast cancer: A randomized pilot trial to reduce persistent postsurgical pain. (2019) · cites this paper as [23]

    The Discussion reports preliminary support for a one-day ACT workshop in at-risk Veterans, consistent with the claim that brief ACT interventions are gaining empirical support. However, the studied intervention also included an individualized postoperative booster session, so it was not strictly single-session. (LLM, conf=0.82)

    Experimental — accuracy not yet measured

  • Attempts to control pain often result in increased pain severity.

    “Research indicates that attempts to control pain often result in increased pain severity [15, 16].”

    From Acceptance and commitment therapy for patients with chronic pain: A systematic review and meta-analysis on psychological outcomes and quality of life (2024) · cites this paper as [15]

    The Introduction says repeated opioid use can cause increased pain sensitivity, a specific way that treatment intended to control pain can make it harder to control. It does not establish that attempts to control pain generally or often increase pain severity; sensitivity is also not the same outcome as measured severity. (LLM, conf=0.83)

    Experimental — accuracy not yet measured

  • A single workshop based on PB-CBT can reduce psychological distress in patients with chronic pain.

    “This is in line with previous findings indicating that a single workshop based on PB-CBT can reduce psychological distress in patients with chronic pain [98].”

    From A Single-Session Process-Based Cognitive-Behavioral Intervention Combined with Multimodal Rehabilitation Treatment for Chronic Pain Associated with Emotional Disorders (2024) · cites this paper as [98]

    The Intervention Groups section describes a one-day ACT workshop, not a PB-CBT workshop. The Introduction and Procedures specify that this pilot study tested pain and opioid-use outcomes in at-risk surgical Veterans; they do not report that the workshop reduced psychological distress. The Discussion notes that many participants had another chronic pain condition, but that does not establish the claimed distress outcome. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • PPIs and ACT have been found to lead to quicker cessation of pain and opioid use in veterans after orthopedic surgery.

    “PPIs and ACT have been found to be effective in the treatment of chronic pain [30-35], improving affect and functional ability after knee surgery [21], and quicker cessation of pain and opioid use in veterans after orthopedic surgery [36].”

    From Benefits, Recruitment, Dropout, and Acceptability of the Strength Back Digital Health Intervention for Patients Undergoing Spinal Surgery: Nonrandomized, Qualitative, and Quantitative Pilot Feasibility Study (2024) · cites this paper as [36]

    The Results (Post-operative Pain and Opioid Cessation) report shorter median times to pain and opioid cessation for veterans receiving ACT plus usual care after orthopedic surgery than for those receiving usual care alone. The paper does not study PPIs, and its Discussion describes the ACT findings as preliminary results from a pilot trial rather than established effectiveness for both interventions. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • In a randomized trial on at-risk veterans undergoing orthopedic surgery and in a non-randomized trial on patients receiving mixed surgical procedures, the groups receiving ACT-based treatments showed reduced recovery time and less prolonged opioid consumption than control groups.

    “In a randomized trial on at-risk veterans undergoing orthopedic surgery and in a non-randomized trial on patients receiving mixed surgical procedures, the groups receiving ACT-based treatments showed reduced recovery time and less prolonged opioid consumption than control groups.10,11”

    From Acceptance and commitment therapy for prevention of chronic pain after total knee arthroplasty. (2026) · cites this paper as [10]

    Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

    Experimental — accuracy not yet measured

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Pain acceptance association for CPVI mean success has a CI that includes 1

    Major

    The text says increased CPVI mean success was associated with a significantly higher pain-cessation rate, but the confidence interval shown for that estimate crosses 1. A CI of 0.82 to 1.21 does not support statistical significance at the conventional 0.05 level.

  • Pain-cessation hazard ratio falls outside its confidence interval

    Major

    The reported hazard ratio of 1.28 is greater than the reported 95% confidence interval's upper limit of 1.21. A point estimate cannot lie outside its own confidence interval.

  • Claim of a significant CPVI association conflicts with its interval

    Major

    The paper describes the association between increased CPVI mean success and pain cessation as significant, but its reported 95% confidence interval includes the null hazard ratio of 1. The interval also conflicts with the point estimate, so the stated result cannot be interpreted as reported.

  • Ineligibility percentage uses the wrong rounded value

    Minor

    Of the 419 people approached, 32 is 7.64%, which rounds to 8%, not the reported 7%.

    Reported 7 · recomputed 7.637232

4 of 4

Cites

Flagged first, then by citations

1 of the 43 references couldn’t be matched to a known paper.

Cited by

Sorted by citations

Related

Authors
Dindo, L., Zimmerman, M. B., Hadlandsmyth, K., StMarie, B., Embree, J., Marchman, J., Tripp-Reimer, T., & Rakel, B.
Affiliations
  • Michael E. DeBakey VA Medical Center (US)
  • University of Iowa (US)
Corresponding author
Dindo, Lilian
ORCID
Venue
The Journal of Pain
Publisher
Elsevier BV
Published
2018-10
Volume
19
Issue
10
Pages
1211-1221
ISSN
1526-5900 (ISSN-L)
DOI
10.1016/j.jpain.2018.04.016
PMC
PMC6163061
OpenAlex
W2803780163
Cited by
121
References
43
Citations by year
2026: 5 · 2025: 21 · 2024: 15 · 2023: 28 · 2022: 14 · 2021: 19 · 2020: 11 · 2019: 7 · 2018: 1
FWCI
11.14
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of Pain (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • National Institutes of Health (U54TR001013)
  • National Institute of Neurological Disorders and Stroke (T32NS045549)
  • National Center for Advancing Translational Sciences
  • National Center for Complementary and Integrative Health (R34AT008349)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
  • Health Sciences › Medicine › Surgery › Anesthesia and Pain Management
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Opioid Use Disorder Treatment
Keywords
acceptance and commitment therapy, chronic postoperative pain, opioid use, veterans, orthopedic surgery, preoperative analgesia, pain acceptance, postoperative complications, opioid cessation
MeSH terms
Adult, Aged, Aged, 80 and over, Analgesics, Opioid, Female, Humans, Male, Middle Aged, Opioid-Related Disorders, Postoperative Pain, Pilot Projects, Veterans, Single-Blind Method, Treatment Outcome, Chronic Pain, Pain Management, Acceptance and Commitment Therapy

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read under definition version 3 (extract-v3) on 2026-09-28.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-28.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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