Where: University of Utah Hospital, a 528-bed facility in Salt Lake City.
The issue: Treating inpatients who report intolerable pain or inadequate pain control.
While the analgesic effects of mind-body therapies like hypnosis were established decades ago, more recent pain research has shown benefits of mindfulness, a state of focus on the present moment where one perceives and accepts one's feelings, thoughts, and sensory experiences. After studying the positive effects of multiweek mindfulness-based interventions for chronic pain, licensed clinical social worker Eric Garland, PhD, wondered if mindfulness might also be effective for relieving acute pain in the hospital. “But to my knowledge, there's been no work done on mindfulness in that setting,” he said, adding that there is also a pressing need for nonpharmacological adjuncts to pain management.
So Dr. Garland and his research group conducted a randomized controlled trial testing the effects of three 15-minute interventions on patients who reported intolerable pain or inadequate pain control: mindfulness meditation, hypnotic suggestion, and a psychoeducational control. He provided about three hours of training in these techniques to hospital social workers, who delivered them to 244 patients using standardized scripts.
How it works
Patients who received the mindfulness intervention were taught to accept their pain experience by focusing on their breathing before attending to their bodily sensations in a nonreactive manner, said Dr. Garland, professor and associate dean for research at the University of Utah College of Social Work. “If at any point the patient felt overwhelmed by sensation, they could always return the focus of their attention back to the breath as a means of recentering themselves,” he said.
In contrast, in the hypnotic suggestion intervention, clinicians guided participants into a relaxed state of mind and then asked them to imagine sensations of warmth or coolness being superimposed over the pain, said Dr. Garland, who also directs the university's Center on Mindfulness and Integrative Health Intervention Development.
The psychoeducational intervention, which served as a control, involved a discussion of the range of pain-coping strategies patients could use to gain better control of their pain. “During that interaction, the social worker displayed empathy and interest in the patient and a caring attitude,” he said.
Patients who received the mindfulness or suggestion techniques reported significantly lower pain severity than those in the education group, according to results published in the October Journal of General Internal Medicine. The mean reduction in pain intensity ratings was 23% in the mindfulness group, 29% in the suggestion group, and 9% in the education group. The numerically greater improvement with hypnotic suggestion versus mindfulness was not statistically significant but could possibly have reached significance had the sample been bigger, Dr. Garland noted.
About one-third of patients receiving one of the two mind-body techniques were able to achieve at least a 30% degree of pain relief, a level which is considered moderately clinically significant in the literature and, in the paper, is compared to the effect of 5 mg of oxycodone.
Before the project, Dr. Garland had been dubious that a brief 15-minute session of a scripted mind-body intervention could significantly reduce pain. “I was really surprised when I saw the robust effects, especially given that it was being delivered by people with only a modest amount of training,” he said.
The biggest challenge was the frenetic nature of the hospital environment. “We would go to a patient's room to deliver a therapy, and then they wouldn't be there because they'd be in surgery, for example,” Dr. Garland said. It was remarkable that patients could achieve pain relief in the midst of beeping machines and people continually entering and exiting their rooms, he added. “It's an oftentimes stressful environment, and in the middle of that context, patients were able to learn these mind-body skills to achieve significant relief,” said Dr. Garland.
University of Utah Hospital has not integrated mindfulness training or hypnotic suggestion into standard care, but this study was an important step in that direction, according to Dr. Garland. “Should these results be replicated, this is the kind of thing that really should be available at medical facilities all throughout the country,” he said. “It's 15 minutes of a social worker's time, so these mind-body interventions are quite low cost and feasible to implement.” The interventions are safe and provide skills that patients can take home and learn to practice on their own, Dr. Garland added.
He plans to replicate this study on a national scale involving multiple hospitals to more definitively determine the efficacy of mindfulness versus hypnotic suggestion and identify patient subgroups that might benefit most from these therapies. Dr. Garland is also interested in assessing whether there is a dose-response relationship between practice of mind-body techniques and degree of analgesia achieved, he said.