Mindfulness as Analgesia for Chronic Pain

Introduction

Chronic pain is defined as pain that persists beyond the expected time of recovery and is still present long after the injury or problem has healed (Lee et al., 2016). Comparatively, acute pain onset lasts for a limited duration and does not persist after the injury or problem has healed. Chronic and acute pain should require different approaches and interventions to help the patient. Mindfulness is a coping technique used for chronic pain that focuses the patient on the present by making them an impartial observer. Once an impartial observer, the patient can acknowledge themselves and their pain, without it affecting them. It is an approach that is often used in conjunction with both acceptance and commitment therapy (ACT) and cognitive behavioural therapy (CBT) (de Boer, Steinhagen, Versteegen, Struys, & Sanderman, 2014). The aim of this literature review is to focus on the clinical practice issue of chronic pain management within New Zealand and the impacts it has individually as well as societally. It will discuss the benefits of ACT and CBT, and compare them with other more pharmacological approaches.

There are several implications of chronic pain present within the clinical and societal setting. As the primary health system is relied on for assistance in treatment, financial strain is placed on the patient as well as the economy. This signals a requirement for increased education of primary health care clinicians to provide for the high need issue.

I am interested in discussing the use of mindfulness to minimise people’s suffering without numbing them with medication that can cause debilitating side effects. This review will discuss the benefits verses disadvantages of medication and mindfulness to assess the effectiveness of both interventions. I will apply the PECOT model, as used by Whitehead (2013) to determine my search question and define the research argument.

Background

The issue of chronic pain management is very personal to me as I have seen first-hand the detrimental effect it can have. I have cared for a grandmother with chronic pain as well as suffered through it myself, so feel a strong duty for this issue to become more widely educated. I think other approaches such as mindfulness are often overlooked and underrated as an intervention. There should be more discussion on alternative methods, not having the theory that “a pill can fix anything” and greater consideration of the potential for different therapies to be used in conjunction with each other.

One in every six New Zealanders suffer from chronic pain for extended periods of time and it is not widely recognised as a prevalent health issue (Lee, et al., 2016). According to Crowe, et al., (2016), mindfulness is helpful for self-management of pain by:

“decreasing perception of pain severity; reduced stress, anxiety and depressions; diminished need for medication; enhanced ability to reflect on choices; improved adherence to treatment; increased motivation for lifestyle change; enriched interpersonal relationships and social connectedness; and alterations to biological pathways affecting health such as the autonomic nervous system, neuroendocrine function and the immune system.” (p. 22).

Development of review question

Currently, 20% of New Zealand adults endure moderate to severe pain at any one time (Colvin, et al., 2014). Within this group, 70% were found to be unhappy with their treatment and management process. The majority of these patients are in the primary health system (Merskey & Bogduk, 1994). Such patients are relying on this public care five times more than the rest of the population (Bawa, et al.,2015). When funding is not correctly allocated, this high-need patient group causes financial stress to both society and the primary health care system (Baer, 2003). In addition, primary health care regarding chronic pain is not as well resourced; by comparison, specialists are better equipped to provide their patients with a substantially higher standard of care because they have increased access to the required means. Neuropathic pain is a common form of chronic pain which is extremely difficult to diagnose. This causes a delay in treatment and worsening of the patient’s condition by the point of diagnosis (Colvin, et al., 2014). In many patients, catastrophising their pain is very common and can often lead to increased levels of pain perception. Literature has shown that pain acceptance in conjunction with mindfulness therapies can improve patients’ experience of the chronic pain. This demonstrates the need for good quality and evidence based clinical guidelines.

Currently, the predominant belief is that medication can fix all of the patient’s pain and the side effects are a manageable trade off if they can provide potential pain reduction (Bawa et al., 2015). Instead of adding to the patients’ health disparities with medication side effects, we need to ask ourselves whether medication experimentation, further education around complimentary therapies, or mental health/stress relief management be used? This prompts us to ask the following questions:

Within these approaches, can mindfulness actually benefit patients with chronic pain?
What are the advantages vs disadvantages of strong pain medication compared to more complimentary therapies?
Can mindfulness and ACT play a part in the decrease of pain related catastrophising, which, in turn, reduces their chronic pain experience?
How much are ‘clinician fear avoidance beliefs’ impacting the treatment being given to patients going through the public health system?
Are clinicians treating patients with chronic pain from their own beliefs instead of in accordance with best practice?
Is it better practice within a clinical setting to look at the bigger picture and use a combination of interventions, from pharmaceutical to complimentary?
What role can the registered nurse play with the treatment and management of pain?

PECOT Model

Comparisons shown in the literature between different interventions include:

Complimentary vs pharmaceutical therapies, well mental health vs depression and stress implications, ‘fear avoidance’ from clinician’s vs best practice treatment, and lastly catastrophising vs acceptance of individual pain. In accordance with Whitehead 2013, the PECOT model and the inclusion and exclusion process was used to identify my research question (Whitehead., 2013). The literature used in the PECOT model includes adults aged 18 and over that have been affected by chronic pain for longer than 13 weeks and assesses how they are managing both in day to day society and in a clinical setting. There are no limitations on sex or sites of their pain. However, to decrease heterogeneity some exclusions needed to be made to lessen the sample. Excluded literature in this review will be children (18 years & under), people suffering from acute pain, and malignant related chronic pain.

Table 1: PECOT model (Whitehead, 2013)

PECOT category	Information relating to question	Explanation
Population	New Zealand adults aged 18 years and over who suffer from non-malignant chronic pain.	To look at this populations’ treatment and management of their pain to compare the different approaches used. While looking at the affectability and benefits of these interventions.
Exposure (intervention)	What factors are contributing to chronic pain management as a clinical issue and how can these be minimised/alternate to form a best practice approach to treatment.	To determine the best practice guidelines for patients with chronic pain and how the nurse’s role can be optimised within this to form the highest standard of pain management, particularly within the primary health care system.
Comparison/ control	A medication based approach compared to a complementary, therapeutic treatment as day to day management.	To research the negative effects of the default approach being medication comparative to a more therapeutic treatment such as mindfulness.
Outcome	To better the treatment and management process for patients with chronic pain in order to decrease their overall health issue, which will therefore decrease the clinical issue on a societal level.	By determining the benefits of mindfulness for chronic pain, while providing education on this new way of dealing with pain, it will potentially decrease the need for pain medication. Therefore decreasing patients experiencing unnecessary side effects from this. This therefore will also better equip the primary health system to help these patients as there will be more research and education surrounding the clinical issue (Bishop, et al., 2004).
Time	As long as the patient suffers from chronic pain.	Chronic pain is a prolonged issue that is often never resolved and lived with throughout their life, however can be effectively managed using the appropriate management for that individual (Sullivan, et al., 2001).

As a result of using the PECOT model, I was able to redefine my previous research questions into:

Does mindfulness have an appropriate amount of benefits to be submitted into best practice guidelines within a clinical setting, compared to a focused pharmaceutical approach? From this, establish what is the best practice for registered nurses in supporting patients with chronic pain?

Evidence and findings

Mindfulness first originated from Buddhist practice and focuses on self-regulated present attention, orientated around acceptance and awareness of the individual’s pain experience (Bawa, et al., 2015). The aim of the process is to attempt not to alter the experience, but to change how the patient responds and reacts to their pain. It is sometimes taught in conjunction with a mindfulness-based stress reduction programme (MBRS) (Bawa, et al., 2015). Clinicians who follow this procedure and practice with mindfulness-based cognitive therapy (MBCT) have the view that this is more complimentary than that of a more hands-on medical treatment approach that targets the patient’s physical symptoms. This is due to the fact that most patients with chronic pain do not have a condition that is visible to the naked eye (Baer, 2003).

A concentrated pharmaceutical approach has been proven to have several disadvantages (Smith, et al., 2014). When a patient goes to a primary health clinic with chronic pain that won’t subside, more clinicians have been found to resort to extremely strong pain medications (Sullivan, et al., 2001). These medications work by disengages hyperactive nerves, however in the process it sedates other neurological activity (Smith, et al., 2014). This can initiate harmful side effects that potentially override the benefits of taking the medication in the first place. In addition, patients taking pain medication have been known to form a dependency and need to increase their dose to have the initial effect (Merskey & Bogduk, 1994). This dependence makes it difficult to function normally when modifying the prescribed medication dosage. In addition, the majority of pain medications have a significant amount of sedation incorporated, leading to a decrease of patient daily activity after medication administration commences (Smith, et al., 2014). In some cases, these pharmaceutical-focused interventions don’t always make enough of a difference for patients to override the disadvantages of the side effects.

Bawa, et al., (2015) discovered that patients needed to practice their mindfulness self-management technique for a minimum of eight weeks to get an accurate representation of its effectiveness. Within this, it was found there was significantly reduced analgesia use in the group that practiced mindfulness (Bawa, et al., 2015). Bawa, et al. (2015) identified that another economic outcome was absence from work as a result of chronic pain. The majority of those adults suffering from chronic pain have been found to be on the sickness benefit as they feel they are incapable of maintaining their job due to their debilitating condition. This review found there was limited evidence to support the true effectiveness of focusing purely on mindfulness-based interventions with no other treatment involved. Mindfulness may have a positive impact on the perception of pain, however there remains insufficient data to indicate an improvement of pain intensity. Bawa, et al., (2015) stated that the reason for the lack of evidence was due to the individual studies being too small, which made the results for most of the outcomes not statistically significant.

Chronic pain is a complex neurological condition that involves neurons on inhibitory pathways (Wojcikowski, et al., 2018). Changes occur on all levels of the pain pathway which inhibits the pain process to start (Wojcikowski, et al., 2018). This phenomenon is sometimes referred to as neuropathic pain, where the neurons firing are hyperactive and medication is used as nerve sedatives (Wojcikowski, et al., 2018). Due to these changes occurring on all levels of the pain pathway, Wojcikowski et al. (2018) showed that a combination of therapies may be necessary to use their different mechanisms of action in order to get the benefits from all sides of interventions. Literary evidence supports the idea that using a variety of complimentary therapies at the same time benefit the patient greatly. The therapies were investigated in conjunction with each other and included: several vitamins, yoga, meditation, mindfulness, acupuncture and lipoic acid (Wojcikowski, et al., 2018). It was found that these methods have varying mechanism of action which effects a different area along the pain pathway (Wojcikowski, et al., 2018). The literature showed that a number of these complimentary therapies proved to be beneficial in reducing the chronic pain experience and/or the patients need for analgesics, which in the long run showed a reduction in adverse effects. However, literature also showed that the response rates of these therapies were extremely variable from person to person. It was found that multimodal individualised treatment was recommended and adjusted to each individual patient case for their personal needs (Wojcikowski, et al., 2018).

Mental health and chronic pain are normally presented in conjunction with one another. It is now established that mental health issues have a higher rate of physical illness, and long-term health conditions, such as chronic pain, are far more prevalent in people with mental health disorders (Bishop, et al., 2004). Research also shows that people with chronic pain are two to three times more likely to suffer from mental health issues than the general population (Bishop, et al., 2004). This is equivalent to 30% of the long-term health condition population having a mental health problem as well (Crowe, et al., 2016). It is estimated that 46% of the population suffering from a mental health disorder also suffer from a long-term health condition (Crowe, et al., 2016). Mindfulness was used to co-treat both of these afflictions that exist together (Crowe, et al., 2016). Research showed that mindfulness interventions were clinically effective to treat depression and anxiety, which possibly, in turn, can decrease an individual’s pain experience (Crowe, et al., 2016). However, it is yet to be determined that mindfulness is effective when it comes to treating the physical symptoms of the health condition. Instead, it has already been acknowledged that it is just useful for the individual’s perception of their pain experience, especially if their mental health issues have decreased or dissipated (Crowe, et al., 2016).

Implications for practice

There are several implications for practice-based evidence found in the literature that impact on the clinical setting in a variety of ways. Interventions that focus on a more integrated, combined method are needed to improve these implications. The rates of chronic pain, within the long-term physical condition population co-existing with the mental health condition population are only going to increase as time goes on (Bishop, et al., 2004).

Increasing numbers are forcing the population’s needs higher as well as the need for action within a clinical setting (Bishop, et al., 2004). Within due course, the co-occurring physical and mental conditions will become the norm rather than the outlier (Crowe, et al., 2016). This clinical issue is only just beginning to become apparent within our everyday practice and is finally being investigated in depth. For example, majority of the literature reviewed in this document was published within the last five years, and the need for this type of research is only going to increase.

Chronic pain practice puts immediate pressure on the primary health system to deliver on a high dependency, high need clinical issue. GPs are expected to effectively assess and treat chronic pain which therefore means they need the adequate education, knowledge and specialist training to provide evidence-based pain management strategies to then educate r the patient with (Smith, et al. 2014). Most likely, within the primary health care setting, these requirements are not met. An implication of this is that most of the evidence available is derived from within a specialist practice which provides a barrier for the primary health system to generate accurate evidence (Smith, et al., 2014). In recent years there has been an increase in the standard guidelines for primary health management of only some pain conditions such as lower back pain and neuropathic pain. Conversely, there is still a gap in guidelines for effectiveness for all chronic pain conditions, and the need for this guideline is urgent in primary care (Merskey & Bogduk, 1994). A greater accessibility to private, specialist care is needed in order to reduce the strain on primary care facilities and to decrease the two-fold financial pressure (Smith, et al., 2014).

Recommendations

After looking at the implications of chronic pain, there are several recommendations present to better future practice guidelines. The best evidence was found when looking at pharmacological management of pain, however self-management approaches to pain evidence was severely lacking. Further evidence is necessary to fully understand the implications of chronic pain in the clinical setting, particularly research focusing on primary health, due to the fact that the majority of evidence is very specialist setting based. A proper up-to-date guideline for primary health care clinicians to use would be extremely beneficial to make a better judgement of the patients’ needs and assess the best practice. This would also limit the ‘fear avoidance’ tactic some clinicians opt to use instead of best practice when dealing with a chronic pain patient, as they would be better equipped and educated in the field (Bawa, et al., 2015).

Another recommendation would be the need for a multimodal and multidisciplinary approach to chronic pain. The literature showed that most patients did not respond to a singular intervention on its own. However, it was shown that the majority of the population did respond well to a variation of interventions used in conjunction with each other (Wojcikowski, et al., 2018). This holistic view combines both pharmaceutical approaches and different complimentary therapies to find the best method for that patient’s self-management. There is cause to treat every case/patient separately as each person reacts to different techniques and interventions completely differently (Crowe, et al., 2016). A recommendation would be to identify the correct intervention that suits each individual and to decrease or halt particular treatments that hindered rather than helped the patient (Smith, et al., 2014). The role of the nurse would be to educate the patient on the different approaches available and to work out together which interventions work best for them. Most nurses within the specialist setting are the ones that take the individual through the mindfulness-based therapy programmes in order for the patient to use as a self-management tool. Therefore, - further education for the nurses, especially within the primary care industry, is paramount.

Conclusions

As outlined in Section 4 of this review, the PECOT model redefined my research questions. In response to these questions, there is still not enough evidence to support the effectiveness of mindfulness to treat chronic pain by itself. Evidence for self-management approaches alone were lacking, however when they were used in conjunction with other approaches and combined with a more medical-based treatment, several sources supported the benefit of these complimentary therapies. I believe that more education is needed and more of a focus on the primary care system is required to provide for the patients involved. Further literature and evidence is required; however, we are heading in the right direction in terms of an increase in awareness of the clinical issue. In my opinion, an encouragement process of mindfulness is vital in order for clinicians and patients alike to truly realise its benefits when used effectively. For example, I believe most medical practitioners would benefit from proper chronic pain and mindfulness education to limit the ‘fear avoidance’ notion and to stop the automatic response being to reach for their prescription pads.

References

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Bawa, F. L., Mercer, S. W., & Bond, C. M. (2015). Does mindfulness improve outcomes in patients with chronic pain? Systemic review and meta-analysis. PMC, 1-15.

Bishop, S., Lau, M., & Shapiro, S. (2004). Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practise 11, 230-231.

Crowe, M., Jordan, J., Burrell, B., Jones, V., Gillon, D., & Harris, S. (2016). Mindfulness-based stress reduction for long-term physical conditions: A systemic review. Australian & New Zealand Journal of Psychiatry, 21-25.

de Boer, M. J., Steinhagen, H. E., Versteegen, G. J., Struys, M. M., & Sanderman, R. (2014). Mindfulness, Acceptance and Catastrophizing in Chronic Pain. PLOS one, 1-6.

Lee, A., Harvey, W., Price, L., Morgan , L., Morgan , N., & Wang , C. (2016). The Role of Mindfulness In Relation To Chronic Pain And Psychological Health In Knee Osteoarthritis. Medicine & Science in Sports & Exercise, 48, 1056-1057.

Merskey, H., & Bogduk, N. (1994). Classification of chronic pain: Descriptions of chronic pain syndromes and definitions of pain terms. Seattle: International Association for the Study of Pain.

Smith, B. H., Hardman, J. D., Stein, A., & Colvin, L. (2014). Managing chronic pain in the non-specific setting: A new SIGN guideline. British Journal of General Practise, 1-3.

Sullivan, M., Thorn, B., Haythornthwaite, J., Keefe, F., & Martin, M. (2001). Theoretical perspectives on the relation between catastrophizing and pain. Clin J Pain, 52-54.

Whitehead, D. (2013). Searching and reviewing the research literature. In Z. Schneider, & D. Whitehead, Nursing and Midwifery Research methods and appraisal for evidence-based practice (p. 44). Chatswood, NSQ, Australia: Elsevier.

Wojcikowski, K., Vigar, V. J., & Oliver, C. J. (2018). New concepts of chronic pain and the potential role of complementary therapies. Altern Ther Health Med, 1-2.