Integrated behavioral treatment for veterans with co-morbid chronic pain and hazardous opioid use: a randomized controlled pilot trial

Vowles, Kevin E.; Witkiewitz, Katie; Cusack, Karen J.; Gilliam, Wesley P.; Cardon, Karen E.; Bowen, Sarah; Edwards, Karlyn A.; McEntee, Mindy L.; Bailey, Robert W.

doi:10.1016/j.jpain.2019.11.007

Cited by 49Opioid Use Disorder TreatmentSubstance Abuse Treatment and OutcomesPain Management and Opioid Use

Integrated behavioral treatment for veterans with co-morbid chronic pain and hazardous opioid use: a randomized controlled pilot trial

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Vowles, Kevin E., Witkiewitz, Katie, Cusack, Karen J., Gilliam, Wesley P., Cardon, Karen E., Bowen, Sarah, Edwards, Karlyn A., McEntee, Mindy L. +1 more·2020·The Journal of Pain

DOI 10.1016/j.jpain.2019.11.007PMC PMC7542006

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Abstract

Opioid prescription in the treatment of chronic pain is frequent and carries a risk of increased morbidity and mortality in a clinically significant number of patients, particularly those who are using opioids in a hazardous manner. Few treatment options are available that target both pain-related interference and hazardous opioid use among patients with chronic pain. In military Veterans, this issue is of particular importance as numerous reports indicate continued high rates of opioid prescription for chronic pain, as well as significant opioid-related problems. The overall aim of the present study was to determine the feasibility of an integrated psychosocial treatment in Veterans with chronic pain, who also have evidence of hazardous opioid use. To examine this aim, a random design was used to assess the feasibility and initial efficacy of integrating 2 empirically supported interventions: Acceptance and Commitment Therapy for chronic pain and Mindfulness Based Relapse Prevention for opioid misuse. Half of participants were randomized to the integrated treatment group and all participants received usual care through a Veteran's Administration co-occurring disorders medical clinic to treat chronic pain and opioid misuse. In total, 37 participants were randomized and included in intent-to-treat analyses and 32 individuals were included in per protocol analyses with 6-month follow-up serving as the primary study endpoint. Feasibility indicators included recruitment, retention, and treatment completion rates. Recruitment fell short of targeted enrollment, although retention and completion were excellent. Primary outcome measures were opioid misuse, pain interference, and pain behavior. Simultaneous multiple regression analyses controlled for pain duration, baseline opioid dose, and baseline value for outcome measures. Results of both the intent-to-treat and per protocol indicated a significant effect in favor of the integrated intervention for opioid misuse, pain interference, and pain behavior. Results support the feasibility of providing an integrated treatment for both opioid risk and pain interference. PERSPECTIVE: Opioid misuse occurs in some opioid-prescribed individuals with chronic pain. Few treatment options exist that target both pain interference and opioid misuse. This study examined feasibility and initial efficacy of an integrated behavioral treatment for Veterans. Feasibility was supported, except recruitment. Efficacy was supported compared to usual care.

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Six trials evaluated an MBI, mostly among patients with OUD.
“In total, 6 trials evaluated an MBI, mostly among pa tients with OUD, 24-30”
From The Effectiveness of Interventions for Improving Chronic Pain Symptoms Among People With Mental Illness: A Systematic Review (2024) · cites this paper as [30]
The Methods (Integrated Intervention) describe this randomized trial’s use of mindfulness-based relapse prevention, supporting its inclusion as an MBI trial. The Methods (Participants) say eligibility required opioid misuse, which could be established by a misuse score and/or an OUD diagnosis. This single trial does not establish that there were six trials or that most enrolled patients had OUD. (LLM, conf=0.86)
Experimental — accuracy not yet measured
Of the remaining 4 SUD trials with a medium-term follow-up, a small-to-medium effect on pain reduction from baseline to medium-term follow-up was reported in all.
“Of the remaining 4 trials with a medium-term followup, 30,39,40,45 although a small-to-medium effect on pain reduction from baseline to medium-term follow-up was reported in all, with 1 reporting a large ES, 30 one trial found this effect was only significant among women participants. 40”
From The Effectiveness of Interventions for Improving Chronic Pain Symptoms Among People With Mental Illness: A Systematic Review (2024) · cites this paper as [30]
The Results (Outcomes Analyses; page unavailable) report that pain interference and pain intensity decreased in the integrated-treatment group from baseline to six months. They report large effect sizes for between-group differences at follow-up (d = .79 and 1.08), however, not a small-to-medium effect size for change from baseline to follow-up. The claimed effect-size magnitude and comparison are therefore not supported for this trial. (LLM, conf=0.85)
Experimental — accuracy not yet measured
Among the 10 SUD trials, two evaluated a CBT-based intervention, three included a MBI (one of which involved integrated MBI and ACT), two examined a MCI, one included a pharmacological-based treatment, and 2 involved a body-based intervention.
“Two trials eval uated a CBT-based intervention, 20,23 three included a MBI, 27,28,30 one of which involved integrated MBI and ACT, 30 two examined a MCI, 39,40 one included a phar macological-based treatment, 45 and 2 involved a bodybased intervention. 35,36”
From The Effectiveness of Interventions for Improving Chronic Pain Symptoms Among People With Mental Illness: A Systematic Review (2024) · cites this paper as [30]
One of those 4 SUD trials reported a large effect size for pain reduction.
“Of the remaining 4 trials with a medium-term followup, 30,39,40,45 although a small-to-medium effect on pain reduction from baseline to medium-term follow-up was reported in all, with 1 reporting a large ES, 30 one trial found this effect was only significant among women participants. 40”
From The Effectiveness of Interventions for Improving Chronic Pain Symptoms Among People With Mental Illness: A Systematic Review (2024) · cites this paper as [30]

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Authors: Vowles, K. E., Witkiewitz, K., Cusack, K. J., Gilliam, W. P., Cardon, K. E., Bowen, S., Edwards, K. A., McEntee, M. L., & Bailey, R. W.
Affiliations: Queen's University Belfast (GB)
University of New Mexico (US)
Raymond G. Murphy VA Medical Center (US)
Mayo Clinic (US)
Pacific University (US)
Arizona State University (US)
Corresponding author: Vowles, Kevin E.
ORCID: Vowles, Kevin E.
Witkiewitz, Katie
Gilliam, Wesley P.
Cardon, Karen E.
Bowen, Sarah
Edwards, Karlyn A.
McEntee, Mindy L.
Venue: The Journal of Pain
Publisher: Elsevier BV
Published: 2020-07
Volume: 21
Issue: 7-8
Pages: 798-807
ISSN: 1526-5900 (ISSN-L)
DOI: 10.1016/j.jpain.2019.11.007
PMC: PMC7542006
OpenAlex: W2990418887
Semantic Scholar: 71c7b659ab277b78c2536cc6462d41a96688983d
Cited by: 49
References: 64
Citations by year: 2026: 4 · 2025: 6 · 2024: 13 · 2023: 8 · 2022: 7 · 2021: 7 · 2020: 4
FWCI: 4.14
Type: journal article
Language: en
Open access: bronze
doi.org
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
www.elsevier.com/legal/tdmrep-license (tdm)
www.elsevier.com/open-access/userlicense/1.0/ (vor, 1167 d)
Locations: Journal of Pain (publishedVersion)
PubMed (publishedVersion)
PubMed Central (acceptedVersion)
Research Portal (Queen's University Belfast) (submittedVersion, cc-by-nc-nd)
Funders: National Institutes of Health
Topics: Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Opioid Use Disorder Treatment
Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Opioid Use
Keywords: chronic pain, veterans, acceptance and commitment therapy, mindfulness-based relapse prevention, opioid misuse, pain interference, pain behavior, feasibility, co-occurring disorders, opioid prescribing
MeSH terms: Adult, Feasibility Studies, Female, Follow-Up Studies, Humans, Male, Middle Aged, Opioid-Related Disorders, Veterans, Comorbidity, Outcome Assessment, Health Care, Chronic Pain, Mindfulness, Acceptance and Commitment Therapy

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Integrated behavioral treatment for veterans with co-morbid chronic pain and hazardous opioid use: a randomized controlled pilot trial

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