I was recently awarded $3.4 million in research funding from the Department of Defense Congressionally Directed Medical Research Program for a five-year clinical trial award entitled “Targeting Chronic Pain and Co-Occurring Disorders in the Community with Mindfulness-Oriented Recovery Enhancement.” To help me to carry out this pragmatic, large-scale randomized controlled trial, I will be supported by an interdisciplinary team of expert co-investigators from the University of Utah, including Jon-Kar Zubieta, Craig Bryan, Yoshio Nakamura, Gary Donaldson, and Bill Marchand.

The co-occurrence of chronic pain, psychological distress, and misuse of prescription opioids undermines the mission of the U.S. Military and inflicts suffering upon Veterans and their families. Approximately one-half of service members have chronic pain following deployment, and nearly one-fifth engage in opioid misusing behaviors like unauthorized dose escalation and use of opioids to self-medicate stress and anxiety. The state of Utah (where the proposed study will be conducted) has one of the highest incidences of nonmedical use of opioids in the U.S. and a rapidly increasing rate of prescription opioid-related deaths. Indeed, an estimated 21% of Utah adults were prescribed opioids during the past year, of which approximately one-in-five report taking more than prescribed. Given that military personnel and Veterans have higher rates of pain-related conditions than the general population, their risk for opioid-related problems is significantly enhanced.

New scientific findings indicate that because stress worsens pain and increases habit responses in the brain, individuals who cope with stress and pain through opioids are likely to have the most serious and difficult-to-treat opioid-related problems. The recent wars in Iraq and Afghanistan have been marked by repeated deployments involving serious combat-related and occupational stress. Unfortunately, there are no evidence-based treatments that simultaneously address pain, opioid misuse, and psychological distress. To fill this gap, this research proposal aims to conduct a pragmatic trial of a novel integrative medicine approach combining Mindfulness-Oriented Recovery Enhancement (MORE) with conventional opioid pain management for service members and Veterans. MORE aims to strengthen self-control over habit behaviors, increase flexible thinking under conditions of stress, and promote the sense of reward and meaning in the face of adversity.

This research project will help active duty service members and Veterans with chronic pain and stress who are at-risk for opioid misuse, and will also inform the treatment of civilians with similar issues. Should MORE prove to be effective in a community-based context, it could be easily transported into military installations and Veterans Administration Medical Centers in the U.S. and around the world, as well as in communities where no major military medical center is present. In these settings, MORE could be offered as a form of standard integrative health care provided to service members and Veterans.

A secondary objective of the proposed project is to utilize lab-based assessments and mobile technology to understand how MORE works to create therapeutic change, and to predict whether and when service members and Veterans are at risk for relapsing back to opioid misuse. To accomplish this objective, lab-based assessments will evaluate physiological reactivity to cues associated with past episodes of pain and opioid use, and a smartphone-based assessment will be used to evaluate opioid craving, pain, and negative mood in “the real world.” Because changes in heart rate and other physiological factors may indicate the extent to which a person’s brain has been triggered by opioid craving, this application of mind-body assessments to predict opioid misuse risk and treatment outcomes could facilitate early risk detection.

The final objective of the project is to understand for whom MORE works best, to help ensure more efficient healthcare resource allocation to the service members and Veterans who need it most.  The proposed project will enable health care providers to more effectively deliver low-cost treatment to prevent progression toward opioid addiction, thereby averting costly inpatient stays, discharge from active duty military service, and social, legal, and occupational problems among Veterans. Ultimately, the proposed research could significantly enhance the psychological and physical health of military personnel and Veterans by addressing the need for new integrative medicine treatment options with findings from the leading edge of science.

It is my pleasure to announce that the very first review paper summarizing the theoretical rationale and empirical evidence for Mindfulness-Oriented Recovery Enhancement (MORE) has been accepted for publication in the prestigious journal Annals of the New York Academy of Sciences. In this paper, I review data from multiple clinical studies on the biobehavioral mechanisms of MORE, and articulate a hedonic regulatory model of the intervention – proposing that restructuring reward processing is the final common pathway through which MORE ameliorates addiction, stress, and pain. I map this novel theoretical model onto an earlier conceptual framework of the neural circuitry underlying mindfulness-centered regulation of addiction (Garland, Froeliger, & Howard, 2014) and then describe new neuroimaging and psychophysiological data in support of the model. The paper abstract is as follows:

“Though valuation processes are fundamental to survival of the human species, hedonic dysregulation is at the root of an array of clinical disorders including addiction, stress, and chronic pain, as evidenced by the allostatic shift in the relative salience of natural reward to drug reward observed among persons with severe substance use disorders. To address this crucial clinical issue, novel interventions are needed to restore hedonic regulatory processes gone awry in persons exhibiting addictive behaviors. This article describes theoretical rationale and empirical evidence for the effects of one such new intervention, Mindfulness-Oriented Recovery Enhancement (MORE), on top-down and bottom-up mechanisms implicated in cognitive control and hedonic regulation. MORE is innovative and distinct from extant mindfulness-based interventions in that in unites traditional mindfulness meditation with reappraisal and savoring strategies designed to reverse the downward shift in salience of natural reward relative to drug reward, representing a crucial tipping point to disrupt the progression of addiction – something that no other behavioral intervention has been designed to do. Though additional studies are needed, clinical and biobehavioral data from several completed and ongoing trials suggest that MORE may exert salutary effects on addictive behaviors and the neurobiological processes that underpin them.”

I am feeling particularly thankful today to my colleagues Norman Farb (University of Toronto), Philippe Goldin (University of California – Davis), and Barbara Fredrickson (University of North Carolina – Chapel Hill), with whom I wrote and recently published the target article for the December issue of the esteemed, international journal Psychological Inquiry. Our target article, entitled “Mindfulness Broadens Awareness and Builds Eudaimonic Meaning: A Process Model of Mindful Positive Emotion Regulation,” articulates the Mindfulness-to-Meaning Theory, a new conceptual model of the cognitive, emotional, and neurobiological processes by which mindfulness might stimulate positive psychological states and lead to a sense of meaning in the face of adversity. In brief, the Mindfulness-to-Meaning Theory asserts that mindfulness allows one to decenter from stress appraisals into a metacognitive state of awareness that broadens attention to previously unnoticed pieces of information about one’s life, accommodating a reappraisal (i.e., a reframing) of adverse circumstances that reduces distress and promotes positive emotions. This reappraisal is then deepened and enriched when one savors what is pleasant, growth promoting, or meaningful in life, a process which motivates values-driven behavior and engenders a deeper sense of purpose and self-actualization.

The entire journal issue is devoted to the discussion of our new Mindfulness-to-Meaning Theory. Our work was the subject of 10 erudite commentaries from leading scholars in the fields of contemplative science, addiction neuroscience, clinical psychology, affective science, psycho-oncology, social psychology, and consciousness studies, who extended, challenged, and pushed our theory into new and wider applications. We responded to the commentaries with our own article “The Mindfulness-to-Meaning Theory: Extensions, Applications, and Challenges at the Attention–Appraisal–Emotion Interface,” which broadens the theory to address how mindfulness re-configures structures within working memory, describes mindfulness as a domain general resource for promoting emotion regulation flexibility, and suggests future directions to be pursued toward the establishment of a more comprehensive contemplative science.

The target article may be downloaded here and our response to the commentaries downloaded here.

May our work help advance the field to promote human flourishing!

Earlier this year, along with colleagues Marieke Wichers, Nicole Geschwind, and Frenk Peeters (Maastrict University and University of Groningen), I published a paper on the effects of mindfulness training on the dynamic change trajectories of positive emotions and thoughts over time. This study analyzed data from a randomized controlled study of 110 individuals with histories of depression who were randomly assigned to receive an 8-week Mindfulness-Based Cognitive Therapy intervention or a control condition. Study participants rated their experiences of positive emotions and thoughts on a daily basis using a method called “experience sampling” (also known as ecological momentary assessment, or EMA), in which they were prompted at random times throughout the day to describe their mental state in the midst of everyday life activities. To analyze this data, we employed a sophisticated statistical technique called multivariate autoregressive latent trajectory modeling (see the Figure above). We found that mindfulness training significantly enhanced positive emotions and positive thoughts from moment-to-moment. Importantly, we also found evidence that mindfulness training may stimulate an upward spiral of positivity, such that increasing experiences of positive emotions on one day stimulated positive emotions and thoughts on the following day, and so forth. In other words, it appears as mindfulness training can enhance positive emotion-cognition interactions that may be important to psychological flourishing (and physical health). These data provide support for my new Mindfulness-to-Meaning Theory (see the Figure above), which will be featured on this website in a month or two when my paper about this theory will be published as the target article of the December issue of the esteemed international journal Psychological Inquiry and receive commentary by some of the leading contemplative scientists in the world. Stay tuned!

A research paper I published along with Adam Hanley (first author) in the journal Mindfulness has received an astounding amount of press, including coverage by the Wall Street Journal, Time Magazine, and television outlets like the Today Show! This deceptively simple study involved randomly assigning college students to read a passage by Thich Nhat Hanh on mindful dishwashing or a textual description of dishwashing procedures like what might be found in a home economics textbook, Then students washed a sink full of dirty dishes, and then completed state measures of mindfulness and positive and negative emotions. After controlling for differences in baseline tendencies towards mindfulness and well-being, we found that individuals who received the mindful dishwashing induction reported significantly deeper states of mindfulness, as well as some improvements in positive and negative emotions following dishwashing. Perhaps most interestingly, people who engaged in mindful dishwashing reported a slowing of perceived time (that is, they overestimated the length of time they spent washing dishes) – a finding that is consistent with research on “flow states” and other studies of mindfulness (e.g., Berkovitch-Ohana et al., 2012). As we note in the published paper, it is fascinating to observe “that a task potentially construed as unpleasant or a “chore” can be experienced as reducing nervousness and being inspirational by simply shifting one’s approach to the task and the quality of attention” (Hanley et al., 2015, p. 1101). This simple study has implications for research on mindfulness, suggesting that the informal practice of mindfulness during everyday life activities may be an important means of cultivating attention and awareness in much the same way as formal mindfulness meditation. More research is needed to outline the differences and similarities between formal and informal mindfulness practices.

I have been honored by being selected as a University of Utah Presidential Scholar. According to the press release, “the Presidential Scholar award was created to support the work of exceptionally promising mid-career faculty at the University of Utah.” The purpose of the award is to honor “individuals who are significant contributors to scholarship, education, and outreach at the University of Utah.” The Presidential Scholar awards provide three years of support for scholarly, teaching, and/or outreach activities. I intend to use this award to support my research on Mindfulness-Oriented Recovery Enhancement as a treatment for addiction, stress, and pain.

An article I published with my colleagues Brett Froeliger from MUSC and Matthew Howard from UNC Chapel Hill in the journal Frontiers in Psychiatry entitled “Mindfulness training targets neurocognitive mechanisms of addiction at the attention-appraisal-emotion interface” was designated in the 93rd percentile of 3,480,147 articles tracked by Altmetric. The Altmetric score is a measure of the quality and quantity of online attention that this article has received. The paper details the model depicted below.

In this review paper, we describe how mindfulness-based interventions (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 paper is free for download here.

Eric Garland, PhD, LCSW, Associate Director of Integrative Medicine in Supportive Oncology at the Huntsman Cancer Institute and Associate Professor in the University of Utah College of Social Work, was recently elected to the position of Distinguished Scholar and Fellow in the National Academies of Practice. Dr. Garland was selected for a Distinguished Fellowship based on his extensive clinical practice and research focusing on mindfulness-based treatments for addiction, stress-related conditions, and chronic pain.

The National Academies of Practice is a non-profit organization founded in 1981 to advise governmental bodies on health care. A select group of distinguished practitioners and scholars from 10 different health professions are elected by their peers to join the only interprofessional group dedicated to supporting affordable, accessible, quality care for all.

Read the full story here.

A new and important research study from my lab was recently accepted for publication in the respected Journal of Behavioral Medicine. This paper, which I wrote with my colleagues Brett Froeliger, Ph.D., and Matthew Howard, Ph.D., describes neurophysiological findings from a pilot randomized controlled trial (RCT) of Mindfulness-Oriented Recovery Enhancement (MORE) for chronic pain patients who had been prescribed long-term opioids for pain management. To my knowledge, this exploratory study is the first in the scientific literature to demonstrate that a mindfulness-based intervention can increase electroencephalographic (EEG) responses to natural, healthy pleasures in life.

In this study, individuals suffering from various chronic pain conditions were randomly assigned to participate in MORE or a social support group led by a therapist. Participants in the MORE group received 8 weeks of instruction in applying mindfulness-oriented techniques to alleviate pain and craving while strengthening positive emotions and the sense of reward and meaning in  life. This latter aspect of MORE may be critically 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. In the absence of positive feelings, they suffer worse from emotional and physical pain, and ultimately may feel compelled to take drugs (such as opioids) to achieve a normal sense of well-being.

To enhance the sense of reward in life, participants were taught a mindful savoring practice, which involved focusing attention intensely 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).

Although people tend to savor beauty naturally, we hoped that training in MORE could enhance savoring, and thereby increase the sensitivity of the brain to naturally-rewarding experiences. As an indicator of this enhanced savoring ability, we hypothesized that MORE would increase brain responses to images representing such positive experiences. To measure this in the lab, we used a computer to present participants with a series of positive photos representing naturally-rewarding objects and events (e.g., smiling babies, beautiful nature scenes, intimate couples in love) and a series of neutral photos (e.g., kitchen items, household objects, neutral faces) presented for 6 seconds each. During this task, we measured EEG brain activity at the scalp (the parietal site Pz) that were time-locked to the onset of the image. We were particularly interested in the component of the EEG known as the late positive potential (LPP), a brain response that tends to occur between 400 – 1000 ms after an emotional image is displayed. The LPP is known to be enhanced to positive images relative to neutral images in healthy individuals, whereas opiate addicts show reduced EEG brain responses to positive images (Lubman et al., 2008; 2009). In addition to measuring brain activity, we also asked participants to rate how positive they felt after viewing each photograph, and how much they desired or craved opioids in general.

In line with our hypothesis, we found that relative to the control group, MORE significantly increased the LPP brain activity to positive images relative to neutral images. In other words, participants showed enhanced brain responses while viewing naturally-rewarding stimuli following treatment with MORE. In addition, patients who exhibited the largest increases in LPP brain response to positive images experienced the greatest increases in positive emotions while viewing those images. Also, individuals who experienced the biggest increases in brain response to positive images experienced the greatest reduction in craving for opioids. These findings are important because they suggest 1) that MORE may help people to become more sensitive to naturally-rewarding objects and events, and 2) as people learn to experience greater pleasure from healthy and meaningful experiences in life, they may feel less of a need to take addictive drugs.

My colleagues and I recently advanced a neurocognitive model that suggests that MORE may alter the function of the mesocorticolimbic dopamine system, and in particular, target activity in the ventral striatum, a brain structure involved in experiencing both natural pleasure and pleasure associated with drug use. Numerous studies have shown that the ventral striatum functions abnormally in people suffering from addiction. MORE may restore normal function in this brain area, although studies using functional magnetic resonance imaging (fMRI) are needed to test this hypothesis.

Taken together, results from this new study, in combination with my previously published findings on cardiac-autonomic responses to positive stimuli, suggest that MORE may ameliorate deficits in natural reward processing among chronic patients taking long-term opioids by strengthening their ability to pay attention to healthy objects and events. Restoration of the ability to extract a sense of reward, fulfillment, and meaning out of everyday pleasures may be crucial to the ability to self-generate positive emotions and to resilience itself (Garland, Fredrickson, et al., 2010). More rigorous and larger-scale research is needed to test my hypothesis that focusing one’s attentional lens to more richly process the pleasurable, interesting, and meaningful experiences in life may make the painful and dissatisfying ones insignificant by comparison.

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.