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Rothman Opioid Foundation
Oct 57 min read

The Role of Mindfulness-Based Interventions in Reducing Perioperative Pain and Opioid Use

JACOB HEILIZER, BS

Sidney Kimmel Medical College at Thomas Jefferson University


SALONI SHARMA, MD

Rothman Orthopaedic Institute at Thomas Jefferson University


Summary Points

  • Mindfulness-Based Interventions have been shown to decrease perioperative pain and opioid use


  • Implementation of the right Mindfulness-Based Intervention is specific to the clinical context it is delivered in – and this will change depending on a number of factors


  • More research is needed to flush out the best delivery mechanisms for Mindfulness-Based Interventions


Analysis


Background


80% of patients that undergo surgery will experience postoperative pain and fewer than half will report adequate pain relief. Of the half without adequate relief, 88% describe their pain as moderate, severe, or extreme, and 10-50% will develop chronic pain (1). Furthermore, poorly managed surgical pain is associated with impaired function, decreased quality of life, delayed recovery times, higher healthcare costs, and higher opioid use (2). Minimizing opioid use in the postoperative setting is important to reduce the risk of adverse events associated with long-term use such as opioid dependence, fatal and non-fatal overdose, endocrinological harms, cardiovascular events, and trauma (3). 


In addressing alternative methods of pain management, it is important to consider that the individual’s experience of acute or chronic pain is multidimensional and driven by both internal factors (sensation, perception, cognition, etc.) and external factors (social setting, environment, culture, etc.) (4). As a result, pain is not solely a biologic experience and psychosocial interventions can reduce its burden in the postoperative context. 




Figure 1. Biopsychosocial factors of the pain experience. SEE ARTICLE from Adams LM, Turk DC. Central sensitization and the biopsychosocial approach to understanding pain. Journal of Applied Biobehavioral Research. 2018 Jun;23(2):e12125.



To this end, mindfulness – a cognitive state typically defined as non-judgmental awareness to the present moment – has been utilized by modern medical practices to address the psychosocial aspect of pain management (5). Mindfulness-Based Interventions (MBIs) such as Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT) are typically delivered over 8 weeks in a group setting and train participants in a variety of meditation techniques, including mindful breathing and body scan meditations (4). Similar interventions like Dialectical Behavior Therapy (DBT) and Acceptance and Commitment Therapy (ACT) have also gained popularity but differ from traditional MBIs in that mindfulness meditation is offered as one module within a larger repertoire of other techniques (5). Mindfulness-Oriented Recovery Enhancement (MORE) is an MBI that was designed specifically for individuals with chronic pain on long-term opioid therapy. MORE combines mindfulness with reappraisal (reinterpreting stressful events) and savoring (putting attentional awareness on positive emotions and body experiences) (4). 


Analysis


While a growing body of evidence links MBIs to improved chronic pain and reduced opioid use in non-surgical patients, a relatively smaller number of studies likewise demonstrate promising outcomes for MBI use with surgical patients (6). One study examining the effects of MBIs on pain surrounding Total Joint Arthroplasty (TJA) revealed that a single 15-minute mindfulness meditation session was effective in significantly reducing preoperative pain, anxiety, and unpleasantness. Following TJA, these patients also exhibited improved physical functioning and a 35% decrease in desire for pain medication at 6-weeks follow-up (7). Pester et al. showed a similar reduction in pain at 6-weeks follow up after Total Knee Arthroplasty though no difference was noted between the MBCT group and control at 3 months (8). In another study, patients who watched a relaxation and breathing video demonstrated decreased narcotic consumption at 2 weeks status post Arthroscopic Rotator Cuff Repair compared to the control group (9). Significant reductions in pain scores were also seen in patients who utilized MBIs while undergoing hysterectomies (10), breast surgery (11), and laparoscopic cholecystectomies (12).


One study investigated how patient outcomes varied with the subject of the patient’s mindfulness. Mindfulness of breath (MoB) was found to decrease preoperative pain scores more effectively while mindfulness of pain (MoP) was more effective in decreasing postoperative pain intensity. Both techniques reduced postoperative opioid use compared to cognitive behavioral therapy (13). 


While the exact process by which mindfulness leads to pain reduction is unknown, one proposed mechanism is by a reduction in pain catastrophizing. Pain catastrophizing is “characterized by the tendency to magnify the threat value of pain stimulus and to feel helpless in the context of pain” (14) and is a risk factor for acute postoperative pain and excessive opioid use (15). Roberts et al. propose that by being mindful, practitioners can experience the sensation of pain without the magnified threat and helplessness felt during catastrophizing (4). The Pester et al. study found that pain catastrophizing indeed accounted for the difference in outcomes between their MBI and control groups (8). 


Discussion


Inconsistencies in the literature demand further clarification of the role of MBIs and mindfulness in the perioperative setting. Differences in the interventions, their delivery, the type of surgical procedure, and the objective measurement of subjective pain experiences all contribute to the challenge in comparing results. Additionally, the literature is mainly composed of studies with small sample sizes lacking generalizability. There remains a need for larger randomized controlled trials with generalizable results that can be used to develop guidelines. Several large trials are currently underway seeking to further elucidate which surgical patient populations may benefit from pain management with mindfulness, including those receiving total knee arthroplasty (16), breast cancer surgery (17,18), and cardiac surgery (19).   


Another barrier to the wider implementation of MBIs in the perioperative context is the timing and staffing requirements for such a robust intervention. To improve the feasibility for providers, Roberts et al. describe a mindfulness-based stepped-care approach that employs brief mindfulness exercises to diminish preoperative pain and anxiety and to prevent development of postoperative chronic pain or opioid use disorder (4). This stepped care framework offers a readymade pathway for providers to embed mindfulness in the surgical course and allows providers to increase the intervention intensity based on the needs of individual patients (4). Patients who are deemed to be at risk for developing chronic pain or opioid use disorder can be referred to a more targeted MBI like MORE. 



Figure 2. A stepped care approach to mindfulness-based interventions SEE ARTICLE from (4)


Effective methods of delivery also require further investigation. Virtual reality has been seen to be a feasible means of delivering mindfulness-based therapy with little burden on providers (20, 21). Similarly, a study that administered ACT via a mobile app demonstrated a reduction in both pain and opioid use for orthopedic trauma patients, offering another potential route of delivery (22).  


Overall, for MBIs to be fully accepted into regular perioperative procedure, there needs to be more high-powered studies comparing different MBIs, their timing and feasibility, and the role that the index procedure plays on outcomes. Regardless, certain medical bodies, including the American Academy of Orthopaedic Surgeons (AAOS), have identified the need for stress reduction in the post-operative setting and point to MBIs as a tool to be leveraged by physicians (23). As physicians expand their toolkits, the inclusion of MBIs represents a low-risk intervention that improves patient experience and has the potential to lessen pain, reduce opioid use, and improve function. 




Bibliography 

14. Quartana PJ, Campbell CM, Edwards RR. Pain catastrophizing: a critical review. Expert Rev Neurother. 2009;9(5):745-758. doi:10.1586/ern.09.34

15. Katz J, Weinrib AZ, Clarke H. Chronic postsurgical pain: From risk factor identification to multidisciplinary management at the Toronto General Hospital Transitional Pain Service. Can J Pain. 2019;3(2):49-58. doi:10.1080/24740527.2019.1574537

23. Postoperative Risk Factors. Accessed July 17, 2023. https://www.aaos.org/quality/quality-programs/quality-toolkits/stress-reduction/





 


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