“Drug-dependent people show decreased behavioral and brain reactivity to natural rewards compared to non-drug users. As a result, drug-dependent users increasingly focus their attention on obtaining the drug instead of attending to natural rewards. Recent research shows that a cognitive-based intervention may help restore natural reward processing in opioid-dependent participants.
In this study, chronic pain patients at risk for opioid misuse were randomized to either eight weeks of a Mindfulness-Oriented Recovery Enhancement (MORE) intervention or to an eight-week support group (control). Participants in the MORE intervention used mindfulness meditation to focus on all sensory features of a pleasant experience or object (for example, a beautiful nature scene like a sunset), while reflecting on any positive emotions arising in response to the pleasant event. The support group discussed topics and emotions related to chronic pain and opioid use/misuse. Following these interventions, all participants were shown images representing natural rewards (such as endearing animals, appealing foods, landscapes) or neutral images (furniture, neutral facial expressions, or household items). Researchers measured late positive potential (LPP) brain activity, which reflects attention to emotionally salient information, while participants viewed these images. In comparison to the control group, participants completing the MORE intervention showed greater LPP responses to natural reward images relative to neutral images and greater the LPP responses predicted reduced opioid cravings as reported by the participants.”
These results suggest that teaching people who misuse opioids to mindfully attend to positive aspects of their life may increase the perceived value of natural rewards – processes that may be diminished in those facing chronic pain or addiction – which may in turn help them to control opioid cravings.”
It is thrilling to see that this line of research is making a positive impact on the scientific community, and of course, the ultimate aim of this work is to alleviate human suffering.
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.
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.
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.
Today I had a new paper accepted for publication in the prestigious addictions journal, Drug and Alcohol Dependence. This paper, coauthored with my colleague Matthew Howard, describes new findings from a randomized controlled trial of Mindfulness-Oriented Recovery Enhancement for chronic pain patients prescribed long-term opioid painkillers. The new findings demonstrate that the extent to which an individual finds his or her attention automatically captured by opioid-related images (e.g., the image of an opioid pill bottle) significantly predicts whether they will misuse opioids 20 WEEKS LATER after completing treatment.
Before patients participated in the research treatments, they completed a dot probe task in which they were shown two pictures (displayed either for 200 ms, or 2000 ms), side by side, on a computer screen, and were asked to “choose the side with the dot” by clicking a button on a keypad. The computer recorded their reaction times down to the millisecond. We found that compared to people who did not misuse opioids at follow-up, people who ended up misusing opioids 3 months after completing treatment were significantly faster to choose the side with the dot when the dot replaced an opioid photo than when it replaced a neutral photo. This reaction time difference indicated that their attention was captivated by opioids. This effect was evident for cues presented for 200 ms (that’s one-fifth of a second!), suggesting that this attentional bias occurred automatically, unconsciously, and before participants even had time to think about what they were doing. Even after statistically controlling for pain levels, opioid dependence, and pre-treatment opioid misuse, people with a stronger opioid attentional bias prior to entering treatment were significantly more likely to misuse opioids 20 weeks later than people with less attentional bias to opioids.
So what is the significance of this research study for helping people with addiction and chronic pain? The study findings suggest that people who take opioids for chronic pain may develop an automatic tendency to be fixated on their medication, even when they don’t want to be. This tendency might make it difficult to stop thinking about opioids, causing craving, distraction, or other kinds of disruption in life. It might even result in or foretell opioid misuse down the line, long after a person has completed treatment. Using a performance-based dot probe test delivered by computer to detect risk for future opioid misuse may help physicians and health care providers make more informed decisions about whether and when to prescribe opioids to patients suffering from chronic pain.
I am thrilled to report that the 2014 Summer Mindfulness-Oriented Recovery Enhancement (MORE) Basic Training Workshop was a smashing success! There were 26 clinicians in attendance from fields like social work, addictions treatment, and nursing who served clients in a wide array of settings ranging from primary care clinics to inpatient mental health facilities to hospice and private practice. We dug into the theory, clinical research, and neuroscience behind MORE, and spent time intensively practicing the core skills of this integrative therapeutic approach: mindfulness training, reappraisal, and savoring. For skill practice we utilized the state-of-the-art training facilities at the Bridge Training Clinic at the University of Utah College of Social Work. I supervised therapists through a one-way mirror and provided them real-time feedback through a wireless headset during their delivery of the various mindfulness techniques and cognitive skills integral to MORE.
I received overwhelmingly positive feedback on the training. One participant wrote: “When I began Mindfulness mediation in 2002, I had no roadmap, no teacher or guide. I had to figure out what to do, when to do it, how to do it, and who to include and NOT include in my attempted meditation experience. I was completely self-schooled and reaching for a way to focus and center myself… Imagine how validating it was for me to sit with a group of colleagues and discuss Mindfulness. Imagine how nurturing it was to have a mentor. Imagine how incredible it was to participate with feedback and discuss the dynamics of what I PERSONALLY experience and not have someone try to adjust my perception… You were a wonderful teacher. I also love the data. I know this discipline works because I have effectively used it to my advantage so many times…including relinquishing the stranglehold pain can have and loss can have, and welcoming the opportunity for reinvention and reframe. Thank you so much, Eric, for sharing. I hope to work with you again.” – Gloria
I intend to offer an advanced training on MORE in the near future. This training will provide in-depth coverage on the application of the basic MORE techniques of mindfulness, reappraisal, and savoring to directly target addictive behaviors, craving, negative emotions, and chronic pain. For information on MORE, click here.
Bridge Training Clinic, College of Social Work, University of Utah
Salt Lake City, UT
A 2-day training workshop in Mindfulness-Oriented Recovery Enhancement will be held July 18-19, 2014, at the University of Utah Bridge Training Clinic in Salt Lake City, UT. This training is designed for licensed health care professionals (social workers, psychologists, counselors, physicians, nurses, etc.) working with clients suffering from addiction, chronic pain, and stress-related conditions.
Participants will receive didactic and experiential instruction in theory, research,and clinical skill practice integral to the implementation of Mindfulness-Oriented Recovery Enhancement (MORE). Research evidence on the MORE model will be presented, along with a review of the latest discoveries in neuroscience and basic biobehavioral science about mindfulness, addiction, and chronic pain.
Participants will practice the therapeutic techniques outlined in the MORE treatment manual (Garland, 2013) via role plays conducted in a clinical observation lab at the Bridge Training Clinic. Participants will receive live supervision in delivery of therapeutic techniques by Dr. Eric Garland, PhD, LCSW, the developer of MORE, who will observe participants through a one-way mirror and provide continual feedback through “bug in the ear” technology to optimize the delivery of therapeutic interventions.
At the completion of this 2-day workshop, participants will have a basic level of competency to use the MORE treatment manual to implement MORE for persons suffering from addictive behaviors and chronic pain conditions.
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.