Americans often seek pain relief from a pill, with some 5 million to 8 million using opioid painkillers to ease their pain, according to a 2015 report from the National Institutes of Health (NIH). That number has greatly increased, from 76 million prescriptions in 1991 to 219 million in 2011.

But medication doesn’t work for everyone, and the number of people addicted to or overdosing on painkillers has been rising, that report says. Surgery, another treatment option for some types of pain, is expensive, often ineffective and can require a long recovery. Meanwhile, research suggests that chronic pain is a complex condition that involves emotions, including stress and anxiety, perceptions and social influences.

In light of these insights, a number of government agencies are launching a national pain strategy to overhaul the research, prevention and treatment of chronic pain (see sidebar). The strategy calls attention to chronic pain’s crippling impact on public health, and maps coordinated, comprehensive care that better addresses each person’s experience of it, says Linda Porter, PhD, policy advisor for pain at the National Institute of Neurological Disorders and Stroke, who co-chairs the project’s oversight committee. “We’re looking for a multidisciplinary approach and multiple modalities, including complementary medicine, and to find a way to reimburse for those strategies — a way that’s really geared to the biopsychosocial aspects of pain,” she says.

In tandem with this shift, scientists are putting more effort into studying complementary therapies, including hypnosis, meditation and yoga, that may ease pain with fewer side effects and help people manage their own symptoms. Care should be tailored to each person’s needs and a pain treatment plan should involve psychologists, primary-care clinicians and physiotherapists exploring these ways to enhance traditional approaches to pain management, experts say.

“None of these therapies is a cure in itself — it’s a factor of matching people to the best treatment,” says psychologist Mark Jensen, PhD, of the University of Washington department of rehabilitation medicine. “Our findings indicate that there are a number of psychological treatments that can benefit subgroups of people tremendously. In fact, given their overall efficacy and lack of negative side effects, these should probably be considered first-line treatments for many chronic pain conditions.”

The promise of hypnosis

Studies using brain-imaging technology, such as fMRI, PET and EEE, have shown that the experience of chronic pain involves multiple brain areas. As Northwestern University neuroscientist Apkar Vania Apkarian, PhD, wrote in Pain Management in 2011, while acute pain generally activates the somatosensory, insular and cingulate cortical regions, chronic pain primarily activates the prefrontal cortex and limbic systems, areas related to emotion and self-reflection. Also, different types of pain activate different patterns of activity.

Several studies have proven that different hypnotic suggestions can reach all of the brain areas involved in pain processing, an ability that is a boon for treating such a complex problem, according to Jensen and his colleague David Patterson, PhD, at the University of Washington, in a 2014 review in American Psychologist. Brain scans show that suggestions to decrease pain intensity draw a response in some regions, while suggestions that increase acceptance of pain — perhaps by encouraging patients to examine it from a distance or realize that it is temporary — will register in others.

“Hypnosis is one of the most promising things we can offer to retrain the brain’s pain response,” says Patterson.

In addition to pain relief, many study participants report that after hypnosis they experienced such benefits as better sleep, increased relaxation and more energy. Self-hypnosis — and suggestions that it will lead to comfort on demand — help patients practice therapy on their own time.

“These are treatments where patients are taught to fish. They’re given the skills to help themselves,” Jensen says.

That said, researchers are still looking for a clear answer as to how hypnosis reduces pain. People with some level of hypnotizability seem to show a reduction in critical judgment while they’re being induced into hypnosis, accepting suggestions passively and without judgment, Patterson says. Jensen points out there is more theta wave electrical activity in the brain during this stage, suggesting a brain activity pattern that is consistent with response to suggestions.

“It’s as if we can talk directly to the areas of the brain that process pain, dampening the part of the brain that tells us that a suggestion is normally impossible,” Patterson says. “We can see remarkable perceptual changes that wouldn’t be anticipated during a normal, waking state.”

Patterson is also studying how hypnotism could be delivered via virtual reality. He tested a program that combined visual images with cues to relax and suggestions for comfort and pain relief in 21 hospitalized patients recovering from injuries (International Journal of Experimental Hypnosis, 2010). Participants who used the technology reported less pain severity and unpleasantness than those in control groups. Using such a program could help address a significant barrier to the widespread use of hypnosis: the lack of clinicians adequately trained in it, especially for pain management, he says.

Yoga’s meditative moments

Research also suggests that yoga can be an effective pain treatment. A 2013 Clinical Journal of Pain review of 10 randomized trials with 967 people in all, led by Holger Cramer, PhD, of the University of Duisburg-Essen in Germany, found strong evidence that yoga is effective for short-term relief of lower back pain — the most common form of pain — and moderately helpful for longer-term back pain.

Yoga has a number of components that may be helpful, including focused, meditative movement, which can have positive effects on the brain, including changing pain perception, says Catherine Bushnell, PhD, an experimental psychologist and senior investigator at the NCCIH, which devotes about 30 percent of its research budget to studying pain.

According to a study in Cerebral Cortex in 2014, led by Chantel Villemure, PhD, a scientist in Bushnell’s lab, experienced yogis had greater tolerance of pain than a control group of non-yogis and also showed increased gray matter volume and white matter connectivity in the insula, a region known to be involved in pain processing.

In fact, as Bushnell wrote in the journal Pain (2015), yoga and meditation can have opposite structural and functional effects on the brain than chronic pain, which is sometimes associated with accelerated gray matter loss and disrupted white matter integrity. Yoga also involves physical exercise, which research shows may itself improve pain symptoms, she says.

Meanwhile, J. Greg Serpa, PhD, a psychologist and Mindfulness-Based Stress Reduction (MBSR) teacher with the Department of Veterans Affairs (VA) in Greater Los Angeles, teaches chair yoga to immobilized veterans, who do little exercise during the therapy yet report big benefits.

“It’s simply bringing awareness to movement within the body, and learning to be in your body even if it’s hurting. It’s observing the experience as you move and reframing it, looking at how pain sensations wax and wane and trying to get away from thinking, ‘I’m in pain all the time and it’s intractable,'” he says.

According to a survey by Robin Toblin, PhD, and colleagues at the Walter Reed Army Institute of Research (JAMA Internal Medicine, 2014), some 44 percent of combat veterans experience chronic pain and 15 percent use opioids regularly, rates much higher than in civilians. The VA, along with the NCCIH, has put new emphasis on studying complementary pain treatments for veterans to find more effective, less costly therapies that promote self-management. Studies suggest that veterans also welcome them.

“The vets love it,” Serpa says. “They frequently say, ‘I’m in a lot of pain but I’m tired of taking all these pills. What else is there?’ ”

An evidence map of reviews prepared for the VA said that yoga was a reasonable treatment option for chronic back pain, though given pain’s “multidimensional nature,” it may not be enough on its own; patients may also benefit by adding cognitive behavioral therapy to their yoga practice (Evidence Based Synthesis Program, 2014). Yoga showed potential benefits for symptoms of depression as well in that review, an important benefit as depression often goes hand in hand with chronic pain, with one condition exacerbating the other.

Pain drugs may make things worse. In a recent study of 1,176 people taking opioids, conducted by Jenna Goesling, PhD, of the University of Michigan and colleagues, more opioid users reported symptoms of depression compared with those not taking opioids for pain, an association that increased over time (Journal of Pain, 2015). That’s another reason why therapy is an asset, says Beverly Thorn, PhD, chair of the psychology department of the University of Alabama.

“I would argue these folks aren’t being appropriately treated for depression,” she says. “They’re presenting to their primary care clinics and they’re getting opioids. A bonus with the cognitive behavioral therapy [for pain] is that there are no negative side effects and it also works for mental health.”

Mindfulness and self-management

Researchers are also exploring mindfulness interventions for pain management. The therapy most often used and studied is MBSR, an eight-week group course that includes education on stress psychology and physiology, yoga and meditation, and Mindfulness Based Cognitive Therapy, which weaves cognitive therapy, including teaching people to examine links between cognition and behavior, into MBSR. An article by Melissa Day, PhD, of the University of Queensland in Australia, and colleagues in The Journal of Pain(2014) concludes that mindfulness-based interventions have similar effect sizes for reducing pain intensity as other psychosocial interventions, such as cognitive-behavioral therapy.

Like psychotherapy, many studies suggest that mindfulness meditation may bring brain changes that help ease pain over time. (See March Monitor, “Mindfulness holds promise for treating depression.”) Specifically, both cognitive-behavioral therapy and mindfulness are associated with increases in gray matter density and neural activity in the default mode network, an interconnected system that is active during wakeful states of rest. Further, research suggests these treatments increase the size and connectivity of the prefrontal cortex and anterior cingulate gyrus, regions associated with attention, working memory, problem solving, and emotional regulation. There are also reductions in neural activity and gray matter in the amygdala — which is associated with the fight-or-flight stress response, anxiety and post-traumatic stress disorder — and the post-cingulate cortex, which is associated with mind wandering, says Thorn.

Mindfulness-based therapies also emphasize helping people reframe responses to pain rather than promising a cure, she says, adding, “It’s teaching someone how to observe their thoughts or feelings without running away from them or self-medicating.”

That sense of self-mastery may be a balm in itself. For example, Peter la Cour, PhD, a psychologist at the Copenhagen Multidisciplinary Pain Center, tested MBSR in 43 patients with chronic pain. Compared with a control group, participants who practiced mindfulness had significant improvements in vitality, well-being and feeling in control of the pain, as well as fewer symptoms of anxiety and depression — even though their pain did not decrease (Pain Medicine, 2015).

With brain imaging, neuroscientists have been able to see how pain experience involves thoughts and emotions, another reason why a one-size-fits-all biomedically focused treatment like opioids or surgery may fail. A study using fMRI and applied heat on 33 people by Tor Wager, PhD, at the University of Colorado at Boulder, and colleagues, found that pain tapped two different brain responses. One network, which the researchers call the neurologic pain signature, reflected physical pain sensations in a number of brain regions. However, when asked to think about their pain in ways that would decrease or increase it — which were effective — people used another brain process that involved the nucleus accumbens and ventromedial prefrontal cortex, areas linked to evaluation and emotion (PLOS ONE, 2015).

Millions of Americans also use acupuncture for chronic pain, according to the NIH. A meta-analysis of almost 18,000 patients by Andrew Vickers, DPhil, and colleagues at Memorial Sloan-Kettering Cancer Center, found that acupuncture eases back, neck and shoulder pain, as well as chronic headaches and the pain associated with osteoarthritis (Archives of Internal Medicine, 2012). However, the differences in results between real and sham acupuncture were “relatively modest,” the authors report, suggesting that a placebo response or treatment contexts were at work. The personal way we perceive pain is one reason the placebo effect is an important factor in treatment, Bushnell says, be it complementary or traditional. “Even if it’s just a very strong placebo, if some of the mechanisms are based on a psychological state, there’s nothing wrong with that.” (See “Great Expectations” in the May Monitor for more about how placebos work.)

Pain literacy

Research suggests that simply understanding how and why we feel physical pain can also help ease symptoms. A study by Jessica Van Oosterwijck, PhD, a postdoctoral researcher in rehabilitation science at Ghent University, found that an intensive course of information about pain physiology led to reduced pain and worry and increased activity in 15 patients with fibromyalgia compared with a control group (The Clinical Journal of Pain, 2013).

One reason may be because pain education may reduce catastrophizing, which means having very negative beliefs about pain and its consequences and prognosis. Catastrophizing worsens outcomes, according to a number of studies that Judith Turner, PhD, professor of psychiatry and behavioral science at the University of Washington, conducted with colleagues.

“Many patients focus on finding and fixing the source of the pain, but providing education so that the patient can understand how chronic pain involves the brain and spinal cord, not just the parts of the body that hurt, can change the experience of pain,” Turner says.

However, access to such education can be a hurdle for some patients, particularly those living in rural areas or with low literacy. To address that problem, Thorn and Joshua Eyer, PhD, of the University of Alabama, are testing a literacy-adapted pain education program for low-income people with chronic pain and comparing its effectiveness with group cognitive-behavioral therapy. (See the protocol in the Journal of Health Psychology, 2015.) The education-only approach uses simple language and illustrations, without introducing therapy concepts, which may make it more accessible and less intimidating, the authors say. A study showed it reduced pain symptoms as much as behavioral therapy (Pain, 2011).

“[Many] patients don’t get enough time with their providers. They are told they have a chronic pain condition, and then they get a prescription for medication,” says Thorn. “But for some, it may be that education alone is therapeutic.”

Such education — as well as other complementary approaches to pain treatment — requires more integrated care than is generally available in today’s health-care system, experts say.

“The field will advance if more psychologists are involved. The pressure for change needs to come from policymakers and individual patients,” Jensen says, adding, “Ultimately, change will happen because a purely biomedical approach costs money, and it doesn’t work that well.”