Anyone living with chronic pain knows: effective treatments are few and far between. Some patients rely on pharmaceutical agents to reduce pain, but this approach doesn’t work for everyone, and drugs like opioids carry significant risks. In the wake of new guidelines provided by the Centers for Disease Control (CDC), physicians are feeling pressure to move away from prescribing opioids to treat chronic pain. Now, new research shows that doctors and patients have a non-pharmacological tool to help provide relief from chronic low back pain, without side effects and at low cost: mindfulness.
Mindfulness, a secular practice adapted from Buddhist meditation techniques, trains people to bring their awareness to the present moment (see RELIEF related feature story). During mindfulness training, practitioners are directed to bring their attention to the physical sensation of breath. When thoughts arise—as they unfailingly do—practitioners are encouraged to acknowledge them without judgment and return their attention to the breath.
In 1979, Jon Kabat-Zinn, working at the University of Massachusetts, Worcester, US, developed a clinical program called Mindfulness-Based Stress Reduction (MBSR). Since then, thousands of studies have investigated the effects of MBSR for dozens of clinical conditions, including pain. But few high-quality studies have been conducted in people with chronic pain—until now.
A clinical trial of MBSR for chronic low back pain in over 300 people now demonstrats that subjects who trained in a typical eight-week course of MBSR were 37% more likely to see significant improvements in disability, and 64% more likely to show improvements in pain “bothersomeness,” compared to those who received their normal care alone (which could include physical therapy and medications). The subjects, aged 20 to 70, had suffered from chronic low back pain with no diagnosable cause for at least three months when the study began.
The study was published in the Journal of the American Medical Association (JAMA) on March 22.
Remarkably, the improvements seen in the mindfulness group lasted for a year after training. Another group of subjects received cognitive-behavioral therapy (CBT), a psychological talk therapy that encourages patients to reframe their situation; CBT has previously been shown effective for chronic pain conditions. CBT and MBSR were equally beneficial for reducing pain in the new study.
The long-term benefits provided by mindfulness are encouraging, says Daniel Cherkin, Group Health Research Institute, Seattle, US, who led the trial. “We speculate that if mindfulness practice really changes how the mind works, the benefits could be permanent.”
Another clinical trial published in March in JAMA Internal Medicine also showed benefits of MBSR for chronic low back pain, in people over the age of 65.
Why Does It Work?
How does mindfulness relieve pain? The answer remains a mystery, but a second new study from Fadel Zeidan, a researcher at Wake Forest School of Medicine in Winston-Salem, North Carolina, US, provides new hints, specifically about how mindfulness affects the brain.
Zeidan and colleagues studied the responses of 78 healthy adult volunteers to heat pain after receiving just four days of mindfulness training. Control subjects listened to a recording of a history book in place of the training.
Those who trained in mindfulness reported significantly lower ratings of pain intensity and unpleasantness compared to control subjects. Specifically, in the meditators, pain intensity was down 21 percent, and unpleasantness down 36 percent, compared to baseline measurements taken before training. In contrast, in control subjects, pain intensity was up 21 percent, and unpleasantness up 18 percent, compared to their own baseline assessments.
To investigate how mindfulness blunted pain, the researchers gave subjects an injection of either saline solution (used as a control) or naloxone, a drug that blocks the effects of opioid drugs and their natural counterparts, called endogenous opioids. Endogenous opioids are known to be responsible for other mind-based manipulations of pain, such as the placebo effect. Endogenous opioids produced in the brain act on neurons in the spinal cord to dampen pain signals.
But, in the new study, Zeidan found that endogenous opioids were not required for pain relief provided by mindfulness, because subjects who received naloxone reported as much pain relief during meditation as did subjects who received saline. Instead, it’s possible that other pain signaling systems, which may or may not interact with endogenous opioids, may be involved in the effects of mindfulness on the brain.
It’s important to emphasize that the study examined healthy people tested in a laboratory setting, so whether the same mechanism is at play in people with chronic pain who benefit from mindfulness is unclear.
But Zeidan hypothesizes that mindfulness might change the way the brain processes incoming pain information, thereby reshaping the experience of pain. Mindfulness changes how people react to pain, Zeidan says. “People ruminate, they catastrophize,” he adds, referring to destructive thought processes that can worsen chronic pain. “We think that mindfulness stops that cycle.”
Mindfulness provides some margin of relief for chronic back pain without drugs and at low cost. But there is a “price” to pay: patients must be willing to take an active role in managing their pain and undergo the training.
“Many of us would rather spend our time doing something other than meditating,” Cherkin says, but unfortunately chronic pain will not be solved with a pill the way that antibiotics clear up an infection.
Zeidan is doing his part “to make mindfulness as close to pill form as possible,” he says. “We are accumulating evidence that meditation’s effects on pain can be realized with very short training. That’s very important for people seeking a fast-acting pain treatment.”
Chronic pain is a condition best managed when patients take an active role and work with the advice and support of knowledgeable clinicians, Cherkin says. And according to the research, mindfulness should now be a part of a multi-disciplinary strategy for those willing to put in the effort. —Stephani Sutherland
To read about the new research in more detail, see the related Pain Research Forum news story here.