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Cognitive and Behavioral Practice 18 (2011) 149–160www.elsevier.com/locate/cabp

Treating Chronic Pain in Veterans Presenting to an AddictionsTreatment Program

Mark A. Ilgen, Elizabeth Haas, Ewa Czyz, and Linda Webster, VA Ann Arbor Healthcare System andUniversity of Michigan

John T. Sorrell, San Mateo Medical CenterStephen Chermack, VA Ann Arbor Healthcare System and University of Michigan

1077© 20Publ

Chronic pain and substance use disorders frequently co-occur. The pharmacological treatment of pain is complicated in individualswith substance use disorders because of the potential for abuse and diversion of many prescription pain medications. One potentialapproach is to use a combination of cognitive-behavioral and acceptance-based strategies to manage pain and decrease substance misusewith chronic pain acceptance to help increase contact with valued life activities. After reviewing the literature on pain and substanceuse, this report provides an overview of a new manualized treatment for chronic pain in those with drug or alcohol misuse. Pilot data arepresented as preliminary evidence for the feasibility of delivering this intervention to individuals in drug or alcohol treatment. Futuredirections for research on co-occurring pain and substance use are discussed.

CHRONIC pain is a common health problem in theUnited States, with over a quarter of all U.S. adults

reporting some form of persistent or significant painwithin the past 12 months. The International Associationfor the Study of Pain (IASP) defines pain as “anunpleasant sensory and emotional experience associatedwith actual or potential tissue damage” (Bonica, 1979,p. 250), highlighting the fact that an individual’sinterpretations of internal stimuli often influence thepain experience. In addition to being associated withmany physical health-related problems (Hagen, Svensen,Eriksen, Ihlebaek, & Ursin, 2006; Hestbaek, Leboeuf-Yde,& Manniche, 2003) and significant loss of productivityand quality of life (Becker et al., 1997; Stewart, 2003),chronic pain is also linked to a higher prevalence ofpsychiatric conditions (Currie & Wang, 2004; Dersh,Polatin, & Gatchel, 2002; Means-Christensen, Roy-Byrne,Sherbourne, Craske, & Stein, 2008; Von Korff, Balderson,et al., 2005). In particular, chronic pain frequently co-occurs with substance use disorders (SUDs). Elevatedrates of SUDs in those with chronic pain have been well-documented in the general population (Demyttenaereet al., 2007; Saunders, Merikangas, Low, Korff, & Kessler,2008; Von Korff, Crane, et al., 2005) and the rates of co-occurrence of these two conditions are generally muchhigher in clinical samples (Dersh, Gatchel, Mayer,

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Polatin, & Temple, 2006; Kinney, Gatchel, Polatin,Fogarty, & Mayer, 1993; Polatin, Kinney, Gatchel, Lillo,&Mayer, 1993; Rosenblum, Joseph, Fong, Kipnis, Cleland,& Portenoy, 2003a; Trafton, Oliva, Horst, Minkel, &Humphreys, 2004).

Several possible explanations have been proposed toexplain why pain and SUDs frequently co-occur, includ-ing: the use of drugs or alcohol to “self-medicate” ordecrease the physical experience of pain (Rosenblumet al., 2003b), the development of pain conditions as theresult of injuries due to the risky lifestyle associated withprolonged substance use (Compton, Darakjian, & Miotto,1998; Karasz et al., 2004), or shared underlying risk factorscommon to both pain and SUDs (Gatchel & Dersh, 2002;Ilgen, Perron, Czyz, McCammon, & Trafton, 2010). In alllikelihood, those with co-occurring pain and SUDs are aheterogeneous group and no single explanation will fitfor all individuals with pain and SUDs.

Although there is a clear need for effective treatmentapproaches for co-occurring chronic pain and SUDs, themanagement of pain in those with a history of substancemisuse remains challenging. Pharmacological treatmentsfor pain in patients with SUDs are problematic due to thepotential for misuse of opioid medications, a lack of dataon the long-term efficacy of opioids to treat chronicnonmalignant pain and the added concern that pro-longed opioid use may be associated with a reducedtolerance for pain, referred to as opioid-induced hyper-algesia (Collins & Streltzer, 2003; Doverty et al., 2001).Moreover, many prescribing guidelines for pain explicitly

150 Ilgen et al.

recommend against prescribing opioid analgesics topatients with past addictive behaviors (Collins & Streltzer,2003; Portenoy, Lussier, Kirsh, & Passik, 2005). Thus, it isimportant to consider other treatment approaches for co-occurring chronic pain and SUDs without the risksassociated with pharmacological treatments.

Psychological interventions for themanagement of pain,such as cognitive-behavioral therapy (CBT; Turk &Meichenbaum, 1983) and acceptance-based interventions(Dahl, Wilson, Luciana, & Hayes, 2005; McCracken &Eccleston, 2005), represent promisingmethods for treatingchronic pain in patients with SUDs. Cognitive-behavioralinterventions have been well-studied in other patientpopulations, and evidence indicates that they can signifi-cantly improve pain and physical functioning in patientssuffering from pain-related problems (Dworkin et al., 1994;Evans, Fishman, Spielman, & Haley, 2003; Morley, Eccles-ton, & Williams, 1999). A comprehensive meta-analysis of25 trials indicates that CBT interventions for pain canproduce significant reductions in pain and negative affectcompared to wait list and attention control conditions(Morley et al., 1999). Emerging evidence supports theefficacy of acceptance-based interventions in improvingpain-related functioning in individuals with chronic pain(Dahl et al., 2005; Dahl, Wilson, & Nilsson, 2004; Vowles &McCracken, 2008; Wicksell, Dahl, Magnusson, & Olsson,2005). Additionally, CBT interventions for pain have asubstantial conceptual overlap with CBT interventions forSUDs, which are also widely used and have solid efficacy(Kadden, Carroll, & Donovan, 1992; Marlatt & Gordon,1985; Witkiewitz & Marlatt, 2004). Acceptance-basedstrategies for treating SUDs are just beginning to be studiedbut show significant promise (Hayes et al., 2004; Stotts,Dodrill, &Kosten, 2009). Despite the demonstrated efficacyof CBT and acceptance-based strategies in reducing painand improving functioning in persons with pain-relatedconditions, this formof treatment has not been well-studiedin those with co-occurring SUDs. In fact, possibly as aconsequence of the generally high level of methodologicalrigor of existing randomized control trials, most studiesexplicitly excluded individuals with co-occurring alcohol ordrug dependence. It is unknown whether CBT for painmanagement will work differently in those with SUDs giventheir potential reliance and/or focus on substance misuseas a method to cope with pain (Pud, Cohen, Lawental, &Eisenberg, 2006).

To the best of our knowledge, only one existing studyhas explicitly examined the effects of an integratedbehavioral intervention for pain in those with SUDs(Currie, Hodgins, Crabtree, Jacobi, & Armstrong, 2003).This observational study examined 44 patients with bothSUDs and chronic pain who were referred to anoutpatient group treatment by their primary carephysician or psychiatrist. This study found significant

reductions in pain intensity, pain-related interference offunctional activity, medication misuse, and more generalmeasures of maladaptive coping from baseline to 12-month follow-up. However, in this intervention, allparticipants were required to be abstinent from alcoholand illicit drugs. This approach may not fit well intooutpatient SUD treatment programs with a harm-reduc-tion treatment model.

The use of psychosocial strategies for the managementof chronic pain and substance misuse could be particu-larly useful in SUD treatment settings where manypatients present with chronic pain. The rates of chronicpain in SUD treatment vary substantially from approxi-mately 16% to over 60%, depending on the type of painexamined and the clinical setting (Jamison, Kauffman, &Katz, 2000; Larson et al., 2007; Potter, Prather, & Weiss,2008; Rosenblum et al., 2003a; Trafton et al., 2004).Comparisons of these data indicate that the prevalence ofpain is higher in clinics that serve older patients and thosewith more extensive drug use histories. Similarly, forpatients seen in SUD treatment, those with pain-relatedproblems tend to report more depression, anxiety,suicidal ideation, greater functional limitations, andmore severe drug and alcohol problems (Jamison et al.,2000; Larson et al., 2007; Potter et al., 2008; Rosenblumet al., 2003a; Trafton et al., 2004).

The presence of chronic pain is associated with apoorer course of posttreatment outcomes following SUDtreatment (Larson et al., 2007). A recent study of patientstreated for SUDs found that persistent pain was present in33% of the sample, and those with pain were more likelyto drop out of treatment early and were less likely to beabstinent at 12 months than those without pain (Caldeiro,Malte, Calsyn, Baer, Nichol, Kivlahan et al., 2008). Intheory, these outcomes could be improved through bettermanagement of pain in SUD patients.

The present report begins by describing an overallapproach to conceptualizing and addressing co-occurringpain and substance use during an episode of SUDtreatment. Next, preliminary results are presented froma pilot study. The pilot study was conducted to determinethe feasibility of delivering a CBT and acceptance-basedintervention for pain management during a course ofSUD treatment and to examine changes in measures ofpain level, tolerance, and substance use during participa-tion in this intervention. This work is intended to lay thefoundation for further evaluation of this intervention inlarger samples of drug and alcohol patients.

Cognitive-Behavioral and Acceptance-BasedTreatment for Improving Pain Management in

Those With SUDs

Cognitive behavioral interventions for pain are basedon a biopsychosocial perspective and view pain as an

151Treating Pain and Substance Misuse

experience that is influenced by both physical andpsychological factors (Andrasik, Flor, & Turk, 2005;Turk & Flor, 1999). CBT is designed to address thefactors leading to poorer functioning and maintenance ofthe negative cycle characterized by the fear-avoidancemodel (Norton & Asmundson, 2003; Otis, 2007; Turk &Meichenbaum, 1983). The present manualized treatmentapproach utilizes a modified protocol for chronic painmanagement (Sorrell, Trafton, & McKellar, 2005), whichhas been shown to help reduce pain-related dysfunctionamong patients with chronic pain (Cucciare, Sorrell, &Trafton, 2009). We modified the treatment manual byintegrating aspects of CBT for SUDs. This was a relativelystraightforward approach given the shared focus of bothinterventions on identifying maladaptive cognitions,decreasing the use of avoidance (e.g., substance use) tocope with problems, and increasing engagement inactivities. We have been using this integrated approachin our pilot studies and have found a natural overlapbetween content areas.

Our approach is different than what has been used inprior work examining psychosocial pain managementinterventions in those with SUDs (Currie, Hodgins, et al.,2003) in that we added an emphasis on chronic painacceptance (Dahl et al., 2005; McCracken, 2005b) andmodified the content for substance users. We includedchronic pain acceptance in light of the increasingliterature that has amassed on its benefits for individualswith chronic pain striving to improve overall functioning(see McCracken, 2005a, for a review). Consistent withprevious studies, we defined chronic pain acceptance asthe willingness to live with pain, without attempts toreduce or eliminate pain, while engaging in importantdaily activities (McCracken, 1998, 1999; McCracken &Eccleston, 2003). Similarities between cognitive behavior-al and acceptance-based interventions and the manner inwhich these approaches were presented make themcompatible. For example, both approaches strive toreduce psychological suffering and increase functioningthrough behavioral processes such as skills training,graded exposure, and behavior change by way of newenvironment-behavior relations (i.e., novel behaviors inthe presence of old environmental stimuli associated withdifferent outcome). Participants were encouraged toutilize the CBT skills to assist with coping, increasefunctioning, and reduce pain-related distress. To theextent that these strategies did not provide sufficientbenefits, participants were encouraged to take anacceptance-based stance to engaging in valued lifeactivities. Thus, a “control what you can and accept whatyou cannot control” perspective was employed, withtraining focused on when to use one approach over theother. Furthermore, this combination of strategies wasutilized in light of data indicating that CBT for chronic

pain alters acceptance-related factors (Geiser, 1992;Vowles, Wetherell, & Sorrell, 2009). These findingssuggest that there may be common, instrumentalprocesses that overlap between these approaches orperhaps that, in the process of using control strategiesfound in CBT, there are meaningful shifts in willingnessto have pain and valued-activity engagement even whilethe pain continues. Regardless of the exact mechanisms atwork, documented benefits of both approaches are foundthroughout the literature ( e.g., McCracken, Vowles, &Eccleston, 2004; Morley, Williams, & Hussain, 2008).

Overview of Content of Cognitive Behavioral andAcceptance-Based Intervention for Pain in Those

With SUDs

Treatment consisted of a 12-week manualized outpa-tient group adapted for individuals with co-occurring painand SUDs. The group was cofacilitated by two clinicians—a clinical social worker and a psychologist—experiencedin CBT and acceptance-based techniques to treat chronicpain, SUDs, and affective disorders. The 90-minute, 12-week, closed-group format allowed for a standardizedprogression with content that built upon the previouslypresented treatment materials. The protocol included anintroduction session consisting of education on GateControl Theory and Adaptation to Pain (Week 1; Melzack& Wall, 1965) and a final session consisting of a review ofthe pain management skills as well as relapse prevention(Week 12). Each session began with a brief check-in ofhomework, a review of Gate Control Theory, and anoverview of how the specific topic for the day (e.g.acceptance, behavioral activation, attention diversion/distraction) related to Gate Control Theory. The specificcontent for the 12 sessions is outlined in Table 1.

The treatment’s main foci included learning newcoping strategies for chronic pain (e.g., relaxation andactivity pacing), chronic pain acceptance (e.g., mindful-ness meditation and values identification and clarifica-tion), and assistance with the development of functionalgoals consistent with stated personal values. No singlesession focused exclusively on substance use. Instead,content related to substance use was integrated into eachsession’s specific pain-related focus. Substance use wasprimarily conceptualized as a maladaptive, avoidancecoping response that interferes with effective pain coping.The treatment addressed substance use by increasing theuse of new coping skills and improving self-efficacy tomanage pain without substance use. The final session ofthe group was entitled Relapse Prevention. For thissession, the word “relapse” was used loosely to mean anyreturn to behavior that was inconsistent with theparticipant’s goals. Thus, the topics covered in this sessionwere related to both pain and substance use. This wasused as a way to talk about all of the skills learned

Table 1Content of CBT Intervention for Pain in SUD Patients

Session Focus Content

1 Overview and Progressive Muscle Relaxation Review general group informationLearn theories of paina. Traditional pain theoryb. Gate Control TheoryLearn responses to pain pathway modelsBrief overview of acceptanceProgressive muscle relaxation ⁎⁎

2 Adaptation to Pain Review goals related to pain/functioningMultidimensionality of chronic painAdaptation to painPain monitoring

3 Pain Cycle and Introduction to Pacing Pain cycleActivity-rest cyclePacing

4 Awareness and Acceptance Identify small fluctuations in pain levelIncrease your awareness of changes in painthroughout the dayUse acceptance-based techniques to manage pain

5 Cognitive Restructuring Rationale and functions of cognitive restructuringImportance of thought monitoringExercise in identifying thoughts

6 Attention Diversion and Behavioral Activation Attention diversionTechniques in attention diversionBehavioral activation

7 Assertiveness Three types of communication stylesAssertiveness related to chronic pain management“SAS” communication technique

8 Cognitive Restructuring Review cognitive restructuringCatastrophic thought cycleExploring ways to change thoughtsa. Brainstorm challenge thoughtsb. Recovery pathc. Thinking nonjudgmentallyd. Cognitive restructuring (putting it all together)

9 Exercise and Sleep Management Importance of exercise and stretchingEmotional factors in exerciseDistinction between hurt and harmSleep management guidelines

10 Problem Solving Chronic pain as a barrier to problem solvingOverview of “generic” method for problem solving

11 Acceptance Review acceptancePractice acceptancePractice visualization as relaxation

12 Relapse Prevention Define relapse preventionReview treatment to datePutting it all togetherSay good-bye to the group

Note. SUD=substance use disorder.⁎⁎ After introducing progressive muscle relaxation in Session 1, all remaining sessions include a relaxation exercise at the end of the session(not explicitly noted in the table).

152 Ilgen et al.

throughout the group and to discuss strategies to preventsignificant deteriorations in functioning following group.

Similarly, the concept of chronic pain acceptance wasan overarching theme emphasized across all sessions.Guidance was provided about when to utilize CBT controlstrategies and when to apply pain-acceptance strategies.This approach generally highlighted the importance of

identifying specific goals consistent with life values forbetter functioning and working towards these goalsduring treatment. Additionally, we emphasized theimportance of tolerating negative emotions/thoughts/experiences while also developing specific cognitive andbehavioral skills. Furthermore, two sessions were focusedprimarily on acceptance, including discussion of the

153Treating Pain and Substance Misuse

willingness to acknowledge new methods of coping andnonjudgmental description of emotions, thoughts, andsituations that influence ability to implement new copingskills.

The aspect of treatment regarding cognitions focusedon thought monitoring and cognitive restructuring. Thebehaviorally oriented content included sessions onpacing, behavioral activation, and attention diversion.Pacing (Fey & Fordyce, 1983), or strategically planningto avoid overactivity, was another theme that wasreiterated throughout the 12 weeks. The life skillsmodules included problem solving, sleep and exercisemanagement, and communication skills; these sessionsgenerally integrated both cognitive and behavioralcomponents of life skills. For example, while learningsleep management, participants were instructed tomodify their sleep behaviors (e.g., time spent in bedprior to sleep) as well as their sleep-related thoughts(e.g., catastrophizing about the negative impact of losingsleep). At the end of each 90-minute session, partici-pants practiced a relaxation exercise that ranged inlength from 5 to 20 minutes. The relaxation exercisesincluded progressive muscle relaxation (PMR), guidedimagery, diaphragmatic breathing, thought monitoring,and thought management. Participants were providedwith a CD of relaxation exercises and encouraged topractice PMR 20 minutes per day, 3 times per week, athome as part of their practicing at-home exercises. Wedid not formally monitor the extent to which partici-pants complied with this recommendation.

While in the group, participants worked on theirpersonal goals and were encouraged to work throughspecific, relevant examples in group. Participants were notrequired to remain abstinent from alcohol, illicit drugs, orprescription pain medications during this treatment.Instead, the group facilitators encouraged participantsto comply with their own substance abuse goals with acommon goal of taking pain medications as prescribed. Inorder to clarify substance use goals, participants complet-ed a decisional balance related to benefits and negativeconsequences of reducing their substance use. Partici-pants discussed desired levels of substance use andcompleted weekly written monitors of frequency/quantityof alcohol use, and any illicit drug and pain medicationuse over the course of the group. The questions related toprescription medication asked participants, for each day,if they took any prescription medications and if thesemedications were taken as prescribed. Throughout thegroup, we reviewed these weekly monitoring forms anddiscussed the inner relationships between substance use,pain, and functioning. Each session began with a groupdiscussion of these forms. As part of these discussions,participants were asked to talk about how their recentbehavior related to their substance- and pain-related

goals. The review of the forms was interactive andparticipants often provided support for one another orsuggestions about how changing their behavior mightrelate to their goals. However, we did specifically trackprogress towards goals for individual participants. Instead,these topics were discussed as a group and individualparticipants were free to share information from theirforms, or not, if they preferred.

Many of the participants in the group reported priornegative interactions with treatment providers in discus-sions of pain medications and had concerns about theextent to which they could trust the therapists in this painmanagement group. In order to directly address thisconcern, participants were informed of exactly whatinformation would be communicated to their treatmentproviders. In our case, we informed participants that wewould not interact with their primary care providersregarding opioid medication issues (these discussionswere to be between the patients and providers directly) orseek out their treatment providers about other issueswithout their request, but, because of the structure of ourclinic, other treatment providers would have access totherapy notes within the electronic treatment recordssystem. For the purposes of this pilot research study, alldata gathered during the baseline and follow-up inter-ventions were completely confidential and in compliancewith our Institutional Review Board (IRB) protocol. Thepurpose of explicitly discussing this topic was to encour-age trust between the patients and facilitators, as well asmodel assertive communication. Interactions with treat-ment providers were often used as specific examples ofsocial situations for the group.

Other embedded goals of this treatment includedincreased insight into the use of the pain medication forthe intended purpose (e.g., pain management versusstress management), reduced pain due to overexertion,increased frustration tolerance, increased emotion regu-lation, increased pain tolerance, and increased dailyfunctioning.

For the present study, this treatment was delivered topatients receiving care from the Department of VeteransAffairs (VA). Within the VA health care system, rates ofchronic pain are high, with approximately half of all VApatients experiencing pain on a regular basis (Kerns, Otis,Rosenberg, & Reid, 2003). Up to 15% of female and 18%of male veterans with a chronic pain condition have beendiagnosed with one or more SUD by their VA provider(Kaur, Stechuchak, Coffman, Allen, & Bastian, 2007).Additionally, veterans with pain report greater utilizationof VA services than those without significant pain (Kauret al., 2007; Kerns et al., 2003). Althoughmany VA facilitiesoffer pain clinics, to the best of our knowledge, integratedpain management and substance-related services are notregularly provided in most VA SUD treatment programs.

154 Ilgen et al.

Pilot Study Methods

All participants were recruited from the Ann ArborVA SUD treatment clinic, a moderate-sized midwesternVA outpatient drug and alcohol treatment program. Forthe present study, it is important to note that theintervention of interest was added onto existing treat-ment for SUDs and many of the participants wereabstinent from alcohol and drugs prior to the start of theCBT and acceptance-based pain management group.Participants were recruited through referral from theirprimary mental health or SUD treatment provider andby placing fliers throughout the clinic. No specificinclusion criteria were used for the study other thaninvolvement in the SUD treatment clinic and report ofsome form of pain. For this study, two treatment groupswere conducted. All study procedures were approved bythe Ann Arbor VA IRB.

A total of 22 participants were referred to the study by aSUD treatment provider. We were unable to enroll 4 ofthese individuals into the study for logistical reasons (e.g.,could not be reached, missed initial intake appointment,etc.) and 1 individual stated that s/he was not interested inparticipating in a group treatment. In all, 17 participants

Table 2Sample Characteristics

Number %

Pain conditionsHeadaches/Migraines 1 8%Neck or Back Pain 8 62%Chest 3 23%Shoulder/Arm Pain 3 23%Ankle/Foot /leg 5 38%Other 3 23%Psych conditionsDepression 6 46%Bipolar 3 23%Anxiety 4 31%PTSD 4 31%Other 4 31%PrescriptionsPsychotropics 9 69%Opioid pain meds 10 77%Non-opioid pain meds 11 85%Other treatmentPT 2 15%Biofeedback 0 0%TENS 0 0%Chiropractic 1 8%Botox injection for Headache 1 8%Pain Clinic 3 23%

Mean # of visits SD

Mental Health Treatment 0.62 1.03SUD Treatment 5.92 7.96

Note. SUD=substance use disorder; TENS= transcutaneouselectric nerve stimulation.

provided informed consent and completed the baselineassessment. Assessments were conducted in person at theSUD treatment facility by a research assistant who was notinvolved in the clinical delivery of the intervention. Allconsented individuals attended at least one group sessionand 13 (76%) completed the posttreatment follow-up.The reasons for dropout in the 4 individuals who were notreassessed included: psychiatric hospitalization (n=1),medical hospitalization (n=1), substance relapse and lackof interest in returning to the clinic (n=1), and traveldistance (n=1).

The 13 participants with complete data were predom-inantly male (92%), Caucasian (85%), or AfricanAmerican (15%). On average, participants were 51.4(SD=8.17) years old, unemployed (92%) at the start ofthe study, and had an average education level of 13.8years. The majority of participants reported experiencingat least 6 months of chronic pain and 8 (62%) endorsed 5or more years of chronic pain. Table 2 presents furtherinformation about participant characteristics and serviceutilization during the study based on information in theirelectronic medical record.

MeasuresParticipants were assessed prior to and following

completion of the group with the measures listed below.Each assessment lasted approximately 1 hour andincluded the self-report and behavioral measures ofpain and substance use. Additionally, following the lastsession, participants provided written feedback to twoopen-ended questions: “What did you like about thegroup?” and “What did you dislike about the group?”

Pain intensity. Participants’ global pain intensity wasmeasured using the Numeric Rating Scale of painintensity (NRS-I; Farrar, Young, LaMoreaux, Werth, &Poole, 2001), an 11-point numeric rating scale (0=nopain, 10=worst pain imaginable). This measure is widelyused in research as well as clinical practice.

Chronic pain acceptance. The Chronic Pain Accep-tance Questionnaire (CPAQ; McCracken et al., 2004) is a20-item self-report measure of pain-related acceptance. Atotal score is derived by adding all items (ranging from 0 –120) and corresponds to pain acceptance withoutattempts to control, struggle with, or change pain-relatedexperiences, and higher scores indicate a greater degreeof chronic pain acceptance.

Self-efficacy. The Chronic Pain Self-Efficacy Scale(CPSS) is a 22-item questionnaire designed to measurethe perceived self-efficacy to adapt to, or manage, chronicpain (Anderson, Dowds, Pelletz, Edwards, & Peeters-Asdourian, 1995). Prior research has demonstrated thehigh reliability of this measure and the relationshipbetween higher self-efficacy and lower pain-relatedinterference (Anderson et al., 1995).

Table 3Measures of Change in Pain and Substance Use Over the Course of the CBT Intervention

Measure Pre Group Mean (SD) Post Group Mean (SD) Change t test p value Effect Size

NRS-1 7.13 4.5 -2.63 5.30 0.001 0.45CPAQ 46.64 52.07 5.43 1.15 0.14 0.17CPSS 137.03 179.59 42.55 3.10 0.001 0.44Cold Pressor Test 51.62 49.46 2.15 0.22 0.42 0.03ASI (alcohol composite) 0.27 0.21 -0.06 1.96 0.04 0.23ASI (drug composite) 0.12 0.11 0.02 0.86 0.20 0.08TLFB Alcohol Frequency 3.07 2.29 -0.79 0.76 0.23 0.06TLFB Drugs Frequency 2.79 0.579 -2.21 0.99 0.17 0.18

Note. NRS-1=Numeric Rating Scale of pain intensity; CPAQ=Chronic Pain Acceptance Questionnaire; CPSS=Chronic Pain Self-EfficacyScale; ASI=Addiction Severity Index; TLFB=Time Line Follow-Back.

155Treating Pain and Substance Misuse

Pain tolerance. Pain tolerance was assessed using awidely used behavioral task known as the cold-pressor test.As used byWilloughby, Hailey, Mulkana, and Rowe (2002),the procedure involved immersion of the nondominanthand and arm to 4 inches above the wrist in a container ofice water. For this purpose, we used a 10×14×10−inchplastic ice chest with a screen partition in the middle. Thelength of time that participants were able to maintain theirhand in the cold water was used as an indicator of paintolerance (with a maximum of 120 seconds).

Patterns and consequences of substance use. The self-report alcohol and drug scales of the Addiction SeverityIndex (ASI; McLellan et al., 1992) were used to measurepatterns and consequences of substance use in the 30 daysprior to each assessment time period. Responses wereused to calculate alcohol and drug composite scoresaccording to standardized scoring procedures. The ASI iswidely used to measure substance use in VA and non-VASUD treatment facilities, and the composite scores havesound reliability and validity in clinical and researchsettings (McLellan, Cacciola, Alterman, Rikoon, & Carise,2006).

Frequency of alcohol and drug use. The Time LineFollow Back Interview (TLFB; Sobell, Sobell, Klajner,Pavan, & Basian, 1986) was also used to assess thefrequency of drinking and other drug use within thepast month. We asked separate questions about use ofalcohol and illicit drugs on each of the last 30 days using acalendar as a visual cue to improve recall. Prior evalua-tions of the TLFB method have found that it can reliablymeasure the past 30 days of substance use (Sobell &Sobell, 2003). Although not typically part of the TLFB, weadded an additional question which inquired aboutwhether or not participants had ever run out of theirpain medications early during the past 30 days.

AnalysesIn order to describe the initial response to this

intervention, we present means and standard deviationsof measures of pain and substance use at baseline and the

post-intervention follow-up assessment. Additionally, wepresent the number and percentage of participants whoreported that they misused their prescription painmedications within 30 days of each assessment. Wepresent tests of significance of changes from baseline toposttreatment follow-up with t-tests as well as estimates ofeffect sizes. Finally, to further illustrate these results, wepresent two case studies.

Pilot Study Results

Treatment Attendance and Qualitative InformationOver 80% (N=17) of individuals who initially con-

sented to this project completed at least 4 sessions of thegroup. The average number of sessions attended was 7.17(SD=3.24). When asked what they liked best about thegroup, participants gave the following responses: “I havecut down on meds and learned to relax”; “Each week I getexposed to new ideas and concepts”; “My attitude hasimproved”; “My stress level went down”; and “Being withpeople going through similar things as I am helps.”Whenprompted to list aspects that they disliked about thegroup, members reported the following two comments:“Getting side tracked” and “When folks seem to not followalong with what’s being talked about, distractions.” Noother negative comments were given.

Changes in Pain and Substance UseDespite the small number of participants in this pilot

trial, we still present descriptive information on theaverage level of each pain and substance use measure atbaseline and posttreatment, along with the change ineach measure, a test of statistical significance of thechange, and an estimate of effect size. These results arepresented in Table 3. On average, pain ratings decreasedsignificantly by over 2.5 points on an 11-point scale. Thechange in CPAQ score was in the direction of improve-ment, but this change was not statistically significant.Participants reported a significant average increase in self-efficacy to manage pain. The changes in the behavioralmeasure of pain tolerance were not significant. It is

156 Ilgen et al.

important to note the wide standard deviation on thismeasure at both baseline and follow-up.

In terms of substance use, the ASI alcohol compositescores improved significantly during the course of thegroup. Drug composite scores did not change substan-tially during group, nor did measures of frequency ofalcohol use or drug use. Finally, the number ofparticipants who reported that they ran out of theirpain medications early was low at baseline (n - 2; 15%) anddecreased to zero at follow-up.

Case Studies

Patient 1

Patient 1 is a 45-year-old white male who was referredto the VA SUD treatment program for assistance inmaintaining abstinence from alcohol and marijuana. Hereported abstinence from alcohol and marijuana for 1month prior to the start of the pain management group.Patient 1′s significant other continued to consumealcohol and other drugs, increasing Patient 1′s relapsepotential. Patient 1 also reported that his relationship withhis teenage son was affected by his history of substance useand his significant other’s current use of substances.

Because of chronic pain in his neck and ankle, Patient1 was offered, but declined, the pain management groupat intake into the Substance Abuse Clinic. After attendinga relapse prevention group focusing on reducing hissubstance use, he agreed to participate in the pain-relatedgroup. He attended all 12 sessions of the pain-relatedgroup.

Patient 1 reported that his main goal was to qkeep a lidon [his] painq without misusing alcohol or drugs. Patient 1reported continued abstinence from alcohol and mari-juana throughout treatment. During the fifth session herevealed that he had been buying opioid pain medica-tions qon the street.q Patient 1 was initially uncomfortablediscussing this in the group but later discussed hisconcerns that he would never be able to cope withoutusing large doses of pain medications. He stated thatparticipating in the group had increased his motivation todecrease his use of pain medications and optimism thatthis would be possible. By using the pain managementskills taught in the group (pacing and cognitive restruc-turing), Patient 1 eventually reported an increase in hisself-efficacy to manage pain and reported that hesignificantly reduced his use of opioid pain medications.Patient 1 noted that as he continued his abstinence fromalcohol and drugs that he decreased his contact with hissignificant other, increased his contact with his son, andincreased participating in pleasant activities with his son.Also, he began attending college courses, which improvedhis self-esteem and confidence. Overall, Patient 1 showedimprovement in his perception of pain and stress whiledecreasing his overall pain medication use.

Patient 2

Patient 2 is a 55-year-old Hispanic male who wasdiagnosed with cocaine dependence, sedative depen-dence, and major depressive disorder as well as chronicknee, shoulder, and neck pain. He attended 7 of the 12sessions and also resided in VA-funded transitionalhousing, which included a weekly support group through-out the duration of the intervention. Patient 2 facednumerous psychosocial stressors, including a lack of stablelong-term housing and frequent conflicts with otherresidents in his transitional housing program.

During the group, Patient 2 reported that his pain didnot completely cease during periods of inactivity orprolonged rest and he decided to increase his activitylevel. During the group, he began taking walks andgolfing. Patient 2 identified that he enjoyed walking,which allowed him to take a break from the interpersonalstressors associated with his living environment. Patient 2also noted that the walking did not significantly affect hispain and, therefore, he decided to continue to walkregardless of his pain level. Patient 2 found that exercisingby walking and golfing helped decrease his negativecognitions, as these activities kept his mind occupied.

Patient 2 reported maintaining abstinence fromalcohol and drugs throughout treatment intervention.During the last session, he reported that this grouphelped him adapt to his current housing situation andstressors as well as reinforcing his long-term abstinencegoals.

Discussion

This report describes the content and feasibility of acognitive-behavioral and acceptance-based interventionto address pain and substance use in patients treated indrug/alcohol clinics. Based on these initial data, acognitive behavioral and acceptance-based pain manage-ment intervention is readily modifiable for the treatmentof co-occurring substance misuse and is feasible to deliverduring an episode of addictions treatment. Patients weregenerally receptive to this intervention and rates oftreatment engagement were reasonably high, especiallygiven the extensive psychiatric and medical comorbidityin this sample of patients. Results for this small pilot studyindicate that participation in the group was associatedwith pre- to posttreatment reductions in pain, alcohol-related problems, and increased pain-related self-efficacy.Also, during the course of the group intervention, thenumber of participants who reported misuse of prescrip-tion drugs dropped from 15% to 0%. Although effect sizeestimates from small pilot studies generally have largestandard errors and are unstable (Kraemer, Mintz, Noda,Tinklenberg, & Yesavage, 2006), these findings do provideinitial support for the potential effectiveness of thisintervention.

157Treating Pain and Substance Misuse

These results are broadly consistent with the extensiveprior research supporting the efficacy of cognitivebehavioral and acceptance-based interventions for painin non-SUD patient samples (Cucciare et al., 2009;Dworkin et al., 1994; Evans et al., 2003; Morley et al.,1999; Vowles & McCracken, 2008). However, the extentto which these results would apply to a group of patientsnot specifically seeking pain treatment was mostlyunknown. The present results indicate that a cognitivebehavioral and acceptance-based intervention for pain isgenerally acceptable to SUD treatment patients. Thepresent results add to the only prior study on thetreatment of co-occurring pain and SUDs (Currie, Clark,Rimac, & Malhotra, 2003) and suggest that treating co-occurring pain and substance use during an episode ofSUD treatment can lead to improvement in both ofthese domains. The potential importance of this work ishighlighted by recent research findings indicating thatpain at treatment entry in SUD patients predicts poorerlong-term posttreatment drug- and alcohol-related out-comes (Caldeiro et al., 2008; Larson et al., 2007). Thepresent report only looked at changes during thetreatment episode; more work is needed to determineif these changes in pain and alcohol-related problemswere maintained over the long term.

The observed change in pain intensity during thecourse of the intervention was slightly greater than 2.5points on an 11-point scale. Others have found thatchronic pain patients typically rate improvements in painon this same scale of 2 or greater as clinically significant(Farrar et al., 2001). These findings support the assertionthat the changes in pain intensity in this pilot trial werenot only statistically significant but also clinically mean-ingful. Also in the pilot study, the improvements in painintensity parallel similar positive changes in pain-relatedself-efficacy. Within this pilot study, the follow-up mea-sures of pain and self-efficacy are collected at the sametime period, so it is not possible to formally test formediation, but the findings are consistent with the ideathat improvements in self-efficacy parallel improvementsin pain level.

The findings with the measure of chronic painacceptance also showed a nonsignificant trend towardsimprovement. The lack of significance of this effect maybe due to the lack of power in the pilot study.Alternatively, although acceptance of chronic pain was acore goal of the intervention, much of the session contentfocused on the discussion of specific cognitive orbehavioral skills. It is possible that this approach mayhave failed to maximize the extent to which theintervention could improve acceptance of pain or thatparticipants were confused by the inclusion of material onboth cognitive- and acceptance-based strategies. Anotherpossibility is that traditional CBT- and acceptance-based

pain management influenced outcomes through differ-ent mechanisms, leading to similar improvement in pain.Also, in the present study, acceptance was presented as astrategy that could be helpful for managing manydifferent unpleasant experiences, such as strong emotionsand craving. It is possible that participants were betterable to use acceptance in dealing with craving (resultingin lower levels of alcohol use), but they were lesssuccessful at applying these strategies to the managementof pain.

Several modifications could be made to the interven-tion in the future. These include (a) providing a moredetailed discussion of acceptance during the first sessionof the intervention, (b) a broader discussion of thebiopsychosocial model of pain, and (c) the developmentof a paradigm to help patients differentiate betweensituations where cognitive restructuring and first-waveCBT techniques are most effective, and where acceptancestrategies should be employed. Within the present study,these were implicit in our discussion of acceptance, butonly limited concrete guidance was given.

Future longitudinal research in larger samples shouldexamine whether both pain acceptance and self-efficacymay partially explain improvements in either pain orsubstance use. The pilot study did not detect anysubstantial changes in pain tolerance as measured bythe behavioral cold-pressor test. The length of time thatparticipants were able to keep their hands submergedvaried substantially between individuals. This measuremay be useful in larger samples, which could be lessstrongly influenced by outliers, or it is possible that theintervention did not meaningfully impact behavioral paintolerance.

The results related to alcohol or drug use areencouraging, but not fully consistent. In terms of alcoholuse, a significant reduction in ASI alcohol compositescores was found. This was primarily driven by thereduction in the number of alcohol-related problems.Using TLFB methods, the reduction in frequency ofalcohol use appeared to be minimal. However, detectingsignificant decreases in alcohol or drug use in this pilotstudy is difficult because all participants received the newintervention as well as an ongoing course of SUDtreatment. At baseline, many participants were alreadyabstinent from alcohol or drugs; this floor effect made themeasurement of decreases in frequency of substance usefrom baseline challenging. The use of a comparisongroup as well as enrolling participants at the initiation of aSUD treatment episode in a larger trial would allow for atest of the comparative impact of the cognitive behavioraland acceptance-based group on posttreatment substanceuse after controlling for a baseline level of use.

Also, it is important to note that measures of drug usemay not adequately detect pain medication misuse in this

158 Ilgen et al.

patient population. Standard assessments of substancemisuse, such as the ASI or TLFB, that were used in thisstudy could be inadequate to measure changes in overuseor abuse of pain medications. We used a modifiedquestion on the TLFB to assess whether participantsreported any misuse of their prescription pain medica-tions. On this measure, few participants endorsedbaseline pain medication misuse, so our ability to formallytest the effect of the intervention on this outcome waslimited; however, the trend that was observed wasencouraging. Other instruments specifically designed tomeasure opioid medication misuse [such as the newlydeveloped Current Opioid Misuse Measure (COMM;Butler et al., 2007)] may be better-suited to detect theeffect of the intervention on pain medication misuse.Finally, even with improved measures, most participantsin the present study were also attending other psychoso-cial treatments as well as SUD treatment. This can beeasily seen in the information presented in Table 1 as wellas the two case examples. Without a control group, it isunknown whether changes in substance use and painwere due to the specific pain management intervention,the impact of other treatments, or other unmeasuredfactors. Also, future work could investigate the extent towhich factors motivating the use of substances (e.g., tomanage pain versus to achieve a “high”) might modify theeffects of the intervention on future substance use.

The present report should be interpreted with cautionfor several additional reasons. First, although thisintervention has been manualized, the evaluation of theintervention is ongoing and it is likely that the specificcontent of the manual will be modified slightly as wereceive additional data and feedback from participants.Further, the pilot study was based on a predominantlymale sample of veterans treated for alcohol and/or druguse disorders. The extent to which these findings apply toother SUD treatment samples is unknown. Additionally,SUD treatment settings are unique in that, somewhat bydefinition, patients have already been identified as havinga substance-related problem. It is likely that, if a similarapproach is used in another setting (e.g., a pain clinic),participants might be more likely to deny substancemisuse and resist attempts to discuss their problematicsubstance use.

The study lacked comprehensive measures of theimpact of pain on other important domains (activities ofdaily living, physical functioning, and overall quality oflife) as well as behavioral measures (e.g., timed 10-meterwalk and repeated sit-to-stand trials), which would haveprovided additional objective assessments in changes infunctioning. Future trials should include a broader arrayof self-report and behavioral measures. When interpret-ing the content of the participants’ feedback, it is likelythat the wording of the questions (e.g., “What did you like

best about the group?”) shaped the nature of theresponses and made them seem overly positive. Weeklymonitoring forms were used to help participants tracktheir pain levels and use of substances. No formalattempts were made to track participant compliancewith the homework or to examine their responses onthese monitoring forms. Future work should examine theextent to which homework compliance, use of relationstrategies, and self-report of pain and substance useexplain the impact of the intervention on outcomes.Additionally, providing more specific feedback to partici-pants based on their responses to the homework couldstrengthen the impact of the intervention.

Additionally, as noted earlier, caution should be usedwhen interpreting the effect sizes of the interventionderived from this small pilot study (Kraemer et al., 2006).This concern is particularly germane to studies withoutcontrol conditions, such as the present pilot study, inwhich changes may be due in large part to regression tothe mean (Finney, 2008). Also, assuming future workconfirms that the intervention has a positive impact onposttreatment pain and substance use, additional studiesare needed to identify the components of the treatmentthat are most beneficial for improving long-term func-tioning. It is possible that additional refinement of theintervention is needed to shift the emphasis to eitherfocus more or less on substance misuse in those with bothSUDs and pain.

Despite these limitations, these recent experiencesprovide evidence that the content of cognitive behavioraland acceptance-based interventions for pain and sub-stance misuse can be readily blended to address both ofthese areas of concern during an episode of SUDtreatment. Delivery of the intervention was feasible andwas positively received by patients. The results of a smallpilot study point toward an improvement in pain level,pain-related self-efficacy, and alcohol problems. Futurework is needed in larger samples to provide further dataon the extent to which a cognitive behavioral andacceptance-based intervention could be used to providebetter pain management to individuals with both chronicpain and alcohol or drug use disorders.

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Address correspondence to Mark Ilgen, Ph.D., 2215 Fuller Road(11H), Ann Arbor, MI 48105; e-mail: marki@umich.edu.

Received: June 23, 2009Accepted: May 9, 2010