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Mind-Body Therapies for Opioid-Treated PainA Systematic Review and Meta-analysis

Educational Objective
To evaluate the association of mind-body therapies (MBTs) with pain and opioid dose reduction in a diverse adult population
1 Credit CME
Key Points

Question  Are mind-body therapies (ie, meditation, hypnosis, relaxation, guided imagery, therapeutic suggestion, and cognitive behavioral therapy) associated with pain reduction and opioid-related outcome improvement among adults using opioids for pain?

Findings  In this systematic review and meta-analysis of 60 randomized clinical trials with 6404 participants, mind-body therapies were associated with improved pain (Cohen d = −0.51; 95% CI, −0.76 to −0.27) and reduced opioid dose (Cohen d = −0.26; 95% CI, −0.44 to −0.08).

Meaning  Practitioners should be aware that mind-body therapies may be associated with moderate improvements in pain and small reductions in opioid dose.


Importance  Mind-body therapies (MBTs) are emerging as potential tools for addressing the opioid crisis. Knowing whether mind-body therapies may benefit patients treated with opioids for acute, procedural, and chronic pain conditions may be useful for prescribers, payers, policy makers, and patients.

Objective  To evaluate the association of MBTs with pain and opioid dose reduction in a diverse adult population with clinical pain.

Data Sources  For this systematic review and meta-analysis, the MEDLINE, Embase, Emcare, CINAHL, PsycINFO, and Cochrane Library databases were searched for English-language randomized clinical trials and systematic reviews from date of inception to March 2018. Search logic included (pain OR analgesia OR opioids) AND mind-body therapies. The gray literature, ClinicalTrials.gov, and relevant bibliographies were also searched.

Study Selection  Randomized clinical trials that evaluated the use of MBTs for symptom management in adults also prescribed opioids for clinical pain.

Data Extraction and Synthesis  Independent reviewers screened citations, extracted data, and assessed risk of bias. Meta-analyses were conducted using standardized mean differences in pain and opioid dose to obtain aggregate estimates of effect size with 95% CIs.

Main Outcomes and Measures  The primary outcome was pain intensity. The secondary outcomes were opioid dose, opioid misuse, opioid craving, disability, or function.

Results  Of 4212 citations reviewed, 60 reports with 6404 participants were included in the meta-analysis. Overall, MBTs were associated with pain reduction (Cohen d = −0.51; 95% CI, −0.76 to −0.26) and reduced opioid dose (Cohen d = −0.26; 95% CI, −0.44 to −0.08). Studies tested meditation (n = 5), hypnosis (n = 25), relaxation (n = 14), guided imagery (n = 7), therapeutic suggestion (n = 6), and cognitive behavioral therapy (n = 7) interventions. Moderate to large effect size improvements in pain outcomes were found for meditation (Cohen d = −0.70), hypnosis (Cohen d = −0.54), suggestion (Cohen d = −0.68), and cognitive behavioral therapy (Cohen d = −0.43) but not for other MBTs. Although most meditation (n = 4 [80%]), cognitive-behavioral therapy (n = 4 [57%]), and hypnosis (n = 12 [63%]) studies found improved opioid-related outcomes, fewer studies of suggestion, guided imagery, and relaxation reported such improvements. Most MBT studies used active or placebo controls and were judged to be at low risk of bias.

Conclusions and Relevance  The findings suggest that MBTs are associated with moderate improvements in pain and small reductions in opioid dose and may be associated with therapeutic benefits for opioid-related problems, such as opioid craving and misuse. Future studies should carefully quantify opioid dosing variables to determine the association of mind-body therapies with opioid-related outcomes.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: August 29, 2019.

Corresponding Author: Eric L. Garland, PhD, Center on Mindfulness and Integrative Health Intervention Development, University of Utah, 395 South, 1500 East, University of Utah, Salt Lake City, UT 84112 (eric.garland@socwk.utah.edu).

Published Online: November 4, 2019. doi:10.1001/jamainternmed.2019.4917

Author Contributions: Dr Garland had full access to all the data and takes full responsibility for the completeness and integrity of the data.

Concept and design: Garland, Hanley, Roseen, Gaylord, Yaffe.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Garland, Brintz, Hanley, Roseen, Gaylord, Yaffe, Fiander, Keefe.

Critical revision of the manuscript for important intellectual content: Garland, Brintz, Hanley, Roseen, Atchley, Gaylord, Faurot, Fiander, Keefe.

Statistical analysis: Hanley, Faurot.

Administrative, technical, or material support: Garland, Roseen, Atchley, Faurot, Yaffe.

Supervision: Garland.

Conflict of Interest Disclosures: Dr Garland reported serving as the director of the Center on Mindfulness and Integrative Health Intervention Development, which provides Mindfulness-Oriented Recovery Enhancement (MORE), mindfulness-based therapy, and cognitive behavioral therapy in the context of research trials for no cost to research participants; receiving honoraria and payment for delivering seminars, lectures, and teaching engagements (related to training practitioners in MORE and mindfulness) sponsored by institutions of higher education, government agencies, academic teaching hospitals, and medical centers; and receiving royalties from the sale of books related to MORE during the conduct of the study Dr Keefe reported a patent pending. No other disclosures were reported.

Funding/Support: Dr Garland was supported by grants R01DA042033 and R61AT009296; Dr Brintz was supported by grant T32AT003378; Dr. Roseen was supported by grant F32AT009272; and Dr Keefe was supported by grants R34DA040954, R01NR013910, and UG3AT009790 from the National Institutes of Health during the preparation of the manuscript.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication.

Additional Contributions: Emilee Naylor, BA, independent research coordinator, assisted with the literature search for an early version of the manuscript. She was compensated for her work.

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