Implications for a mindfulness-enhanced positive affect induction: A brief commentary toward acute pain management.

Over the past decade research has increased on dynamics between mindfulness, positive affect, and pain. While there have been studies examining the direct use of positive psychology for pain management, few have examined the use of a specific mindfulness-enhanced positive affect induction (i.e. a singular brief technique engendering mindfulness and strong positive affect) toward acute pain and pain flare management. This topical commentary discusses the need for such a technique toward bolstered gold-standard interventions, related studies, and possible future directions for acute and post-surgical pain management. Future research is encouraged to build from prior research on loving-kindness meditation and examine novel, brief mindfulness-enhanced positive affect inductions for acute pain management.

Barriers, perceived benefits and preferences to exercise in adults with an opioid use disorder in the U.S.

Introduction: Over 10 million Americans misuse opioids and more than 5 million have been diagnosed with an opioid use disorder (OUD). In 2021, over 100,000 Americans died of a drug overdose and more than 75% of these deaths involved an opioid. Exercise has been shown to increase abstinence and decrease anxiety and depression in people with a substance use disorder. However, only a few small trials have focused on persons with OUD who often experience additional challenges including chronic pain, mental health disorders and cardio-metabolic abnormalities. Methods: We aimed to describe the barriers, perceived benefits and preferences to exercise in adults with OUD in residential treatment in the U.S. as part of a larger study. We conducted 33 individually administered, semi-structured interviews and transcribed audiotapes verbatim, conducted coding and thematic analysis using NVivo v12 software (QSR International Inc.). Results: Our sample had nearly equal representation of males and females and, was predominantly Caucasian (88%) with a mean of age of 34.5 (s.d. 7.5) years old. Participants stated that exercise helps to reduce drug cravings, anxiety, depression and pain and improve mood, physical health and build "normalcy". Barriers included lack of time, access to resources, fear of poor health and triggering pain. Participants preferred moderate intensity exercise 3 times/week and 30-60 min sessions. Conclusions: Our findings indicate that adults with OUD believe exercise is a valuable tool to use in their recovery but they encounter several barriers. Many barriers, however, could be overcome with structured programs offered by residential treatment centers.

Distress Tolerance in the Comorbid Chronic Pain and Opioid Use Disorder Population.

OBJECTIVES: The risk of opioid addiction among people with chronic pain is elevated in those using opioids to self-medicate physical or emotional pain or distress. The purpose of this study is to test the main effect of distress tolerance (DT) on opioid use disorder (OUD) status in people with chronic pain, and the potential moderating effect of DT in the relationship between known addiction risk factors and the development of OUD. METHODS: One hundred twenty people with chronic pain were recruited to 1 of 3 groups according to their opioid use status (ie, current methadone or buprenorphine/naloxone for OUD [n = 60], history of OUD but current prolonged opioid abstinence [n = 30, mean abstinence = 121 weeks, SD = 23.3], and opioid naive [n = 30]). Participants completed self-report measures and a cold pressor task. Multinomial logistic regression analyses were used to test if DT associated with OUD status in people with chronic pain and to compare DT to other known indicators of OUD risk. Multinomial linear regression analyses were used to test the moderation effects of DT on the relationship between various risk factors and OUD in people with chronic pain. RESULTS: Analyses revealed that DT was significantly related to OUD status but did not moderate the effects of most OUD risk factors. CONCLUSIONS: These results suggest that decreasing distress (eg, pain levels, craving responses, etc) may be more effective than improving tolerance to distress for the comorbid chronic pain and OUD population.

Negative impact of chronic pain: The role of locus of control and perceived family validation of chronic pain.

The present study investigates how participants' locus of control and their family and friends' validation of their pain influences participants' chronic pain experiences. Four thousand, 25 adults were recruited through the Chronic Pain In America survey. Results show that individuals who endorse an internal locus of control and experience family and friends' validation of their chronic pain reported better chronic pain outcomes and less negative life impact due to chronic pain. The current results indicate the locus of control and family and friends' validation of chronic pain experience plays an important role in chronic pain and the impact of chronic pain across the life course.

Developing a novel treatment for patients with chronic pain and Opioid User Disorder.

BACKGROUND: It is critical to develop empirically based, community-treatment friendly, psychotherapy interventions to improve treatment for patients with comorbid chronic pain and Opioid Use Disorder. Understanding factors that increase patient adherence and attendance is important, along with strategies targeted to address those issues. METHODS: Based on initial psychophysiology research on adults with OUD and chronic pain, we created an integrated cognitive-behavioral, 12-week outpatient group therapy called STOP (Self-regulation Therapy for Opioid addiction and Pain). In this study, we pilot tested STOP in a Stage 1a feasibility and acceptability study to identify unique treatment needs and factors that increased session attendance, adherence to treatment, and improved outcomes. Fourteen individuals on medication for OUD with co-occurring chronic pain participated. RESULTS: STOP had high attendance rates (80%; and active patient engagement). Urine toxicology showed no illicit drug use after week 8. Data analysis from pre-intervention to a 3-month follow-up showed significant functional improvement (F(1,12) = 45.82;p < 0.001) and decreased pain severity levels (F(1,12) = 37.62;p < 0.01). Participants reported appreciation of the unique tools to counteract physiological activation during a pain flare or craving. Participants also reported benefit from in-session visual aids, applicable pain psychology information, take-home worksheets, tools for relaxation practice, learning to apply the therapy tools. DISCUSSION: STOP is a 90-min 12-week rolling-entry group therapy based on previous research identifying psychophysiological needs of pain and OUD patients that can be seamlessly incorporated into community addiction treatment clinics. CONCLUSION: Preliminary results of STOP are promising with high patient engagement and adherence and significant reductions in drug use and pain. TRIAL REGISTRATION: ClinicalTrials.Gov NCT03363243 , Registered Dec 6, 2017.

The relationship between sleep and opioids in chronic pain patients.

BACKGROUND: Sleep problems are common among chronic pain patients who take opioids. There are documented effects of opioids on sleep architecture; however, the long-term effects of opioids on sleep remain unknown. This study examined whether opioid-naïve participants have better sleep quality than current and previous chronic users of opioids. We also explored whether sleep differed between methadone and buprenorphine users, and whether amount of time since abstaining from opioids was associated with sleep quality. METHOD: Participants were 120 people with chronic pain (84.2% Caucasian, Mage = 42.0 years, SD = 11.44). They were in one of four groups of 30 participants each: (1) current users of methadone for opioid use disorder (OUD); (2) current users of buprenorphine for OUD; (3) a history of medication-assisted therapy for OUD but currently opioid-abstinent for at least 6 months; (4) those who have less than one month of cumulative lifetime opioids (opioid-naïve group). Only participants in group 1 and group 2 were taking opioids during the time of the study. Participants completed the Pittsburgh Sleep Quality Index and the SF-36. RESULTS: A MANCOVA revealed that all three groups with current or previous opioid use (i.e., groups 1-3) differed significantly from the opioid-naïve group (group 4) on sleep quality, sleep duration, sleep disturbances, and daytime dysfunction after controlling for sleep medications (all p < .05). For group 1 (methadone users), 2 (buprenorphine users), and 3 (prolonged abstinence), there were no statistically significant differences between each group. There was also a significant relationship between opioid-abstinent weeks and sleep disturbances in the opioid-abstinent group (r = - 0.604, p < .001). DISCUSSION: The results of this study suggest that opioids interfere with sleep quality, even after months of abstention. Further research into the long-term effects of opioids is warranted and may contribute further to the importance of addressing sleep problems in this population.

Feasibility and Acceptability of Digital Legacy-Making: An Innovative Story-Telling Intervention for Adults With Cancer.

BACKGROUND: This study examined the feasibility, burden and acceptability of a legacy-making intervention in adults with cancer and preliminary effects on patient quality-of-life (QOL) measures. METHOD: We conducted a Stage IB pilot, intervention study. The intervention was a digital video legacy-making interview of adults with advanced cancer to create a digital video of their memories and experiences. Baseline and post-video QOL assessments included: Functional Assessment of Cancer Therapy-General (FACT-G), Patient Dignity Inventory (PDI), Hospital Anxiety and Depression Scale (HADS), and Emotional Thermometers for distress, anxiety, anger, help and depression. Participants received a final copy of the digital video for distribution to their families. RESULTS: Adults (n = 16) ages 38-83 years old with an advanced or life-limiting cancer diagnosis completed an intervention. Feasibility and acceptability was strong with 0% attrition. While the pilot study was not powered for quantitative significance, there were changes from baseline to post-intervention in the participants' total or subscale FACT-G scores, PDI, HADS anxiety or depression scores, and Emotional Thermometer scores. CONCLUSIONS: A digital video legacy-making intervention is feasible for adults with cancer without significant negative outcomes for individuals completing the study. It remains unclear whether this intervention contributes to positive quality of life outcomes.

Attentional Patterns Toward Pain-Related Information: Comparison Between Chronic Pain Patients and Non-pain Control Group.

Although the evidence for attentional bias to pain-related information among individuals with chronic pain has been well established, there are a number of inconsistencies in the research that have been observed due to sample characteristics. Therefore, the present study expanded upon previous studies by including patients with a variety of chronic pain conditions and compared a chronic pain patient sample with healthy community sample. We also investigated how pain catastrophizing and other psychological factors in chronic pain patients affected attentional patterns to pain-related information. Forty chronic pain patients from the departments of neurology and rheumatology of an academic medical center hospital and 40 participants without chronic pain from a university that is located in Seoul, South Korea were recruited for the present study. Patients observed pictures of faces displaying pain that were presented simultaneously with faces with neutral expressions, while their eye movements were measured using an eye-tracking system. Independent t-tests were conducted to investigate attentional preferences to pain stimuli between the chronic pain and control groups. No significant attentional differences in pain-neutral pairs were found for both chronic pain and control group. A one-way MANOVA was conducted to examine the role of pain catastrophizing on psychological factors and attentional engagement to pain stimuli. No significant results for the attentional bias to pain stimuli among chronic pain patients may indicate that chronic pain patients who have suffered from chronic pain for a long time and have been treated for their chronic pain in the hospital may interpret pain-related information not as threatening. Clinical implications related to use in pain treatment and future research suggestions are discussed.

I'm tired and it hurts! Sleep quality and acute pain response in a chronic pain population.

OBJECTIVE/BACKGROUND: There are bidirectional links between sleep quality and pain, with recent research suggesting that sleep impairment more strongly predicts future pain than vice versa. Relatively few studies have examined the relationship between sleep quality and acute pain among chronic pain patients. The purpose of the current study is to investigate relationships among subjective sleep quality and behavioral and physiological responses to a cold pressor pain task (CPT) in chronic pain patients. PATIENTS/METHODS: In sum, 120 individuals with chronic pain were included. Participants completed a series of questionnaires followed by the CPT. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Physiological baseline state and stress response were assessed before and during the CPT using heart rate (HR), electromyography frontalis (EMGF), galvanic skin response conductance (GSR), and skin temperature (°C). Multiple linear regressions adjusting for opioid usage were performed. RESULTS: After adjusting for opioid use, PSQI global score explained significant variance in pain tolerance (B = -5.37, ß = -0.23, p = 0.01), baseline GSR (B = -0.66, ß = -0.24, p = 0.01), and HR change from baseline to CPT (B = 1.33, ß = 0.25, p = 0.01). CONCLUSIONS: Worse perceived sleep quality was associated with lower pain tolerance, lower baseline GSR conductance, and greater HR change from baseline to CPT. These findings underscore the importance of accounting for opioid usage and psychological dimensions of pain in the relationship between sleep and acute pain response in chronic pain populations.

A reanalysis of a randomized trial on meditation for migraine headaches: Distraction is not enough but meditation takes time.

OBJECTIVE: Migraine headaches affect about approximately 15% of the population and some notable efforts have been made to develop meditation interventions to address pain and mood among this population. However, key active ingredients and the necessary duration of meditation interventions to produce an effect are still unknown. The purpose of this study is to assess key meditation ingredients that positively impact mood and headache factors across different meditation techniques and to establish an initial time or" dose" needed to reach proactive treatment efficacy. METHOD: In this longitudinal study, three active management forms of meditation were compared to a cognitive distraction meditation to assess the effects on migraine headaches and emotions over a 30 day period when practiced 20 min per day. RESULTS: The active group showed significant decreases in anger (p = .005) and migraine pain (p = .002) over time. Further analysis showed that the bulk of the change for the active management group occurred in the final 10 days, after 20 days of practice of the technique (p < .05). CONCLUSION: This suggests that cognitively active forms of meditation are more effective in reducing migraine headache pain and negative mood than distraction techniques. However, individuals engaging in these strategies need to consistently practice these techniques for approximately 20 days to proactively reduce migraine headache pain and negative mood.

Psycho-physiological response to pain among individuals with comorbid pain and opioid use disorder: Implications for patients with prolonged abstinence.

Background: Individuals with comorbid opioid addiction and pain (COAP) relapse 3-5 times more often than patients with opioid use disorder (OUD) but without pain. However, psychophysiological responses to pain among a COAP population are unknown. Objectives: We hypothesized that those on Medications for Opioid Use Disorder (MOUD) with chronic pain, relative to opioid-naïve chronic pain individuals, would show greater psycho-physiological pain reactivity and slower recovery when exposed to acute pain. Methods: Four groups with chronic pain were recruited (N = 120; 60% Female): 1) MOUD-methadone; 2) MOUD-buprenorphine; 3) history of completed MOUD with prolonged opioid abstinence (PA; Mabstinence = 121 weeks; SD = 23.3); and 4) opioid-naïve. We assessed heart rate (HR), galvanic skin conductance (GSC), peripheral temperature, and frontalis electromyography (EMG) during a cold pain task. Results: MOUD subjects had delayed HR reactivity to pain compared to those not on MOUD (PA & opioid-naïve; F(3,119) = 2.87, p < .04). The PA group showed a normal HR reactivity pattern, but had higher HR compared to the opioid-naïve group. The GSC group x time analysis showed the PA group had greater baseline levels and pain reactivity than the other groups (F(3,119) = 3.84, p < .02). The opioid-naïve group had lower reactivity on peripheral temperature compared to other groups (F(3,119) = 9.69, p < .001). Conclusion: Greater psychophysiological reactivity to pain was experienced by co-morbid OUD/chronic pain subjects who had been opioid abstinent for an extended period, possibly due to the lack of a buffering effect of opioid agonists. These subjects may develop coping skills to tolerate pain distress, thereby avoiding relapse in response to pain triggers. Understanding how pain creates more intense psychophysiological responses among COAP patients may lead to better treatments.

Quality of life comparison between smokers and non-smokers with chronic pancreatitis.

OBJECTIVES: The aim of this study was to evaluate the impact of smoking on quality of life in patients with chronic pancreatitis. METHODS: This is a cross-sectional study of chronic pancreatitis patients followed at a single institution comparing smokers with non-smokers. The primary outcome was quality of life and secondary outcomes included demographics, drug and alcohol use, anxiety and depression, pain level, nutritional status, and metabolic factors. RESULTS: 48 smokers and 45 non-smokers participated in this study. Smokers had a worse overall quality of life and higher rates of opioid addiction and depression than non-smokers. Smokers also had less racial diversity, lower education levels, and higher amounts of narcotic use than non-smokers. Furthermore, smokers had a lower BMI and a higher proportional use of pancreatic enzyme replacement therapy. Smoking was found to be independently associated with worse quality of life on multivariable regression. CONCLUSIONS: The worse overall quality of life and higher rates of depression and anxiety create cause for concern in chronic pancreatitis patients who smoke. Smoking cessation should be an important target in chronic pancreatitis patients. Multicenter, multiethnic studies are needed to further elucidate this relationship.

The Relationship of Anxiety and Depression to Subjective Well-Being in a Mainland Chinese Sample.

This pilot study examines anxiety, depression, and well-being in a mainland Chinese sample and discusses the implications for mental health care. The Hospital Anxiety and Depression Scale, Functional Assessment of Chronic Illness Therapy-Spiritual Well-being, and the Body Mind Spirit Well-Being Inventory were administered to 60 mainland China residents. Correlational analyses revealed significant relationships among depression, anxiety, and every domain of well-being except the faith domain. Levels of depression and anxiety are inversely related to levels of well-being in a mainland Chinese sample. Chinese culture was expected to moderate this relationship; however, this was not confirmed by the results.

Advancing our understanding of religion and spirituality in the context of behavioral medicine.

Recognizing and understanding the potentially powerful roles that religiousness and spirituality (RS) may serve in the prevention and amelioration of disease, as well as symptom management and health related quality of life, significantly enhances research and clinical efforts across many areas of behavioral medicine. This article examines the knowledge established to date and suggests advances that remain to be made. We begin with a brief summary of the current knowledge regarding RS as related to three exemplary health conditions: (a) cardiovascular disease; (b) cancer; and, (c) substance abuse. We then focus on particular concerns for future investigations, emphasizing conceptual issues, possible mediators and moderators of relationships or effects, and methodology. Our discussion is framed by a conceptual model that may serve to guide and organize future investigations. This model highlights a number of important issues regarding the study of links between RS and health: (a) RS comprise many diverse constructs, (b) the mechanisms through which RS may influence health outcomes are quite diverse, and (c) a range of different types of health and health relevant outcomes may be influenced by RS. The multidimensional nature of RS and the complexity of related associations with different types of health relevant outcomes present formidable challenges to empirical study in behavioral medicine. These issues are referred to throughout our review and we suggest several solutions to the presented challenges in our summary. We end with a presentation of barriers to be overcome, along with strategies for doing so, and concluding thoughts.

Effect of Different Meditation Types on Migraine Headache Medication Use.

Spiritual meditation has been found to reduce the frequency of migraines and physiological reactivity to stress. However, little is known about how introducing a spirituality component into a meditation intervention impacts analgesic medication usage. In this study, 92 meditation-naïve participants were randomly assigned to one of four groups: (1) Spiritual Meditation, (n = 25), (2) Internally Focused Secular Meditation (n = 23), (3) Externally Focused Secular Meditation (n = 22), or (4) Progressive Muscle Relaxation (n = 22); and practiced their technique for 20 min/day over 30 days while completing daily diaries. Headache frequency, headache severity, and pain medication use were assessed. Migraine frequency decreased in the Spiritual Meditation group compared to other groups (p < 0.05). Headache severity ratings did not differ across groups (p = ns). After adjusting for headache frequency, migraine medication usage decreased in the Spiritual Meditation group compared to other groups (p < 0.05). Spiritual Meditation was found to not affect pain sensitivity, but it does improve pain tolerance with reduced headache related analgesic medication usage.

More is not Always Better: An Epidemiological Assessment of Migraine Frequency and the Impact on Relationships.

OBJECTIVE: Chronic pain negatively impacts spouse/partner relationships, with greater impact associated with higher pain severity and co-morbid mood disturbance. This study investigated the role of pain episode frequency in migraineurs on relationship effects. METHODS: An online survey was conducted, collecting information about migraine, psychological distress, and relationship impact using standardized measures. Adults previously diagnosed with migraine were invited to participate through postings on migraine community websites and social media. Impact was evaluated based on four migraine frequency categories (migraines/month): less than weekly (0-3), one to two episodes weekly (4-9 and 10-15), and more than twice weekly (>15). RESULTS: A total of 1,399 adult migraineurs were included. Spouse/partner relationships had been mildly-moderately damaged for 30% with 0-3 migraine monthly, increasing to 40% with >15 migraine monthly. Migraine had contributed to a break-up for 4% with 0-3 migraines monthly, increasing to 8% for those with >15 migraines monthly. About 57% of participants reported satisfaction with their current spouse/partner, with satisfaction unaffected by migraine frequency among those who were satisfied with their partners. Negative impact on relationships with children and close friends also increased with migraine frequency. Depression and anxiety were significantly correlated with migraine frequency (P<0.001) and modulated relationship impact. CONCLUSION: As migraine frequency increased, negative impact on relationships also increased. Interestingly, satisfaction with current spouse/partner was high for all migraine frequency categories. Clinically, this suggests that frequent migraineurs may benefit from a referral to couples counseling with a therapist that specializes in medically ill.

The effect of perceived stress on life satisfaction : The mediating effect of self-efficacy.

Lazarus and Folkman's theory of cognitive appraisal of coping inspired the present study to test a mediation model examining the effects of self-efficacy on the relationship between perceived stress and life satisfaction. A total of 282 Korean undergraduate students participated in the present study. Perceived Stress Scale, the Satisfaction with Life Scale, and the Self Efficacy Scale were used for this study. A series of hierarchical regressions investigated the mediating effect of self-efficacy on the relationship between perceived stress and life satisfaction. Results indicated that there was a partial mediation effect of self-efficacy on the relation between perceived stress and life satisfaction. The results supported the mediation of secondary cognitive appraisal (i.e., self-efficacy) on the relationship between primary cognitive appraisal (i.e., perceived stress) and life satisfaction among South Korean college students. Implications of the present study and future research suggestions are discussed.

Depression treatment decreases healthcare expenditures among working age patients with comorbid conditions and type 2 diabetes mellitus along with newly-diagnosed depression.

BACKGROUND: There are many studies in the literature on the association between depression treatment and health expenditures. However, there is a knowledge gap in examining this relationship taking into account coexisting chronic conditions among patients with diabetes. We aim to analyze the association between depression treatment and healthcare expenditures among adults with Type 2 Diabetes Mellitus (T2DM) and newly-diagnosed depression, with consideration of coexisting chronic physical conditions. METHODS: We used multi-state Medicaid data (2000-2008) and adopted a retrospective longitudinal cohort design. Medical conditions were identified using diagnosis codes (ICD-9-CM and CPT systems). Healthcare expenditures were aggregated for each month for 12 months. Types of coexisting chronic physical conditions were hierarchically grouped into: dominant, concordant, discordant, and both concordant and discordant. Depression treatment categories were as follows: antidepressants or psychotherapy, both antidepressants and psychotherapy, and no treatment. We used linear mixed-effects models on log-transformed expenditures (total and T2DM-related) to examine the relationship between depression treatment and health expenditures. The analyses were conducted on the overall study population and also on subgroups that had coexisting chronic physical conditions. RESULTS: Total healthcare expenditures were reduced by treatment with antidepressants (16 % reduction), psychotherapy (22 %), and both therapy types in combination (28 %) compared to no depression treatment. Treatment with both antidepressants and psychotherapy was associated with reductions in total healthcare expenditures among all groups that had a coexisting chronic physical condition. CONCLUSIONS: Among adults with T2DM and chronic conditions, treatment with both antidepressants and psychotherapy may result in economic benefits.

Does complementary and alternative medicine (CAM) use reduce negative life impact of headaches for chronic migraineurs? A national survey.

BACKGROUND: Chronic migraine is a disabling condition that impacts multiple aspects of migraineurs' lives. Although pharmacological treatments can help to treat the pain associated with migraine headache, chronic migraineurs often experience side-effects of pharmacological treatments. Those experiences may contribute to the observed growth in complementary and alternative medicine (CAM) use among migraineurs. Relatively little is known about the patterns of CAM treatment and the characteristics of chronic migraineurs. Therefore, the purpose of the present study is to investigate the characteristics of chronic migraineurs who use CAM treatment and the relationship among satisfaction with current CAM use, negative life impact, migraine outcomes, and psychiatric comorbidities among chronic migraineurs. METHODS: 2907 participants were recruited from a well-known online migraine headache resource. All participants were US adults aged 18 years or older. Migraineurs are referred to this website through various routes (e.g., referral from healthcare providers, internet search, obtaining information from research papers, personal invitation from other users, and information shared on social media etc.). Participants completed a 30-min self-report-survey in the spring of 2014. RESULTS: Almost half of the participants reported that they are currently using more than three different CAM treatments even though the majority of the participants reported neutral or dissatisfied with their current CAM treatment. Chronic migraineurs who use CAM treatments were more likely to experience prolonged or frequent migraine headaches (p = .018, η(2) = .0021), and experience greater negative life impact from their headaches (p = .000, η(2) = .0172) compared to non-CAM users. CAM treatment satisfaction was inversely related to the number of psychiatric comorbidities, frequency of migraines, and number of migraine symptoms (p's < .05). However, CAM treatment satisfaction was more strongly correlated with migraine outcomes than psychiatric comorbidities. CONCLUSIONS: Chronic migraineurs often pursue multiple CAM treatments in spite of low levels of satisfaction with those treatments. Patients who experience relief from traditional treatments are less likely to seek the out additional CAM treatments. Thus it is often the sicker migraine patients who use CAM. More attention is needed to consider migraine treatment resistance, and psychological factors in planning the treatment of chronic migraineurs as those factors may play an important role in treatment choices by patients.

A Comprehensive Approach to the Patient at End of Life: Assessment of Multidimensional Suffering.

Pain is a multidimensional, complex experience. There are many challenges in identifying and meeting the needs of patients experiencing pain. Evaluation of pain from a bio-psycho-social-spiritual framework is particularly germane for patients approaching the end of life. This review explores the relation between the psychospiritual dimensions of suffering and the experience of physical pain, and how to assess and treat pain in a multidimensional framework. A review of empirical data on the relation between pain and suffering as well as interdisciplinary evidence-based approaches to alleviate suffering are provided.