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Spirituality and Chronic Pain: Empirical Research Findings and

Clinical Applications

Amy Wachholtz, PhD, MDiv, MS University of Colorado Denver

Sept 20, 2016

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Amy Wachholtz, Disclosures

• The author declares that there are no conflict of interests or financial relationships with any of the information in this presentation

The contents of this activity may include discussion of off label or investigative drug uses. The faculty is aware that is their responsibility to disclose this information.

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Planning Committee, Disclosures

AAAP aims to provide educational information that is balanced, independent, objective and free of bias and based on evidence. In order to resolve any identified Conflicts of Interest, disclosure information from all planners, faculty and anyone in the position to control content is provided during the planning process to ensure resolution of any identified conflicts. This disclosure information is listed below:

The following developers and planning committee members have reported that they have no commercial relationships relevant to the content of this webinar to disclose: AAAP CME/CPD Committee Members Dean Krahn, MD, Kevin Sevarino, MD, PhD, Tim Fong, MD, Tom Kosten, MD, Joji Suzuki, MD; and AAAP Staff Kathryn Cates-Wessel, Miriam Giles, and Justina Andonian.

All faculty have been advised that any recommendations involving clinical medicine must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to, reported, or used in the presentation must conform to the generally accepted standards of experimental design, data collection, and analysis. The content of this CME activity has been reviewed and the committee determined the presentation is balanced, independent, and free of any commercial bias. Speakers must inform the learners if their presentation will include discussion of unlabeled/investigational use of commercial products.

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Target Audience

• The overarching goal of PCSS-O is to offer evidence-based trainings on the safe and effective prescribing of opioid medications in the treatment of pain and/or opioid addiction.

• Our focus is to reach providers and/or providers-in-training from diverse healthcare professions including physicians, nurses, dentists, physician assistants, pharmacists, and program administrators.

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Educational Objectives

• At the conclusion of this activity participants should be able to: State the empirical evidence of the effect of

spirituality on pain Identify the 4 major types of religious or spiritual

(R/S) coping Identify how to assess for R/S coping types

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Outline

1. Bio-psycho-social-spiritual model of pain

2. Major questions in R/S and pain research

3. Intervention Studies

4. Clinical Resources

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R/S and Health

• Regular attendance (2+/month) protects health as smoking is health deleterious (Strawbridge, et al, 1997)

• Regular worship attendance increases lifespan 7 years (Hummer, et al, 2000)

• Prayer for health concerns increased from 2001-2008 (Wachholtz & Sambamthoori, 2012)

• Protective effects from faith-based behaviors rather than cognitions (Baetz, & Bowen, 2008)

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What is Pain?

• Physiological (6+ months) Musclo-skeletal Neuropathic

• Psychological Stress Depression Social/Relationships Spiritual

• Spiritual…Or

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Influences on Chronic Pain

Chronic Pain

Biological Factors

Psychological Factors

Social Factors

Spiritual Factors

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Gate/Neuromatrix Theory of Pain

Injury Signals

Gate

Thoughts Emotions

Behaviors

Ouch! I feel good!

Melzack & Wall, 1965

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R/S and Chronic Pain

• 35% of American adults report recent use of prayer for health concerns (Wachholtz & Sambamthoori, 2011)

69% report prayer as helpful

• 61% of pain patients use prayer to cope with pain (Glover-Graf, et al., 2007)

• 40% of pain patients report becoming more R/S after the onset of the painful condition (Glover-Graf, et al., 2007)

• 4% report becoming less R/S due to pain (Glover-Graf, et al., 2007)

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Major Questions of R/S and Pain

• 1. What are the mechanisms that may affect the link between R/S factors and pain?

• 2. Who uses R/S to cope with pain?

• 3. When do people choose to use R/S to cope with pain?

• 4. How do people chose which R/S tools they will use to cope with pain?

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Question 1: What are the mechanisms linking R/S

factors and pain?

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Altered Pain Perception Increased/Decreased Sensitivity Increased/Decreased Tolerance

Physiological/Neurological Changes Altered neurotransmitter levels Changed conduction of pain signals Different threshold for recognizing pain signals Decreased HPA activity levels

Psycho-Social Changes Meaning Making Attributions Self-Efficacy Distraction Social Support Instrumental Support Relaxation

Possible Unique R/S Factor Spiritual Support Spiritual Growth Spiritual Meaning Making Attributions Additional Efficacy Beliefs

Spiritual Beliefs and Practices Positive vs. Negative Public vs. Private Intrinsic vs. Extrinsic Existential vs. Religious

(Wachholtz, Pearce & Koenig, 2007)

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Question 2: Who uses R/S to cope with pain?

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• Older (>33 years)

• Female

• More Educated (> High School)

• Have chronic mental or physical health issues: depression, chronic headaches, back and/or neck pain (McCaffrey, et al., 2004, Klemmack, et al, 2007)

Who?

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Question 3: When do people use R/S to cope with pain?

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• The initial R/S pain coping response to acute pain (self-directive), is the least likely R/S coping response to chronic pain (collaborative) (Dunn & Horgas, 2004)

• Terminal stage illnesses with co-morbid pain (e.g. cancer)

(Ironson, et al, 2002)

• Long-term chronic pain (Dezutter, Wachholtz & Corevlyn, 2012)

• Uncontrollable, intermittent pain (OConnell, Edwards, Wachholtz et al., 2009)

• When other coping mechanisms fail and R/S is efficacious

(Keefe, et al., 2001; Pargament, 2002)

• R/S coping AND secular coping- not either/or

When?

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Question 4: How do people choose which R/S tools to use

for coping with pain?

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Religious Coping Techniques

• Initially thought to be only 1 type (all Positive)

• Later research: 4 types Religious/Spiritual Coping

Deferential-Giving all control of problem to God

Collaborative-Joint problem solving with God

Independent-God not involved due to no belief Abandoned- God not involved because feel abandoned

(Pargament, Smith, Koenig, Perez, 1998; Schottenbauer, Rodriguez, Glass, & Arnkoff,2006)

Person

God

“Its all in God’s hands and out of my control” Person

God

“We’re in this together. God will do his/her part, and I’ll do mine”

Person God

“I will do it myself. I don’t believe in God”

Person

God

“I’m on my own because God has abandoned/punished me”

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Common R/S Tools

• Prayer • Hope • Meditation • Reading faith-based literature • Finding spiritual role models for coping • Seeking spiritual support/connection • Seeking instrumental support • Religious reappraisal • Church attendance

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Positive vs. Negative R/S Coping

Positive Forms • Seek spiritual connection • Seek spiritual support • Religious assistance to

forgive others • Asking forgiveness • Benevolent religious re-

appraisal • Religion as distraction • Collaborative problem

solving w/God

Negative Forms • Interpersonal religious

discontent • Punishing God reappraisal • Demonic reappraisal • Spiritual discontent • Reappraisal of God’s

power

Pargament, et al.,1998

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Positive vs. Negative R/S

• Previously R/S individuals have better outcomes when using R/S tools (Pargament, Tarakeswar, Ellison, & Wolff, 2001)

• Positive R/S coping is associated with positive outcomes

among chronic pain patients (Bush, 1999, Wachholtz & Pargament, 2005; Wachholtz & Pargament, 2008; Wachholtz, Malone, & Pargament, 2015)

• Prayer is #1 or #2 most frequently used R/S coping method in

dealing with chronic pain (Koenig, 2001)

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Positive vs. Negative R/S

• Why chose positive or negative R/S coping tools?

• May be demographic differences R/S background R/S salience Ethnic background Gender Position in a religious framework (e.g. gender, class) Age

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Bonus Question: What do we do with all of these

questions?

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Intervention Studies

• Comparing spiritual vs. secular interventions on pain

• Spiritual interventions affect physiological outcomes (Carlson, Bacaseta, and Simanton, 1988; Ironson, et al., 2002, Pargament et al., 2005; Wenneberg, et al., 1997)

• Increase pain tolerance in healthy, non-chronic pain

individuals (Wachholtz & Pargament, 2005)

• Improved pain tolerance among a chronic pain group

(Wachholtz & Pargament, 2008, Wachholtz, Malone, & Pargament, 2015)

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Conversation Fears

1. Fears about getting into the conversation

2. Fears about the content of the conversation

3. Fears about how to get out of the conversation

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But you can overcome it…

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FICA

• F Faith or beliefs “Tell me something about your faith or beliefs.”

• I Importance & influence “How does this influence your health/well-being?”

• C Community “Are you part of a supportive community?”

• A Address or application “How would you like me to address these issues in your health care?

Puchalski, 1999

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OASIS Patient-Centered Spirituality Inquiry

2. INQUIRE FURTHER,

ADJUSTING INQUIRY TO PATIENT’S INITIAL RESPONSE

Kristeller, et al., 2005

Positive-Active Faith Response

Neutral-Receptive Response

Spiritually Distressed Response

Defensive/Rejecting Response

1. INTRODUCE ISSUE IN NEUTRAL INQUIRING MANNER

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6. OFFER ASSISTANCE TO ACCESS RESOURCES (AS APPROPRIATE AND AVAILABLE)

3. CONTINUE TO EXPLORE FURTHER AS INDICATED

4. INQUIRE ABOUT WAYS OF FINDING

MEANING AND A SENSE OF PEACE

5. INQUIRE ABOUT RESOURCES

7. BRING INQUIRY TO A CLOSE

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Future Directions

• Identification of sub-groups that may be at greater risk for using negative R/S coping tools

• Further exploring potential mediators for R/S and pain relationship (mood, self-efficacy, etc.)

• Developing and testing of R/S interventions to improve outcomes in pain patients

• Move beyond self-reported pain levels to include bio-markers and objective outcome measures

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Key Points

• Spirituality can have a powerful effect on pain and health Both positive and negative

• Assessing spiritual health is an important component of a

health assessment

• Critical to assess for type of spiritual coping

• Do not attempt to do spiritual counseling, but know available professional resources in your area

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Thank you

Amy.Wachholtz@UCDenver.edu

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References

• Baetz M, Bowen R. (2008). Chronic pain and fatigue: Associations with religion and spirituality. Pain Res Manage, 13(5):383-388. • Borneman T, et al. (2010). Evaluation of the FICA tool for spiritual assessment. J Pain Symptom Manage, 40(2): 163-173. • Bush EG, et al. (1999). Religious coping with chronic pain. Appl Psychophysiol Biofeedback, 24(4): 249-260. • Carlson CR, Bacaseta PE, Simanton, DA. (1988). A controlled evaluation of devotional meditation and progressive relaxation. J Psychol

Theol, 16(3): 362–368. • Dezutter J, Wachholtz A, Corveleyn J. (2011). Prayer and pain: The mediating role of positive reappraisal. J Behav Med, 34(6): 542-549. • Dunn KS, Horgas, AL. (2004). Religious and nonreligious coping in older adults experiencing chronic pain. Pain Mgmt Nursing, 5(1): 19-28. • Ellison C, et al. (2000). Religious involvement and mortality risk among African-American adults. Research on Aging, 22 (6): 630-667. • Glover-Graf NM, et al. (2007). Religious and spiritual beliefs and practices of persons with chronic pain. Rehab Couns Bull, 5(1): 21-33. • Ironson G, et al. (2002) The Ironson-Woods Spirituality/Religiousness Index is associated with long survival, health behaviors, less distress,

and low cortisol in people with HIV/AIDS. Ann Behav Med, 24(1): 34-48. • Klemmack D, et al. (2007). A cluster analysis typology of religiousness/spirituality among older adults. Research on Aging, 29(2): 63-83. • Koenig H. (2001). Religion and medicine IV: Religion, physical health, and clinical implications. Intl J Psychiat Med, 31(3): 321:336. • Kristeller J, et al. (2005). Oncologist assisted spiritual intervention study (OASIS): Patient acceptability and initial evidence of effects. Intl J

Psychiat Med, 35(4):329-347. • McCaffrey, A, et al. (2004). Prayer for health concerns: Results of a national survey on prevalence and patterns of use. Arch Intern Med,

164(8): 858-862. • Melzack R, Wall PD. (1967).Pain mechanisms: A new theory. Surv of Anesthesiol, 11(2): 89-90. • O’Connell-Edwards CF, et al. (2009). Religious coping and pain associated with sickle cell disease: Exploration of a non linear model. J Afr

Am St, 13(1): 1-13. • Keefe FJ et al. (2001). Pain and emotion: New research directions. J Clin Psychol, 57(4): 587-607. • Strawbridge WJ, et al. (1997). Frequent attendance at religious services and mortality over 28 years. Am J Public Health, 87(6):957-961. • Pargament K. (2002). The bitter and the sweet: An evaluation of the costs and benefits of religiousness. Psychol Inq, 13(2): 168-181 • Pargament, K. et al. (1998). Patterns of positive and negative religious coping with major life stressors. J Sci St Relig, 37: 710-724.

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References

• Pargament K, et al. (2001). Religious coping among the religious: The relationships between religious coping and well-being in a national sample of Presbyterian clergy, elders, and member. J Sci St Relig, 40: 497-513.

• Puchalski C, Romer A. (2000) Taking spiritual history allows clinicians to understand patients more fully. J Pall Med, 3(1): 129-137. • Schottenbauer M, et al. (2006). Religious coping research and contemporary personality theory: An exploration of Endler’s (1997) integrated

personality theory. Brit J Psychol, 97(4):499-519. • Wachholtz A, Pargament K. (2005). Is spirituality a critical ingredient of meditation: Comparing the effects of spiritual meditation, secular

meditation, and relaxation on spiritual, psychological, cardiac, and pain outcomes. J Behav Med, 28(4): 369-384. • Wachholtz A, Pargament K. (2008). Migraines and meditation: Does spirituality matter? J Behav Med, 31(4): 351-366. • Wachholtz A, Pearce M, Koenig H. (2007). Exploring the relationship between spirituality, coping, and pain. J Behav Med, 30(4): 311-318. • Wachholtz A, Malone C, Pargament K. (2015; online ahead of print). Effect of different meditation types on migraine headache medication

use. Behav Med, http://dx.doi.org/10.1080/08964289.2015.1024601. • Wachholtz A, Sambamoorthi U. (2011). National Trends in Prayer Use as a Coping Mechanism for Health concerns: Changes From 2002 to

2007. Psychol Relig Spirituality, 3(2):67–77. • Wachholtz A, Sambamthoori U. (2013). National trends in prayer use as a coping mechanism for depression: changes from 2002-2007. J

Relig Health, 52(4): 1356-1368. • Wenneberg, SR, et al. (1997). A controlled study of the effects of the Transcendental Meditation program on cardiovascular reactivity and

ambulatory blood pressure. Intl J Neuroscience, 89: 15-28.

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PCSS-O Colleague Support Program and Listserv

• PCSS-O Colleague Support Program is designed to offer general information to health professionals seeking guidance in their clinical practice in prescribing opioid medications.

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For more information on requesting or becoming a mentor visit: www.pcss-o.org/colleague-support

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PCSS-O is a collaborative effort led by American Academy of Addiction Psychiatry (AAAP) in partnership with: Addiction Technology Transfer Center (ATTC), American Academy of Neurology (AAN), American

Academy of Pain Medicine (AAPM), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Dental Association (ADA), American Medical Association (AMA), American

Osteopathic Academy of Addiction Medicine (AOAAM), American Psychiatric Association (APA), American Society for Pain Management Nursing (ASPMN), International Nurses Society on Addictions (IntNSA), and

Southeast Consortium for Substance Abuse Training (SECSAT).

For more information visit: www.pcss-o.org For questions email: pcss-o@aaap.org

Twitter: @PCSSProjects

Funding for this initiative was made possible (in part) by Providers’ Clinical Support System for Opioid Therapies (grant no. 5H79TI025595) 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

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