P-119 - A Preliminary Examination of the Feasibility, Appropriateness, and Effectiveness of Virtual Group-Based Acceptance and Commitment Therapy for Chronic Pain (ACT-CP) in Veterans

Abstract Title: A Preliminary Examination of the Feasibility, Appropriateness, and Effectiveness of Virtual Group-Based Acceptance and Commitment Therapy for Chronic Pain (ACT-CP) in Veterans


Background: Chronic pain disproportionately affects Veterans compared to the general public. Veterans are diagnosed with chronic pain at high rates (25 – 72%; Van Den Kerkhof et al., 2014) and report severe pain at a rate almost 50% higher than non-Veterans (Nahin, 2017). Additionally, Veterans with chronic pain experience decreased ability to complete daily living activities (Duong et al., 2005), increased medical and psychiatric co-morbidities, and increased risk of suicide (Calati et al., 2015). Importantly, since 2003, the Department of Veterans Affairs (VA) has emphasized non-opioid treatments for chronic pain (Frank et al., 2019). Thus, there is a need to develop accessible, evidence-based, non-opioid interventions for the self-management of chronic pain. One VA-approved and evidence-based approach to the treatment of chronic pain is Acceptance and Commitment Therapy for Chronic Pain (ACT-CP). Meta-analytic studies have found that acceptance-based interventions for the treatment of chronic pain lead to improvements in functional pain outcomes and overall impact of chronic pain (Veehof et al., 2011; Hann & McCracken, 2014).

Purpose/Objectives:

Purpose:

To date, one clinical trial among Veterans demonstrated that a virtual 8-session ACT-CP group was noninferior to in-person group-based ACT-CP treatment (Herbert et al., 2017), indicating that this is a viable treatment approach. A virtual-format for ACT-CP would increase Veterans’ ability to access, utilize, and apply skills from this evidence-based intervention. This may be particularly important for Veterans with limited access to services due. Thus, there is a need for virtual options to increase access to ACT-CP, as well as systematic evaluation of the feasibility, acceptability, and effectiveness of such an intervention approach.

This study aimed to evaluate the feasibility and appropriateness of a virtual ACT-CP group intervention for Veterans with chronic pain. A secondary aim is to evaluate the effectiveness of ACT-CP by examining relevant clinical outcomes (comparison of pre- and post-scores), such as pain, pain interference, pain acceptance, and pain locus of control.


Methods: Veterans with chronic pain participated in a 10-week virtual group intervention. Veterans were recruited from the Southeast Louisiana Veterans Health Care System (SLVHCS) via referrals from various services. Veterans with noncancer chronic pain occurring longer than three months were eligible. Each session lasted 90 minutes and were facilitated by a pain psychologist and/or post-doctoral resident. Session content was adapted from evidence-based ACT-CP protocols (e.g., Vowles & Sorrell, 2006; Dahl & Lundgren, 2006; McCracken, 2015) including psychoeducational content adapted from VA’s Brief Cognitive Behavioral Therapy for Chronic Pain manual (Beehler et al., 2019).

To evaluate the feasibility and appropriateness of the intervention, recruitment, enrollment, and attendance were measured. Veterans completed the Intervention Appropriateness Measure (IAM, Weiner et al., 2017) post-intervention assessing appropriateness of the treatment for chronic pain and the virtual format with scores averaged.

Veterans also completed the Pain Outcomes Questionnaire – Short Form (POQ, Clark & Gironda, 2003), Chronic Pain Acceptance Questionnaire—Revised (CPAQ-R; McCracken et al., 2004),and Multidimensional Health Locus of Control (MHLC; Wallston et al., 2010) at both pre- and post-intervention to assess specific pain-related variables. Pre- and post-scores were compared using pair samples t-tests.

This study was approved by the SLVHCS Institutional Review Board (IRB).


Results: From September 2022 to June 2023, a total of 53 veterans were primarily recruited by the pain psychologist during interdisciplinary pain clinic appointments (61.5%), followed by referrals from the Pain Evaluation Program (11.5%) and Behavioral Medicine consults from various hospital services (11.5%). Remaining referral sources included behavioral medicine psychologists during interdisciplinary clinics (e.g., Spinal Cord Injury/Disease, Amputee; 7.7%) and outpatient mental health providers (7.7%). Five virtual ACT-CP groups were conducted and completed, with 42 veterans enrolled and 28 completing treatment resulting in a 29% attrition rate. Veterans that completed treatment attended an average of 9 of 10 sessions, and those that ceased attending group completed an average of one session. Of the 22 veterans that completed the IAM, they rated ACT as highly appropriate for the treatment of chronic pain (M = 4.6 ,SD = 0.9) and rated the virtual format as highly appropriate (M = 4.7 ,SD = 1.2).

Veterans that completed treatment reported increased internal locus of control post-treatment (M = 24.2 ,SD = 6) compared to pre-treatment(M = 18.5 ,SD = 4.8), t(18) = 3.3, p = .004. Additionally, Veterans scores reflected increase in willingness (M₁ = 22.4 ,SD₁ = 15.1; M₂ = 35.3 ,SD₂ = 9), t(26) = 4.2, p < .001.and meaningful activity engagement (M₁ = 26.1 , SD₁ = 14.9; M₂ = 44.2 ,SD₂ = 9.4), t(26) = 6.5, p < .001). Other variables analyzed reflected no significant changes in pre- and post-scores.

Conclusions/Implications for future research and/or clinical care: Chronic pain in continues to impact Veteran’s daily lives, resulting in increased disability. Acceptance-based behavioral interventions are effective in treating the impact of chronic pain. The primary outcomes of this study found that virtual group-based ACT for chronic pain treatment was both feasible and appropriate for addressing the impact of chronic pain in this group of Veterans. The attrition rate of the virtual group was similar to in person group based psychotherapy interventions (de Haan et al., 2013) with improvement in the willingness of Veterans to experience pain, increased belief of behavioral control, and improved engagement in meaningful activities. Future work would benefit to continue assessing the use of virtual care to increase access to care to ensure appropriateness and effectiveness of virtual treatment.


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