Today I had a new paper accepted for publication in the prestigious addictions journal, Drug and Alcohol Dependence. This paper, coauthored with my colleague Matthew Howard, describes new findings from a randomized controlled trial of Mindfulness-Oriented Recovery Enhancement for chronic pain patients prescribed long-term opioid painkillers. The new findings demonstrate that the extent to which an individual finds his or her attention automatically captured by opioid-related images (e.g., the image of an opioid pill bottle) significantly predicts whether they will misuse opioids 20 WEEKS LATER after completing treatment.
Before patients participated in the research treatments, they completed a dot probe task in which they were shown two pictures (displayed either for 200 ms, or 2000 ms), side by side, on a computer screen, and were asked to “choose the side with the dot” by clicking a button on a keypad. The computer recorded their reaction times down to the millisecond. We found that compared to people who did not misuse opioids at follow-up, people who ended up misusing opioids 3 months after completing treatment were significantly faster to choose the side with the dot when the dot replaced an opioid photo than when it replaced a neutral photo. This reaction time difference indicated that their attention was captivated by opioids. This effect was evident for cues presented for 200 ms (that’s one-fifth of a second!), suggesting that this attentional bias occurred automatically, unconsciously, and before participants even had time to think about what they were doing. Even after statistically controlling for pain levels, opioid dependence, and pre-treatment opioid misuse, people with a stronger opioid attentional bias prior to entering treatment were significantly more likely to misuse opioids 20 weeks later than people with less attentional bias to opioids.
So what is the significance of this research study for helping people with addiction and chronic pain? The study findings suggest that people who take opioids for chronic pain may develop an automatic tendency to be fixated on their medication, even when they don’t want to be. This tendency might make it difficult to stop thinking about opioids, causing craving, distraction, or other kinds of disruption in life. It might even result in or foretell opioid misuse down the line, long after a person has completed treatment. Using a performance-based dot probe test delivered by computer to detect risk for future opioid misuse may help physicians and health care providers make more informed decisions about whether and when to prescribe opioids to patients suffering from chronic pain.
I am thrilled to report that the 2014 Summer Mindfulness-Oriented Recovery Enhancement (MORE) Basic Training Workshop was a smashing success! There were 26 clinicians in attendance from fields like social work, addictions treatment, and nursing who served clients in a wide array of settings ranging from primary care clinics to inpatient mental health facilities to hospice and private practice. We dug into the theory, clinical research, and neuroscience behind MORE, and spent time intensively practicing the core skills of this integrative therapeutic approach: mindfulness training, reappraisal, and savoring. For skill practice we utilized the state-of-the-art training facilities at the Bridge Training Clinic at the University of Utah College of Social Work. I supervised therapists through a one-way mirror and provided them real-time feedback through a wireless headset during their delivery of the various mindfulness techniques and cognitive skills integral to MORE.
I received overwhelmingly positive feedback on the training. One participant wrote: “When I began Mindfulness mediation in 2002, I had no roadmap, no teacher or guide. I had to figure out what to do, when to do it, how to do it, and who to include and NOT include in my attempted meditation experience. I was completely self-schooled and reaching for a way to focus and center myself… Imagine how validating it was for me to sit with a group of colleagues and discuss Mindfulness. Imagine how nurturing it was to have a mentor. Imagine how incredible it was to participate with feedback and discuss the dynamics of what I PERSONALLY experience and not have someone try to adjust my perception… You were a wonderful teacher. I also love the data. I know this discipline works because I have effectively used it to my advantage so many times…including relinquishing the stranglehold pain can have and loss can have, and welcoming the opportunity for reinvention and reframe. Thank you so much, Eric, for sharing. I hope to work with you again.” – Gloria
I intend to offer an advanced training on MORE in the near future. This training will provide in-depth coverage on the application of the basic MORE techniques of mindfulness, reappraisal, and savoring to directly target addictive behaviors, craving, negative emotions, and chronic pain. For information on MORE, click here.
2-day MORE Training Workshop July 18-19, 2014
Bridge Training Clinic, College of Social Work, University of Utah
Salt Lake City, UT
A 2-day training workshop in Mindfulness-Oriented Recovery Enhancement will be held July 18-19, 2014, at the University of Utah Bridge Training Clinic in Salt Lake City, UT. This training is designed for licensed health care professionals (social workers, psychologists, counselors, physicians, nurses, etc.) working with clients suffering from addiction, chronic pain, and stress-related conditions.
Participants will receive didactic and experiential instruction in theory, research,and clinical skill practice integral to the implementation of Mindfulness-Oriented Recovery Enhancement (MORE). Research evidence on the MORE model will be presented, along with a review of the latest discoveries in neuroscience and basic biobehavioral science about mindfulness, addiction, and chronic pain.
Participants will practice the therapeutic techniques outlined in the MORE treatment manual (Garland, 2013) via role plays conducted in a clinical observation lab at the Bridge Training Clinic. Participants will receive live supervision in delivery of therapeutic techniques by Dr. Eric Garland, PhD, LCSW, the developer of MORE, who will observe participants through a one-way mirror and provide continual feedback through “bug in the ear” technology to optimize the delivery of therapeutic interventions.
At the completion of this 2-day workshop, participants will have a basic level of competency to use the MORE treatment manual to implement MORE for persons suffering from addictive behaviors and chronic pain conditions.
The cost of the training is $500.00 USD and includes two lunches and breakfasts. To register, click http://tiny.utah.edu/more2014.
A new and exciting research study from my lab was recently accepted for publication in the esteemed journal Psychopharmacology. This paper describes a subset of findings from a randomized controlled trial (RCT) of Mindfulness-Oriented Recovery Enhancement (MORE) for chronic pain patients who had been prescribed long-term opioid treatment (e.g., oxycontin, vicodin) for pain management. To my knowledge, the study is the first in the scientific literature to demonstrate that a mindfulness-based intervention can increase physiological sensitivity to natural, healthy pleasures in life.
In this study, individuals suffering from low back pain, neck pain, arthritis, fibromyalgia, and other pain conditions were randomly assigned to participate in the experimental MORE treatment or a control condition consisting of a social support group led by a therapist. Participants in the MORE group received 8 weeks of instruction in applying mindfulness and other psychological techniques to alleviate pain and craving while strengthening positive emotions and a sense of meaningfulness in life.
In that regard, participants were taught a savoring practice, which involved using mindfulness to intentionally focus on the sensory features (e.g., sight, sound, smell, or touch) of a pleasant experience or object (e.g., a beautiful nature scene like a sunset or the feeling of connection with a loved one) while noticing, appreciating, and absorbing any positive emotions arising in response to the pleasant event. For example, in one meditation session, participants were taught to mindfully focus on the colors, textures, and scents of a bouquet of fresh flowers, and to absorb and appreciate the emotions of contentment and joy arising from this savoring practice. Participants were asked to practice savoring in everyday life as part of a weekly homework assignment (along with a daily practice of mindful breathing meditation).
Due to its emphasis on savoring naturally rewarding experiences, we hypothesized that MORE would increase the sensitivity of the autonomic nervous system to images representing such positive experiences. To measure this in the lab, we used a computerized task, in which participants were asked to pay attention to series of pain-related (e.g., a picture of someone grimacing in pain), opioid-related (e.g., a picture of a bottle of prescription painkillers), or pleasure-related images (e.g., a picture of a smiling baby) rapidly presented for 200 – 1000 milliseconds. During this task, we measured heart rate variability – that is, the beat-to-beat changes in heart rate controlled by the parasympathetic nervous system, the branch of the nervous system responsible for rest and recovery from stress. We also asked participants to rate how much they desired or craved their opioids before and after the task.
In summary of our study results, we found that MORE significantly decreased the desire to take opioids and led to large heart rate decelerations while participants focused their attention on the pain-, opioid-, and pleasure-related photographs. In other words, after completing the MORE training, participants’ heart rates slowed down from resting levels while they were paying attention. Heart rate variability analysis indicated that this heart rate slowing was caused by increased activation of the parasympathetic nervous system following MORE. The heart rate decelerations were dramatic, and particularly so for the pleasure photos; on average, the heart rate of participants in the MORE intervention dropped 10 beats per minute while they focused on the pleasure photos! Importantly, although heart rate slowed to all three types of photos, only the heart rate slowing to pleasure photographs was related to changes in opioid craving. Participants who experienced the most heart rate slowing to pleasure photographs experienced the greatest reduction in the desire to take opioids.
This finding is extremely important. A large body of research suggests that as chronic pain and addiction progresses, people may become less physiologically responsive to natural pleasure. As their brains become less sensitive to naturally-rewarding experiences, they get less enjoyment out of life. Consequently, they may feel more compelled to take drugs (such as opioids) to achieve a normal sense of well-being.
Results from this new study suggest that through mindful savoring practices, MORE may help people to become more sensitive to healthy, positive experiences in everyday life, and in doing so, assist them to become freer from the clutches of addiction.
Today I had the opportunity to speak about the treatment, neuroscience, and genetics of chronic pain with Dr. Dan Gottlieb, host of Voices in the Family, and Dr. Jeffrey Mogil, head of the Pain Genetics Lab at McGill University, on radio station WHYY in Philadelphia (a local NPR station). I spoke about how negative emotions and stress can influence pain processing in the brain, and about how Mindfulness-Oriented Recovery Enhancement can reduce the harmful impact of negative emotions on pain by teaching people to change the way they focus their attention and to reinterpret chronic pain as innocuous sensory signals from the body.
The entire interview can be found here:
With the advance online publication of “Mindfulness-Oriented Recovery Enhancement for Chronic Pain and Prescription Opioid Misuse: Results from an Early Stage Randomized Controlled Trial” in the Journal of Consulting and Clinical Psychology on February 3rd, over 10 news stories have covered this work. For example, the study was covered by the University of Utah news department in the story “Mind Over Matter: Beating Pain and Painkillers”, by Medical Daily in “Pain Management: M.O.R.E. Therapy uses Mental Interventions to Combat Chronic Pain, Opioid Painkillers Misuse”, by Science World Report in “New Pain Treatment Aims to Reduce Prescription Opioids” and by Healthline in “A Mindful Way to Beat Chronic Pain.” It is my sincere hope that this news coverage will ultimately help more people suffering from chronic pain to find the relief and comfort they are seeking.
My colleagues Brett Froeliger, Matthew Howard, and I recently authored an invited conceptual review paper for a special issue of Frontiers in Psychiatry: Addictive Disorders and Behavioral Dyscontrol. Prominent neuroscience models suggest that addictive behavior occurs when environmental stressors and drug-relevant cues activate a cycle of cognitive, affective, and psychophysiological mechanisms, including dysregulated interactions between bottom-up and top-down neural processes, that compel the user to seek out and use drugs. Mindfulness-based interventions (MBIs) target pathogenic mechanisms of the risk chain linking stress and addiction. This review describes how MBIs may target neurocognitive mechanisms of addiction at the attention-appraisal-emotion interface. Empirical evidence is presented suggesting that MBIs ameliorate addiction by enhancing cognitive regulation of a number of key processes, including: clarifying cognitive appraisal and modulating negative emotions to reduce perseverative cognition and emotional arousal; enhancing metacognitive awareness to regulate drug-use action schema and decrease addiction attentional bias; promoting extinction learning to uncouple drug-use triggers from conditioned appetitive responses; reducing cue-reactivity and increasing cognitive control over craving; attenuating physiological stress reactivity through parasympathetic activation; and increasing savoring to restore natural reward processing. Treatment and research implications of our neurocognitive framework are presented. We conclude by offering a temporally sequenced description of neurocognitive processes targeted by MBIs through a hypothetical case study. Our neurocognitive framework has implications for the optimization of addiction treatment with MBIs.
The conceptual framework outlined in this paper clarifies and contextualizes the recent results from our randomized controlled trial of Mindfulness-Oriented Recovery Enhancement as a treatment for prescription opioid misuse and chronic pain.