Reduce Opioid Use after Surgery for Orthopedic Trauma with Mindfulness
By John M. de Castro, Ph.D.
“mindfulness-based interventions could help people dependent on opioids increase their self-awareness and self-control over cravings and be less reactive to emotional and physical pain.” – Pain Week
Substance abuse and addiction is a terrible problem, especially opioid pain relievers. Opioid addiction has become epidemic and is rapidly increasing affecting more than 2 million Americans and an estimated 15 million people worldwide. In the U.S more than 20,000 deaths yearly were attributed to an overdose of prescription opioids. An effective treatment for addiction has been elusive. Most programs and therapies to treat addictions have poor success rates.
An encouraging alternative is mindfulness training. It has been found to be effective in treating addictions. One way that mindfulness may produce these benefits is by reducing cravings for opioids. The vast majority of the mindfulness training techniques, however, require a trained therapist. This results in costs that many patients can’t afford. In addition, the participants must be available to attend multiple sessions at particular scheduled times that may or may not be compatible with their busy schedules and at locations that may not be convenient. As an alternative, mindfulness training over the internet has been developed. This has the tremendous advantages in decreasing costs, making training schedules much more flexible, and eliminating the need to go repeatedly to specific locations.
Acceptance and Commitment Therapy (ACT) is a mindfulness-based psychotherapy technique that is employs many of the techniques of Cognitive Behavioral Therapy (CBT). ACT focuses on the individual’s thoughts, feelings, and behavior and how they interact to impact their psychological and physical well-being. It then works to change thinking to alter the interaction and produce greater life satisfaction. ACT employs mindfulness practices to increase awareness and develop an attitude of acceptance and compassion in the presence of painful thoughts and feelings. ACT teaches individuals to “just notice”, accept and embrace private experiences and focus on behavioral responses that produce more desirable outcomes. Hence it would make sense to study ACT delivered over the internet to reduce opioid use with pain patients.
In today’s Research News article “Acceptance and Commitment Therapy Delivered via a Mobile Phone Messaging Robot to Decrease Postoperative Opioid Use in Patients With Orthopedic Trauma: Randomized Controlled Trial.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7458063/ ) Anthony and colleagues recruited hospital patients who had a bone fracture requiring surgery and randomly assigned them to a treatment as usual control condition or to receive automated text based messages communicating a Acceptance and Commitment Therapy (ACT) message twice a day for the two weeks following surgery.
A day 1 example message was:
“Maintaining focus on what you value most in life is sometimes difficult after surgery. Do not let the momentary discomforts due to surgery take away from what you want most in life. Pick 3 things that matter most to you in life. Remind yourself of these 3 things you value most during your recovery process.”
They were measured before and after the 2-week messaging period for opioid use, pain intensity, pain interference, and anxiety.
They found that although both groups were prescribed the same amount of opioids after surgery, the Acceptance and Commitment Therapy (ACT) message group consumed significantly fewer, 37% less, opioid pills during the 2 weeks following surgery than the control group. In addition, the ACT group reported significantly lower pain intensity and pain interference than the control group two weeks after surgery.
The ability of Acceptance and Commitment Therapy (ACT) to reduce perceived pain and to reduce opioid use have been previously documented. The important contribution of the present study is that it demonstrated that these benefits can be attained with ACT taught through automated text messages. This suggests that the benefits of the therapy can be provided routinely, inexpensively and conveniently to large numbers of patients. Although there was no long term follow up, it would be hoped that this treatment would result in lower likelihood of opioid addiction resulting from post-surgical use in these patients.
So, reduce opioid use after surgery for orthopedic trauma with mindfulness.
“People suffering from opioid addiction and chronic pain may have fewer cravings and less pain if they use both mindfulness techniques and medication for opioid dependence.” – Science Daily
CMCS – Center for Mindfulness and Contemplative Studies
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Anthony, C. A., Rojas, E. O., Keffala, V., Glass, N. A., Shah, A. S., Miller, B. J., Hogue, M., Willey, M. C., Karam, M., & Marsh, J. L. (2020). Acceptance and Commitment Therapy Delivered via a Mobile Phone Messaging Robot to Decrease Postoperative Opioid Use in Patients With Orthopedic Trauma: Randomized Controlled Trial. Journal of medical Internet research, 22(7), e17750. https://doi.org/10.2196/17750
Acceptance and commitment therapy (ACT) is a pragmatic approach to help individuals decrease avoidable pain.
This study aims to evaluate the effects of ACT delivered via an automated mobile messaging robot on postoperative opioid use and patient-reported outcomes (PROs) in patients with orthopedic trauma who underwent operative intervention for their injuries.
Adult patients presenting to a level 1 trauma center who underwent operative fixation of a traumatic upper or lower extremity fracture and who used mobile phone text messaging were eligible for the study. Patients were randomized in a 1:1 ratio to either the intervention group, who received twice-daily mobile phone messages communicating an ACT-based intervention for the first 2 weeks after surgery, or the control group, who received no messages. Baseline PROs were completed. Two weeks after the operative intervention, follow-up was performed in the form of an opioid medication pill count and postoperative administration of PROs. The mean number of opioid tablets used by patients was calculated and compared between groups. The mean PRO scores were also compared between the groups.
A total of 82 subjects were enrolled in the study. Of the 82 participants, 76 (38 ACT and 38 controls) completed the study. No differences between groups in demographic factors were identified. The intervention group used an average of 26.1 (SD 21.4) opioid tablets, whereas the control group used 41.1 (SD 22.0) tablets, resulting in 36.5% ([41.1-26.1]/41.1) less tablets used by subjects receiving the mobile phone–based ACT intervention (P=.004). The intervention group subjects reported a lower postoperative Patient-Reported Outcome Measure Information System Pain Intensity score (mean 45.9, SD 7.2) than control group subjects (mean 49.7, SD 8.8; P=.04).
In this study, the delivery of an ACT-based intervention via an automated mobile messaging robot in the acute postoperative period decreased opioid use in selected patients with orthopedic trauma. Participants receiving the ACT-based intervention also reported lower pain intensity after 2 weeks, although this may not represent a clinically important difference.