Ronald D. Siegel, Psy.D.

Center for Mindfulness and Compassion

Cambridge Health Alliance Harvard Medical School

Tuesday, September 8, 2020

12:00 – 1:00 PM EDT

Mindfulness for Chronic Pain & Opiate Dependence

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Meet Our Speaker

Ronald Siegel, PsyD.

• Assistant Professor of Psychology,

part-time, at Harvard Medical School,

Cambridge Health Alliance,

• Dr. Siegel is a longtime student of

mindfulness meditation and is a faculty

and board member at the Institute of

Meditation and Psychotherapy.

• He teaches internationally about

mindfulness and psychotherapy and

mind-body treatment, while maintaining

a private practice in Lincoln,

Massachusetts.

• His books include The Mindfulness

Solution, Wisdom and Compassion in

Psychotherapy, and Mindfulness and

Psychotherapy.

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Disclosures

• I have no financial relationships with an ACCME

defined commercial interest

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Learning Objectives

By the end of this presentation, attendees will be able to:

1. Identify the core components of mindfulness practices and

mechanisms of therapeutic action.

2. Describe cognitive, affective, and behavioral components of

chronic pain cycles and how mindfulness practices can help

interrupt them.

3. Examine how mindfulness practices can disrupt or address the

common patterns of dependent behavior.

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Chronic Back Pain

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Bad Back?

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The Orthopedic Story

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What’s the Evidence?

• 2/3 of people who have never suffered from

serious back pain have the same sorts of

“abnormal” back structures that are often blamed

for the pain

• Millions of people who suffer from chronic back

pain show no “abnormalities” in their backs

• Many people continue to have pain after

“successful” surgical repair

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“Smoking Gun” Studies

• What countries have chronic back pain

epidemics?

• Who gets chronic back pain?

• What is the quickest way out of acute back pain?

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Autonomic Nervous System

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HPA Axis

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A Well-Adjusted Brain

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Cartesian Model of Pain

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Cold Pressor Test

Liu, X., Wang, S., Chang, S., Chen, W., & Si, M. (2012) Effect of brief mindfulness

intervention on tolerance and distress of pain induced by cold-pressor task. Stress Health,

Sept 7

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Gate Control Models of Pain

• Pain is not proportional to extent of tissue damage

• Pain is exacerbated by fear

• Chronic back pain is thus due to both effects of

muscle tension and increased sensitivity to pain

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Not Imaginary Pain

• While psychological stressors of all types can

contribute to chronic back pain, the pain is

not imagined or “All in the head”

• Caused by real muscle tension and

amplification of pain signals by fear

• Patients need to hear this repeatedly

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Mindfulness for Rehabilitation

1. Medical Evaluation

2. Cognitive Restructuring

3. Resuming Normal Activity

4. Working with Negative Emotions

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Mindfulness

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Therapeutic Mindfulness

1. Awareness

2. Of present experience

3. With loving acceptance

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Adapting Practices

Centrality of culture

• Racial, ethnic, and religious

identity

• Secular vs. religious

presentations of mindfulness

practice

• Adaptations for personal and

cultural trauma history

Burnett-Zeigler, I., Schuette, S., Victorson, D., & Wisner, K. L. (2016). Mind-body approaches to

treating mental health symptoms among disadvantaged populations: a comprehensive review.

Journal of Alternative & Complementary Medicine, 22, 115–124

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(Pain) x (Resistance) = Suffering

• Pain can be observed to be separate from “suffering”

• Apparently solid pain states are observed to be like frames in a movie, ever-changing

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Pain is Inevitable,

Suffering is Optional

Suffering Includes:

• Grimacing, wincing, bracing.

• Aversive thoughts.

• Wishes for relief.

• Self-punitive thoughts.

• Anger, fear, depression regarding condition.

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Mindfulness for Experimentally Induced Pain

Compared to novices, Experienced Meditators:

• find pain less unpleasant

• can observe pain less reactively

• find that open monitoring reduces pain

unpleasantness

• have less anticipatory pain anxiety

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Insula

• Associated with

interoception

• Visceral and “gut” feelings

• Processes transient body

sensations

• Activated during meditation

practice

Craig, A. D. (2009). How do you feel—now? The anterior insula and human awareness.

Nature Reviews Neuroscience, 10(1), 59-70.

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Prefrontal Cortex (PFC)

Evaluates emotional responses and regulates emotion

• “Yes, looks like a lion, but lions aren’t found here,

so it’s probably a beige rock”

Lutz, A., McFarlin, D. R., Perlman, D. M., Salomons, T. V., Davidson, & R. J.

(2012). Altered anterior insula activation during anticipation and experience of

painful stimuli in expert meditators. NeuroImage, Sept 19.

doi:10.1016/j.neuroimage.2012.09.030

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Neurobiology of Mindfulness and Pain

Meditators practicing mindfulness when

exposed to pain:

• had decreased activity in the lateral

prefrontal cortex (lPFC) – evaluates

sensation

• had increased activation in the posterior

insula – registers sensation

Gard, T., Hölzel, B. K., Sack, A. T., Hempel, H., Lazar, S. W., Vaitl, D., & Ott, U. (2012).

Pain attenuation through mindfulness is associated with decreased cognitive control

and increased sensory processing in the brain. Cerebral Cortex, 22(11), 2692-2702.

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Mindfulness & Cognitive

Restructuring

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Enhancing Metacognitive Awareness

• Notice prevalence of anxious thought and

feeling

• Notice future-oriented catastrophizing

• Notice “budgeting” activity

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Mindfulness & Resuming

Normal Life

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Creative Hopelessness

• Attempts to get rid of pain intensify and

perpetuate disorder

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Relinquishing Control

• Letting go of quest to fix

alleviate pain

• Useful to control behavior

• Impossible to control

sensations

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Resuming Lost Activities

• Exposure and response

prevention central to

treating kinesiophobia

• Resume activities often

enough to be convinced

that they are not

damaging

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The Importance of Exercise

• Strength, flexibility, and

endurance training

• To treat kinesiophobia

• To rehabilitate muscles

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Increasing Symptom Tolerance

• Pain as object of

awareness

• Bring attention to wider

area if necessary

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Mindfulness & Working

with Negative Emotions

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Opening to Painful Emotions

• Experiential avoidance increases anxiety &

muscle tension

• Mindfulness practice

• Enhances interoception

• Develops affect awareness and tolerance

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Other Pain Disorders

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Same 4 Steps

1. Medical Evaluation

2. Cognitive Restructuring

3. Resuming Normal Activity

4. Working with Negative Emotions

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Is it Serious?

• Danger of insufficient response to distress

• Neglecting medical evaluation and treatment

• Danger of excessive response to distress

• Maladaptive pursuit of pain relief

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Mindfulness for Opiate

Use Disorder

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We’re All Addicts

• Most behavior is

compulsive

• Seeking pleasure

• Reducing pain

• Don’t notice unless we

pay attention

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Adapted from Judson Brewer, MD PhD, Yale School of Medicine

Addictive Loop

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How Can Mindfulness Help?

• Cultivating acceptance of changing experience

• Learning to tolerate negative emotional states and not take relapses personally

• No longer believing in our thoughts

• Practicing experiential approach

Bowen, S., Witkiewitz, K., Clifasefi, S. L., Grow, J., Chawla, N., Hsu, S. H., et al. (2014). Relative efficacy of mindfulness-based relapse prevention, standard relapse prevention, and treatment as usual for substance use disorders: a randomized clinical trial. Journal of the American Medical Association Psychiatry, 71, 547–556

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Breaking Free

• Notice sensation

• Notice impulse

• Watch impulse wax &

wane

• Be conscious of

movement

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Exposure Treatment

• Mindfulness practice develops distress tolerance

• Allows us to bear experience

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For back pain worksheets, visit:

www.backsense.org

For recorded meditations, visit:

www.mindfulness-solution.com

Email: rsiegel@hms.harvard.edu

Additional Resources

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Additional References

• Cherkin, D. C., Sherman, K. J., Balderson, B. H., Cook, A. J., Anderson, M. L., Hawkes, R. J., et al. (2016). Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: A randomized clinical trial. Journal of the American Medical Association, 315, 1240–1249.

• Day, M. A., Thorn, B. E., Ward, L. C., Rubin, N., Hickman, S. D., Scogin, F., & Kilgo, G. R. (2014). Mindfulness-based cognitive therapy for the treatment of headache pain: a pilot study. The Clinical Journal of Pain, 30, 152–161

• Garland, E. L., Roberts-Lewis, A., Tronnier, C. D., Graves, R., & Kelley, K. (2016). Mindfulness-oriented recovery enhancement versus CBT for co-occurring substance dependence, traumatic stress, and psychiatric disorders: proximal outcomes from a pragmatic randomized trial. Behaviour Research and Therapy, 77, 7–16.

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Additional References

• Hölzel, B. K., Carmody, J., Evans, K. C., Hoge, E. A., Dusek, J. A., Morgan, L.,… & Lazar., S.W. (2010). Stress reduction correlates with structural changes in the amygdala. Social Cognitive and Affective Neuroscience, 5, 11-17.

• Schutze, R., Rees, C., Preece, M., & Schutze, M. (2010). Low mindfulness

predicts pain catastrophizing in a fear-avoidance model of chronic pain. Pain, 148(1), 120-127.

• Siegel, R. D. (2015). Mindfulness in the treatment of trauma-related chronic pain. In V. Follette, J. Briere, J. Hopper, D. Rozelle, & D. Rome (Eds.), Contemplative methods in trauma treatment: Integrating mindfulness and other approaches. New York, NY: Guilford.

• Zeidan, F., Gordon, N. S., Merchant, J., & Goolkasian, P. (2010). The effects of brief mindfulness meditation training on experimentally induced pain. The Journal of Pain: Official Journal of the American Pain Society, 11(3), 199-209

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PCSS Mentoring Program

PCSS Mentor Program is designed to offer general information to clinicians

about evidence-based clinical practices in prescribing medications for opioid

use disorder.

PCSS Mentors are a national network of providers with expertise in addictions,

pain, evidence-based treatment including medications for addiction

treatment.

• 3-tiered approach allows every mentor/mentee relationship to be unique and

catered to the specific needs of the mentee.

• No cost. For more information visit:

https://pcssNOW.org/mentoring/

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PCSS Discussion Forum

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PCSS is a collaborative effort led by the American Academy of Addiction

Psychiatry (AAAP) in partnership with:

Addiction Technology Transfer Center American Society of Addiction Medicine

American Academy of Family Physicians American Society for Pain Management Nursing

American Academy of Pain Medicine Association for Multidisciplinary Education and Research in

Substance use and Addiction

American Academy of Pediatrics Council on Social Work Education

American Pharmacists Association International Nurses Society on Addictions

American College of Emergency Physicians National Association for Community Health Centers

American Dental Association National Council for Behavioral Health

American Medical Association The National Judicial College

American Osteopathic Academy of Addiction Medicine Physician Assistant Education Association

American Psychiatric Association Society for Academic Emergency Medicine

American Psychiatric Nurses Association

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Funding for this initiative was made possible (in part) by grant no. 1H79TI081968 from SAMHSA. The views expressed in written conference materials or publications and

by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial

practices, or organizations imply endorsement by the U.S. Government.