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Original Investigation
November 4, 2019

Mind-Body Therapies for Opioid-Treated Pain: A Systematic Review and Meta-analysis

Author Affiliations
  • 1Center on Mindfulness and Integrative Health Intervention Development, University of Utah, Salt Lake City
  • 2College of Social Work, University of Utah, Salt Lake City
  • 3Program on Integrative Medicine, Physical Medicine and Rehabilitation, University of North Carolina at Chapel Hill, Chapel Hill
  • 4Department of Family Medicine, Boston University and Boston University School of Medicine, Boston, Massachusetts
  • 5Department of Rehabilitation Science, Massachusetts General Hospital Institute of Health Professions, Boston, Massachusetts
  • 6Department of Anesthesiology, Brigham and Women’s Hospital, Harvard University, Boston, Massachusetts
  • 7Independent consultant, Halifax, Nova Scotia
  • 8Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina
  • 9Department of Anesthesiology, Duke University, Durham, North Carolina
  • 10Department of Medicine, Duke University, Durham, North Carolina
JAMA Intern Med. Published online November 4, 2019. doi:https://doi.org/10.1001/jamainternmed.2019.4917
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.

Abstract

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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