Tag: Chronic Pain

What is Mindfulness-Based Stress Reduction?

Published on by Andrew Marshall1 Comment

Introduction

Mindfulness-based stress reduction (MBSR) is an eight-week evidence-based programme that offers secular, intensive mindfulness training to assist people with stress, anxiety, depression and pain.

Developed at the University of Massachusetts Medical Centre in the 1970s by Professor Jon Kabat-Zinn, MBSR uses a combination of mindfulness meditation, body awareness, yoga and exploration of patterns of behaviour, thinking, feeling and action. Mindfulness can be understood as the non-judgemental acceptance and investigation of present experience, including body sensations, internal mental states, thoughts, emotions, impulses and memories, in order to reduce suffering or distress and to increase well-being. Mindfulness meditation is a method by which attention skills are cultivated, emotional regulation is developed, and rumination and worry are significantly reduced. During the past decades, mindfulness meditation has been the subject of more controlled clinical research, which suggests its potential beneficial effects for mental health, as well as physical health. While MBSR has its roots in Buddhist wisdom teachings, the programme itself is secular. The MBSR programme is described in detail in Kabat-Zinn’s 1990 book Full Catastrophe Living.

Brief History

In 1979, Jon Kabat-Zinn founded the Mindfulness Based Stress Reduction Clinic at the University of Massachusetts Medical Centre, and nearly twenty years later the Centre for Mindfulness in Medicine, Health Care and Society at the University of Massachusetts Medical School. Both these institutions supported the growth and implementation of MBSR into hospitals worldwide. Kabat-Zinn described the MBSR program in detail in his bestselling 1990 book Full Catastrophe Living, which was reissued in a revised edition in 2013. In 1993, the MBSR course taught by Jon Kabat-Zinn was featured in Bill Moyer’s Healing from Within. In the year 2015, close to 80% of medical schools are reported to offer some element of mindfulness training, and research and education centres dedicated to mindfulness have proliferated.

Programme

A meta-analysis described MBSR as “a group programme that focuses upon the progressive acquisition of mindful awareness, of mindfulness”. The MBSR programme is an eight-week workshop taught by certified trainers that entails weekly group meetings (2.5 hour classes) and a one-day retreat (seven-hour mindfulness practice) between sessions six and seven, homework (45 minutes daily), and instruction in three formal techniques: mindfulness meditation, body scanning and simple yoga postures. Group discussions and exploration – of experience of the meditation practice and its application to life – is a central part of the program. Body scanning is the first prolonged formal mindfulness technique taught during the first four weeks of the course, and entails quietly sitting or lying and systematically focusing one’s attention on various regions of the body, starting with the toes and moving up slowly to the top of the head. MBSR is based on non-judging, non-striving, acceptance, letting go, beginners mind, patience, trust, and non-centring.

According to Kabat-Zinn, the basis of MBSR is mindfulness, which he defined as “moment-to-moment, non-judgmental awareness.” During the programme, participants are asked to focus on informal practice as well by incorporating mindfulness into their daily routines. Focusing on the present is thought to heighten sensitivity to the environment and one’s own reactions to it, consequently enhancing self-management and coping. It also provides an outlet from ruminating on the past or worrying about the future, breaking the cycle of these maladaptive cognitive processes. The validity and reliability of a weekly single-item practice quality assessment have been confirmed by research. Increases in practice quality predicted improvements in self-report mindfulness and psychological symptoms but not behavioural mindfulness, and longer practice sessions were linked to better practice quality.

Scientific evidence of the debilitating effects of stress on human body and its evolutionary origins were pinpointed by the work of Robert Sapolsky, and explored for lay readers in the book Why Zebras Don’t Get Ulcers. Engaging in mindfulness meditation brings about significant reductions in psychological stress, and appears to prevent the associated physiological changes and biological clinical manifestations that happen as a result of psychological stress. According to early neuroimaging studies, MBSR training has an influence on the areas of the brain responsible for attention, introspection, and emotional processing.

Extent of Practice

According to a 2014 article in Time magazine, mindfulness meditation is becoming popular among people who would not normally consider meditation. The curriculum started by Kabat-Zinn at University of Massachusetts Medical Centre has produced nearly 1,000 certified MBSR instructors who are in nearly every state in the US and more than 30 countries. Corporations such as General Mills have made MBSR instruction available to their employees or set aside rooms for meditation. Democratic Congressman Tim Ryan published a book in 2012 titled A Mindful Nation and he has helped organise regular group meditation periods on Capitol Hill.

Methods of Practice

Mindfulness-based stress reduction classes and programs are offered by various facilities including hospitals, retreat centres, and various yoga facilities. Typically the programs focus on teaching

  • mind and body awareness to reduce the physiological effects of stress, pain or illness
  • experiential exploration of experiences of stress and distress to develop less emotional reactivity
  • equanimity in the face of change and loss that is natural to any human life
  • non-judgemental awareness in daily life
  • promote serenity and clarity in each moment
  • to experience more joyful life and access inner resources for healing and stress management
  • mindfulness meditation

Evaluation of Effectiveness

Mindfulness-based approaches have been found to be beneficial for healthy adults for adolescents and children, healthcare professionals, as well as for different health-related outcomes including eating disorders, psychiatric conditions, pain management, sleep disorders, cancer care, psychological distress, and for coping with health-related conditions. As a major subject of increasing research interest, 52 papers were published in 2003, rising to 477 by 2012. Nearly 100 randomised controlled trials had been published by early 2014.

The development of therapies to improve individuals’ flexibility in switching between using and not using emotion regulation (ER) methods is necessary because it is linked to better mental health, wellbeing, and resilience. According to research, those who attended MBSR training exhibited greater regulatory decision flexibility. In post-secondary students, research on mindfulness-based stress reduction has demonstrated that it can reduce psychological distress, which is common in this age range. In one study, the long-term impact of an 8-week Mindfulness-Based Stress Reduction (MBSR) treatment extended to two months after the intervention was completed.

Individuals with eating disorders have benefited from the mindfulness-based approach. MBSR therapy has been found to assist individuals improve the way they view their bodies. Interventions, such as mindfulness-based approaches, which focus on effective coping skills and improving one’s relationship with themselves through increased self-compassion can positively impact a person’s body image and contribute to overall well-being.

Research suggests mindfulness training improves focus, attention, and ability to work under stress. Mindfulness may also have potential benefits for cardiovascular health. Evidence suggests efficacy of mindfulness meditation in the treatment of substance use disorders. Mindfulness training may also be beneficial for people with fibromyalgia.

In addition, recent research has explored the ability of mindfulness-based stress reduction to increase self-compassion and enhance the well-being of those who are caregivers, specifically mothers, for youth struggling with substance use disorders. Mindfulness-based interventions allowed for the mothers to experience a decrease in stress as well as a better relationship with themselves which resulted in improved interpersonal relationships.

It has been demonstrated that mindfulness-based stress reduction has beneficial impacts on healthy individuals as well as suffering individuals and those close to suffering individuals. Roca et al. (2019) conducted an 8-week mindfulness-based stress reduction programme for healthy participants. Five pillars of MBSR, including mindfulness, compassion, psychological well-being, psychological distress, and emotional-cognitive control were identified. Participants psychological functioning were examined and assessed using questionnaires. Mindfulness and overall well-being was significant between the five pillars observed.

Mindfulness-based interventions and their impact have become prevalent in every-day life, especially when rooted in an academic setting. After interviewing children, of the average age of 11, it was apparent that mindfulness had contributed to their ability to regulate their emotions. In addition to these findings, these children expressed that the more mindfulness was incorporated by their school and teachers, the easier it was to apply its principles.

Mindfulness-based stress approaches have been shown to increase self-compassion. Higher levels of self-compassion have been found to greatly reduce stress. In addition, as self-compassion increases it seems as though self-awareness increases as well. This finding has been observed to occur during treatment as well as a result at the conclusion, and even after, treatment. Self-compassion is both a result and an informative factor of the effectiveness of mindfulness-based approaches.

MBIs (mindfulness-based intervations) showed a positive effect on mental and somatic health in social when compared to other active treatments in adults. This effects may be gender dependent. However, the effects seemed independent of duration and compliance with these kind of intervention.

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What is Phenacetin?

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Introduction

Phenacetin (acetophenetidin, N-(4-ethoxyphenyl)acetamide) is a pain-relieving and fever-reducing drug, which was widely used following its introduction in 1887.

It was withdrawn from medicinal use as dangerous from the 1970s (e.g. withdrawn in Canada in 1973, and by the US Food and Drug Administration (FDA) in 1983).

Brief History

Phenacetin was introduced in 1887 in Elberfeld, Germany by German company Bayer, and was used principally as an analgesic; it was one of the first synthetic fever reducers to go on the market. It is also known historically to be one of the first non-opioid analgesics without anti-inflammatory properties.

Prior to World War One, Britain imported phenacetin from Germany. During the war, a team including Jocelyn Field Thorpe and Martha Annie Whiteley developed a synthesis in Britain.

Known Mechanism of Action

Phenacetin’s analgesic effects are due to its actions on the sensory tracts of the spinal cord. In addition, phenacetin has a depressant action on the heart, where it acts as a negative inotrope. It is an antipyretic, acting on the brain to decrease the temperature set point. It is also used to treat rheumatoid arthritis (subacute type) and intercostal neuralgia.

In vivo, one of two reactions occur. Usually Phenacitin’s ether is cleaved to leave paracetamol (acetaminophen), which is the clinically relevant analgesic. A minority of the time the acetyl group is removed from the amine, producing carcinogenic P-Phenetidine. This reaction is quite rare, however, as evidenced by the fact that the drug was on the market for almost 100 years before a statistical link was established, when Canada, followed by the United States, withdrew it from the market.

Preparation

The first synthesis was reported in 1878 by Harmon Northrop Morse.

Phenacetin may be synthesized as an example of the Williamson ether synthesis: ethyl iodide, paracetamol, and anhydrous potassium carbonate are heated in 2-butanone to give the crude product, which is recrystallised from water.

Uses

Phenacetin was widely used until the third quarter of the twentieth century, often in the form of an A.P.C., or “aspirin-phenacetin-caffeine” compound analgesic, as a remedy for fever and pain. An early formulation (1919) was Vincent’s APC in Australia.

In the United States, the FDA ordered the withdrawal of drugs containing phenacetin in November 1983, due to its carcinogenic and kidney-damaging properties. It was also banned in India. As a result, some branded, and previously phenacetin-based, preparations continued to be sold, but with the phenacetin replaced by safer alternatives. A popular brand of phenacetin was Roche’s Saridon, which was reformulated in 1983 to contain propyphenazone, paracetamol and caffeine. Coricidin was also reformulated without phenacetin. Paracetamol is a metabolite of phenacetin with similar analgesic and antipyretic effects, but the new formulation has not been found to have phenacetin’s carcinogenicity.

Phenacetin has been used as a cutting agent to adulterate cocaine in the UK and Canada, due to the similar physical properties.

Due to its low cost, phenacetin is used for research into the physical and refractive properties of crystals. It is an ideal compound for this type of research.

In Canada phenacetin is used as a laboratory reagent, and in a few hair dye preparations (as a stabiliser for hydrogen peroxide). While it is considered a prescription drug, no marketed drugs contain phenacetin.

Safety

Phenacetin, and products containing phenacetin, have been shown in an animal model to have the side effect and after-effect of carcinogenesis. In humans, many case reports have implicated products containing phenacetin in urothelial neoplasms, especially urothelial carcinoma of the renal pelvis. Phenacetin is classified by the International Agency for Research on Cancer (IARC) as carcinogenic to humans. In one prospective series, phenacetin was associated with an increased risk of death due to urologic or renal diseases, death due to cancers, and death due to cardiovascular diseases. In addition, people with glucose-6-phosphate dehydrogenase deficiency may experience acute haemolysis, or dissolution of blood cells, while taking this drug. Acute haemolysis is possible in the case of patients who develop an IgM response to phenacetin leading to immune complexes that bind to erythrocytes in blood. The erythrocytes are then lysed when the complexes activate the complement system.

Chronic use of phenacetin is known to lead to analgesic nephropathy characterized by renal papillary necrosis. This is a condition which results in destruction of some or all of the renal papillae in the kidneys. It is believed that the metabolite p-phenetidine is at least partly responsible for these effects.

One notable death that can possibly be attributed to the use of this drug was that of the aviation pioneer Howard Hughes. He had been using phenacetin extensively for the treatment of chronic pain; it was stated during his autopsy that phenacetin use may have been the cause of his kidney failure.

Feeling the Pain: Substance Misuse & Generalised Anxiety Disorder

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Research Paper Title

An Examination of Comorbid Generalized Anxiety Disorder and Chronic Pain on Substance Misuse in a Canadian Population-Based Survey.

Background

Chronic pain and generalized anxiety disorder (GAD) are co-occurring, and both conditions are independently associated with substance misuse.

However, limited research has examined the impact of comorbid GAD and chronic pain on substance misuse.

The aim of this article was to examine the associations between comorbid GAD and chronic pain conditions compared to GAD only with non-medical opioid use, drug abuse/dependence, and alcohol abuse/dependence in a Canadian, population-based sample.

Methods

Data came from the 2012 Canadian Community Health Survey-Mental Health (N = 25,113). Multiple logistic regressions assessed the associations between comorbid GAD and chronic pain conditions (migraine, back pain, and arthritis) on substance misuse.

Results

Comorbid GAD + back pain and GAD + migraine were associated with increased odds of non-medical opioid use compared to GAD only.

However, the relationship was no longer significant after controlling for additional chronic pain conditions.

No significant relationship was found between GAD + chronic pain conditions with drug or alcohol abuse/dependence.

Conclusions

Comorbid GAD + back pain and GAD + migraine have a unique association with non-medical opioid use in Canadians compared to GAD only, and chronic pain multi-morbidity may be driving this relationship.

Results emphasise the need for screening for substance misuse and prescription access in the context of GAD and comorbid chronic pain.

Reference

Bilevicius, E., Sommer, J.L., Keough, M.T. & El-Gabalawy, R. (2020) An Examination of Comorbid Generalized Anxiety Disorder and Chronic Pain on Substance Misuse in a Canadian Population-Based Survey. Canadian Journal of Psychiatry. doi: 10.1177/0706743719895340. [Epub ahead of print].