Another massive study has shown the power mindfulness-based therapy can have on the brain.
A randomized clinical trial by Utah researchers compared the efficacy of mindfulness-based therapy with cognitive behavioral therapy (CBT) in reducing both opioid use and pain in chronic pain patients.
The trial, published in JAMA Internal Medicine in February 2022, was the latest in a series of studies that use mindfulness-based techniques to reduce pain and opioid use in people with chronic pain. The lead study author, Eric Garland, PhD, a licensed clinical social worker, distinguished professor, and the director of the Center on Mindfulness and Integrative Health Intervention Development at the University of Utah in Salt Lake City, designed the Mindfulness-Oriented Recovery Enhancement (MORE) approach. It combines mindfulness training, changes to the course of negative thoughts, relearning how to appreciate positive experiences, and positive psychology, which encourages people to focus on their strengths rather than weaknesses.
The randomized clinical trial included 250 adults with chronic pain who were misusing the opioids they were prescribed to treat their pain. Half met criteria for opioid use disorder (OUD) at the time they were enrolled in the trial. Roughly half the patients underwent group mindfulness training for eight weeks using MORE. The control group received standard CBT in a group setting.
The researchers encouraged the patients to do what was right for them and did not force anyone to wean themselves off medication. For patients who wanted or needed to remain on opioids, MORE helped them reduce their risk of misuse and relieved pain.
Opioid misuse decreased by an average of 45 percent in the MORE group, double that of the CBT group. More than 35 percent of people in the MORE group cut their opioid use by at least half. The people in the MORE group also reported less pain, opioid cravings, and emotional distress, even though they were taking fewer pain pills. The effects lasted at least until the researchers’ nine-month follow-up period. And although the effects appeared to plateau between six and nine months for the MORE group, the effects of CBT actually waned in the control group.
“It’s difficult to make blanket statements about chronic pain since it’s so different in everyone, but there seems to be a way of modulating how one’s relationship with pain modulates the amount of craving they have for a drug,” says Fadel Zeidan, PhD, an associate professor of anesthesiology at the University of California in San Diego and the director of the Pain, Health, and Mindfulness Lab, who was not involved in the new research.
Dr. Garland and his colleagues also asked the participants to record their own mindfulness practices for the first month following their eight-week treatment.
“Those data show that the more people practice, the greater the benefit they get,” says Garland, noting that future research will focus on the longevity of mindfulness-based treatment for chronic pain and opioid use.
The new research was the longest and most advanced of the trials that tested the specifically designed mindfulness intervention in chronic pain patients who misused opioids. The goal with these patients is twofold: Reduce opioid dependence and still manage pain.
“We need adjunctive, non-opioid therapies that are safe and effective that can help address unrelieved pain,” says Garland. “This study demonstrates the efficacy of an intervention that can help people who are prescribed opioids continue to get the adequate pain relief they need while reducing opioid-related risks and harm.”
According to Dr. Zeidan, what makes the MORE approach unique is its focus on helping people who have used opioids long-term learn how to savor pleasure again.
“Because of opioids, their reward systems are completely out of whack. The physiology has been changed in a way where the drive for the drug has taken over their reward pathways,” he says. “Garland is showing that this component of savoring, something that opiate-using chronic pain patients have a deficiency in, can be modulated through this very multimodal approach.”
Opioids Provide Only Temporary Relief for Pain
One thing Garland notes is that despite relatively high doses of opioids, people in the trial were still suffering from high levels of chronic pain.
That’s because “opiates don’t work for chronic pain,” says Zeidan.
Rather, opiates like morphine can relieve acute pain that is temporary, such as post-surgery pain. Chronic pain, on the other hand, is often lifelong. According to Zeidan, this makes mindfulness a particularly good modality for helping people cope with chronic pain.
“From the research we’ve seen to date, the immediate effect that mindfulness can have is on pain,” says Zeidan. “It's one of the only techniques that can immediately reduce pain, and we’re just now starting to understand that.”
According to Zeidan, research has so far shown that the effect mindfulness has on pain perception is not just a placebo effect, and unlike other pain-relieving modalities, it appears to work outside the body’s internal opioid system.
Medications like prescription opioids, and even over-the-counter pain relievers like ibuprofen, work within the body’s opioid system to block signals from reaching the brain, where they are processed and perceived as pain.
“Mindfulness engages neural and physiological processes that are quite unique. The theory is we cannot relieve pain outside of the opioid system using any other method,” says Zeidan.
Chronic Pain Is Not ‘in Your Head’
In recent years, there’s been a debate about whether chronic pain has psychological origins.
“I take issue with this idea that chronic pain is mostly psychological,” says Garland. “There are certainly psychological factors that influence people's pain, but people also suffer from medical conditions that are very painful, and we shouldn’t reduce all their pain to being psychological.”
Even when pain is coming from a purely physiological source, like a herniated disk or an arthritic knee, mindfulness can still be a great way to reduce pain.
“That is not because pain is psychological. It’s because all pain is processed in the brain and mindfulness changes how the brain processes the signals of damage from the body,” says Garland.
The latest MORE trial showed that mindfulness can also quell the emotional side effects of living with chronic pain. At the beginning of the trial, nearly 70 percent of patients met criteria for major depressive disorder (MDD). By the end of the trial, people treated with MORE showed reduced symptoms of depression that no longer qualified as MDD.
According to Zeidan, this effect is just as important as pain relief and reduced dependence on opioids.
“In chronic pain patients, the pain will always be there. The pain is not the problem; it’s the snowball effect of the depression, anxiety, sleeplessness, suffering, and inability to savor the joys in life that makes you become your pain,” he says.
Zeidan views a multimodal approach, rather than pain medications, to be the core of chronic pain management.
“I don’t think of mindfulness-based therapies, physical therapy, or exercise as alternative therapies,” says Zeidan. “They are central.”