Treating Chronic Pain With Meditation

Sarah Kehoe tried Aleve for her back pain. She tried stretching. She tried yoga. She tried forgetting about it. She tried pain patches. She tried acupuncture. A shot of painkillers into her back. Prescription anti-inflammatory pain patches. Opiates. Surgery. Physical therapy. Heat and compresses. Ignoring it again. Steroids. More opiates. Acupuncture again. She couldn’t sit, stand up straight, lie down on her back. She was weak, had lost muscle tone. She fainted on the subway. Sarah Kehoe, an otherwise healthy 36-year-old woman, a former high school and college athlete, a yogi of 10 years, was falling apart.

Sometime during the summer of 2011, Kehoe doesn’t know exactly when, a disc in her back herniated. After her surgery that September, pain seized hold of her again in the winter: the surgeon said the disc had reherniated slightly. Neither he nor Kehoe wanted to do surgery again, leaving Kehoe to search for other pain management options. Her brother had recently completed a meditation course to treat his depression and bought her a course for Christmas.

In early January 2012, Kehoe stood in the back corner of a barre studio on 29th Street in Manhattan. She and the one other class member listened quietly, each holding a white flower, while their instructor Emily Fletcher sang tranquilly in Sanskrit to begin the initiation ceremony. A ribbon of perfume danced gently off the end of an incense stick in the dim, candlelit room. Peace settled over the studio quickly, despite the calls of actors rehearsing next door bursting through the wall. Kehoe was hinging her last hope on the mantra she was given while the instructor and the other student closed their eyes. Silence swelled in the room and the meditation began.

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Millions of Americans live with chronic pain. The Medical Expenditure Panel Survey, conducted in 2008, approximated 100 million adults are affected by pain, including joint pain and arthritis. Other studies, discounting joint pain and arthritis, estimate chronic pain prevalence at around 15 percent of American adults.

Persistent pain is not only life-altering for the patient, (causing missed worked days or early retirement, traumatic experiences, discomfort, and lack of sleep), but it is extremely costly to the nation. And at this moment, the U.S. has turned its eyes to healthcare cost and management. One article by Darrell Gaskin in The Journal of Pain estimated persistent pain to cost from $560 to $635 billion annually, far exceeding the price of other costly diagnoses such as cardiovascular disease, injury, and cancer. These costs arise from medical expenditures for the pain, as well as for other conditions complicated by pain, and a hindering of the patient’s ability to work or function.

Aside from being costly, pain is difficult to manage. Narcotics are the mainstay for treating pain. Narcotics, also known as opiates, are a class of drug that affects the brain and helps reduce pain, while also producing euphoria. Oxycodone and morphine are both narcotics, as is heroin. While a number of specialists advocate for opiate use for intractable pain, and a growing number of physicians dole out narcotic prescriptions, guidelines for safe prescribing have conflicting recommendations.

With such a large number of patients with chronic pain, and such a large number of narcotics being prescribed, prescription drug abuse is rampant. (So much so that in April 2011 President Obama released a multi-agency plan aimed at reducing the “epidemic” of prescription drug abuse.) Studies show that hydrocodone and oxycodone are by far the most abused prescription drugs in the country.

While narcotics can help patients considerably, many patients on opiates whom I have worked with feel they can’t function as well. They develop a drug high, have cloudy thought processes, and while they do not feel the pain as strongly (many still have pain despite taking drugs), they are not at a their baseline functioning level.

Chronic pain is not the same as the pain you feel from an injury. That’s acute pain—the sensing of tissue damage by nerves. Your body gets injured and you hurt. Chronic pain often, though not always, begins with an injury or tissue damage, but is perpetuated, usually by other factors, long after a reasonable time has passed for the injury to heal. Data have shown that an accurate diagnosis can only be established in approximately one-third of patients with low back pain. The relentless nature of chronic pain suggests that stress, environmental, and emotional effects likely overlay the original tissue damage in an injury, adding to the intensity and tenacity of the pain.

Mental processes can alter sensory phenomena, including pain. This is how war wounds can go unnoticed until after battle, athletes can continue to play with debilitating injuries, or minor traumas can lead to incapacitating pain. As knowledge of the nervous system has expanded and technology allowing scientists to visualize the nervous system has advanced, the last five to 10 years have seen a dramatic increase in the amount of studies focusing on how meditation works.

In hundreds of studies conducted over the past decade, researchers have examined meditation’s effects on people, such as attention regulation, awareness of the body, depression, post-traumatic stress disorder, and addiction. Scientists have also studied the use of meditation as a treatment for pain. In these studies, meditation has been shown to help pain, sometimes significantly, though not cure it.

In research on meditation and pain, scientists have asked two questions: “Does meditation help?” and “How does meditation help?” The first question proved much simpler to answer. A Wake Forest University study conducted by Fadel Zeidan in April 2011 took 15 healthy volunteers and performed MRI scans of their brains while inducing pain. In the four days that followed, a certified instructor taught the subjects mindfulness meditation (in which the pupil is taught to focus on a sense, often his or her breath, while accepting transient thoughts). On the fifth day, the researchers scanned the volunteers again, once while not meditating, and another time while meditating, with pain induced during both sessions. The study showed an approximately 40 percent reduction in pain intensity ratings during meditation when compared with non-meditation.

The study discovered that by activating and reinforcing some areas of the brain used in pain processing, meditation has the overall effect of helping to reduce pain intensity in patients. Other theories on how meditation helps pain exist, including that it decreases stress, which in turn decreases pain. Zeidan explained that meditation has known to be helpful for a while, but he has shown through this study and another conducted in 2010 that it takes much less time to see results than previously thought.

“It worked for beginners,” he said excitedly. It seems a patient does not need to be a zen master of 10 years to reap the rewards of the practice.

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Back in the summer of 2011 when Sarah Kehoe’s pain started, the event that pushed her over the edge and into an emergency room was a yoga session. While positioned in a twist, her instructor came over and gently pressed on her, trying to help Kehoe reach her maximum stretch. Instead, the slight push released the full potential of Kehoe’s pain. Overwhelmed, she left the class and went home. There, the pain began to creep down Kehoe’s left buttocks. After a quick shower, the tightness turned to spasming and every muscle felt as if it was severely contracting. A stabbing, burning pain shot down her left leg from her lower back, and left her on her floor in the only position in which she felt she could breathe—on her hands and knees.

“At this point it was still something I thought would go away," she says. "So I went to the acupuncturist. I walked in hunched. It was crowded. I told the check-in girl I was desperate and she said I could wait. It hurt so bad I had to lay down in the waiting room. The check in girl looked so scared. It made me realize how bad it was, so we left.”

Kehoe's fiancé drove her to the emergency room. Her doctor, after asking a few questions, told her he originally thought it was sciatica, a disorder where one of the five spinal nerves that gives rise to the sciatic nerve is compressed, thereby causing shooting, electric pains in the legs, buttocks, and lower back. But he changed his mind and now thought she had a muscle strain. He gave her a shot of painkillers into her back, a prescription for opiates, and a referral for the physical therapist.

Two days after her emergency room visit, Kehoe went to an orthopedic surgeon. He told her he thought it was piriformis syndrome, which is similar to sciatica. To prove his hypothesis he ordered an MRI. The painkillers prescribed in the ER did little, and by mid-September, Kehoe could no longer sit or lie down. She tried physical therapy but thought it was a waste of time: At each session, she says, the therapist would apply heat to the area, and that was all. Kehoe slept only a couple hours each night these weeks, and only when heavily drugged.

After the results of the first MRI came back incomplete, her orthopedic surgeon ordered a second. Then he called her with the results: a very serious herniated disc. She needed to see a spine surgeon as soon as possible.

The day she went to the surgeon, she could hardly walk into his office. She rarely slept anymore. Due to the severity of the herniated disc, the surgeon told her, he recommended doing the surgery as soon as possible. Kehoe, scared and willing to do anything to ease her pain, had back surgery the next day. The surgeon removed the part of the disc that had herniated.

“Pain relief was pretty much instant,” she said. “I started walking the next day.” She wore a brace for a month, and gradually built up her endurance to walk. Where her pain had once felt like a 10 on a 1 to 10 scale, she now described it as a two or three. Unfortunately, the improvement didn’t last.

Near Thanksgiving it worsened. Her job as a freelance photographer overwhelmed her. She fought with her family. The stress in her life mounted. The pain followed suit. While in Los Angeles, visiting her family, her condition declined further. In order to make it home, she had to take painkillers on the plane. Back in New York, she began to take oxycodone, the only opiate that didn’t make her feel nauseated. She started with only half a pill as needed. But she slowly increased the dosage throughout the month. She started to feel that she couldn’t function without it. A vegan who rarely drank or took any form of medication, Kehoe hated that she was taking an opiate. Her surgeon did another MRI, and found that the disc had re-herniated slightly. He did not want to do another surgery right away and advised her to keep an eye on it.

In mid-December, while on her way to see an “energetic healer” in another attempt at treating her pain, Kehoe began to feel lightheaded on the subway. Hot and flushed, she removed her jacket and scarf and fainted suddenly, falling to. She awoke frightened soon after. Kehoe says she had never been a melodramatic person, had never sought attention or let illness control her, but once again felt that she was losing control of herself. She called the surgeon’s nurse who said the oxycodone would not have made her faint.

Her brother had tried meditation and found it helpful, and gave her the class for Christmas. She started in January hoping that something would finally work.

According to Dr. John D. Loeser, a neurologic surgeon and pain expert at the University of Washington, “Pain is a very complex phenomenon that involves biological things, psychological things, and sociological or environmental things.”

Acute pain is primarily biological. The body contains many types of nerves: afferent nerves, which conduct information from the senses to the central nervous system; efferent nerves, which conduct movement information from the central nervous system to the muscles; spinal nerves; and cranial nerves. Since pain is part of the sensory perception, it travels along the afferent nerves from the body to the brain. The specific nerves for pain and temperature conduct information slowly. Thus, when a person touches a burning stone, it takes a fraction of a second to move his or her finger, and a fraction of a second more for it to hurt.

This explanation describes pain at its most basic, tangible, straightforward level. Pain is when something injures body tissue, and the body tells this to the brain. This model for acute pain is called nociception.

“Tissue damage, or the nociception, normally leads to pain, but pain always has a sensory component: where it is, what it feels like. It makes you feel bad,” Loeser said. What physicians respond to, he explained, is the behaviors of a patient. A person comes into the clinic and expresses and shows how bad he suffers from the pain he feels. The doctor cannot see or measure the pain and suffering. This scenario explains Loeser’s model of pain, which he conceived and wrote about in 1982.

The complexity of pain lies in the fact that physical stimuli do not reliably lead to specific responses, Loeser said in his article "What Is Chronic Pain?" Whole pain disorders, such as fibromyalgia, about which the medical community knows very little, may arise without any tissue injury at all. There are at least 12 disorders, such as phantom limb pain or atypical facial pain, where pain occurs in the absence of tissue damage.

For Dr. Nomita Sonty, a psychologist who works with pain patients at Columbia University, Loeser’s model demonstrates the individuality of pain.

“Who I am then starts to affect the perception of pain,” she explained. “As soon as I perceive it, I then appraise it.” The patient will then act on his or her appraisal appropriately. Who we are determines how we react when we have pain. Sonty does not use meditation specifically in her practice; instead, she uses visualization and relaxation as a means to give patients control over their pain.

In her most dramatic example of her technique’s success, a paraplegic patient came to visit her at the National Rehabilitation Hospital in Washington, DC. After being paralyzed by an accidental spinal cord injury during surgery, he suffered horrible pain in his lower back so bad he had to lay down in the car as his wife drove him to his appointment. When he arrived, Sonty put him on a bed in the room, and placed electrodes on his back to measure the electrical activity in his muscles. The higher the readings, the more activity in the muscles, meaning the more strained they were. Relaxed muscles have a baseline reading of two to three mV, she said.

Sonty told her patient to visualize an image of his pain. The man pictured his surgeon holding a knife and stabbing it into his back over and over. The electrodes displayed more than 150mV. She then told him to picture a way for that knife to be removed. He envisioned an ethereal hand—perhaps that of an angel—pulling the hand with the knife back, slowly pulling the knife out of the skin. As he pictured that, the EMG readings continued to drop. When the knife was completely out of his back, the levels on the screen were below 10mV. On the ride home, the patient was able to sit up without any pain. It was an extreme case for Sonty, but she says it showed her the power our brain can have over our body, and our pain.

Meditation has long been thought to be a means to harness this power. Between the 1930s and 1950s, accounts spilled across the pages of scientific journals relating the almost superhero powers of meditating monks. Reports surfaced of yogis in India voluntarily stopping their heartbeat, or enduring over lengthy periods of time in airtight pits or in extreme cold with no food.

In 1935, Thérèse Brosse, a French cardiologist investigating the field of meditation, reported that one of her subjects was able to stop his heart. As monitoring equipment improved, researchers could not find any meditator to replicate Brosse’s observation; however, they did find meditators who could slow their heart rate or respiration rate.

In 1972, Robert Keith Wallace and Herbert Benson published a groundbreaking study about the science behind meditation. The study, an investigation following 36 subjects ranging in meditation experience from one month to nine years, found that meditating reduced activity in the sympathetic nervous system, otherwise known as the fight or flight response. This response increases blood pressure and heart rate, constricts blood vessels, and increases metabolism. Many forms of stress, including such things as a busy schedule or exhaustion, induce these conditions. Sonty said she believes meditating reduces pain by reducing stress. When a person is upset and agitated, she explained, their nervous system is aroused. This arousal aggravates pain, which in turn becomes another stressor. By relaxing the sympathetic nerves, stress decreases, thereby decreasing pain.

However, studies conducted within the past 10 years have shown that meditation may be able to change the brain. Four areas of the brain involved in pain processing or emotional and behavioral regulation have been shown by Zeidan to have differing activity levels during and after meditation. Seven other separate researchers have shown these same areas to be affected by meditation in other studies as well.

The primary somatosensory cortex, anterior insula, anterior cingulate cortex, and prefrontal cortex all experienced altered levels of activation due to meditation. The primary somatosensory cortex is the area of the brain directly involved in pain processing. If a person cuts himself with a knife, this area of the brain figures out where the pain is and an initial pain level. The anterior insula, the brain region involved in perceiving and regulating the body (it participates in monitoring a person’s heart rate and blood pressure for example), appraises pain in the body. After the person’s hand has been cut by the knife, the insula judges how painful the resulting wound is.

The anterior cingulate cortex regulates a person’s emotional response to various stimuli. The person who cut his hand then feels angry, scared, or frustrated by the wound. Finally, the prefrontal cortex, the command center of the brain, takes information and guides thoughts and actions, including the inhibition of inappropriate thoughts, distractions, and feelings. After beginning to feel angry, the man with the cut on his hand acts out because of the wound.

Meditation has been shown to alter these four areas of the brain. By decreasing activity in the primary somatosensory cortex, the pain processing area, and increasing activity in the three other regions, pain is reduced. Consider from the previous example that the man who cut his hand meditates. Zeidan’s study showed a reduction in activity in the pain processing area of the brain, meaning the cut won’t hurt as much from the beginning. Meditation also increases activity in the pain and emotion regulating areas of the brain. After the man cuts his hand, he won’t judge the pain to be as strong, and he will regulate his emotional response to the pain as well as his behaviors. Zeidan’s study showed overlap between pain and meditation in all four regions of the brain. Other studies investigating the science of meditation, without its relationship to pain, had previously shown three of these four regions to be involved in meditation.

“Meditation teaches patients how to react to the pain,” Zeiden said. “People are less inclined to have the ‘Ouch’ reaction, then they are able to control the emotional reaction to pain.” He explained that the meditator learns while sitting on the cushion that pain is fleeting and doesn’t deserve such a strong emotional reaction.

For a patient with chronic pain, Loeser explained, meditation gives patients a way to take hold of their life again. Over the months, or even years, of undiagnosed pain, patients feel like they lose control of their life and body, like Sarah Kehoe did. Traditional medications no longer work.

“For most people, you can’t treat chronic pain with opiates,” Loeser said, “but primary care is dumping narcotics into people.”

Pain medications ignore the psychological and social aspects of pain. Meditation, however, can treat pain from every level of Loeser’s model of pain, suffering, and behaviors. It diminishes the anxiety surrounding pain, leaving the patient happier, and more in control.

* * *

For six weeks after her class in January 2012, Sarah Kehoe meditated twice daily for 20 minutes at a time. During this period, her pain fell from a 6 out of 10, to a 2 out of 10, to unnoticeable unless she actively thought about it. That is, until late that February.

One day, too many things went wrong. Her teacher chose another student for a project she wanted in class. Her fiancé came home drunk, unwilling to help her with her frustrations. Her friend visiting from France remained for eight days past her designated two-day stay. That day, Kehoe’s pain grew from zero to 5 out of 10. Over the following two weeks, Kehoe didn’t meditate regularly, and her pain stayed. However, she refused to take any drugs. Only after confronted with the possibility that the lingering pain could be linked to the absence of meditation did Kehoe begin to consider how much meditating had done for her pain up to this point.

Kehoe said she notices when she doesn’t meditate; it feels the same as abandoning an exercise routine. She has decided it will be something she continues for the rest of her life.

As far as the pain is concerned, Kehoe explained that she is convinced it will just go away with time. She says she’s sure of this because she felt it go away after a few months of consistent meditation. Perhaps, she said, it’s because meditating will help her forget about it. She often wonders if she lived in Colorado and life was manageable, whether it would all stop. Instead, she’s a freelance photographer in New York City, a life and career that is anything but mellow.

At the time the pain started, she was dealing with the death of her father two years earlier, a new engagement, and a heavy push to sign an agent for work. The stresses and the changes hung heavily on her, and she thought maybe they had finally caught up with her. After beginning to meditate, as her wedding approached and she dealt with those stresses, moved on from her father’s death, and as she settled in with her new agent, her back and leg felt better. Hopefully the pain will completely disappear but until then, and even after, Kehoe plans to meditate regularly. It makes her feel good.