Kevin E. Vowles, Ph.D. Department of Psychology 28 May 2015 Living a Valued Life with Chronic Pain

4 Questions 1. What is valued living?

Is “life uninterrupted” the goal? If so, how are we doing? If so, how are we doing?

Chronic Pain Common Common e.g., Breivik et al., 2006, Gureje et al., 1998 e.g., Breivik et al., 2006, Gureje et al., 1998 Persistent Persistent e.g., Andersson, 2004; Elliott et al., 2002 e.g., Andersson, 2004; Elliott et al., 2002 Gureje et al., 2001 Has a extraordinarily widespread impact on life Has a extraordinarily widespread impact on life E.g., Fordyce, 1988; Gatchel et al., 2007 E.g., Fordyce, 1988; Gatchel et al., 2007 Pain remains

Figure 7: The impact of chronic pain on daily activities. 27% 47% 43 % 30 % 61% 48% 47% 54% 72% 73% 65%

Also, durable and problem- free pain reduction is pretty darn hard to achieve

Opioids - No supportive evidence for long-term pain reduction (i.e., > 15 weeks). Martell et al., 2007 – Ann. of Internal Medicine – Systematic Review Chou et al., Ann. of Internal Medicine – Clinical Guidelines Surgery - Continued pain and disability are the norm following spinal surgery (i.e., discectomies & fusions). Franklin et al., 1994; Hoffman et al., 1993; Turk, 2002; Turner et al., 1992; 1995 Spinal Cord Stimulators - Pain reduction is relatively transient 3, 4, & 5 year f/u). No evidence of improvement in functioning or quality of life. Kemler et al., 2000 NEJM; 2002 J Neurosurgery; 2006 NEJM; 2008 J Neurosurgery Epidural Steroid Injections – Lumbar - “Probably not” effective for long-term pain relief, improving functioning, or decreasing rates of surgery. Cervical - No evidence available upon which to base a conclusion. Armon et al., 2007., Neurology – Systematic Review & Clinical Guidelines commissioned by the Amer. Acad. of Neurology

“As a guiding principle in my life: (Importance of area rated)” “As a guiding principle in my life: (Importance of area rated)” Assessed 36 samples (n = 159 – 295 in most samples) across 20 countries Assessed 36 samples (n = 159 – 295 in most samples) across 20 countries Multidimensional Scaling of terms Multidimensional Scaling of terms

4 Questions 1. What is good living? 2. Do people with pain want good living?

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Excerpts from patient letter: “trying to do more to take load off of husband/daughter” “If there are no carers and I’m bad, I don’t wash, eat, etc.” “(Pain is) ok, but neck hurts, tight chest and cough, starts in spine, pins/needles in arms/hands” “I can cope with the pain... but clumsiness and weakness is dangerous!” “the house is a mess, (husband) is stressed/depressed, (daughter) stays away” “I’m very positive and cheery (driven) and I think it does me no favours as I think people think I am ok”

4 Questions 1. What is valued living? 2. Do people with pain want valued living? 3. What is the clinical rationale for valued living with pain?

Clinical Rationale Valued living: Only happens when valued living happens. Only happens when valued living happens. See Vowles, 2015, Introduction to Special Issue on Modern Behavior Therapies, Current Opinion in Psychology

The problem of pain can be conceptualized as one of behavior (not of pain). The problem with this behavior is that it is often directed towards pain control and away from areas that bring meaning and importance to living. 1976! 2014!

Goal and Assumptions Valued living: Only happens when valued living happens. Only happens when valued living happens. Does not require feeling better, good, happy – or being pain free. Does not require feeling better, good, happy – or being pain free. Is about having options for behavior - AKA a “broad behavioral repertoire” Is about having options for behavior - AKA a “broad behavioral repertoire” See Vowles, 2015, Introduction to Special Issue on Modern Behavior Therapies, Current Opinion in Psychology

“I can’t go on” ThoughtAction Stopping Context Overwhelmed by private content Unwillingness to Experience Valued Behavior Failures

“I can’t go on” ThoughtAction Stopping Context Willingness to experience Contact with thoughts & wider experience Persistence in values-based action Carrying on or

4 Questions 1. What is valued living? 2. Do people with pain want valued living? 3. What is the clinical rationale for valued living with pain? 4. What do the data have to say?

Does it work? “To meet this standard, well-designed studies conducted by independent investigators must converge to support a treatment’s efficacy.”

Possible prerequisites for change?

Improved willingness to have the experience of pain + More frequent engagement in valued activity over the longer term = (should) WITH Pain

The impact of more willingness and more values-based activity Better: Current emotional and physical functioning Vowles & McCracken, 2008, Health Psych; Vowles et al., 2008, Pain; Vowles & Thompson, 2012; Vowles et al., CJP; Vowles et al., 2014, Beh Ther Future emotional and physical functioning McCracken & Vowles, 2008, Health Psych; Vowles et al., 2011, BRAT Improvements in emotional and physical functioning in the months and years following treatment Vowles et al., 2007, Eur J Pain; Vowles & McCracken, 2008, J Consult Clin Psych; Vowles et al., 2011, BRAT; Vowles et al., 2014, J Pain; Vowles et al., 2014 J Contextual Beh Psychology

Treatment Success?

From: Connecting the dots... In at least some patients, at least some of the time, pain no longer appears to be the paramount problem. In responding normally to pain, behavior can be directed towards pain control at the expense of areas that bring meaning and importance to living. Treatment methods can: directly target these losses and restrictions in living. work towards willingness to have the thoughts and feelings associated with them in the service of improving living. measure outcomes in terms of successful living, not severity of symptoms.

“People who have something better to do don’t suffer as much.” - Wilbert Fordyce (1988) “Friendship in adversity”, Ray Byrne,

Thanks for your attention. Questions?