Mindfulness-Based Cognitive Therapy for Chronic Pain

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1 Mindfulness-Based Cognitive Therapy for Chronic Pain Work Wellness Disability Prevention Institute Webinar January 29, 2018 Melissa A. Day, Ph.D.

2 Objectives 1 Background on chronic pain 2 Describe the basic tenants of MBCT theory 3 Use mindfulness for self-care to prevent burnout 4 Understand how to administer groupbased MBCT for pain 5 Summarize the effects & mechanisms of MBCT for pain

3 Pfizer Australia, 2011; Walker, Muller, Grant, 2004 Epidemiology Affects 3.2 million Australians Low back pain & headache = most prevalent conditions Costs $34.4 billion annually

4 Institute of Medicine, 2011; National Centres for Health Statistics for Health Statistics 2013 Pain Treatment Opioids most common tx In U.S., opioid misuse = healthcare crisis Between : 300% increase in opioid consumption Death rates for opioid poisoning tripled >16,000 opioid involved overdose deaths in 2010

5 Day, 2016; Eccleston, Palermo, et al., 2009 Psychosocial Tx As effective as surgery & medication CBT considered 1 st line tx option Evidence for Mindfulness-Based Interventions rapidly increasing

6 In Focus: MBCT Theory

7 Day, M.A. Mindfulness Based-Cognitive Therapy for Chronic Pain: A Clinical Manual & Guide, Wiley, 2017 Goals & Themes Aim freedom from pain Aim = freedom from the extra baggage Approach is non-striving, emphasizes: Non-judgmental attitude Kindness

8 Day, M.A. Mindfulness Based-Cognitive Therapy for Chronic Pain: A Clinical Manual & Guide, Wiley, 2017 Why MBCT? Cognitive exercises facilitate awareness of: 1 Stressful/pleasant events 2 Patterns of automatic thoughts 3 Idea that thoughts fact 4 Nourishing/depleting activities

9 Day, M.A. Mindfulness Based-Cognitive Therapy for Chronic Pain: A Clinical Manual & Guide, Wiley, 2017 Why MBCT? (cont.) Mindfulness Meditation (MM) facilitates: 1 Awareness of the nature of thoughts, emotions, sensations; 2 Learning how to respond vs. react; 3 Decreased stress response

10 How this Applies to Self-Care

11 Practitioner Burnout Burnout is common among therapists Rates: 25%-60%, & up to 75% in one study Shanefelt, Bradley, Wipf, Back, 2002; Wallace, Lemaire, Ghali, 2009 Burnout leads to: Depression Anxiety Low mental quality of life High career turnover Dunn, Iglewicz, Moutier, 2008; Shanafelt, Oreskovich, Dyrbye et al., 2012

12 Prevention > Cure Self awareness = optimal functioning To improve self-awareness: mindfulness An 8-week MM training with physicians (N=70) led to improved: Mindfulness Burnout symptoms Mood disturbance & stability Conscientiousness Krasner, Epsteain, Beckman et al., 2009, JAMA See Norcross, 2000, Prof Psychol: Research and Practice for a great overview of practitioner tested, research informed self-care strategies

13 MBCT for Chronic Pain Protocol

14 Day, M.A. Mindfulness Based-Cognitive Therapy for Chronic Pain: A Clinical Manual & Guide, Wiley, 2017 Tx Structure Typically group delivered Manualized 8 x 2-hour in-person sessions At home daily guided MM practice & CBT exercises

15 Day, M.A. Mindfulness Based-Cognitive Therapy for Chronic Pain: A Clinical Manual & Guide, Wiley, 2017 Importance of Practice At home MM practice is key Homework: 1 Guided MM practice 2 Brief cog-behavioural exercises 3 Reading materials/handouts

16 Day, M.A. Mindfulness Based-Cognitive Therapy for Chronic Pain: A Clinical Manual & Guide, Wiley, st Half of MBCT Session 1: Gate Control; Automatic Pilot; Raisin; Body Scan; 3-min Breathing Space*; Session 2: Body Scan; HW review**; Exploring Thoughts & Feelings Connection; Stress-Pain-Appraisal Connection & ABC model; Awareness of Pleasant Events Session 3: Mindful Seeing/Hearing Exercise; MM of Breath & Body; Awareness of Stressful Events Session 4: MM of Sounds & Thoughts; Unhelpful Habits of Mind; Mindful Movement, Mindful Walking *3-minute Breathing Space is a part of all subsequent sessions **Homework review is a part of all subsequent sessions

17 Day, M.A. Mindfulness Based-Cognitive Therapy for Chronic Pain: A Clinical Manual & Guide, Wiley, nd Half of MBCT Session 5: Silent Practice; Steps towards increasing Acceptance; MM of Breath, Body, Sounds & Thoughts* Session 6: MM of Breath, Body, Sounds & Thoughts*; Moods, Thoughts, & Alternative Views; Identifying Red Flags for Rising Stress-Pain Thermostat; Maintenance Session 7: MM of Breath, Body, Sounds & Thoughts*; Links Between Activity & Mood; Relapse Prevention Session 8: Body Scan; Relapse Prevention Plan Discussion; Course Review Mindfulness Knapsack; Concluding MM *This practice also includes instruction on how to work with difficulties

18 Day, M.A. Mindfulness Based-Cognitive Therapy for Chronic Pain: A Clinical Manual & Guide, Wiley, min Breathing Space Three basic steps: 1 Awareness 2 Gathering 3 Expanding Let s practice

19 Guided MM Resources Provided in my book, Also UCSD Center for Mindfulness UCLA Mindful Awareness Research Center

20 The Efficacy of Mindfulness-Based Cognitive Therapy for Headache Pain Research Funded by Grants from the: Anthony Marchionne Foundation ClinicalTrials.gov Pre-Registration ID: NCT

21 Day, Thorn, Ward et al., 2014, Clinical Journal of Pain, 30(2) Pilot Trial Design: Randomised Controlled Trial MBCT vs. Wait List (WL) Control Sample: Adult, Primary Headache Pain diagnosis, N=36 Primary outcomes pain related variables Secondary outcomes cognitive variables

22 Day, Thorn, Ward et al., 2014, Clinical Journal of Pain, 30(2) Results Intensity (d=.80) Interference (d=1.29**) Pain Cat (d=.94*) Acceptance (d=1.22*) Self-Efficacy (d=1.65***) *p<.05, **p<.01, ***p<.001

23 Other Studies: Parra-Delgada, P.M., Latorre-Postigo. (2013). Effectiveness of Mindfulness-Based Cognitive Therapy in the Treatment of Fibromyalgia: A randomised Trial. Cog Ther Res, 37. Dowd, H. et al. (2015). Comparison of an online mindfulness-based cognitive therapy intervention with online pain management psychoeducation: A randomized controlled pilot study. Clin J Pain, 31. Mansourishad, H., et al. (2017). Effectiveness of mindfulness-based cognitive-behavioral therapy on relieving migraine headaches. Arch Neurosci, 4.

24 Coping Skills Training for Living with Chronic Low Back Pain: Preliminary Results Research Funded by: ClinicalTrials.gov Pre-Registration ID: NCT ; Australian & New Zealand Clinical Trials Registry ID:

Outcome: Pain Interference ClinicalTrials.

25 Comparative Trial - Design: Randomized Controlled Trial - CT vs. MM vs. MBCT - Sample: Adult, Chronic Low Back Pain - N=69 (ITT sample) - Primary Outcome: Pain Interference ClinicalTrials.gov Pre-Registration ID: NCT ; Australian & New Zealand Clinical Trials Registry ID:

26 Pain Interference ns MM (n=23): d = 1.00 CT (n=23): d =.58 MBCT (n=23): d = Sig. Time effect, F(1,66)=43.86, p < Non-sig. Time x TX interaction, F(2,66)=.65, p =.52

27 Pain Intensity ns MM (n=23): d =.25 CT (n=23): d =.43 MBCT (n=23): d =.69 - Sig. Time effect, F(1,66)=14.26, p < Non-sig. Time x TX interaction, F(2,66)=1.90, p =.16

28 The Current Mechanism Evidence

29 Simplified Model

30 Day, Jensen, Ehde, Thorn, 2014, Journal of Pain

31 Jensen, Day, & Miró, 2014, Nature Reviews Neurology Effects of MM on Neuromodulation Increased grey matter Associated with decreased pain sensitivity Decreased activation in somatosensory cortices Reduced pain processing lower pain intensity Alpha activity, increased power Decreased anxiety, increased calm & positive affect Theta activity, increased power Heightened attention, reduced sympathetic nervous system activity

32 So there are a lot of possibilities

33 Conclusions

34 Conclusions MBCT is based on a rich theoretical tradition Evidence for MBCT for pain treatment is building Also useful for your own use to: Prevent Burnout Perform optimally Enhance mental health & QoL

35 Conclusions In the last several decades, great strides have been made Despite all these advances, many patients continue to endure unremitting, disabling chronic pain We still have more work to do!

Acknowledgments Prof. Beverly Thorn, Ph.D. The University of Alabama Prof. Mark Jensen, Ph.D. The University of Washington Prof. Dawn Ehde, Ph.D. The University of Washington Prof. John Burns, Ph.D. Rush University Medical Center Hon.

36 Acknowledgments Prof. Beverly Thorn, Ph.D. The University of Alabama Prof. Mark Jensen, Ph.D. The University of Washington Prof. Dawn Ehde, Ph.D. The University of Washington Prof. John Burns, Ph.D. Rush University Medical Center Hon. Prof. Chuck Ward, Ph.D. The University of Queensland Prof. Jason Mattingley, Ph.D. The University of Queensland Dr. Natasha Matthews, Ph.D. The University of Queensland Prof. Amanda Barnier, Ph.D. Macquarie University The Anthony Marchionne Foundation

37 Thank you Questions? Comments? Feel free to contact me:

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