CLINICAL SCHOLARSHIP

Behavioral Interventions Targeting Chronic Pain, Depression,

and Substance Use Disorder in Primary Care
Kathleen Barrett, MS, DNP, FNP-BC1 , & Yu-Ping Chang, PhD, RN2
1 Beta Omicron, Adjunct Assistant Professor, College of Health Sciences, Lienhard School of Nursing, Pace University, Pleasantville, NY, USA
2 Gamma Kappa, Associate Professor, School of Nursing, The State University of New York at Buffalo, Buffalo, NY, USA

Key words Abstract

Behavioral interventions, chronic pain,
depression, primary care, substance use Background: Patients with chronic pain, depression, and substance use disor-
disorders der (SUD) are often treated in primary care settings. An estimated 52% of pa-
tients have a diagnosis of chronic pain, 5% to 13% have depression, and 19%
Correspondence have SUD. These estimates are likely low when considering the fact that 50%
Dr. Yu-Ping Chang, 3435 Main Street Wende
of primary care patients with depression and 65% with SUD are undiagnosed
301C, Buffalo, NY 14214. E-mail:
or do not seek help. These three conditions have overlapping neurophysiolog-
[email protected]
ical processes, which complicate the treatment outcomes of a primary physical
Accepted March 7, 2016 illness. Behavioral interventions have been widely utilized as adjunctive treat-
ments, yet little is known about what types of behavioral interventions were
doi: 10.1111/jnu.12213 effective to treat these comorbidities. This systematic review aimed to iden-
tify behavioral interventions targeting chronic pain, depression, and SUD in
primary care settings.
Methods: The Cumulative Index to Nursing and Allied Health Literature,
Medline, PsycInfo, and Google Scholar databases were searched to identify
randomized controlled trials, using a behavioral intervention, involving adults
with at least two of the three conditions.
Results: This search yielded 1,862 relevant records, and six articles met final
selection criteria. A total of 696 participants were studied. Behavioral interven-
tions varied in content, format, and duration. Mindfulness Oriented Recovery
Enhancement (MORE), Acceptance and Commitment Therapy (ACT), Inter-
personal Psychotherapy adapted for pain (IPT-P), and Cognitive Behavioral
Therapy (CBT) showed promising improvements across all studies, albeit with
small to moderate effects.
Conclusions: MORE, ACT, and CBT combined with mindfulness and Moti-
vational Interviewing had the most promising results for treating chronic pain,
depression, and SUD in various combinations in primary care settings.
Clinical Relevance: The evidence is mounting that behavioral interventions
such as mindfulness-based or cognitive-behavioral interventions are effective
strategies for managing patients with comorbidities of chronic pain, depression,
and SUD in primary care. Integrated delivery of behavioral interventions via
group sessions, computers, and smart phones may increase patient access to
treatment; save time and cost; reduce stigma, patient distress, family burden,
and healthcare fragmentation; and provide a ray of hope to amplify conven-
tional treatments.

Journal of Nursing Scholarship, 2016; 48:4, 345353. 345

C 2016 Sigma Theta Tau International
Behavioral Interventions in Primary Care Barrett & Chang

In primary care, researchers have employed behavioral has been shown to exist in 72% of patients diagnosed
interventions to address a wide variety of behavioral with chronic pain (Poole, White, Blake, Murphy, &
health issues, including depression and substance abuse, Bramwell, 2009). Depression is diagnosed in 5% to 13%
as well as medication adherence in individuals with of patients in primary care (Maurer & Darnall, 2012).
chronic conditions such as hypertension, diabetes, and However, about 50% of primary care patients with de-
HIV (Hamrin & McGuinness, 2013). Although shown to pression are underdiagnosed or undiagnosed (Wittchen
be effective for changing behaviors and improving health et al., 2002).
outcomes, these behavioral interventions have been de- In 2013, out of 4.1 million who received substance
veloped and tested in people who only have a single con- use disorder (SUD) treatment, about 19% were treated
dition. Focusing on one condition does not adequately in primary care and roughly 65% had not even tried
address the interrelationship between multiple conditions to seek help (Substance Abuse and Mental Health
(Nilsen & Olster, 2013). Services Administration, 2014). In 2013, an estimated
Primary care providers throughout the world, even in 24.6 million Americans were current illicit drug users,
countries with robust healthcare systems, face significant 17.3 million had alcohol dependence or were alcohol
challenges ranging from ageing populations to an increas- abusers, 4.2 million had marijuana dependence or were
ing prevalence of patients with more than two comorbid marijuana abusers, 1.9 million had prescription pain
conditions (Barnett et al., 2012). This is especially true reliever dependence or were prescription pain reliever
in the presence of co-existing chronic pain, substance use abusers, 855,000 had cocaine dependence or were co-
disorder, and mental health conditions, which often com- caine abusers, and 55.8 million were currently smoking
plicate the treatment outcomes of a primary chronic con- cigarettes (NIDA, NIH, U.S. Department of Health and
dition (Burke, Mathias, & Denson, 2015). The presence Human Services, 2015). In the first decade of the 21st
of comorbidity significantly affects quality of life, func- century, the U.S. population consumed roughly 80% of
tional disability, healthcare utilization, and healthcare the worlds supply of prescription opioids, demonstrating
costs, and most likely affects women, older persons, and not only a problem of chronic pain, but also the increas-
persons from lower socioeconomic groups (Marengoni ing use of opioids as a panacea for expeditious treatment
et al., 2011). Estimates from the 2012 National Health and its potential for harm (Vowles et al., 2015).
Interview Survey (NHIS) indicated that 25.5% of nonin- Research indicates that there is a complex overlapping
stitutionalized American adults had two or more chronic of neurophysiological pathways in the prefrontal cortex
conditions (Ward, Schiller, & Goodman, 2014). In order of the brain with clinical symptomatology related to pain
to better address co-occurring substance use disorder and signals, regulation of emotions, cognitions, memory, and
mental health issues, the National Institutes of Health attention (Brewer, Bowen, Smith, Marlatt, & Potenza,
(NIH) has been investigating methods of integrating be- 2010). Studies show that individuals with chronic
havioral interventions into primary care, where most pa- pain were more likely to have symptoms of anxiety,
tients with multiple comorbidities are treated (Nilsen & depression, substance abuse, and low self-efficacy, which
Olster, 2013). potentially impede desirable patient outcomes if left
Chronic pain (longer than 3 months) is a major health, untreated (Chang & Compton, 2013; Gureje, 2008).
social, and economic challenge (Institute of Medicine, Depression has been shown to increase pain intensity,
2011), which affects an estimated 100 million Ameri- disability, and the risk for chronicity in chronic pain
cans (one third of the U.S. population) and 20% to 30% populations, and can negatively influence the outcomes
of the worlds population (National Institute on Drug of pain treatment (Bair et al., 2004; Garland, Froeliger,
Abuse [NIDA], NIH, U.S. Department of Health and Hu- & Howard, 2014). Depression and inflammation are
man Services, 2015). In a typical month, 52% of patients traveling companions that can induce central ner-
with chronic pain sought care in a primary care prac- vous system changes that result in increased pain
tice (Breuer, Cruciani, & Portenoy, 2010). Chronic pain sensitivity, anhedonia (inability to feel pleasure), neg-
is associated with significantly poor perception of health, ative mood, and poor appetite, among other symptoms
lower functional status, poor social relationships, isola- (Kiecolt-Glaser, Derry, & Fagundes, 2015). SUD is known
tion, financial difficulties, and higher healthcare expen- to affect areas of the brain associated with reward and
ditures (Butchart, Kerr, Heisler, Piette, & Krein, 2009; motivation, memory and learning, and inhibitory control
Morasco, Duckart, & Dobscha, 2011), and is often con- of behavior (NIDA, NIH, U.S. Department of Health and
comitant with substance use disorder and depression Human Services, 2012). SUD is associated with several
(Burke et al., 2015). mental health diagnoses, but is most commonly associ-
Depression affects approximately 350 million peo- ated with major depressive disorder (Tripp, Skidmore,
ple worldwide (World Health Organization, 2015), and Cui, & Tate, 2013). A systematic review of 21 studies

346 Journal of Nursing Scholarship, 2016; 48:4, 345353.

C 2016 Sigma Theta Tau International
Barrett & Chang Behavioral Interventions in Primary Care

showed that the overall prevalence of current SUD in ria for this review, authors discussed disagreements un-
patients with chronic pain can be as high as 48%, and til resolved. When intervention details of a study were
these patients are among those less likely to comply unclear, an author (E. Poleshuck) was contacted and re-
with prescribed medical regimens (Morasco et al., 2011). sponded via email with clarification.
Although the origin and sequence of these co-occurring
conditions may be unclear, the subsequent negative
Results
health outcomes pose significant effects on the person,
family, workplace, and community (NIDA, NIH, U.S. A search of four databases yielded 1,862 relevant
Department of Health and Human Services, 2012). records that were screened by title. Two hundred and
In summary, behavioral interventions have been five articles were screened by title and abstract. Fifty
widely utilized in primary care settings to address a single records, identified by title and abstract, were screened for
behavioral health issue. Little is known about what in- full text. Six studies met the final criteria and were in-
terventions were designed to effectively treat more than cluded in this review. The geographical settings within
one behavioral health condition in primary care settings. the selected articles included Florida (n = 1), Califor-
Therefore, this systematic review aimed to identify be- nia (n = 1), England (n = 1), Australia (n = 2), and
havioral interventions in the current literature that tar- New York (n = 1). Studies meeting final selection criteria
get the three conditions of chronic pain, depression, and utilized formal assessment tools for diagnoses and vali-
substance use disorder in primary care settings. dated outcome measurements with reliable psychometric
properties. Two studies focused on pain and depres-
sion (McCracken, Sato, & Taylor, 2013; Poleshuck et al.,
Methods
2014). Three studies focused on depression and SUD
Four electronic databasesCumulative Index to Nurs- (Baker et al., 2009; Brown et al., 2006; Kay-Lambkin,
ing and Allied Health Literature (CINAHL), Medline, Baker, Lewin, & Carr, 2009), and one study focused on
PsycInfo, and Google Scholarwere used to search cur- chronic pain and SUD (Garland et al., 2014). Accord-
rent literature. Multiple key words including chronic ing to a PRISMA Quality Appraisal score (Liberati et al.,
pain, depression, depressive disorders, substance use dis- 2009), two studies achieved the highest score of 9 (Gar-
orders, behavioral interventions, primary care, and across land et al., 2014; Kay-Lambkin et al., 2009). Four studies
all settings were employed singularly and in combination. were of good quality, scoring 7 or more points on the 9-
Limiters included (a) articles published between 1995 and point scale (Baker et al., 2009; Garland et al., 2014; Kay-
2015, (b) available in English, (c) original randomized Lambkin et al., 2009; McCracken et al., 2013; Table 1).
controlled trials (RCT), (d) adult population, and (e) stud- The interventions tested included Interpersonal Psy-
ies that contained a behavioral intervention. Since no ar- chotherapy Treatments adapted for pain (IPT-P; n = 1);
ticle addressed all three conditions, our search criteria Acceptance and Commitment Therapy (ACT; n = 1);
had to be modified to include studies using behavioral Mindfulness Oriented Recovery Enhancement (MORE;
interventions designed to treat at least two of the three n = 1); Integrated Cognitive Behavioral Therapy (ICBT;
conditions of interest. Commentaries, reviews, reports of n = 1); combined mindfulness, Motivational Interview-
duplicate studies, and ongoing protocol studies were ex- ing (MI), and CBT (n = 1); and combined MI and CBT
cluded. Records were carefully reviewed for relevant ti- (n = 1). Interventions were administered in group for-
tles, abstracts, and finally full texts. We conducted this mat, individually, or by computer. Treatment session
review using Preferred Reporting Items for System- time allocation varied from 60 to 240 min, and treat-
atic Reviews and Meta-Analyses (PRISMA) guidelines ment frequency ranged from one to four times a week.
(Moher, Liberati, Tetzlaff, Altman, & The PRISMA Group, Overall, follow-up assessment time varied from 1 week to
2009). The selection process is outlined in Figure 1. Both 12 months (Table 2).
article authors independently reviewed the titles and ab- Overall, 696 participants (316 males, 380 females,
stracts and then met to discuss their reviews. They further mean age 45.3) were studied for the efficacy of be-
classified studies as potentially relevant, irrelevant, or un- havioral interventions targeted for at least two of the
clear using the inclusion criteria. The studies described three conditions of interest. Two of the six studies in-
as potentially relevant and unclear were then evaluated cluded participants strictly from primary care (McCracken
by the same two authors using the inclusion criteria to et al., 2013; Poleshuck et al., 2014). One study (Garland
ensure the integrity of the selection. Additional review et al., 2014) recruited participants from primary care,
of the reference sections in relevant articles was also pain, and neurology clinics, and one study also recruited
performed to expand the search. When there was a ques- participants from a Veterans Administration clinic
tion of any relevant study meeting the selection crite- (Brown et al., 2006). Both Baker et al. (2009) and

Journal of Nursing Scholarship, 2016; 48:4, 345353. 347

C 2016 Sigma Theta Tau International
Behavioral Interventions in Primary Care Barrett & Chang

Records identified (RCTs) through database

search screened by title Additional records identified

Identification
(n = 212) through other sources,reference
sections (n=10)

Records after duplicates removed Records excluded lacked

(n =195) population, behavioral
intervention, RCT, two or
more conditions of interest
(n=155)
Screening

Records screened by title &

abstract Fulltext articles excluded:
(n=205) One condition only 23
Protocolongoing 3
Not avail in English 1
Not a study 11
Not primary care 3
Eligibility

Fulltext articles assessed for Not condition of interest 1

eligibility Not behavioral intervention 1
(n=50)
Not original RCT 1
(n=44)
Included

Studies includedin synthesis (n=6)

Studies conductedin primary care setting (n=2)
Studies conducted across primary care, specialty clinic, other (n=4)

Figure 1. Flow chart of record selection.

Table 1. Quality Assessment

Authors

Baker et al., Brown et al., Garland et al., Kay-Lambkin et al., McCracken et al., Poleshuck et al.,
Criteria 2009 2006 2014 2009 2013 2014

Study design RCT RCT RCT RCT RCT RCT

Main purpose/question clearly stated 1 1 1 1 1 1
Power analysis performed 0 0 1 1 0 0
Inclusion/exclusion criteria specified 1 1 1 1 1 1
Groups similar at start of study 1 1 1 1 1 1
Patient/clinician blinding 1 0 1 1 1 0
Allocation concealment 1 0 1 1 0 0
Intention to treat analysis performed 1 0 1 1 1 1
Statistical analysis appropriate 1 1 1 1 1 1
Follow-up sufficiently long and complete 1 1 1 1 1 1
Quality score 8 5 9 9 7 6

Note. Criteria met = 1; criteria not met = 0. Randomized controlled trial (RCT) score of 7 or greater = good methodological quality.

Kay-Lambkin et al. (2009) recruited participants from a fer to Tables S1 through S3, available with the online
variety of sources, including media ads, professional and version of this article, for summaries of studies).
self-referral, government and nongovernment services,
primary care, and mental health sources. Sample sizes
Interventions for Depression and Substance Use
ranged from 61 to 284. No studies included participants
with diagnoses of psychotic, suicidal, pain due to cancer, CBT stands on the principle that cognitive factors
or inability to participate due to living too far from the are the source of behavioral problems and distress, as
testing site. None of the studies used a wait list group (re- pioneered by Beck in 1970 and Ellis in 1962 (cited
348 Journal of Nursing Scholarship, 2016; 48:4, 345353.
C 2016 Sigma Theta Tau International
Barrett & Chang Behavioral Interventions in Primary Care

Table 2. Behavioral Interventions Utilized in Studies

MORE ACT CBT ICBT IPT-P MI Mindfulness

Mindful savoring Targets avoidance, Thoughts and beliefs Pain management Ability to change exists A deep sense of
may help patients and exposes it. about the self, strategies if individual has the self-awareness in the
cope by consciously A form of CBT, includes others, the future, change in healthy desire, need, and present moment;
appreciating and psychological and the world self. commitment. association with
attending to more flexibility. trigger automatic Activity pacing and Includes empathy, decreased avoidance
pleasant Control what you can. opinions in certain relaxation. active and reflective and
experiences and situations. listening, and increased tolerance to
events Changes in behavior treating client as unpleasant states;
and emotional partner. OARS unlearning of
distress can result method of maladaptive behaviors;
from recognizing interviewing based ameliorate deficits in
and reworking on open ended natural reward
maladaptive questions about a processing
thoughts. clients motivation
for change.

Note. ACT = Acceptance and Commitment Therapy; CBT = Cognitive Behavioral Therapy; ICBT = Integrated CBT, focused on more than one con-
dition; IPT-P = Interpersonal Psychotherapy Treatments adapted for Pain; MI = Motivational Interviewing; MORE = Mindfulness Oriented Recovery
Enhancement; OARS = open questions, affirmation, reflection, and summaries.

in Hofmann, Asnanni, Vonk, Sawyer, & Fang, 2012). tion (BI) alone, but responded even better with inten-
In other words, thoughts and beliefs about the self, sive intervention. Interestingly, individualized computer-
others, the future, and the world trigger automatic opin- delivered intervention yielded similar results in terms of
ions, and changes can result from patients use of strate- depression improvement at 12 months as had the face-
gies to rework maladaptive thoughts (Hofmann et al., to-face delivery at 3 and 6 months. The therapist delivery
2012). Brown and associates (2006) studied the effect of (face-to-face) method surpassed the computer delivery
ICBT interventions on outcomes of depression and SUD method regarding results for alcohol use outcomes, while
in 66 outpatients from a veterans health clinic. Find- the computer delivery method outdid face-to-face deliv-
ings showed that both study groups had improvements ery for cannabis use outcomes. An unexpected finding
in depression and SUD during treatment. At follow- was that over the course of the study, approximately 79%
up the control group, which received 12-step facilita- of therapist time was saved when using the computer-
tion, showed an increase in depressed mood by 3 and delivered intervention.
6 months. The ICBT group maintained a stable decrease Mindfulness, MI, and CBT were combined for individu-
in depressed mood for as long as 12 months. Both study ally delivered sessions in a study by Baker and colleagues
groups also received standard pharmacotherapy. A pos- (2009). They compared integrated focused therapy ver-
sible limitation of the study was that the intervention sus single focused behavioral therapy in 284 adults
group was not queried regarding 12-step involvement in with depression symptoms and hazardous alcohol use.
the community, which may have boosted their response Depression outcomes did not vary with duration of treat-
to treatment. ment in any of the groups. Compared to the BI only
MI fundamental skills include empathy, active and re- group, integrated interventions targeting alcohol and de-
flective listening, believing in the client, and treating pression seemed to reduce depression symptoms and oc-
client as partner (Miller, Forcehimes, & Zweben, 2011). casions of alcohol use more than decreasing the amount
It is composed of a relational (client and therapist) com- consumed per drinking occasion. A decrease in average
ponent and a technical (clients talk of change) compo- number of drinks per occasion and increased overall gen-
nent. MI combined with CBT was employed in a study eral functioning was found in males after alcohol-focused
by Kay-Lambkin and colleagues (2009). They studied intervention and in females after depression-focused in-
97 adults who had depression and either hazardous al- tervention. Sample selection in both the Kay-Lambkin
cohol or cannabis misuse problems. Findings reported et al. (2009) and Baker et al. (2009) studies included
that all groups had significant reduction in depression at self-referred participants from media ads rather than just
12 months (p < .001). Patients with alcohol problems medical settings. It is unclear if that influenced motiva-
and cannabis use responded well to the brief interven- tion to improve.

Journal of Nursing Scholarship, 2016; 48:4, 345353. 349

C 2016 Sigma Theta Tau International
Behavioral Interventions in Primary Care Barrett & Chang

Interventions for Pain and SUD primary care settings, albeit quite modest sample sizes.
Each condition, alone and in combination, can be difficult
Multiple studies of MORE suggest that mindful savor-
to treat. It is important to note that no study measured
ing may help patients cope by consciously appreciating
the same variable in the same way, and definitions such
and attending to more pleasant experiences and events
as integrated interventions have not been standardized,
(Garland et al., 2015). In a study by Garland and col-
so results from these studies should be interpreted care-
leagues (2014), adults with chronic pain and prescrip-
fully. Our findings indicated that MORE, ACT, and CBT
tion opioid use were randomized to group therapy using
combined with mindfulness and MI had the most promis-
MORE or a support group (SG). At postintervention,
ing results for improving chronic pain symptoms (pain ac-
the MORE group had statistically significant reductions
ceptance more frequently than pain severity), comorbid
in pain severity and pain interference, as well as de-
depression, and SUD in various combinations. MORE was
creased sympathetic arousal and desire for opioids com-
the only intervention that showed efficacy for pain sever-
pared to the SG. However, at 3-month follow-up, effects
ity. In a recent study, the MORE intervention was further
for opioid desire declined in the MORE group, suggest-
tested by a research team using a subset of 29 participants
ing booster sessions may be needed. Change in desire
from the Garland and colleagues (2014) study. The use of
for opioids was not significantly correlated with change
event related brain potentials (ERBP) & late positive po-
in pain severity or interference.
tentials (LPP) [EEG data on brain events] revealed con-
crete neurophysiological evidence that MORE regimens
Interventions for Chronic Pain and Depression fostered selective attention to natural rewards, boosted
deficits in reward processing skills, may have offset an-
ACT encourages individuals to allow their negative hedonia, and decreased opioid cravings (Garland et al.,
feelings, but despite them, try to identify what they can 2015, pp. 332333).
control and make changes where they can (Hayes & ACT was effective for patients with chronic pain accep-
Wilson, 2006; Veale, 2008). McCracken and colleagues tance, but not pain severity. ACT, IPT-P, MI with CBT,
(2013) studied adults with chronic pain and depression and ICBT showed effectiveness for reducing depression
in a primary care setting, using group-delivered ACT ver- symptoms in four out of the five studies involving pa-
sus treatment as usual (TAU). Postintervention, the ACT tients with depression. MORE, ICBT, CBT combined with
group had lower depression (small effect), higher over- mindfulness and MI, and CBT combined with MI were
all improvement ratings, no change in disability ratings, helpful interventions studied in patients with SUD. In-
slightly higher pain acceptance, and no change in pain tegrated therapy compared to single focused therapy for
severity. At 3-month follow-up the ACT group had lower patients with depression and SUD was shown to be supe-
depression and lower disability ratings (medium effect), rior for number of drinking days and level of dependence,
higher overall improvement ratings, significantly higher supporting the assumption that tailored behavioral inter-
pain acceptance (compared to those in the TAU group), ventions can be effective for a combination of conditions.
and no change in pain severity. A possible limitation is None of the studies compared individual treatment deliv-
the short duration of the study (2 weeks) and the intense ery with group-delivered treatment.
length and frequency of four 4-hr treatment sessions in Limiting the search to only published studies, in the
the first week. English language, published within the past 20 years may
Pain management strategies such as change in healthy have excluded worthy studies. Absence of strict inter-
self, activity pacing, and relaxation are components of rater reliability for screening titles, abstracts, and records
IPT-P. Poleshuck and colleagues (2014) studied a small leaves room for professional bias or human error. Studies
sample of women with chronic pelvic pain and de- were based in large cities in industrialized countries, so
pression. Findings reported that the intervention group results may not be generalizable to remote areas or pop-
showed significant improvement for depression and so- ulations with fewer resources in other parts of the world,
cial interactions, but not for pain severity and interfer- or in countries where SUDs, depression, or chronic pain is
ence. The enhanced treatment as usual provided to the not prevalent. Reliable scientific databases were used, and
control group was not standardized, making comparison strict reproducible methods were executed to improve the
potentially inconsistent. validity of the study.

Discussion Conclusions
Overall, results were promising for the use of be- Due to the complex overlapping of the psychologi-
havioral interventions in samples recruited heavily from cal and physical aspects of chronic pain, depression, and

350 Journal of Nursing Scholarship, 2016; 48:4, 345353.

C 2016 Sigma Theta Tau International
Barrett & Chang Behavioral Interventions in Primary Care

SUD, it remains unclear which condition overrides the References

others, or how (Brewer et al., 2010). For patients with
three conditions, no single behavioral intervention has Bair, M. J., Robinson, R. L., Eckert, G. J., Stang, P. E.,
been studied or found helpful to date in the literature. Croghan, T. W., & Kroenke, K. (2004). Impact of pain on
Despite this, several effective interventions have been depression treatment response in primary care.
found to be effective for at least two of those conditions. Psychosomatic Medicine, 66, 1722.
In our review, mindfulness-based interventions appear to doi:10.1097/01.PSY.0000106883.94059.C5
be promising options worthy of further study. With re- Baker, A. L., Kavanagh, D. J., Kay-Lambkin, F. J., Hunt, S. A.,
cent incentives to improve quality, satisfaction, and cost Lewin, T. J., Carr, V. J., & Connolly, J. (2009). Randomized
controlled trial of cognitive-behavioral therapy for
(Stiefel & Nolan, 2012), patients with such complex pre-
coexisting depression and alcohol problems: Short term
sentations may benefit from integrated behavioral health
outcome. Addiction, 105, 8799.
treatments delivered by a team of medical, nursing, psy-
doi:10.1111/j.1360-0443.2009.02757x
chology, and social work professionals (Poleshuck et al.,
Barnett, K., Mercer, S. W., Norbury, M., Watt, G., Wyke, S., &
2014) as an adjunct to standard medical treatments. This
Guthrie, B. (2012). Epidemiology of multimorbidity and
would improve the access to treatment, as well as reduce
implications for health care, research, and medical
perceived stigma, patient distress, family burden, health- education: A cross sectional study. Lancet, 380, 3743.
care fragmentation, and costs (Nilsen & Olster, 2013). doi:10.1016/S0140-6736(12)60240-2
Collaboration with researchers to explore behavioral Breuer, B., Cruciani, R., & Portenoy, R. K. (2010). Pain
interventions in special populations, and studies with management by primary care physicians, pain physicians,
stratification for gender, age, culture, medications, pres- chiropractors, and acupuncturists: A
ence of other comorbidities, use of various delivery national survey. Southern Medical Journal, 103(8), 738747.
systems, intensities and durations, and assuring for treat- Brewer, J. A., Bowen, S., Smith, J. T., Marlatt, G. A., &
ment fidelity in both the patients and the therapists are Potenza, M. N. (2010). Mindfulness-based treatments for
needed (Garland et al., 2014; Jhanjee, 2014). New tech- co-occurring depression and substance use disorders: What
nology (computers and smart phones) and use of group can we learn from the brain? Addiction, 105(10),
sessions for treatment delivery may prove to be a time- 16981706. doi:10.1111/j.1360-0443.2009.02890.x
saving alternative. However, modern digital devices may Brown, S. A., Glasner-Edwards, S. V., Tate, S. R., McQuaid, J.
be a generational preference, as well as impractical for R., Chaleekian, J., & Granholm, E. (2006). Integrated
patients who are homeless or disadvantaged. cognitive behavioral therapy versus twelve-step
facilitation therapy for substance-dependent adults with
depressive disorders. Journal of Psychoactive Drugs, 38(4),
Acknowledgments 449460.
Burke, A. L. J., Mathias, J. L., & Denson, L. A. (2015).
This manuscript was partially supported by the Coletta Psychological functioning of people living with chronic
A. Klug Funds at University at Buffalo School of Nursing. pain: A meta-analytic review. British Journal of Clinical
The authors wish to thank Miss Sharon Murphy of the Psychology, 54(3), 345360. doi:10.1111/bjc.12078
UB Health Sciences Library for her support and guidance. Butchart, A., Kerr, E., Heisler, M., Piette, J., & Krein, S.
(2009). Experience and management of chronic pain
among patients with other complex chronic conditions.
Clinical Resources Clinical Journal of Pain, 25, 293298.
r National Institutes of Health, National Library of
Chang, Y. P., & Compton, P. (2013). Management of chronic
pain with chronic opioid therapy in patients with substance
Medicine: https://www.nlm.nih.gov/
r PainEDU: https://www.painedu.org/
use disorders. Addiction Science and Clinical Practice, 8(21).

r Substance Abuse and Mental Health Services Ad-

doi:10.1186/1940-0640-8-21
Garland, E. L., Froeliger, B., & Howard, M. O. (2015).
ministration: http://www.samhsa.gov/ Neurophysiological evidence for remediation of reward
r U.S. Department of Health and Human Services: processing deficits in chronic pain and opioid misuse
http://www.hhs.gov/ following treatment with mindfulness-oriented recovery
r U.S. Preventive Services Task Force: http://www. enhancement: Exploratory ERP findings from a pilot RCT.
uspreventiveservicestaskforce.org/ Journal of Behavioral Medicine, 38, 327336.
r World Health Organization: http://www.who. doi:10.1007/s10865-014-9607-0
int/en/ Garland, E. L., Manusov, E. G., Froeliger, B., Kelly, A.,
Williams, J. M., & Howard, M. O. (2014).

Journal of Nursing Scholarship, 2016; 48:4, 345353. 351

C 2016 Sigma Theta Tau International
Behavioral Interventions in Primary Care Barrett & Chang

Mindfulness-oriented recovery enhancement for chronic Retrieved from www.aafp.org/afp/2012/0115/

pain and prescription opioid misuse: Results from an p139.pdf
early-stage randomized controlled trial. Journal of Consulting McCracken, L. M., Sato, A., & Taylor, G. J. (2013). A trial of a
and Clinical Psychology, 82(3), 448459. brief group-based form of acceptance and commitment
doi:10.1037/a0035798 therapy (ACT) for chronic pain in general practice: Pilot
Gureje, O. (2008). Treating chronic pain in the context of outcome and process results. Journal of Pain, 14(11),
comorbid depression [Editorial]. Pain, 134, 34. 13981406. doi:10.1016/j.jpain.2013.06.011
doi:0.1016/j.pain.2007.10.029 Miller, W. R., Forcehimes, A. A., & Zweben, A. (2011).
Hamrin, V., & McGuinness, T. M. (2013). Motivational Treating addiction: A guide for professionals. New York, NY:
interviewing: A tool for increasing psychotropic medication Guilford Press.
adherence for youth. Journal of Psychosocial Nursing and Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., and The
Mental Health Services, 51(6), 1518. PRISMA Group. (2009). Preferred reporting items for
Hayes, S. C., & Wilson, K. G. (2006). Mindfulness: Method systematic reviews and meta-analyses: The PRISMA
and process. Clinical Psychology: Science and Practice, 10(2), statement. PLoS Med 6(6), e1000097.
161165. doi:10.1093/clipsy/bpg018 doi:10.1371/journal.pmed1000097. Retrieved from
Hofmann, S. G., Asnanni, A., Vonk, I. J. J., Sawyer, A. T., www.prismna-statement.org
& Fang, A. (2012). The efficacy of cognitive behavioral Morasco, B. J., Duckart, J. P., & Dobscha, S. K. (2011).
therapy: A review of meta-analyses. Cognitive Therapy Adherence to clinical guidelines for opioid therapy for
and Research, 36, 427440. doi:10.1007/s10608-012-9476-1 chronic pain in patients with substance use disorder.
Institute of Medicine. (2011). Relieving pain in America: A Journal of General Internal Medicine, 26(9), 965971.
blueprint for transforming prevention, care, education, and doi:10.1007/s11606-011-1734-5
research. Washington, DC: National Academies Press. National Institute on Drug Abuse, National Institutes of
Retrieved from https://www.nationalacademies.org/ Health, U.S. Department of Health and Human Services.
hmd//media/Files/Report%20Files/2011/Relieving-Pain- (2012). Principles of drug addiction treatment: A research based
in-America-A-Blueprint-for-Transforming-Prevention-Care- guide (3rd ed.). NIH Publication No. 124180. Bethesda,
Education-Research/Pain%20Research%202011%20Report% MD: Author. Retrieved from https://www.drugabuse.gov/
20Brief.pdf publications/principles-drug-addiction-treatment-research-
Jhanjee, S. (2014). Evidence based psychosocial interventions based-guide-third-edition/principles-effective-treatment
in substance use. Indian Journal of Psychological Medicine, National Institute on Drug Abuse, National Institutes of
36(2), 112118. doi:10.4103/0253-7176.130960 Health, U.S. Department of Health and Human Services.
Kay-Lambkin, F. J., Baker, A. L., Lewin, T. J., & Carr, V. J. (2015). Drug facts: Nationwide trends. Bethesda, MD: Author.
(2009). Computer-based psychological treatment for Retrieved from https://www.drugabuse.gov/publications/
comorbid depression and problematic alcohol and/or drugfacts/nationwide-trends
cannabis use: A randomized controlled trial of clinical Nilsen, W. J., & Olster, D. H. (2013). News from the NIH:
efficacy. Addiction, 104, 378388. Effective behavioral treatments for patients with multiple
Kiecolt-Glaser, J. K., Derry, H. M., & Fagundes, C. P. (2015). chronic conditions [Commentary]. Translational Behavioral
Inflammation: Depression fans the flames and feasts on the Medicine, 3(1), 12. doi:10.1007/s13142-012-0184-x
heat. American Journal of Psychiatry, 172(11), 10751091. Poleshuck, E. L., Gamble, S. A., Bellinger, K., Lu, N., Tu, X.,
doi:10.1176/appi.ajp.2015.15020152 Sorensen, S.,. . . Talbot, N. L. (2014). Randomized
Liberati, A., Altman, D. G., Tetzlaff, J., Mulrow, C., Gotzsche, controlled trial of interpersonal psychotherapy versus
P. C., Ioannidis, J. P.,. . . Moher, D. (2009). The PRISMA enhanced treatment as usual for women with co-occurring
statement for reporting systematic reviews and depression and pelvic pain. Journal of Psychosomatic Research,
meta-analyses of studies that evaluate health care 77, 264272. doi:10.1016/j.psychores.2014.07.0160022-
interventions: Explanation and elaboration. [Consensus 3999
development conference guideline reliability and validity of Poole, H., White, S., Blake, C., Murphy, P., & Bramwell, R.
systematic reviews, 26, research support, non-U.S. Govt]. (2009). Depression in chronic pain patients: Prevalence
Journal of Clinical Epidemiology, 62(10), e1e34. and measurement. Pain Practice, 9(3), 173180.
doi:10.1016/j.jclinepi.2009.06.006 doi:10.1111/j.1533-2500.2009.00274
Marengoni, A., Angleman, S., Melis, R., Mangialasche, F., Stiefel, M., & Nolan, K. (2012). A guide to measuring the triple
Karp, A., Garmen, A.,. . . Fratiglioni, L. (2011). Ageing aim: Population health, experience of care, and per capita cost.
with multimorbidity: A systematic review of the literature. Institute for Healthcare Improvement [IHI] Innovation Series
Ageing Research Reviews, 10(4), 430439. White Paper. Cambridge, MA: IHI.
doi:10.1016/j.arr.2011.03.003 Substance Abuse and Mental Health Services Administration.
Maurer, D. M., & Darnall, C. R. (2012). Screening for (2014). Results from the 2013 national survey on drug use and
depression. American Family Physician, 85(2), 139144. health: Summary of national findings. NSDUH Series H-48, HHS

352 Journal of Nursing Scholarship, 2016; 48:4, 345353.

C 2016 Sigma Theta Tau International
Barrett & Chang Behavioral Interventions in Primary Care

Publication No. (SMA) 144863. Rockville, MD: Author. Wittchen, H.-U., Kessler, R. C., Beesdo, K., Krause, P., Hofler,
Retrieved from http://www.samhsa.gov/data/sites/ M., & Hoyer, J. (2002). Generalized anxiety and depression
default/files/NSDUHresultsPDFWHTML2013/Web/ in primary care: Prevalence, recognition, and management.
NSDUHresults2013.pdf Journal of Clinical Psychology, 63(Suppl. 8), 2434.
Tripp, J. C., Skidmore, J. R., Cui, R., & Tate, S. R. (2013). World Health Organization. (2015). Fact sheet 369: Depression.
Impact of physical health on treatment for co-occurring Retrieved from http://www.who.int/mediacentre/
depression and substance dependence. Journal of Dual factsheets/fs369/en
Diagnosis, 9(3), 239248.
doi:10.1080/15504263.2013.806111
Veale, D. (2008). Behavioural activation for depression.
Advances in Psychiatric Treatment, 14, 2936. Supporting Information
doi:10.1192/apt.bp.107.004051 Additional Supporting Information may be found in
Vowles, K. E., McEntee, M. L., Julnes, P. S., Frohe, T., Ney, J.
the online version of this article at the publishers web
P., & van der Goes, D. N. (2015). Rates of opioid misuse,
site:
abuse, and addiction in chronic pain: A systematic review
and data synthesis. Pain, 156(4), 569576. Table S1. Summary of Setting, Location, Population,
doi:10.1097/01.j.pain.0000460357.01998.f1
Condition, Completion Rate
Ward, B. W., Schiller, J. S., & Goodman, R. A. (2014).
Table S2. Summary of Interventions, Outcome Measures
Multiple chronic conditions among US adults: A 2012
Table S3. Summary of Population, Treatment, Outcome
update. Preventing Chronic Disease, 11.
Measures
doi:10.5888/pcd11.130389

Journal of Nursing Scholarship, 2016; 48:4, 345353. 353

C 2016 Sigma Theta Tau International
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.