Monday, January 27, 2020

Decreasing opioid use with mind-body therapies

Jennifer Middleton, MD, MPH

Decreasing the amount of opioids patients with acute or chronic pain use is often desired, as opioid medications carry a sizable risk of adverse effects, including the risk of addiction. Less well understood, though, has been just how to decrease the amount of opioid pain medication needed without undertreating patients' pain. A recently published systematic review may have the answer; the studied "mental techniques to ameliorate pain" may improve pain and decrease the amount of opioid pain medication patients require.

The researchers' literature search identified 60 articles, including Cochrane meta-analyses, that examined the effect of adding various mind-body techniques (MBTs) to opioid pain medication for patients with either acute or chronic pain. They sought to focus on psychological treatments:
We elected to focus our review on MBTs that primarily use mental techniques because they may be more accessible to people whose mobility is compromised by pain or used for pain relief during inpatient procedures when patients are immobilized.
Most of the included studies were randomized controlled trials. Outcome variables included pain severity, opioid misuse, time to opioid cessation, and amount of opioid use. The most effective modalities were meditation, hypnosis, and cognitive behavioral therapy. Included studies regarding relaxation, guided imagery, and therapeutic suggestion found less consistent benefit for these modalities. The authors included a bias assessment which found most included studies designated an appropriate control group and had a low risk of bias.

Although hypnosis and cognitive behavioral therapy typically require referral to a trained practitioner, patients can engage in simple meditation techniques with only a little guidance. A 2018 FPM article reviews "Five Mobile Apps for Mindfulness," some of which are subscription-based, but all of which include at least some content for free (and Insight Timer, available for iOs and Android, has thousands of free mediations). Mindfulness-based interventions, such as meditation, have shown promise for improving mental health and quality of life in the primary care setting. Most patients are willing to consider alternative treatment modalities after discussion with their primary care physician. Expanding our toolkit for treating pain beyond medication may not only benefit our patients but may also protect them from unnecessary opioids.

There's a recent Curbside Consultation on "Tapering Long-Term Opioid Therapy" and an AFP By Topic on Complimentary and Alternative Medicine that includes a sub-section on Mind-Body Modalities if you've like to read more.