Mindfulness-Oriented Recovery Ehancement Reduces Opioid Misuse and Chronic Pain

Eric Garland, PhD

Guidelines recommend treating individuals living with chronic pain who also have a history of opioid misuse with nonopioid therapies. Mindfulness-based interventions are an option, but the efficacy of these practices haven’t been determined for this population.

Investigators decided to address this gap by evaluating the impact of mindfulness-oriented recovery enhancement (MORE) for the reduction of opioid misuse and chronic pain. The outcomes of the clinical trial were promising.

In the new study, individuals who utilized the MORE intervention had sustained improvements in opioid misuse and chronic pain symptoms as well as reductions in opioid dosing, emotional distress, and opioid craving. The results of this group were compared to individuals who received supportive group psychotherapy instead of mindfulness-oriented recovery enhancement.

The Mindfulness-Oriented Recovery Enhancement Approach

Treating chronic pain with long-term opioid therapy (LTOT; lasting 90 days or longer) is common in primary care settings. Literature has indicated the possibility that the effects of prolonged opioid use on stress and reward circuitry in the brain can lead an individual with chronic pain to misuse opioids or even develop opioid use disorder (OUD).

According to investigators, approximately 25% of individuals receiving long-term opioid therapy misuse opioid medications, which is defined as aberrant drug-related behaviors inconsistent with prescription directions, such as using opioids to alleviate negative emotions. Successful treatment of misuse and OUD is difficult among this population due to the complex pathogenic mechanisms at play and lack of relevant research.

The team of investigators, led by Eric Garland, PhD, Center on Mindfulness and Integrative Health Intervention Development, College of Social Work, University of Utah, Veterans Health Care Administration, Veterans Integrated Service Network, performed an interviewer-blinded randomized clinical trial that included 250 adults with chronic pain who were receiving long-term opioid therapy and misusing opioid medications. Patients were enrolled from primary care clinics in Utah from January 2016-January 2020.

Individuals were either randomized to participate in supportive group psychotherapy (the control group) or to mindfulness-oriented recovery enhancement. The treatment consisted of 8 weekly 2-hour group sessions with 6-12 participants.

Mindfulness-oriented recovery enhancement included sequenced training in mindfulness techniques, reappraisal, and savoring positive experiences. Meditation on breathing and body sensations was taught to strengthen the individuals’ ability to self-regulate compulsive opioid use and mitigate opioid craving by reinterpreting these experiences as nothing more than sensory information.

Maladaptive thoughts were reframed with the reappraisal approach to reduce the prevalence of negative emotions and instill meaning in life. The practice of savoring involved amplifying positive emotions and reward by directing attention to pleasurable events and sensations.

Primary outcomes were opioid misuse assessed by the Drug Misuse index which included a self-report, interview, and urine screen, along with pain severity and pain-related functional interference, assessed by subscale scores on the Brief Pain Inventory through 9 months of follow-up. Secondary outcomes included opioid dose, emotional distress, and ecological momentary assessments of opioid craving.

Unique from other Mindfulness-Based Treatments

A total of 203 individuals received a minimum of 4 or more completed sessions in either intervention group in order to be included in the study. At 9 months, 45% (36/80) of individuals in the MORE group were no longer misusing opioids compared with 24.4% (19/78) of the supportive therapy group.

The mindfulness-oriented recovery enhancement approach appeared to be superior to supportive psychotherapy for pain severity, and pain-related functional interference. Individuals in the MORE group were also able to further reduce emotional distress, opioid craving, and their dosing compared to those in the therapy group.

Opioid misuse also decreased among individuals in the therapy group, which investigators said could possibly reflect the therapeutic activity of this approach, however the effects of the MORE intervention were substantially greater. This intervention differs from many mindfulness approaches, like mindfulness-based stress reduction, by restructuring reward processing to value natural rewards as opposed to drug-related rewards.

“Unlike many interventions with effects that are greatest immediately after treatment but gradually diminish, MORE’s effect was sustained, likely a function of the intervention’s unique mechanisms of action, including enhanced neuro- physiologic responsivity to natural, healthy rewards and improved self-regulation of reactivity to opioid-related cues,” investigators wrote.

“Integrated health care teams comprising social workers, psychologists, nurses, and/or physicians could potentially deliver MORE in primary care settings via group medical visits,” they concluded.

This study "Mindfulness-Oriented Recovery Enhancement vs Supportive Group Therapy for Co-occurring Opioid Misuse and Chronic Pain in Primary Care" was published in Jama Internal Medicine.