An estimated 2 million Americans are hooked on prescription painkillers, along with another 600,000 hooked on heroin. As the damage of opioids becomes clear, doctors are increasingly looking for alternatives for managing pain. Miles O’Brien reports that Biofeedback can reduce chronic pain, as can mindfulness training and yoga.
Credit: Getty Images: Six months post-treatment, the study found that about 25% of people who learned self-hypnosis reported clinically meaningful improvements in pain intensity.
Adults who pursued pain relief through mindfulness-focused meditation and hypnosis had better long-term effects than those who received education in pain management, according to one of the largest studies of its kind on nonpharmaceutical pain control and relief.
The findings of this joint UW Medicine/Veterans Affairs Puget Sound Health Care System study were published in the medical journal Pain. The researchers tested the effects of two nonpharmaceutical pain interventions against an educational (control) protocol in a population of military veterans who received care from the VA between 2015 and 2020. Participants had experienced chronic pain not related to cancer for at least three months.
“For many years, I noticed that patients with chronic pain were only offered pain medications. But even with so-called painkillers, these patients continued to experience significant pain, but now also with side effects of the medications. I thought there had to be a better way,” said senior author Mark Jensen, professor of rehabilitation medicine at the University of Washington School of Medicine.
Research estimates that about 19% of adults in the United States deal with chronic pain, and as many as 65% of veterans experience pain.
At the study’s outset, the 328 participants reported moderate or worse pain. Many also had depression, post-traumatic stress disorder and sleep disturbance. They comprised a very diverse population for a clinical trial of pain treatments, said lead author Rhonda Williams. She is a UW professor of rehabilitation medicine and a clinician scientist at VA Puget Sound Health Care System.
“We wanted to see which of the interventions led to the most improvement in pain intensity, pain interference, anxiety, depression, sleep, opioid medication use, and global perceptions of change,” said Williams.
All three interventions were associated with improvements, to varying degrees, across multiple outcome measures. What surprised Williams was how enthusiastic the veterans were to receive the treatments, even after the study concluded.
“While it’s normally hard to keep participants engaged in clinical research trials, this study had very high rates of retention,” she said. The VA is continuing to offer the test treatments and more than 200 veterans have pursued these outside of the study.
By six months post-treatment, clinically meaningful improvements in pain intensity were reported by:
Participants in all three study cohorts experienced improvements in pain intensity, pain interference, and mood at the end of treatment, but the maintenance of benefits differed by treatment. Participation in mindful meditation resulted in greater decreases in average pain intensity and pain interference, relative to education, at six months post-treatment. Participation in hypnosis resulted in greater decreases in average pain intensity, pain interference, and depressive symptoms at three and six months post-treatment, compared with the educational cohort, the report stated.
No significant differences between hypnosis and mindful meditation were seen in any outcome measures. Findings show that all three interventions provide post-treatment benefits over a range of outcomes, but the benefits of hypnosis and mindful meditation appeared more likely to persist, while the improvements associated with pain education seemed to dissipate over time, the study noted.
Williams and Jensen observed that some individuals appear to benefit more from specific treatments. They said one next research step would be to try to match individuals to the treatment more likely to provide benefit.
Research at the University of Wisconsin–Madison’s Center for Healthy Minds has isolated the changes in pain-related brain activity that follow mindfulness training — pointing a way toward more targeted and precise pain treatment.
The study, published today (July 27) in The American Journal of Psychiatry, identified pathways in the brain specific to pain regulation on which activity is altered by the center’s eight-week Mindfulness Based Stress Reduction course.
These changes were not seen in participants who took a similar course without the mindfulness instruction — important new evidence that the brain changes are due to the mindfulness training itself, according to Joseph Wielgosz, who led the work while he was a graduate student at UW–Madison and is now a postdoctoral researcher at Stanford University. The study is the first to demonstrate pain-related brain changes from a standardized mindfulness course that is widely offered in clinical settings.
Around one-third of Americans experience pain-related problems, but common treatments — like medications and invasive procedures — don’t work for everyone and, according to Wielgosz, have contributed to an epidemic of addiction to prescription and illicit drugs.
Popular with patients and promising in its clinical outcomes, mindfulness training courses like MBSR have taken a central place in the drive for a more effective approach to pain management. By practicing nonjudgmental, “present-centered” awareness of mind and body, participants can learn to respond to pain with less distress and more psychological flexibility — which can ultimately lead to reductions in pain itself.
To measure neural pain response, study participants had their brains scanned while receiving a carefully controlled heat-based stimulus on their forearm. The researchers recorded two brain-wide signatures of pain-related activity, developed by collaborator Tor Wager, a professor of neuroscience at Dartmouth College. This innovative technique dramatically improves the ability to detect pain-related signals in the brain’s complex activity. Changes in signatures can also be more easily interpreted in psychological terms.
Participants in the MBSR course showed reduction in a signature associated with the sensory intensity of pain.
“Our finding supports the idea that for new practitioners, mindfulness training directly affects how sensory signals from the body are converted into a brain response,” says Wielgosz, whose work was supported by the National Institutes of Health.
The study also looked at longer-term mindfulness training. Intriguingly, practice on intensive meditation retreats was associated with changes in the neural signature for influences that shape pain indirectly — for example, differences in attention, beliefs and expectations, factors that often increase the perceived levels of distress in non-meditators.
“Just like an experienced athlete plays a sport differently than a first-timer, experienced mindfulness practitioners seem to use their mental ‘muscles’ differently in response to pain than first-time meditators,” Wielgosz says.
These findings help show the potential for mindfulness practice as a lifestyle behavior.
The study is also significant for the field of pain research in its use of brain-based measures of pain alongside the subjective ratings of the participants in a randomized trial. Pain researchers have long sought ways to biologically measure the effect of treatment.
“Looking at neural signatures together with patient experiences revealed insights about mindfulness that we could never have detected through either one alone,” Wielgosz says.
Thus, in addition to the insights it provides about mindfulness, the researchers believe that their study can also provide a model for future research, helping to untangle the complexity of pain and ultimately reduce the burden it places on our lives.
Fadel Zeidan, PhD, is an associate professor of anesthesiology at UC San Diego School of Medicin CREDIT UC San Diego Health Sciences
For centuries, people have been using mindfulness meditation to try to relieve their pain, but neuroscientists have only recently been able to test if and how this actually works. In the latest of these efforts, researchers at University of California San Diego School of Medicine measured the effects of mindfulness on pain perception and brain activity.
The study, published July 7, 2022 in PAIN, showed that mindfulness meditation interrupted the communication between brain areas involved in pain sensation and those that produce the sense of self. In the proposed mechanism, pain signals still move from the body to the brain, but the individual does not feel as much ownership over those pain sensations, so their pain and suffering are reduced.
“One of the central tenets of mindfulness is the principle that you are not your experiences,” said senior author Fadel Zeidan, PhD, associate professor of anesthesiology at UC San Diego School of Medicine. “You train yourself to experience thoughts and sensations without attaching your ego or sense of self to them, and we’re now finally seeing how this plays out in the brain during the experience of acute pain.”
On the first day of the study, 40 participants had their brains scanned while painful heat was applied to their leg. After experiencing a series of these heat stimuli, participants had to rate their average pain levels during the experiment.
Participants were then split into two groups. Members of the mindfulness group completed four separate 20-minute mindfulness training sessions. During these visits, they were instructed to focus on their breath and reduce self-referential processing by first acknowledging their thoughts, sensations and emotions but then letting them go without judging or reacting to them. Members of the control group spent their four sessions listening to an audio book.
On the final day of the study, both groups had their brain activity measured again, but participants in the mindfulness group were now instructed to meditate during the painful heat, while the control group rested with their eyes closed.
Researchers found that participants who were actively meditating reported a 32 percent reduction in pain intensity and a 33 percent reduction in pain unpleasantness.
“We were really excited to confirm that you don’t have to be an expert meditator to experience these analgesic effects,” said Zeidan. “This is a really important finding for the millions of people looking for a fast-acting and non-pharmacological treatment for pain.”
When the team analyzed participants’ brain activity during the task, they found that mindfulness-induced pain relief was associated with reduced synchronization between the thalamus (a brain area that relays incoming sensory information to the rest of the brain) and parts of the default mode network (a collection of brain areas most active while a person is mind-wandering or processing their own thoughts and feelings as opposed to the outside world).
One of these default mode regions is the precuneus, a brain area involved in fundamental features of self-awareness, and one of the first regions to go offline when a person loses consciousness. Another is the ventromedial prefrontal cortex, which includes several sub regions that work together to process how you relate to or place value on your experiences. The more these areas were decoupled or deactivated, the more pain relief the participant reported.
“For many people struggling with chronic pain, what often affects their quality of life most is not the pain itself, but the mental suffering and frustration that comes along with it,” said Zeidan. “Their pain becomes a part of who they are as individuals — something they can’t escape — and this exacerbates their suffering.”
By relinquishing the self-referential appraisal of pain, mindfulness meditation may provide a new method for pain treatment. Mindfulness meditation is also free and can be practiced anywhere. Still, Zeidan said he hopes trainings can be made even more accessible and integrated into standard outpatient procedures.
“We feel like we are on the verge of discovering a novel non-opioid-based pain mechanism in which the default mode network plays a critical role in producing analgesia. We are excited to continue exploring the neurobiology of mindfulness and its clinical potential across various disorders.”
Results from a new clinical trial demonstrate that an eight-week mindfulness-based therapy—Mindfulness-Oriented Recovery Enhancement (MORE)—decreased opioid use and misuse while reducing chronic pain symptoms, with effects lasting as long as nine months. This is the first large-scale clinical trial to demonstrate that a psychological intervention can simultaneously reduce opioid misuse and chronic pain among people who were prescribed opioid pain relievers.
The study, published in the peer-reviewed journal JAMA Internal Medicine, followed 250 adults with chronic pain on long-term opioid therapy who met the criteria of misusing opioids. Most participants took oxycodone or hydrocodone, reported two or more painful conditions and met the clinical criteria for major depression. More than half of participants also had a diagnosable opioid use disorder.
Study participants were randomly assigned to either a standard supportive psychotherapy group, or a MORE group, both engaging in eight weekly two-hour group sessions, as well as 15 minutes of daily homework. The study treatment groups were delivered in doctor’s offices, in the same clinical care setting where patients received their opioid pain management. Researchers measured the participants’ opioid misuse behaviors; symptoms of pain; depression, anxiety and stress; and opioid dose through a nine-month follow-up. Opioid craving was measured at three random times a day, prompted by a text message sent to the participants’ smartphones.
Nine months after the treatment period ended, 45% of participants in the MORE group were no longer misusing opioids, and 36% had cut their opioid use in half or greater. Patients in MORE had more than twice the odds of those in standard psychotherapy to stop misusing opioids by the end of the study. Additionally, participants in the MORE group reported clinically significant improvements in chronic pain symptoms, decreased opioid craving and reduced symptoms of depression to levels below the threshold for major depressive disorder.
“MORE demonstrated one of the most powerful treatment effects I’ve seen,” said Eric Garland, lead author of the study, director of the Center on Mindfulness and Integrative Health Intervention Development at the University of Utah and the most prolific author of mindfulness research in the world. “There’s nothing else out there that works this well in alleviating pain and curbing opioid misuse.”
“Remarkably, the effects of MORE seem to get stronger over time,” said Garland, who developed MORE and has been studying it for over a decade. “One possible explanation is that these individuals are integrating the skills they’ve learned through MORE into their everyday lives.” Garland also hypothesized that, based on previous research, the sustained benefits might be related to MORE’s ability to restructure the way the brain processes rewards, helping the participants’ brains shift from valuing drug-related rewards to valuing natural, healthy rewards like a beautiful sunset, the bloom of springtime flowers or the smile on the face of a loved one.
MORE combines meditation, cognitive-behavioral therapy and principles from positive psychology into sequenced training in mindfulness, savoring and reappraisal skills.
Participants are taught to break down the experience of pain or opioid craving into their sensory components, “zooming in” on what they are feeling and breaking it down into different sensations like heat, tightness or tingling. They are trained to notice how those experiences change over time, and to adopt the perspective of an observer. They are also taught to savor pleasant, healthful and life-affirming experiences, amplifying the sense of joy, reward and meaning that can come from positive, everyday events. Finally, participants are taught to reframe stressful events to find a sense of meaning in the face of adversity, to recognize what can be learned from difficult events and how dealing with those experiences might make a person stronger.
Garland explained, “Rather than getting caught up in the pain or craving, we teach people how to step back and observe that experience from the perspective of an objective witness. When they can do that, people begin to recognize that who they truly are is bigger than any one thought or sensation. They are not defined by their experiences of pain or craving; their true nature is something more.”
People experiencing both chronic pain and opioid misuse present a significant treatment challenge, since opioid use disorder has been shown to increase pain sensitivity, which in turn promotes further opioid misuse. By simultaneously reducing pain and opioid use, MORE may offer an effective, economical and lifesaving intervention to help halt the ongoing opioid crisis.