Compassion and Chronic Pain

The traditional approach to the management of chronic pain focuses on pharmacological strategy with a primary goal of reducing or eliminating the symptom. In the majority of patients, however, the complete and lasting elimination of pain is rarely achieved, and in some patients, no improvement is achieved. 

Chronic pain is a global epidemic reported to affect more than 1.5 billion people worldwide. Incidence rate is increasing in parallel with the aging population. The economic burden and impact of persistent chromic pain on quality of life is significant.¹ 

In the United States alone, chronic pain affects approximately 100 million American adults with a reported annual cost in excess of $600 billion.² Given the significant social and economic cost of chronic pain, and the challenges of its optimal management with pharmacological therapy, there is a critical need to explore alternative and novel treatment approaches.

A connection between emotion and pain has been well documented – at the neurobiological, psychological and social levels – and appears to have a powerful influence on coping ability and response to treatment.³ A clear example is the correlation between oxytocin release and the alleviation of distress, or the release of µ-opioid agonists, known to ameliorate pain responses, during close social contact.³ Exploring emotion as a therapeutic strategy may offer a new treatment approach, with the goal to reduce the impact of chronic pain and the associated suffering.

Chronic pain is a complex condition in which physical and emotional experience of pain are intertwined. Anger is increasingly recognized as an important component of the chronic pain experience.⁴

David Hanscom, MD, an orthopedic surgeon at the Swedish Neuroscience Institute in Seattle, Washington writes:“Patients in chronic pain are usually angry. They are trapped by a very unpleasant physical sensation, and itis easy for them to feel (sometimes rightly) that friends, family, employers, and even physicians do not understand or believe them. They are offered endless treatments, few of which have proven to be effective, meaning their hopes are regularly dashed.”⁵

Anger directed towards a caregiver or self, which may include disappointment and frustration with pain, self-blame, shame, self-criticism and poor acceptance of their physical limitations, is known to be detrimental. Such anger is often associated with greater pain intensity, perceived injustice and disability, poorer function, reduced pain treatment response, as well as impaired social interactions and personal relationships.^6-11 Reducing anger directed to others or to self is therefore a logical approach to improving chronic pain management.

Empathy is a construct that is central to the practice of medicine, and a critical component of effective physician-patient communication. Compassion however is not the same as empathy, and must be nurtured, requiring time and emotional investment. While chronic pain sufferers seek, and gain benefit from the compassion offered by a healthcare practitioner, in reality, maintaining a sense of connection between practitioner and patient is challenging given the constraint of time in every day clinical practice, and the emotional needs of chronic pain patients. Furthermore, technological advance, while important in improving treatment and medical efficiencies, can create an emotional barrier, reducing opportunities for interaction and compassion.

Compassion intervention has been shown to influence emotional processing, reduce physical discomfort and pain severity, as well as increase the acceptance of chronic pain.⁶

Compassion through loving-kindness programs has also been shown to be beneficial in reducing negative bias, pain, anger, and psychological distress in patients with persistent low back pain.¹² Thus, compassion meditation may be a useful adjunctive treatment for reducing both anger and pain severity, and for increasing chronic pain acceptance.⁶ Among individuals with chronic pain, self-compassion – defined as being aware of, and sensitive to, the suffering of self and others, with a commitment to mitigate pain – has been shown to be associated with improved psychological functioning (lower negative affect, higher positive affect), more adaptive pain coping (ie, higher pain self-efficacy, lower pain catastrophizing), and lower levels of pain disability.^3,13

Acceptance correlates strongly with outcomes in chronic pain, and interventions that target and increase acceptance show promise in reducing pain and its associated emotional and functional burdens.¹⁴

While loving-kindness and compassion-based interventions have been shown to be associated with reductions of pain and improved coping mechanisms,^6,12,15 the majority of the studies are small scale, based on self-reports, and therefore may be challenging to replicate or meet the rigors or scientific methods. 

Nonetheless, self-compassion is being explored and gaining acceptance as a potential therapeutic intervention.^16-18 The approach being explored centers on psychoeducation, which includes relaxation, mindfulness, guided imagery and compassionate reappraisal, and focused on normalizing and de-shaming difficult emotions.

The goal is to help individuals suffering from chronic pain to develop their capacity to respond with compassion to their pain, so that they are better able to regulate their stressors and find a more compassionate inner dialogue when faced with difficulties.³ Well-designed robust studies are needed to explore the role and benefit of self-compassion in chronic pain management.³ If significant benefit is unequivocally demonstrated, self-compassion may offer an additional treatment modality to complement existing evidence-based pain management strategies.

Summary and Clinical Applicability

Compassion directed to others, and particularly to self is gaining acceptance as a potential therapeutic modality to complement existing treatment options for chronic pain. While research is still in its infancy and existing studies are small scale and based on self-report, available evidence suggests that compassion intervention is associated with reduction in anger, improved emotional well-being, pain reduction and increased acceptance. Compassion intervention can potentially offer a therapeutic approach that may help individuals to develop their capacity to respond with compassion to their pain and improve their outcome.

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References

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