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.
Results from a new Stage 2 randomized controlled trial of Mindfulness-Oriented Recovery Enhancement (MORE), to be published later this summer in the Journal of Consulting and Clinical Psychology, have been covered in a news story that also details findings from a recently published study of the effects of mindfulness on deautomatization of habit behaviors. A second news story also did a really nice job describing results from this study.
Results from this study, conducted in 95 people with chronic pain who had been prescribed long-term opioid therapy, demonstrate that MORE significantly decreased chronic pain intensity and significantly decreased the risk of future opioid misuse. Further, MORE boosted a range of positive psychological functions, including positive emotions, savoring, meaning in life, and the sense of self-transcendence. Importantly, the MORE’s effects on reducing pain and opioid misuse were linked with these increases in positive psychological functioning, suggesting that teaching people to “savor the good” and increase the sense of joy, meaningfulness, and natural healthy pleasure in life may be an antidote to the current pain and opioid crises in America – modern epidemics that have been termed “diseases of despair.”
This is the second randomized controlled trial to demonstrate therapeutic effects of MORE on chronic pain symptoms and opioid misuse, providing compelling evidence of MORE’s efficacy as a means of alleviating the suffering caused by the opioid crisis.
Eric Garland, PhD has been appointed by Francis Collins, MD, PhD, Director of the National Institutes of Health, to the NIH HEAL Multidisciplinary Working Group focused on a $1.1 billion federal effort to speed scientific solutions to stem the opioid crisis.
The Helping to End Addiction Long-term (HEAL) Initiative’s working group—comprised of 16 national experts on issues of pain and addiction research—is part of NIH’s efforts to “bring the very best science to the task of addressing our national crisis of opioid addiction and chronic pain,” explained Collins.
The working group is charged with providing input on HEAL research, drafting recommendations for various NIH institute and federal advisory committees, prioritizing future research areas, increasing harmonization across HEAL research projects, offering input on proposed funding plans and providing a public venue for discussion of HEAL research by stakeholders, among other tasks.
Garland is director of the Center on Mindfulness and Integrative Health Intervention Development (C-MIIND) and the developer of Mindfulness-Oriented Recovery Enhancement (MORE), an innovative mind-body therapy designed to address addiction, pain and stress.
His current research program, supported by nearly $50 million in grant funding, focuses on testing MORE and other behavioral therapies for chronic pain and opioid misuse. In addition to providing care to hundreds of study participants, his work is also contributing to a deeper understanding of the neuroscience behind pain, addictive behaviors and their effects on reward processing in the brain.
“I am deeply humbled by the opportunity to serve on this national working group,” said Garland. “The current opioid crisis is one of the greatest and most urgent public health issues confronting society today. I’m tremendously honored to work closely with NIH and contribute what I’ve learned to advance scientific solutions to this grand challenge.”
The National Institute on Drug Abuse (NIDA) covered a recently published study of Mindfulness-Oriented Recovery Enhancement (MORE) on their NIDA Notes page. NIDA Notes has provided in-depth coverage of research findings on drug abuse and addiction for the past 25 years. Each month, 2-4 research articles from the entirety of addiction science are covered on NIDA’s webpage, so this is great recognition for the MORE research program.
We previously demonstrated that MORE can reduce chronic pain patients’ misuse of opioids (Garland et al., 2014, Journal of Consulting and Clinical Psychology). Now, a follow-up analysis of data from that study found these reductions in opioid misuse to be associated with an increase in patients’ cardiac-autonomic responsiveness to cues for natural rewards relative to cues for drug rewards (Garland et al., 2017, Psychotherapy and Psychosomatics). This is one of the most important discoveries I have made in the past decade, and suggests that MORE may reduce risk for opioid misuse by increasing physiological sensitivity to natural rewards. Thus, using mindfulness to amplify savoring of natural, healthy pleasures and promote meaning in life may be an antidote to opioid misuse, a condition that has been called a “disease of despair.”
I am pleased to announce that my colleague Matthew Howard and I had a new, invited manuscript accepted in the journal Addiction Science and Clinical Practice, an open access forum for clinically-relevant research that was previously published by the National Institute on Drug Abuse. The abstract for this paper (which is freely available to the public), entitled Mindfulness-Based Treatment of Addiction: Current State of the Field and Envisioning the Next Wave of Research is appended below:
“Contemporary advances in addiction neuroscience have paralleled increasing interest in the ancient mental training practice of mindfulness meditation as a potential therapy for addiction. In the past decade, mindfulness-based interventions (MBIs) have been studied as a treatment for an array addictive behaviors, including drinking, smoking, opioid misuse, and use of illicit substances like cocaine and heroin. This article reviews current research evaluating MBIs as a treatment for addiction, with a focus on findings pertaining to clinical outcomes and biobehavioral mechanisms. Studies indicate that MBIs reduce substance misuse and craving by modulating cognitive, affective, and psychophysiological processes integral to self-regulation and reward processing. This integrative review provides the basis for manifold recommendations regarding the next wave of research needed to firmly establish the efficacy of MBIs and elucidate the mechanistic pathways by which these therapies ameliorate addiction. Issues pertaining to MBI treatment optimization and sequencing, dissemination and implementation, dose–response relationships, and research rigor and reproducibility are discussed.”
I participated in the invitation-only NIH meeting “Contributions of Social and Behavioral Research in Addressing the Opioid Crisis” on March 5-6, 2018 (for a link to the webcast of the entire meeting, click here). This meeting was part of the series of NIH meetings on Cutting Edge Science to End the Opioid Crisis. The goals of this meeting were to: 1) specify the key social and behavioral science findings that can be brought to bear immediately to address the opioid crisis and 2) identify critical short-term research priorities that have to the potential to improve the opioid crisis response. The meeting participants represented some of the most accomplished researchers involved in the social and behavioral research relevant to the opioid crisis as well as senior leaders of various federal agencies and national organizations. I was tremendously honored to be invited as a subject matter expert to present my research to inform real-world policy and practice initiatives to address the opioid crisis.
I spoke on a panel entitled “Incorporating Nonpharmacologic Approaches to the Treatment of Opioid Abuse and Chronic Pain Management” along with luminaries in the pain research field including Francis Keefe (Duke University), Dennis Turk (University of Washington), and Dan Cherkin (Kaiser Permanente). In my talk, I discussed my research on Mindfulness-Oriented Recovery Enhancement (MORE) as a treatment for chronic pain and opioid misuse, and emphasized hedonic dysregulation (e.g., anhedonia) as a pathogenic process in opioid misuse/addiction and a key mechanistic target for novel behavioral therapies.
We presented our work to federal administrators including Francis Collins (Director of the National Institutes of Health), Nora Volkow (Director of the National Institute on Drug Abuse), Eliseo Pérez Stable (Director of the National Institute on Minority Health and Health Disparities), William Riley (Director of the Office of Behavioral and Social Science Research), David Shurtleff (Acting Director of the National Center for Complementary and Integrative Health), David Atkins (Director of Health Services Research and Development Service, U.S. Department of Veteran Affairs), and Sherry Ling (Deputy Chief Medical Officer of the Center for Clinical Standards and Quality, Centers for Medicare and Medicaid Services).
Areas of focus at the meeting included discussion of 1) Sociocultural and Socioeconomic Underpinnings of the Opioid Crisis in the United States; 2) Behavioral and Social Factors Preventing Opioid Initiation and Mitigating the Transition from Acute to Chronic Opioid Use; 3) Incorporating Nonpharmacologic Approaches to the Treatment of Opioid Abuse and Chronic Pain Management; 4) Prevention, Treatment and Recovery: Challenges and Barriers to Implementation; and 5) Effective Models of Integrated Approaches.
To summarize the meeting, research leaders and healthcare policy makers were highly focused on implementation and dissemination of evidence-based interventions and practices to target opioid misuse in chronic pain patients and to prevent/treat opioid addiction among those who have transitioned to illicit opioid use. There was much emphasis on the role of negative affect (e.g., despair), suicidality, and trauma as precipitants and correlates of opioid addiction, and the role of social support and meaningful engagement as protective factors against opioid addiction. Non-pharmacologic approaches (specifically, mindfulness and cognitive-behavioral therapy) were directly highlighted as empirically supported means of treating chronic pain and preventing opioid addiction. Finally, there was much discussion of the need to advance integrative treatment models that combine medication assisted treatment (e.g., buprenorphine, methadone) with behavioral interventions (e.g., mindfulness, exercise/physical therapy) to stop the crisis.
I was particularly struck by the framing of the opioid crisis as a “disease of despair” driven by socioeconomic disparity and disenfranchisement. Early in the morning on March 5, Nobel Prize winning economist Angus Deaton presented his work showing that mortality by opioids, alcohol, and suicide is differentially elevated in U.S. counties struck by structural inequalities. If opioid misuse and addiction are diseases of despair, then therapies like Mindfulness-Oriented Recovery Enhancement that aim to enhance joy and meaning in life may be a key part of the much-needed multifaceted solution to the greatest public health crisis of our era.
NPR recently covered another news story about my research on Mindfulness-Oriented Recovery Enhancement (MORE) as a therapy for chronic pain patients who are taking long-term prescription opioids. This story details the experience of a participant in the MORE intervention, and describes how mindfulness can be used to cope with pain and strengthen self-control.
National Public Radio recently covered a story on Mindfulness-Oriented Recovery Enhancement (MORE) as an intervention for chronic pain and prescription opioid-related problems. The story details new discoveries about the biobehavioral mechanisms of this novel therapy, as well as how mindfulness can be used to improve well-being in individuals suffering from chronic pain.
My colleagues and I just published a new paper in the Journal of General Internal Medicine demonstrating that mindfulness training and hypnotic suggestion significantly reduced acute pain experienced by hospital inpatients. After participating in a single, 15-minute session of one of these mind-body therapies, patients reported an immediate decrease in pain levels similar to what one might expect from an opioid painkiller.
This study is the first to compare the effects of mindfulness and hypnosis on acute pain in the hospital setting.
The yearlong study’s 244 participants were patients at the University of Utah Hospital in Salt Lake City who reported experiencing unmanageable pain as the result of illness, disease, or surgical procedures. Willing patients were randomly assigned to receive a brief, scripted session in one of three interventions: mindfulness, hypnotic suggestion or pain coping education. Hospital social workers who completed basic training in each scripted method provided the interventions to patients.
While all three types of intervention reduced patients’ anxiety and increased their feelings of relaxation, patients who participated in the hypnotic suggestion intervention experienced a 29% reduction in pain, and patients who participated in the mindfulness intervention experienced a 23% reduction in pain, compared to a 9% reduction experienced by those who participated in the pain coping intervention. Patients receiving the two mind-body therapies also reported a significant decrease in their perceived need for opioid medication.
About a third of the study participants receiving one of the two mind-body therapies achieved close to a 30% reduction in pain intensity. This clinically significant level of pain relief is roughly equivalent to the pain relief produced by five milligrams of oxycodone.
My previous research has indicated that an 8-week long course of Mindfulness-Oriented Recovery Enhancement can be an effective way to reduce chronic pain symptoms and decrease prescription opioid misuse. This new study added a new dimension to my work by revealing the promise of brief mind-body therapies for acute pain patients.
It was really exciting and quite amazing to see such dramatic results from a single mind-body session. Given our nation’s current opioid epidemic, the implications of this study are potentially huge. These brief mind-body therapies could be cost-effectively and feasibly integrated into standard medical care as useful adjuncts to pain management.
My interdisciplinary team at Center for Mindfulness and Integrative Health Intervention Development plan to continue to investigate mind-body therapies as non-opioid means of alleviating pain by conducting a national replication study in a sample of thousands of patients in multiple hospitals around the country.
Because of its public health relevance, so far the study has been covered by more than 40 television stations around the country. Here is a brief clip about the study.
Please join us for the University of Utah’s new Center on Mindfulness and Integrative Health Intervention Development’s (C-MIIND) first symposium, which focuses on “Translating Basic Biobehavioral Science into Integrative Health.”
The keynote will be delivered by Susan Bauer-Wu, PhD, RN, FAAN, President of the Mind & Life Institute, the world’s premier multidisciplinary organization for the scientific study of mindfulness and meditation, founded in 1991 by the Dalai Lama and neurobiologist Francisco Varela. Dr. Bauer-Wu will discuss how scientific research on ancient contemplative practices is positively impacting healthcare, education, and society.
Next, Brett Froeliger, PhD, Associate Professor of Neuroscience at the Medical University of South Carolina, will discuss the neural mechanisms of emotion dysregulation in addiction as a target for treatment development research.
Finally, C-MIIND Director Eric Garland, PhD, LCSW, Associate Dean for Research at the University of Utah College of Social Work, will discuss the latest discoveries from his psychophysiological research on mind-body interventions for addiction, stress, and chronic pain, with a specific focus on addressing the prescription opioid epidemic.
This event is free and lunch is included, however pre-registration is requested: http://bit.ly/cmiind2017symposium
Wednesday, July 26, 2017
11:30 am – 12:00 pm
Lunch & Networking
12:00 pm – 1:30 pm
Keynote & Presentations
Okazaki Community Meeting Room (155)
395 South 1500 East, Salt Lake City
The University of Utah has launched a new center dedicated to providing a transformative influence on healthcare by unifying research on mindfulness and other integrative behavioral health interventions.
Eric Garland, Associate Dean for Research at the U’s College of Social Work, will serve as Director of the new Center on Mindfulness and Integrative Health Intervention Development (C-MIIND). The Center, which will assume oversight of more than $17 million in federal research grants, will be housed in the College of Social Work.
“The center will advance a vision of a new model of healthcare, in which behavioral health experts work in tandem with medical providers to address the physical, psychological and social needs of people suffering from an array of health conditions,” said Garland, whose research focuses on using mindfulness to help individuals who experience chronic pain.
The center will bring together researchers and clinicians from across main campus and University of Utah Health, including faculty in social work, psychiatry, primary care, anesthesiology, neuroscience, oncology, psychology, and health, who are pioneering integrative interventions aimed at improving physical and mental well-being. C-MIIND will strive to attract top faculty and provide research opportunities for undergraduate, graduate and post-doctoral fellows interested in studying mindfulness and integrative behavioral health.
A focus of the center also will be to train post-graduates and health care providers in innovative therapies to be used in primary care clinics, hospitals, community mental health centers and addiction treatment facilities.
News coverage of the Center launch can be found here.
I‘m pleased to announce that the first fMRI brain imaging study of Mindfulness-Oriented Recovery Enhancement (MORE) has been published in the open-access journal Evidence-Based Complementary and Alternative Medicine (Froeliger et al., 2017). My colleague Brett Froeliger and I conducted this proof-of-concept pilot study at his TRAIN Lab at the Medical University of South Carolina to examine the effects of MORE on reward processes in the brains of people addicted to cigarettes. A sample of 13 smokers participated in a study testing MORE versus a comparison group. All participants underwent two fMRI scans 8 weeks apart. Between the first and second fMRI scan, participants in the MORE group learned mindfulness and reappraisal skills to decrease addictive reactions to cigarettes and savoring skills to increase responsiveness to natural rewards (e.g., social connection, natural beauty, healthy behaviors). Participants in the comparison group completed research measures but did not receive any treatment. Relative to the comparison group, MORE was associated with significant decreases in smoking (66% decrease) and significant increases in positive emotions. Crucially, MORE participants evidenced significant decreases in neural activity while viewing cigarette images in reward-related brain regions including the ventral striatum and ventromedial prefrontal cortex. MORE participants also demonstrated significant increases in neural activity in these same reward-related brain regions while they savored positive, natural-reward related images. Importantly, increases in brain activity during savoring were significantly correlated with smoking reduction and increased positive affect. These pilot findings provide preliminary evidence that MORE may facilitate the restructuring of reward processes and play a role in treating the pathophysiology of nicotine addiction. These findings converge with results from our other psychophysiological studies indicating that MORE may restructure reward processes in prescription opioid misuse (Garland, Froeliger, & Howard, 2014; Garland, Froeliger, & Howard, 2015; Garland, Howard, Zubieta, & Froeliger, 2017). Taken together, these data provide initial support for my restructuring reward hypothesis which asserts that mindfulness training may enhance a domain-general cognitive resource for restructuring reward learning from valuation of drug-related rewards to valuation of natural rewards and thereby reverse the downward spiral of addiction.
Recently, I was awarded a R01 grant from the National Institute on Drug Abuse to conduct a full-scale clinical trial of Mindfulness-Oriented Recovery Enhancement (MORE) as an intervention to reduce chronic pain and prescription opioid misuse in primary care. This five-year study will compare the efficacy of MORE to supportive therapy for 260 chronic pain patients receiving long-term opioid therapy who are at risk for opioid misuse.
Opioids may be medically necessary for some individuals experiencing prolonged and intractable pain, and most patients take medicine as prescribed. Unfortunately, opioids rarely completely alleviate chronic pain, and when taken in high doses or for long periods of time, can lead to serious side effects, including death by overdose, as well as risk for opioid misuse, which affects about 1 in 4 opioid-treated patients. Misusing opioids by taking higher doses than prescribed or by taking opioids to self-medicate negative emotions can alter the brain’s capacity for hedonic regulation, making it difficult to cope with pain (e.g., causing hyperalgesia – an increased sensitivity of the nervous system to pain) and experience pleasure in life (e.g., reducing sensitivity of the brain to natural reward). As such, non-opioid pain treatments that target hedonic dysregulation may be especially helpful for reducing chronic pain and prevent opioid misuse.
Multiple studies suggest that MORE improves hedonic regulation in the brain, resulting in decreased pain and an increased ability to savor natural, healthy pleasure. People who participate in MORE show heightened brain and body responses to healthy pleasures, and report feeling more positive emotions by using of mindfulness as a tool to enhance savoring. These therapeutic effects of MORE on savoring may be critically important, because findings from several studies show that increasing sensitivity to natural reward through savoring may lead to decreased craving for drugs – a completely novel finding for the field of addiction science (Garland, 2016). Our NIDA-funded R01 will provide a rigorous test of whether MORE improves chronic pain and opioid misuse by targeting hedonic dysregulation.
In our NIDA-funded R01, patients are receiving MORE at community medical clinics throughout Salt Lake City. Providing MORE in the naturalistic setting where most chronic pain patients seek medical care will make the therapy accessible to the people who need it the most. Ultimately, my hope is that this project will advance a new form of integrative healthcare, in which doctors and nurses work alongside social workers and other behavioral health professionals to help patients reclaim a meaningful life from pain.
I was recently interviewed by Michael Juberg for the Mind and Life Institute, the world’s premier multi-disciplinary organization for the study of contemplative science. Michael and I had a wide ranging discussion that covered the span from philosophy to science to alleviating human suffering. He asked me some seriously thought-provoking questions that made me reflect back on the roots of my career and where it is all headed in the future. At the end of the interview, I offered a bit of advice for folks aspiring to become scientists in this field. The interview was really well done and I’m pleased to share it with you here.
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.