A research article published last month in the Journal of the American Medical Association (JAMA) offers hope for the pain and opioid crises. In “Mind-Body Therapies for Opioid-Treated Pain: A Systematic Review and Meta-analysis,” researchers report that mind-body therapies like Cognitive Behavioral Therapy (CBT), mindfulness, and guided imagery are associated with decreased pain and reduced opioid cravings (Garland et al, 2019). Once considered “alternative” and summarily dismissed, interventions targeting both mind and body are now considered critical components of effective pain management plans. Why? Because brain and body are connected 100% of the time. When you treat your brain, you treat your pain.
Mind-body therapies (MBTs) specifically target interactions between brain and body, focusing on thoughts, emotions, and behaviors to change biology, physiology, physical sensations and bodily functions. Research indicates that MBTs can be effective for chronic pain, and neuroscience literature has even uncovered mechanisms of action by which mindfulness and CBT modulate pain (Flor, 2014; Zeidan et al, 2011). But until this study, no one had ever examined the utility of MBTs for patients with opioid-treated pain.
For decades, we erroneously believed that pain was a purely biomedical phenomenon – due exclusively to biological processes like tissue damage, genetics, and system dysfunction alone. Pain was therefore primarily treated with biomedical solutions, like pills and procedures. But these interventions are reportedly not enough. Up to 100 million adults continue to live with chronic pain in the US alone (IOM, 2011), and incidence is on the rise (Nahin et al, 2019). To make matters worse, we find ourselves in the midst of an opioid crisis of epic proportions.
Thanks to decades of research, we now understand pain better than ever before. And what we know is this: Pain is never purely biomedical. Rather, it is biopsychosocial, informed by biological processes (e.g. genetics, tissue damage, system dysfunction), psychological processes (e.g. perceptions, thoughts, beliefs, emotions, coping behaviors) and social factors (e.g. socioeconomic status, access to care, social support, environmental context) (Gatchel & Maddrey, 2004). All 3 domains are critical for the creation – and reduction – of pain. The role of thoughts and emotions in pain is confirmed by neuroscience research revealing the central role of the cerebral cortex, responsible for thoughts, and the limbic system, the brain’s emotion center (Martucci & Mackey, 2018). Biomedical solutions like pills and procedures that target exclusively biological factors – and that skip psychosocial factors entirely – therefore miss two-thirds of the pain problem.
To examine the impact of MBTs on pain across the scientific literature, Garland and colleagues conducted a systematic review and meta-analysis of 60 randomized clinical trials with over 6,400 participants. All patients had been prescribed opioid medications. The researchers found that mindfulness had a significant, strong association with pain reduction, and was associated with significant improvements in opioid cravings. CBT had a significant and moderate association with pain reduction, and more than half of the studies examining the impact of CBT on opioid dose reported a significant therapeutic effect.
While it may seem counterintuitive that interventions like these can change pain, neuroscience reveals a mechanism by which pain volume can be turned up or down via a “pain dial” in our central nervous system (Melzack, 1999; Zoffness, 2019) that operates much like the volume knob on your stereo. When this metaphorical dial is turned up, pain is amplified; when the pain dial is turned down, pain is quieter and feels less bad. Biopsychosocial factors that amplify pain volume are fairly well-established, and include negative emotions (stress, anxiety, anger, depression), catastrophic and fearful thoughts, focusing on and ruminating about pain, withdrawing, isolating, and prolonged periods of inactivity (Edwards et al, 2019; Linton & Shaw, 2011). However, research shows that the opposite is also true: Positive emotions like happiness and relaxation, calm and hopeful thoughts, distracting and engaging in activities, and movement can all turn pain volume down (Hansen & Streltzer, 2005).
What are CBT and mindfulness?
CBT is an evidence-based treatment shown to be effective for anxiety, depression, sleep issues, family distress, and chronic pain (Hofmann et al, 2012; Kerns et al, 2011). It focuses on the interconnected cycle of thoughts, emotions, physical sensations and coping behaviors that can keep us feeling hopeless and stuck – particularly when we have pain. Treatment involves three main components: (1) pain education, connecting neuroscience and physiology; (2) cognitive and emotional strategies for pain management; and (3) changes in coping behaviors to maximize functionality, decrease disability, and turn down pain volume. Mindfulness is often woven into CBT-for-pain programs. Mindfulness, a technique that combines science with meditation, involves cultivating a focus on the present moment to regulate stress, tension, and brain function, as well as an acceptance of difficult emotions and physical sensations. It’s an integral part of many pain management programs, including Mindfulness-Based Stress Reduction (MBSR), which has a vast and growing evidence-base (Cherkin et al, 2016).
The researchers report that mindfulness and CBT may contribute to an alleviation of the opioid epidemic “given their association with reduced pain severity and functional interference, and their potential to improve opioid-related outcomes.” As such, these treatments should be considered part of any comprehensive pain-management plan. This conclusion echoes the cry of national and global calls to action (Darnall et al 2017; Khidir & Weiner, 2016), which call for a biopsychosocial approach to chronic pain; wider implementation of safe, biobehavioral treatments like CBT in pain clinics and hospitals; reimbursement of these approaches by insurance companies; and greater pain education for all.
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