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.
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.
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!
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!
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.
In December 2020, I gave a lecture on my research entitled “Mindfulness-Oriented Recovery Enhancement Heals Opioid Misuse and Chronic Pain by Restructuring Reward: From Hedonic Pleasure to Self-Transcendent Meaning” to the Brown University Contemplative Studies Initiative. Following this talk, I enjoyed a fascinating dialogue about the relationship between mindfulness and self-transcendence with a leading scholar of Classical Chinese Philosophy and Taoism, Hal Roth, PhD. The video of my talk is below. Enjoy!
MORE is an evidence-based, transdiagnostic therapy that unites complementary aspects of mindfulness training, third-wave CBT, and principles from positive psychology into an integrative treatment approach for addiction, stress, and chronic pain. MORE’s therapeutic effects have been demonstrated in ten clinical trials, and the MORE research program is currently supported by more than $25 million in federal research grants from the National Institutes of Health (NIH), the Department of Defense (DOD), and the Patient Centered Outcomes Research Institute (PCORI). Rigorous experiments have demonstrated effects of MORE on modifying neurophysiological reactivity to drug cues and natural rewards – indicating that MORE leads to therapeutic changes in the brain.
Participants receive intensive didactic and experiential instruction in implementing specialized mindfulness techniques and other clinical skills integral to 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 clinical role plays. Participants will receive live supervision from Dr. Garland in the delivery of therapeutic techniques via real-time feedback to optimize the delivery of the MORE intervention.
Unique mind-body therapy techniques, advanced cognitive-behavioral skills, and strategies from positive psychology will be presented to address common clinical problems including:
Craving and unhealthy habit behaviors
Physical and emotional pain
Catastrophizing and rumination
Stress reactivity and anhedonia
At the completion of the training 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.
Training in MORE is provided at institutions of higher education, government agencies, academic teaching hospitals, and medical centers. To date, Dr. Garland has provided training in MORE to >475 clinicians from a range of settings, including Johns Hopkins Medical School (Maryland), Mt. Sinai Hospital (New York), Essentia Health (Minnesota, Wisconsin, and North Dakota), Medical University of South Carolina (South Carolina), Intermountain Healthcare (Utah), Southwest Care Center (New Mexico), New Roads Behavioral Health (Utah), Philadelphia Veterans Affairs Medical Center (Pennsylvania), Neuroscience Associates of New York (New York), Triangle Options for Substance Abusers (North Carolina), the University of Zurich (Switzerland), among others.
The cost of the training is $500 for 13 NASW-approved CEUs (with a 20% discount for graduate students). Register here.
I was recently interviewed by renowned psychotherapist Lisa Dale Miller for her Groundless Ground Podcast about a range of topics. It was definitely my favorite interview I’ve had to date. Lisa and I had a really fun conversation ranging from the treatment of chronic pain and addiction with mindfulness, to the neuroscience of reward, to Buddhist philosophy, to self-transcendence, and finally, to the arcane Tantric notion that the dynamic Primordial Bliss of Consciousness lies at the heart of all experience.
Eric Garland Interviewed on Groundless Ground Podcast by Lisa Dale Miller
Using my research on Mindfulness-Oriented Recovery Enhancement (MORE) as a launchpad, Lisa and I delve into specific clinical issues around the use of meditation as a means of alleviating physical pain and drug craving, providing mindfulness instruction to people suffering trauma, and how to enhance the sense of meaning and joy in life through reappraisal and savoring. We dig deep into the science of restructuring reward processes in the brain as novel approach to addictions treatment. Finally, we give a brief history of the science of mindfulness and how it developed from a core of mechanistic cognitive psychology to begin to explore the outer edge of meditative states of consciousness – including the study of how people can transcend their limited sense of self and come to feel intimately interconnected with the world around them.
We let it all hang out! Come check it out! The podcast is also available on Spotify.
New research shows that a specific mind-body therapy, Mindfulness-Oriented Recovery Enhancement (MORE), increases the brain’s response to natural, healthy rewards while also decreasing the brain’s response to opioid-related cues.
Brain function during viewing of opioid- and natural reward-related images was assessed with EEG
The study, published today in the journal Science Advances, examined data from four experiments involving 135 adults who took opioids daily for chronic pain. The study participants were randomly assigned to two groups where they participated in eight weeks of MORE or eight weeks of a therapist-led support group. At the beginning and end of the study period, researchers collected electroencephalogram (EEG) data, which measures brain function through electrical activity at the scalp.
The results showed that over the course of the study, the
brains of the study participants in the MORE group became significantly less
reactive to cues related to their opioid medications, while also becoming
significantly more responsive when participants used mindfulness to savor natural
pleasure.
“Previous research shows that prolonged use of opioids makes our brains more sensitive to pain and less receptive to the joy one might normally experience from natural rewards, like spending time with loved ones or appreciating a beautiful sunset,” explained Eric Garland, associate dean for research at the University of Utah College of Social Work and lead author of the study. “This blunted ability to experience natural positive feelings leads people to take higher and higher doses of opioids just to feel okay, and ultimately propels a downward spiral of opioid dependence and misuse. Because of this downward spiral, scholars are increasingly referring to chronic pain and opioid misuse as ‘diseases of despair.’”
“The results of this study show that MORE can actually
reverse that devastating trajectory,” said Garland.
In addition to these objective EEG findings, participants in MORE also reported feeling enhanced joy and more meaning in life, results which Garland detailed in a paper published earlier this month in the Journal of Consulting and Clinical Psychology. They also reported experiencing significantly less pain and greater positive psychological health (positive emotions, the ability to savor natural pleasure and self-transcendence) than those in the support group. The study concluded that three months after treatment, MORE reduced risk of opioid misuse by increasing positive psychological health and decreasing pain.
Garland developed MORE as an integrative mind-body therapy designed to promote positive psychological health while simultaneously addressing addiction, pain and stress. MORE teaches mental training techniques to help people to find meaning in the face of adversity while simultaneously alleviating physical and emotional pain by cultivating positive feelings and experiences.
“MORE teaches people to better notice, appreciate and
amplify the good things in life, while also deriving meaning and value from
difficult situations,” said Garland.
Taken together, Garland explains, these studies indicate
that by changing brain function and promoting positive psychological health, MORE
may increase happiness and an enhanced sense of meaningfulness in the face of
adversity. These positive psychological effects, in turn, appear to reduce pain
and prevent the misuse of opioids. Thus, enhancing joy and meaning in life
through mindfulness may be an antidote to diseases of despair, Garland
explains.
It is estimated that approximately 20-30 percent of U.S. adults
experience chronic pain. Opioid painkillers are often prescribed to these
patients, but a quarter of those who take these powerful drugs long-term end up
misusing them. With opioids accounting for 63 percent of all drug overdose
deaths in 2015, the widespread misuse of this class of drugs has been deemed a
public health crisis.
“Our nation’s opioid crisis kills more than 100 people a day,”
said Garland. “So it is critical that we help develop new and effective ways to
prevent opioid misuse. The data shows that MORE can play that key role.”
Results from a research study on Mindfulness-Oriented Recovery Enhancement have been covered as a research spotlight on the webpage of the National Institutes of Health – National Center for Complementary and Integrative Health (NCCIH). This randomized controlled pilot study, funded by NCCIH, tested the effects of MORE among individuals receiving medication assisted treatment (MAT) for opioid use disorder (OUD). Participants received 112 random assessments delivered by smartphone over the course of 8 weeks of treatment with MORE or treatment as usual (TAU). Compared to TAU, participants in the MORE intervention reported a 50% reduction in the intensity of their opioid cravings, as well as significantly greater self-control over cravings. In addition, participants reported significant improvements in pain unpleasantness, stress, and positive emotions. Although participants in TAU received more than 6 hours of therapy per week, the effects of MORE were evident above and beyond that intensive degree of treatment, suggesting that MORE may be a useful adjunct to community-based MAT. The full study results were published in the flagship addictions journal Drug and Alcohol Dependence.
Along with my colleagues Drs. Brett Froeliger and Michael Saladin (Medical University of South Carolina), I was recently awarded a 5-year, $2.3 million grant from the National Institute on Drug Abuse to study the neural mechanisms of Mindfulness-Oriented Recovery Enhancement (MORE) as a smoking cessation intervention. In this study, 100 smokers will be randomly assigned to receive eight sessions of MORE or eight sessions of cognitive-behavioral therapy (CBT) to assist them in quitting smoking. Before and after the eight session intervention, participants will complete a task while their brain activity is being recorded in a fMRI scanner to measure their neural response natural rewards and cigarette cues. According to the allostatic model of addiction, as addiction progresses, the brain becomes hypersensitive to drug-related cues and triggers, and insensitive to natural, healthy rewards and pleasures, resulting in a lack of hedonic pleasure and dysphoria that pushes the individual to take higher and higher doses of the drug just to feel okay. This study is designed to test my restructuring reward hypothesis, which states that mindful savoring can reduce addictive behaviors by causing a shift in brain reward circuitry from valuing of drug-related rewards back to valuing natural rewards – reversing the allostatic process of addiction. This new research grant builds upon our earlier published proof-of-concept study showing that MORE increases savoring-related neural activation in the medial prefrontal cortex and ventral striatum – key reward-related brain areas. This increase in brain activity was associated with significant reductions in cigarette smoking. Here we will seek to replicate this finding using a rigorous, randomized clinical trial design. It is my sincere hope that this work will help to free people from smoking – the leading cause of preventable death in the United States.
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.
Michael Saladin (Medical University of South Carolina), I was recently awarded a 5-year, $2.3 million grant from the National Institute on Drug Abuse to study the neural mechanisms of 
medial prefrontal cortex and ventral striatum – key reward-related brain areas