Mindful Action for Pain: An Integrated Approach to Improve Chronic Pain Function

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Chronic pain, defined as persistent or episodic pain that does not resolve with treatment, affects up to 50% of Veterans, costs the nation between $560 and $635 billion dollars annually, and is associated with high rates of disability and low quality of life. According to the 2009 Veterans Health Administration (VHA) Directive, the goal of pain treatment is to improve physical and psychosocial functioning, emphasizing non- pharmacological approaches, such as psychosocial interventions, to target psychosocial factors that maintain disability. Unfortunately, the gold standard psychosocial intervention for chronic pain, Cognitive Behavioral Therapy (CBT), does not reliably produce meaningful increases in function. Veterans would greatly benefit from innovative and theoretically-grounded alternative psychosocial interventions for chronic pain. An emerging scientific model that has been applied to chronic pain is the psychological flexibility (PF) model. PF refers to the ability to behave consistently with one's values even in the face of unwanted thoughts, feelings, and bodily sensations such as pain. Acceptance and Commitment Therapy (ACT) is the best known treatment derived from the PF model and is as effective as the gold standard CBT, but still falls short on achieving meaningful changes in functional improvement. Although ACT was designed to impact PF, methods from different treatment approaches are also consistent with the model. An experiential strategy that holds promise for enhancing PF is formal mindfulness meditation, a practice used to train non-judgmental awareness and attention to present-moment experiences, which has never been tested within the PF model. There is compelling theoretical and empirical rationale that the mechanisms underlying formal mindfulness meditation will bolster PF processes and thereby can be applied to facilitate functional improvement. To test this, Dr. Herbert, the principal investigator (PI), has developed a novel 8-week group-based intervention, Mindful Action for Pain (MAP), which integrates formal mindfulness meditation with experiential methods from different evidence-based treatment approaches in accordance with the PF model. MAP is designed such that daily mindfulness meditation practice is used to develop the capacity to more completely utilize strategies to address the key psychosocial barriers (e.g., pain catastrophizing) to optimal functioning. The proposed CDA-2 consists of two phases. Phase 1 (years 1 – 2) consists of using qualitative and quantitative methods to iteratively develop and refine MAP (n = 20). Phase 2 (years 3 – 5) consists of a pilot randomized trial (n = 86) of MAP vs. CBT for chronic pain (CBT-CP) in order to establish feasibility of a future large-scale trial and estimate the preliminary impact of MAP. Functional improvement will be measured by reductions in pain interference (primary clinical outcome). Further, meditation adherence will be assessed to explore dose-response relationships with functional improvement, and objective measures of physical activity (actigraphy) will be captured to explore the psychophysical impact of MAP. The PF model is a progressive scientific model that is consistent with VHA goals for chronic pain management, but so far interventions developed based on this model (i.e., ACT) are not accomplishing the goals set forth by the VHA. Therefore, we seek to fully develop and estimate the preliminary impact of a novel, integrated intervention that is consistent with the PF model. In MAP, formal mindfulness meditation and evidence-based experiential methods are taught as practical tools to help participants remain present moment focused while accepting and creating distance with ongoing unpleasant thoughts, emotions, and pain in order to actively pursue meaningful life directions. Findings from the proposed study have the potential of substantially increasing the physical and psychosocial functioning of Veterans with chronic pain, and also have the potential of reducing the social and economic burden of chronic pain.