Pain is a multidimensional experience consisting of both sensory and affective components involving how “strong” and how “unpleasant” the painful sensation is perceived to be by the individual. The experience of pain also includes a cognitive component, which strongly influences how an individual perceives their overall well-being in relation to their experience of pain. Patients experiencing pain, especially those living with chronic pain, are often willing to try a myriad of methods to help reduce these components in hopes for an overall reduction in their discomfort. While medications and surgical procedures typically aim to directly target the sensory component of pain, the cognitive component is too frequently overlooked. Therefore, there is much debate regarding what methods and techniques can effectively be utilized by the average patient in hopes of better addressing this psychological component. 
What is Mindfulness Meditation?
There is growing evidence favoring the implementation of mindfulness meditation for the use of pain regulation, as well as pain relief. While there are increasing numbers of studies attempting to verify the efficacy of using such mindfulness techniques, the evidence is often challenging to interpret and generalize. This is because there exists a wide variety of different meditative practices under the umbrella of “mindfulness,” and therefore the specific meditative technique utilized is not always well defined or adequately explained in studies. Such differentiation among meditative techniques is imperative, as practices can vary from techniques to help promote relaxation, to techniques geared more toward achieving greater self-awareness and heightened well-being .
In general, two types of mindfulness techniques have been especially prevalent in research. These include focused attention meditation and open monitoring meditation.
During focused attention meditation, the individual focuses on a chosen object and monitors the quality of their attention to this object. For example, if the individual feels their attention drifting from their object of choice to the presence of their pain, they are instructed to recognize the presence of this distraction, gently disengage from it, and return to their original focus .
Open monitoring meditation utilizes many of the same core principles as focused attention to reduce distractions and help calm the mind. Using this method, the individual aims to remain in a monitoring state, in which they remain attentive, moment-by-moment, to anything that occurs. However, they do not focus on any one stimulus or object. Therefore, they are seemingly experiencing every sensory and cognitive stimulus that arises without evaluation or interpretation .
Effects of Mindfulness Meditation During Episodes of Pain
Utilizing the principles of focused attention or open monitoring can be considered effective in the treatment of clinical pain. These methods of mindfulness meditation can help attenuate the overall experience of pain by impacting the expectation of pain, the attention toward the painful stimuli, and the overall emotional and psychological response toward the pain . In fact, after 8-weeks of mindfulness training in patients with chronic low back pain, fibromyalgia, and irritable bowel syndrome, significant improvements were noted in pain symptoms and quality of life [6, 7, 8]. In some studies these improvements were observed for up to 5 years post-training, indicating the enormous value not only of the initial training but of the ability to utilize such techniques on an on-going basis.
Mindfulness meditation practices are often considered to be synonymous with “distraction” and “relaxation.” While these principles can be incorporated into or result from a meditative session, these frequently over-simplify the practices of focused attention and open monitoring. For example, when subjects were taught principles of both focused attention and open monitoring, they reported significantly reduced ratings of pain as compared to simply distraction and relaxation techniques. Those who performed distraction with arithmetic reported reductions in “high” pain ratings but did not report significant changes in “low” pain ratings, indicating that distraction was not as effective in reducing the more constant, duller levels of pain that are often common with chronic pain syndromes. Meanwhile, relaxation was found to have no effect on pain in either group. Therefore, it can be concluded that while mindfulness meditation in the forms of focused attention and open monitoring can serve distractive or relaxation purposes, training in mindfulness meditation can reduce pain beyond simply distraction or relaxation .
Implementing mindfulness meditation results in a cascade of gradual changes within the brain that alter how the individual processes pain. For example, the rostral anterior cingulate cortex, which is involved with the cognitive control and regulation of emotion, is activated to a greater extent during meditation. Meanwhile, orbitofrontal cortex activity is increased and thalamic activity is decreased . This increase in orbitofrontal cortex activity leads to greater inhibition of nociceptive processing in the thalamus, and this decrease in thalamic activity leads to greater reported reductions in pain “unpleasantness.” [figure 3]
Brown, C. “Meditation experience predicts less negative appraisal of pain: electrophysiological evidence for the involvement of anticipatory neural response.” Pain 150(3):428-438, Sept 2010. https://www.ncbi.nlm.nih.gov/pubmed/20494517
Prior Meditation Experience on Pain
As previously stated, brief training sessions in mindfulness meditation can have positive effects on a patient’s subjective experience of pain. However, can the positive effects of focused attention and open monitoring meditation carry over even when the individual is not actively meditating?
Studies have assessed the differences in pain sensitivity during periods of non-meditation on long-term meditators and have found that just from having this increased background in mindfulness meditation, they reported lower pain unpleasantness ratings .
Therefore, it seems that trained meditators undergo changes that allow them to process nociceptive information differently than the average individual through improved emotional and cognitive control, as well as a greater acceptance towards potential impending stimuli . Experienced meditators have decreased activation in both the right inferior parietal cortex, as well as the mid-cingulate cortex, and increased activation in the ventromedial prefrontal cortex. These findings correlate with decreases in anticipation of potentially noxious stimuli, as well as less reported pain “unpleasantness” .
Additionally, meditators have greater activation in the dorsal anterior cingulate cortex, insula, and thalamus, and decreased activity in the medial prefrontal cortex, amygdala, and hippocampus . These areas are involved in sensory encoding and emotional memory respectively. Therefore, while activity in these sensory areas increases, the activity of these emotional areas decreases, demonstrating that while meditators are fully aware of the sensation of pain, they are simultaneously able to inhibit any emotional response to this pain.
The changes that occur in the overall cortical wiring of trained meditators at rest varies somewhat from the general changes observed during a meditative session. For example, during meditative sessions performed by novice meditators, decreases in thalamic activity are present, correlating with a reduction in the “unpleasantness” of their pain. However, in trained meditators at rest, thalamic activity increases, demonstrating that they are perhaps more aware of the stimulus, but also more capable of controlling their actual emotional responses, or lack thereof. With increased practice in mindfulness meditation, it can be assumed that an individual will be able to move from a state of decreased focus on a painful sensation to a state of enhanced emotional control.
The summative evidence regarding mindfulness meditation in the forms of focused attention and open monitoring indicates that it is effective in helping to modify the overall sensory and emotional experiences of pain. However, given the differences in focused attention and open monitoring, it is likely that each practice would affect pain in a somewhat different way. Focused attention involves the ability to sustain attention, while open monitoring involves a more non-judgmental approach toward surrounding sensory events . Thus, while both can have a positive impact on pain perception, open monitoring may decrease pain to a larger extent, but may also require a much higher level of training and practice.
Training in mindfulness meditation can prove to be beneficial for patients who have not previously meditated, but the practice of such principles would require more initial practice and cognitive control than those with prior experience meditating. Therefore, while patients could benefit from education regarding mindfulness and its potential ability to reduce pain, such training alone may not yield lasting effects. Patients would also need to be provided mentoring and support in incorporating principles of focused attention and open monitoring into their daily lives and routines, as opposed to isolated bouts of meditation. With time and practice, the brain will be able to essentially “rewire” its cognitive perception of the experience of pain, leading to increases in the quality of life, decreases in the need for medication, and over reductions in the cost of burden of the disease. Thus, we should consider referring patients to resources for mindfulness meditation, especially those populations with chronic or recurring episodes of pain.