Updates on Using Mindfulness Interventions to Manage Pain

Directions in Pharmacy, October 2015, Volume 2, Issue 4

Pain is recognized as a common, but complex, multifaceted experience that can interfere with quality of life and contribute to psychological problems, social awkwardness, and work-related disability.

Pain is recognized as a common, but complex, multifaceted experience that can interfere with quality of life (QOL) and contribute to psychological problems, social awkwardness, and work-related disability. Despite the availability of myriad pharmacologic and medical—surgical modalities, such as nerve blocks, people continue to suffer from unmanaged pain. Furthermore, pharmacologic agents, such as opioids, may carry unwelcome sequelae, especially for patients with chronic pain conditions. Thus, gaining knowledge of alternative supportive modalities for relieving pain to augment or complement traditional strategies is essential.

Pain perception is affected by psychological factors. For example, fear of pain and unpleasant emotional memories that accrue over time can intensify the pain experience.1 Patients with chronic pain may develop selective attentional biases with associated hypervigilance toward pain stimuli2 or catastrophize about their pain, building negative cognitive appraisals that reinforce aversive qualities of the pain experience.3,4 Pain catastrophizing and hypervigilance are associated with negative consequences, such as lower QOL, higher levels of disability, and heightened usage of medications and health services.2,4 Patients with chronic pain may also learn to ignore and/or avoid the pain experience.5

Given the importance of both cognition and affect to the experience of pain, strategies that target higher cognitive function have gained influence.6,7These types of interventions teach new coping skills to manage pain and stress.7 For example, mindfulness-based strategies may help patients to separate the cognitive and emotional experience from the sensory components of pain, leading to a changed experience that carries potential to reduce suffering.6,8

The foundation of mindfulness practices stem from ancient Buddhist teachings aimed at the cultivation of awareness, insight, and regulation of attention to alleviate suffering.9,10

Most mindfulness-based interventions provide training in meditation and gentle yoga practices to build nonjudgmental acceptance of physical and psychological states. In this regard, mindfulness-based interventions differ from distraction, a tool commonly used to control pain. With distraction, attention is diverted away from the pain toward external stimuli.3 During mindfulness practice, however, patients use breathing techniques to effortlessly pay attention to body states with an attitude of acceptance, open awareness, and nonattachment.3

In a study that compared distraction with mindfulness effects on experimental pain, no differences were found in pain perception between the 2 groups. However, the mindfulness instruction was a better strategy to manage pain among participants who catastrophized about the pain experience.3 Because mindfulness practices teach patients to increase attention and awareness of internal states including pain, patients who have lived with chronic pain over time may experience only limited changes in their perceived pain levels, but still gain benefit from learning to relate to the pain differently.5

Mindfulness-based stress reduction (MBSR), a leading program pioneered by Jon Kabat-Zinn to help manage chronic pain and reduce emotional distress, combines 8 weekly group sessions with a meditation retreat and daily home practice.6 Other programs that also incorporate mindfulness training include acceptance and commitment therapy; dialectical behavioral therapy; and mindfulness-based cognitive therapy, which combines cognitive therapy with MBSR components.4,11-13

In Canada, a mindfulness-based chronic pain management program that incorporated telehealth delivery for patients living in rural areas was developed and tested.14 Another promising program is Mindfulness-Oriented Recovery Enhancement (MORE), which was developed to manage chronic pain, opioid craving, and misuse behaviors.15 The MORE program integrates Kabat-Zinn MBSR components, cognitive therapy principles, and training to build capacity for the enjoyment of natural rewards.15

In general, mindfulness training programs include teachings on managing pleasant and unpleasant experiences; bringing mindfulness to everyday tasks and behaviors, such as showering and eating; caring for the self and others with compassion; and wellness behaviors. Participants are asked to make a personal commitment to meditation practice, complete homework assignments, and share their experiences in the group format. Many courses augment the classes with compact disc meditation tracks that participants can use at home between sessions. Mindfulness practice can lead to improved focus, self-regulation, perceptions of well-being, and enhanced capacity to manage stressors.6,11,12,16

Studies that integrate mindfulness-based therapies in pain management have increased with study results showing promise in modifying pain intensity.8 Most of this research has focused on chronic pain conditions, but there have also been studies targeting acute pain, opioid addiction, pain catastrophizing tendencies, and specific somaticization disorders.3,5,8,11,15,17,18

Many of the pain-related studies have incorporated variations of the Kabat-Zinn MBSR intervention.17,19

Studies involving patients with chronic pain have focused on a variety of conditions, including lower back and musculoskeletal pain, rheumatoid arthritis, headache, irritable bowel syndrome, and fibromyalgia.8,17 Most of these studies have evaluated findings by relying on patient-reported outcomes using questionnaires, numeric rating scales, and survey items.17 Studies that have examined the effectiveness of mindfulness training for pain management have identified significant improvements in mood indices, such as depression and anxiety; QOL parameters, such as physical and social function; mental health; having a positive outlook; and engagement in activities.17,18

Limitations cited in the measurement of pain in mindfulness research are variations in how aspects of pain outcomes are evaluated. For example, some studies have examined pain interference, bodily pain, and pain intensity as part of global tools appraising other QOL parameters.8 Further, many of the studies examining the effectiveness of mindfulness training on pain are limited by small samples, the use of convenience sampling, limited information about characteristics of drop-outs, reliance on self-report, and poor accounting of type I error (also referred to as “false positive.”).17 Although research demonstrates promise for early efficacy of mindfulness-based therapies for pain management, additional studies are needed secondary to methodological variation, small sample sizes, incomplete intervention fidelity information, limited research in diverse populations, and inadequate information on sustained effects over time. At present, there is limited discussion of the use of mindfulness interventions as adjunct to pharmaceutical management.

Whereas mechanisms of action behind mindfulness meditation practices for managing pain are not substantiated, evidence from MRI brain scans suggest that practicing mindfulness for 8 weeks contributed to growth in brain areas that are engaged in emotion regulation, attention, learning, and memory function.16 Furthermore, other research results have indicated that meditative practices result in increased parasympathetic and decreased sympathetic nervous system activity, which contribute to relaxation and reduced stress.20 Although research is ongoing, study results also suggest that meditative practices may impact neurogenic modulation of immune system receptiveness.21,22

Mindfulness-based therapies represent a range of options that are becoming more widely utilized and may promote improved QOL for many people, but not all, from both healthy and ill populations. Mindfulness-based therapies can be cost-effective and once learned, may be used independently by patients. Furthermore, many of the mindfulness program components, such as yoga movements, walking meditation, and retreat sessions, can be modified to accommodate vulnerable patients with physical limitations, frailty, and reduced endurance. Given the growth in popularity of mindfulness programs, patients may have ready access to meditation information and downloadable recordings online. It is essential that all pain, whether acute or chronic, be thoroughly evaluated by a health care provider, with sustained follow-up over time.

Rebecca Lehto, PhD, RN, is an associate professor at Michigan State University College of Nursing. Dr. Lehto’s program of research focuses on symptom management and the promotion of health-related quality of life in cancer. She recently developed and conducted pilot testing of a supportive mindfulness-based intervention to promote adaptation for patients undergoing treatment for advanced lung cancer.

References

  • Baliki MN, Chialvo DR, Geha PY, et al. Chronic pain and the emotional brain: Specific brain activity associated with spontaneous fluctuations of intensity of chronic back pain. J Neurosci. 2006;26(47):12165-12173.
  • Garland EL, Howard MO. Mindfulness-oriented recovery enhancement reduces pain attentional bias in chronic pain patients. Psychother Psychosom. 2013;82(5):311-318. doi: 10.1159/000348868.
  • Prins B, Decuypere A, Van Damme S. Effects of mindfulness and distraction on pain depend upon individual differences in pain catastrophizing: an experimental study. Eur J Pain. 2014;18(9):1307-1315. doi: 10.1002/j.1532-2149.2014.491.x.
  • de Boer MJ, Steinhagen HE, Versteegen GJ, Struys MM, Sanderman R. Mindfulness, acceptance, and catastrophizing in chronic pain. PLOS One. 2014;9(1):e87445. doi: 10.1371/journal.pone.0087445.
  • la Cour P, Petersen M. Effects of mindfulness meditation on chronic pain: a randomized controlled trial. Pain Med. 2015;16(4):641-652. doi: 10.1111/pme.12605.
  • Kabat-Zinn J. Full Catastrophe Living: Using The Wisdom Of Your Body And Mind To Face Stress, Pain, and Illness. 15th ed. New York, NY: Delta Trade Paperbacks; 2009.
  • Garland E, Gaylord S, Park J. The role of mindfulness in positive reappraisal. Explore (NY). 2009;5(1):37-44. doi: 10.1016/j.explore.2008.10.001.
  • Reiner K, Tibi L, Lipsitz JD. Do mindfulness-based interventions reduce pain intensity? a critical review of the literature. Pain Med. 2013;14(2):230-242. doi: 10.1111/pme.12006.
  • Garland E, Gaylord S, Park J. The role of mindfulness in positive reappraisal. Explore (NY). 2009;(1):37-44. doi: 10.1016/j.explore.2008.10.001.
  • Shapiro SL, Carlson LE, Astin JA, Freedman B. Mechanisms of mindfulness. J Clin Psychol. 2006;62(3):373-386.
  • Evans DR, Eisenlohr-Moul TA, Button DF, Baer RA, Segerstrom SC. Self-regulatory deficits associated with unpracticed mindfulness strategies for coping with acute pain. J Appl Soc Psychol. 2014;44(1):23-30.
  • Kuyken W, Watkins E, Holden E, et al. How does mindfulness-based cognitive therapy work? Behav Res Ther. 2010;48(11):1105-1112. doi: 10.1016/j.brat.2010.08.003.
  • McCracken LM, Thompson M. Components of mindfulness in patients with chronic pain. J Psychopathol Behav Assess. 2008;31(2):75-82.
  • Gardner-Nix J, Backman S, Barbati J, Grummitt J. Evaluating distance education of a mindfulness-based meditation programme for chronic pain management. J Telemed Telecare. 2008;14(2):88-92. doi: 10.1258/jtt.2007.070811.
  • Garland EL, Froeliger B, Howard MO. Effects of mindfulness-oriented recovery enhancement on reward responsiveness and opioid cue-reactivity. Psychopharmacol (Berl). 2014;231(16):3229-3238. doi: 10.1007/s00213-014-3504-7.
  • Hölzel BK, Carmody J, Vangel M, et al. Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Res. 2011;191(1):36-43. doi: 10.1016/j.pscychresns.2010.08.006.
  • Garmon B, Philbrick J, Becker D, et al. Mindfulness-based stress reduction for chronic pain: A systematic review. J Pain Manage. 2014;7(1):23-36.
  • Lakhan SE, Schofield KL. Mindfulness-based therapies in the treatment of somatization disorders: a systematic review and meta-analysis. PLoS One. 2013;8(8):e71834. doi: 10.1371/journal.pone.0071834.
  • Chiesa A, Serretti A. Mindfulness-based interventions for chronic pain: a systematic review of the evidence. J Altern Complement Med. 2011;17(1):83-93. doi: 10.1089/acm.2009.0546.
  • Nesvold A, Fagerland MW, Davanger S, et al. Increased heart rate variability during nondirective meditation. Eur J Prev Cardiol.2012;19(4):773-780. doi: 10.1177/1741826711414625.
  • Rosenkranz MA, Davidson RJ, MacCoon DG, Sheridan JF, Kalin NH, Lutz A. Comparison of mindfulness-based stress reduction and an active control in modulation of neurogenic inflammation. Brain Behav Immun. 2013;27(1):174-184. doi: 10.1016/j.bbi.2012.10.013.
  • Davidson RJ, Kabat-Zinn J, Schumacher J, et al. Alterations in brain and immune function produced by mindfulness meditation. Psychosom Med. 2003;65(4):564-570.