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The review of 21 clinical trials involving nearly 2,000 people looked at the effects of two drug-free options for chronic pain: cognitive behavioral therapy (CBT) and a program called mindfulness-based stress reduction (MBSR). It combines meditation and gentle yoga postures.
In general, patients fared better with either therapy than with no treatment or with standard care, including pain medication.
Experts said the results point to the value of drug-free alternatives for dealing with chronic pain. That's especially important in the context of the current opioid crisis, said Dr. Muhammad Hassan Majeed, a psychiatrist at Natchaug Hospital in Mansfield Center, Conn.
Majeed, who was not involved in the new report, has published his own reviews of the evidence for mindfulness and other non-drug approaches for chronic pain.
The bottom line, he said, is that there is no "one-size-fits-all" treatment. Instead, there is a range of potentially effective options that people can try.
"Medication is not the only one," Majeed said.
That's not a controversial message. Guidelines for managing chronic pain -- from the U.S. Centers for Disease Control and Prevention and other groups -- already discourage doctors from prescribing opioids for most people. They also stress that non-drug choices -- from physical therapy to psychological approaches like CBT -- should be among the "preferred options."
Why would psychological therapies help? Because chronic pain is not purely physical, Majeed said. There is an emotional component, he explained, and the ways people perceive and respond to their pain are crucial.
CBT helps people change their habitual thought patterns and reactions around their pain, according to Majeed. Mindfulness practices, like meditation, have a similar goal: The typical definition of mindfulness is to focus on what's happening in the moment, rather than letting the mind spin off.
Right now, CBT is the most widely used psychological approach to treating chronic pain, said Wei Cheng, one of the researchers on the review.
Only one study in the review directly compared CBT with mindfulness-based stress reduction. So it's not clear whether mindfulness is as effective as CBT, said Cheng, of the Ottawa Hospital Research Institute in Ontario, Canada.
But, he added, not everyone who tries CBT for chronic pain finds it helpful. Mindful practices offer "an alternative and potentially helpful approach," he said.
The review, published Jan. 31 in Evidence Based Mental Health, pulled together 21 clinical trials. Thirteen compared CBT against a "control" -- either no treatment or standard therapies like pain medication. In each study, CBT patients had eight to 12 group sessions with a therapist.
In seven trials, patients were randomly assigned to either MBSR or a control group. MBSR involved eight to 12 weekly sessions with a therapist trained in the program -- along with 45 minutes of daily home practice.
Overall, Cheng's team found, patients who received either CBT or MBSR typically fared better than the control group. They reported more improvements in pain intensity, physical functioning and depression symptoms.
On average, those effects were "small," however, the researchers noted.
But that's to be expected, according to Majeed. He said patients vary widely in how much relief they get from CBT or mindfulness -- in part, because of the motivation it takes to incorporate what they learn into daily life.
Plus, Majeed said, while these approaches can help people manage their pain and "feel better," they won't erase the pain.
For any one person, the choice of whether to try CBT or MBSR will partly depend on personal preferences, according to Majeed. But there are also practical matters, he added, including availability of therapists and insurance coverage.
MBSR is a specific program. But its components -- mindfulness meditation and gentle yoga -- are available in many formats.
An important thing to keep in mind, Majeed noted, is that these approaches do not produce instant relief.
"It takes time to heal, and to adopt a new lifestyle," he said.
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