A case report on the treatment of complex chronic pain and opioid dependence by a multidisciplinary transitional pain service using the ACT Matrix and buprenorphine/naloxone

Abstract

In an era of growing concern about opioid prescribing, the postsurgical period remains a critical window with the risk of significant opioid dose escalation, particularly in patients with a history of chronic pain and presurgical opioid use. The purpose of this case report is to describe the multidisciplinary care of a complex, postsurgical pain patient by an innovative transitional pain service (TPS). A 59-year-old male with complex chronic pain, as well as escalating long-term opioid use, presented with a bleeding duodenal ulcer requiring emergency surgery. After surgery, the TPS provided integrated pharmacological and behavioral treatment, including buprenorphine combined with naloxone and acceptance and commitment therapy (ACT) using the ACT Matrix. The result was dramatic pain reduction and improved functioning and quality of life after 40+ years of chronic pain, thus changing the pain trajectory of a chronic, complex, opioid-dependent patient.

Keywords: acceptance and commitment therapy; chronic pain; opioid dependence; opioid weaning; postsurgical pain; transitional pain service.

Figure 1

Timeline of patient’s medical and psychological treatment by the TPS. Notes: Closed circles indicate TPS MD appointment. Closed squares indicate buprenorphine/naloxone transition period. Open circles indicate clinical Psych-I appointment. Open squares indicate clinical Psych-G appointment. ^aAssessment was conducted by TPS physician, and patient was seen by APS nurse daily until hospital discharge. Abbreviations: APS, acute pain service; MD, medical doctor; Psych-I, psychologist individual (i.e., one-on-one appointment with psychologist); Psych-G, psychologist group (i.e., group session with psychologist and other pain patients); TPS, transitional pain service.

Figure 2

The ACT matrix,, a visual tool for teaching the ACT approach, is applied here to pain management. Abbreviation: ACT, acceptance and commitment therapy.

Figure 3

Example of the ACT matrix used by Mr. P. Notes: The heart represents the “inside world” – the realm of private, internal experience including pain (what hurts) and personal values (what matters). The video camera represents the “outside world” of observable actions. The psychologist asks the key question, “What would you see yourself do on camera (to move toward X or away from Y)?” to focus awareness on behavior. The left side of the diagram represents pain-based avoidance behavior (i.e., moving away from what hurts), whereas the right side of the diagram represents values-based approach behavior (i.e., moving toward what matters). Abbreviation: ACT, acceptance and commitment therapy.

Figure 4

Average pain intensity scores and engagement in meaningful activities over follow-up period. Notes: Pain was measured using a numeric pain rating scale ranging from 0 (no pain) to 10 (worst pain imaginable). Level of engagement in meaningful activities was assessed from the start of group therapy using a numeric rating scale ranging from 0 (not doing anything that matters) to 10 (doing everything that matters). Abbreviation: TPS, transitional pain service.