Mindfulness-Oriented Recovery Enhancement (MORE) reduced opioid use to a significantly greater extent than standard group (SG) therapy. Garland et al. (2024). Amer J Psychiatry.
Dr. Garland was recently featured on Dr. Sanjay Gupta’s CNN podcast, “Chasing Life,” for an episode entitled, “Should You ‘Lean Into’ Your Chronic Pain to Relieve It?” In this exciting interview, acclaimed journalist and neurosurgeon Sanjay Gupta and Dr. Garland had a wide ranging discussion about how the brain constructs chronic pain, the impact of opioids on the brain’s reward system, and how mindfulness can facilitate healing from pain and addiction. Click here to listen.
In a new study published in the top medical journal JAMA Psychiatry, my colleagues and I found that Mindfulness-Oriented Recovery Enhancement (MORE) can help rewire the brain’s response to natural healthy pleasure in individuals with opioid use disorder (OUD), leading to improved mood, greater attention to positive experiences, and reduced opioid cravings. The findings add to the body of evidence demonstrating that MORE is an effective tool to help people heal from addiction.
Opioid addiction decreases the brain’s ability to experience natural healthy pleasure, driving increased cravings for the drug. This new study shows that MORE helps restore this capacity, reducing cravings and preventing opioid misuse.
In the study, participants with OUD showed difficulty enhancing positive emotions, as seen in weakened brain responses when they tried to savor images representing naturally rewarding objects and experiences, such as smiling babies, puppies or a beautiful sunset. The responses were measured through electroencephalogram (EEG) scans. This positive emotional blunting or numbing was directly linked to higher opioid cravings. However, the MORE therapy helped to heal this inability to savor by increasing brain responses to positive stimuli, which correlated with lower cravings and improved emotional well-being. The findings suggest that MORE can play a vital role in helping people with OUD increase their well-being and regain control over their cravings, thereby reducing opioid misuse.
Opioid addiction can sometimes develop when individuals misuse opioids originally prescribed for chronic pain, a condition affecting 50 million Americans each year. As people become increasingly dependent on opioids, they begin to lose the ability to feel joy and pleasure in everyday life, driving them to seek higher doses to maintain a fleeting sense of well-being — a downward spiral that leads to opioid addiction.
MORE is an evidence-based therapy developed and tested over the past two decades that integrates mindfulness training, cognitive behavioral therapy, and principles from positive psychology into a treatment that can simultaneously address addiction, emotional distress and chronic pain. MORE teaches mindfulness skills to regulate craving, relieve pain, and recover the ability to savor natural healthy pleasure, joy and meaning in life.
To date, MORE has been tested in over 16 randomized clinical trials involving more than 2,000 people. In the largest clinical trial of MORE involving 250 patients — published in JAMA Internal Medicine in early 2022 — MORE decreased opioid misuse by 45% at a 9-month follow-up, nearly tripling the effect of standard group therapy. In addition, 50% of patients treated with MORE reported clinically significant decreases in chronic pain. In a 2024 study published in JAMA Psychiatry, my colleagues and I showed that adding MORE to standard addictions care resulted in 42% less relapse and 59% less dropout from treatment when compared to standard addictions care alone.
Multiple rigorous, well-controlled clinical trials have demonstrated the efficacy of the MORE therapy. I’m now seeking support from policymakers and healthcare organizations, and the national opioids settlement, to disseminate this evidence-based treatment widely throughout the United States to help alleviate the opioid crisis.
The opioid crisis arose in part due to the attempt to relieve chronic pain. Meeting a huge need, this is the authoritative presentation of Mindfulness-Oriented Recovery Enhancement (MORE) for chronic pain and opioid use by Guilford Press. MORE is one of the few evidence-based treatments shown to simultaneously reduce opioid use and/or addiction, pain, and co-occurring emotional distress. MORE integrates mindfulness training with principles of cognitive-behavioral therapy and positive psychology. In a convenient large-size format, this book provides everything needed to set up and run MORE groups. This new book by Guilford Press offers session-by-session guidelines, sample scripts, clinical pointers, guided practices, and psychoeducational resources, including 15 reproducible handouts that can be photocopied or downloaded. To pre-order the book, click this link and receive a 15% discount.
My colleagues and I had a new paper published in the top scientific journal Nature Mental Health showing that Mindfulness-Oriented Recovery Enhancement (MORE) led to clinically significant reductions in post-traumatic stress symptoms in 59% of patients with comorbid PTSD, chronic pain, and opioid misuse. In this NIH-funded study involving 241 patients, MORE significantly reduced PTSD symptoms by increasing the capacity to regulate negative emotions through reappraisal. In turn, the effects of MORE on reducing opioid misuse were statistically mediated by decreases in PTSD symptoms. This study is important because PTSD is highly prevalent among people with chronic pain and addiction, yet there are no evidence-based treatments for this complex comorbidity. These data suggest that MORE is a highly effective therapy that can simultaneously treat traumatic stress, chronic pain, and addictive behavior.
Mindfulness-Oriented Recovery Enhancement (MORE) reduced PTSD symptoms to a significantly greater extent than supportive group (SG) psychotherapy.
Mindfulness-Oriented Recovery Enhancement Amplified Frontal Midline Theta EEG Power During Meditation
The study, published in the top journal Science Advances, provides new insight into the neurobiological mechanisms by which mindfulness treats addiction. Study findings provide a promising, safe and accessible treatment option for the more than 9 million Americans misusing opioids. Eric Garland is the lead author on the paper and is a distinguished professor, and associate dean for research at the University of Utah College of Social Work. He also directs the University of Utah’s Center on Mindfulness and Integrative Health Intervention Development.
Garland’s study builds on previous research measuring the positive effects of theta waves in the human brain. Researchers have found that individuals with low theta waves tend to experience a wandering mind, trouble concentrating or they ruminate on thoughts about themselves. Theta waves can best be viewed on electroencephalogram, or EEG scans of the frontal midline regions of their brains. Low theta waves result in a loss of self-control as the brain slips into its default mode of automatic habits. In contrast, when a person is focused, present and fully absorbed in a task, EEG scans will show increased frontal midline theta wave activity.
“With high theta activity, your mind becomes very quiet, you focus less on yourself and become so deeply absorbed in what you are doing that the boundary between yourself and the thing you are focusing on starts to fade away. You lose yourself in what you are doing,” said Garland.
Garland’s new study showed it is in this mindful, theta wave state that people begin to experience feelings of self-transcendence and bliss, and the brain changes in ways that actually reduce one’s addictive behaviors.
ABOUT THE STUDY
Garland’s research team recruited 165 adults with long-term opioid use for study. Participants were randomly placed into either the control group that participated in supportive group psychotherapy, or the experimental group taught to incorporate Mindfulness-Oriented Recovery Enhancement (MORE) into their daily lives. Before and after the eight weeks of study treatment, all participants were brought into the research lab and had their brain waves measured with EEG while they were asked to try to practice mindfulness meditation. Participants were assessed for opioid misuse for nine months after the treatment ended.
Study participants in the MORE group learned to practice mindfulness meditation by focusing their attention on their breath or body sensations for sustained periods of time, and to refocus their attention when their minds began to wander into obsessive thinking about drugs or life stressors.
STUDY FINDINGS
Participants showed more than twice as much frontal midline theta brain activity following treatment with MORE, whereas those in supportive therapy showed no increase in theta. Participants in MORE who showed the biggest increases in theta waves reported more intense experiences of self-transcendence during meditation, including the sense of one’s ego fading away, a sense of oneness with the universe or feelings of blissful energy and love.
Mindfulness-Oriented Recovery Enhancement Significantly Increased Self-Transcendent ExperiencesThe Effect of MORE on Reducing Opioid Misuse was Mediated by Increased Frontal Midline Theta
MORE also led to significant decreases in opioid misuse through the nine-month follow-up. These reductions in opioid misuse were caused in part by the increases in frontal midline theta brain waves. Garland explained that by achieving “tastes of self-transcendence” through meditation, the mindfulness therapy boosted theta waves in the frontal lobes of the brain to help participants gain self-control over their addictive behaviors.
“Mindfulness can create a pathway for us to transcend our limited sense of self,” said Garland. “Civilizations have known for thousands of years that self-transcendence, the experience of being connected to something greater than ourselves, has powerful therapeutic benefits.”
This, he explained, is a part of why some cultures engage in spiritual practices, practice deep meditation or use psychedelic substances like psilocybin mushrooms. Even in the popular 12-step addiction treatment program, the 11th step—seeking conscious contact with a higher power through prayer or meditation—taps into this same mechanism to promote recovery from addiction.
The state of transcendence can be like a blissful, natural high. Garland stated, “Rather than seeking a high from something outside of yourself like a drug, meditation can help you to find an even greater sense of pleasure, peace and fulfillment from within.”
The largest trial of Mindfulness-Oriented Recovery Enhancement (MORE) ever conducted “Mindfulness-Oriented Recovery Enhancement vs Supportive Group Therapy for Co-occurring Opioid Misuse and Chronic Pain in Primary Care: A Randomized Clinical Trial” was just published in JAMA Internal Medicine! The results of this $2.8 million NIH-funded clinical trial (N=250) for people with chronic pain and opioid misuse were outstanding: MORE reduced opioid misuse by 45%, more than doubling the effect of standard supportive therapy.This is one of the strongest effect sizes ever shown for a treatment for opioid misuse among people with chronic pain. MORE also reduced opioid use; 36% of patients treated with MORE were able to reduce their opioid dose in half or greater. At the same time, 50% of patients treated with MORE experienced clinically significant reductions in pain severity. And, although nearly 70% of patients met criteria for major depressive disorder (MDD) at the beginning of the trial, the mean depression symptom severity score for patients treated with MORE no longer surpassed the threshold for MDD by the end of the study. These therapeutic effects lasted for 9 months after the end of treatment, demonstrating the sustained efficacy of MORE. We followed patients for almost a year after they enrolled in the study, representing the longest follow-up ever conducted for the MORE intervention.
MORE resulted in long-term reductions in chronic pain and emotional distress.
The timing of this publication is highly serendipitous, given that the opioid pharmaceutical settlements are just now reaching the states. My hope is that governors and legislators will consider using MORE as part of the solution to help stem the tide of the opioid crisis. Please help me get the word out! #MOREworks!
In a recent bibliometric analysis of mindfulness research published over the past 55 years, I was found to be the most prolific author of mindfulness research in the world. While I’m truly honored and humbled by this achievement, the real meaning of this body of work goes beyond numbers and world records. My deepest aspiration is that the scientific discoveries I’ve made over the past 15 years will reduce suffering and advance human flourishing.
Are you a behavioral health clinician (social worker, psychologist, counselor, etc.) looking for a job centered on mindfulness? Here’s a full-time job opportunity delivering Mindfulness-Oriented Recovery Enhancement (MORE) to active duty military personnel undergoing knee replacement surgery for a new research study funded by the Department of Defense. I am the PI on the study, but the position is through the Geneva Foundation. If you are interested, please reach out to me (dr.eric.garland@gmail.com), or apply at the link below:
On May 4, I had the honor of giving an invited lecture for the National Center for Complementary and Integrative Health (NCCIH) of the National Institutes of Health, entitled “Healing the Opioid Crisis with Mindfulness-Oriented Recovery Enhancement: Clinical Efficacy and Neurophysiological Mechanisms.” The full video of this lecture can be found here. In this lecture, I described my decade-long research program focused on developing and testing MORE as a treatment for chronic pain, opioid misuse, and addiction, and reported results from the largest clinical trial of MORE to date.
Dr. Garland presents his research on Mindfulness-Oriented Recovery Enhancement to NIH Leadership
I began the talk discussing the destructive processes that unwittingly propel a person suffering from prolonged pain down the path toward an eventual loss of control over opioid use. I have been studying these risk mechanisms undergirding opioid misuse and OUD in people with chronic pain for more than a decade, and the discoveries I have made, along with great science from the field, informed the development of MORE. Then I described the Mindfulness-to-Meaning Theory, a key theoretical framework underlying MORE, as well as MORE’s treatment components, including mindfulness meditation, reappraisal, and savoring. Finally, I detailed MORE’s clinical outcomes and mechanisms of action across four randomized controlled trials involving nearly 500 patients. MORE works by strengthening self-control, reducing the brain’s reactivity to drug cues, increasing the brain’s response to natural, healthy rewards, enhancing meaning in life, and eliciting experiences of self-transcendence.
Following the lecture, I had a fascinating dialogue with the Director of NCCIH, Dr. Helene Langevin, and the Deputy Director of NCCIH, Dr. David Shurtleff about the emergence of self-transcendence in biological systems and its impact on health, and the use of mindfulness as a prevention and treatment strategy. This dialogue then opened up into a fantastic question and answer period. After the talk, I had the honor of discussing my research with multiple program directors and branch chiefs at NIH. If you didn’t have a chance to listen in, you can still watch the videocast here!
The National Center for Complementary and Integrative Health (NCCIH) invites you to join us this spring for exciting lectures on the theme of “Novel Approaches at the Intersection of Mental Health and Pain.” These virtual talks, part of our Integrative Medicine Research Lecture Series will take place on Tuesday, May 4, 2021, and Tuesday, June 8, 2021. The lectures, rescheduled from spring 2020, will be streamed live on NIH VideoCast.
May 4 Lecture Featuring Eric Garland, Ph.D., L.C.S.W.
Dr. Garland notes that some of our most pressing “diseases of despair,” such as addiction and chronic pain, disrupt the brain’s capacity to experience healthy pleasure and extract meaning from naturally rewarding events and experiences. Prolonged opioid use, for example, in the context of chronic pain and distress can blunt positive emotions and compel opioid misuse as a way to hold on to the shrinking sense of well-being. Dr. Garland will describe development and testing of MORE, an integrative treatment strategy.
In anticipation of the lecture, the Blog Team asked Dr. Garland a couple of questions.
1) What are the building blocks of MORE?
Dr. Garland: MORE unites complementary aspects of training in several skill areas:
Mindfulness skills enhance self-awareness, alleviate pain, and strengthen self-control over automatic, addictive habits.
Reappraisal skills facilitate reframing of adverse life events as a potential source of psychological growth.
Savoring skills increase a healthy sense of pleasure, joy, and meaning in life and elicit experiences of self-transcendence—the sense of being connected to something greater than oneself.
2) What are some of the insights from affective neuroscience that inform MORE?
Dr. Garland: First, the brain’s reward system computes the relative value of competing rewards. As addiction progresses, the brain’s reward system changes to become more sensitive to drug-related rewards and less sensitive to natural, healthy pleasures. MORE incorporates mindfulness, reappraisal, and savoring skills to reverse this process. A second fundamental insight is that the brain constructs the pain experience from bodily signals. In MORE, we teach patients to use mindfulness to view their chronic pain as harmless sensory information, not a threat to bodily well-being. This approach reduces the emotional suffering associated with pain, which in turn can decrease the severity of pain.
My new theory paper was just published online in Current Opinion in Behavioral Sciences. This paper outlines my recent ideas about how an addictions treatment approach based on mindfulness can enhance healthy pleasure, joy, and meaning in life. Most addictions treatments are focused on decreasing negative psychological experiences (e.g., stress, craving) and unhealthy behaviors. Few have focused on increasing positive psychological experiences as a core treatment approach. This oversight ignores fundamental discoveries from addiction neuroscience that demonstrate the plasticity of the brain reward circuitry underlying addiction. Therapies that use mindfulness techniques to savor natural rewarding objects and events, self-generate internal reward responses, and access self-transcendence may remediate the dysfunction in the reward system and thereby reduce addictive behavior.
The abstract is below:
Chronic drug use is theorized to induce cortico-striatal neuroplasticity, driving an allostatic process marked by increased sensitivity to drug-related cues and decreased sensitivity to natural rewards that results in anhedonia and a dearth of positive affect. As such, positive emotion regulation represents a key mechanistic target for addictions treatment. This paper provides a conceptual model detailing how mindfulness may synergize a range of positive affective mechanisms to reduce addictive behavior, from savoring the hedonic pleasure derived from natural rewards, to self-generating interoceptive reward responses, and ultimately to cultivating self-transcendent meaning. These therapeutic processes may restructure reward processing from overvaluation of drug-related rewards back to valuation of natural rewards, and hypothetically, ‘reset’ the default mode network dysfunction that undergirds addiction.
This is one of the strongest effect sizes ever shown for a treatment for opioid misuse among people with chronic pain. MORE also reduced opioid use; 36% of patients treated with MORE were able to reduce their opioid dose in half or greater. At the same time, 50% of patients treated with MORE experienced clinically significant reductions in pain severity. And, although nearly 70% of patients met criteria for major depressive disorder (MDD) at the beginning of the trial, the mean depression symptom severity score for patients treated with MORE no longer surpassed the threshold for MDD by the end of the study. These therapeutic effects lasted for 9 months after the end of treatment, demonstrating the sustained efficacy of MORE. We followed patients for almost a year after they enrolled in the study, representing the longest follow-up ever conducted for the MORE intervention.
