Chronic Pain Treatment, Neuroscience, and Genetics – Mindfulness-Oriented Recovery Enhancement on the Radio

Today I had the opportunity to speak about the treatment, neuroscience, and genetics of chronic pain with Dr. Dan Gottlieb, host of Voices in the Family, and Dr. Jeffrey Mogil, head of the Pain Genetics Lab at McGill University, on radio station WHYY in Philadelphia (a local NPR station). I spoke about how negative emotions and stress can influence pain processing in the brain, and about how Mindfulness-Oriented Recovery Enhancement can reduce the harmful impact of negative emotions on pain by teaching people to change the way they focus their attention and to reinterpret chronic pain as innocuous sensory signals from the body. 

The entire interview can be found here:

Research on MORE Highlighted in the News

With the advance online publication of “Mindfulness-Oriented Recovery Enhancement for Chronic Pain and Prescription Opioid Misuse: Results from an Early Stage Randomized Controlled Trial” in the Journal of Consulting and Clinical Psychology on February 3rd, over 10 news stories have covered this work. For example, the study was covered by the University of Utah news department in the story  “Mind Over Matter: Beating Pain and Painkillers”, by Medical Daily in “Pain Management: M.O.R.E. Therapy uses Mental Interventions to Combat Chronic Pain, Opioid Painkillers Misuse”, by Science World Report in “New Pain Treatment Aims to Reduce Prescription Opioids”  and by Healthline in “A Mindful Way to Beat Chronic Pain.” It is my sincere hope that this news coverage will ultimately help more people suffering from chronic pain to find the relief and comfort they are seeking.

New Paper Accepted for Publication: Mindfulness Training Targets Neurocognitive Mechanisms of Addiction at the Attention-Appraisal-Emotion Interface

mindfulness centered regulation
Neurocognitive Model of Mindfulness-Centereted Regulation (Garland, Froeliger, & Howard, 2014)

My colleagues Brett Froeliger, Matthew Howard, and I recently authored an invited conceptual review paper (FREE TO DOWNLOAD) for a special issue of Frontiers in Psychiatry: Addictive Disorders and Behavioral Dyscontrol. Prominent neuroscience models suggest that addictive behavior occurs when environmental stressors and drug-relevant cues activate a cycle of cognitive, affective, and psychophysiological mechanisms, including dysregulated interactions between bottom-up and top-down neural processes, that compel the user to seek out and use drugs. Mindfulness-based interventions (MBIs) target pathogenic mechanisms of the risk chain linking stress and addiction. This review describes how 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 conceptual framework outlined in this paper clarifies and contextualizes the recent results from our randomized controlled trial of Mindfulness-Oriented Recovery Enhancement as a treatment for prescription opioid misuse and chronic pain.

New Paper Accepted for Publication: Mindfulness-Oriented Recovery Enhancement for Chronic Pain and Prescription Opioid Misuse – Results from an Early Stage Randomized Controlled Trial

Results from my NIH-funded clinical trial of Mindfulness-Oriented Recovery Enhancement (MORE) as a treatment for chronic pain and prescription opioid misuse were recently accepted for publication in the prestigious, top-tier Journal of Consulting and Clinical Psychology. Study findings demonstrated that MORE significantly reduced chronic pain, pain-related impairment, and stress while decreasing craving and opioid misuse among a sample of 115 people who had taken prescription opioid painkillers for more than three months. The effects of MORE on reducing pain severity and pain-related impairment were maintained for 3 months after the end of treatment, and MORE reduced disordered opioid use by 63%. These positive outcomes were linked with the development of mindfulness skills that are specifically strengthened by MORE, like the ability to “step back” and objectively observe negative thoughts and feelings in a non-reactive manner,  the ability to reinterpret pain sensations as harmless sensory information, and the ability to reappraise adverse life events as opportunities for personal growth and meaning.  In addition, participation in MORE weakened the link between desire for opioids and opioid misuse, suggesting that people who learned to use mindfulness to deal with craving were less likely to take inappropriate doses of opioids or to use opioids to self-medicate stress and negative emotions.

In some circumstances, opioids may be medically necessary for individuals experiencing prolonged and intractable pain, and most patients take medicine as prescribed. Nonetheless, opioids rarely completely alleviate chronic pain, and may lead to serious side effects, including death by overdose, as well as risk for developing opioid-related problems and addiction. As such, new interventions are needed to target chronic pain and prevent opioid misuse. Study findings indicate that MORE is a promising treatment for this growing problem. Over the next few years, additional social, psychological, and neuroscientific studies will reveal the many pathways by which MORE produces its therapeutic effects.

New Paper Accepted for Publication: State Mindfulness During Meditation Predicts Enhanced Cognitive Reappraisal

My colleagues Adam Hanley (Florida State University), Norm Farb (University of Toronto), Brett Froeliger (Medical University of South Carolina), and I had a new research paper accepted for publication in the journal Mindfulness. In a sample of people receiving brief mindfulness training (one to four sessions delivered by audio CD), we found that the state of mindfulness achieved during the act of mindfulness meditation predicted enhanced cognitive reappraisal over the following week. In other words, people who attained deeper states of mindfulness during meditation experienced an increased tendency to think in more helpful and healthy ways about the stressors in their lives over the following week. This research finding suggests that the state of mindfulness may enhance cognitive flexibility and allow individuals to adopt a broadened perspective on their current life challenges. Study results provide support for a theoretical model I developed, the Mindful Coping Model, and reveal one more piece of the puzzle linking mindfulness with human flourishing. More experimental tests of this theory are needed to replicate and expand these results.mind-reappraise-savor

New Paper Accepted for Publication! The Downward Spiral of Chronic Pain, Prescription Opioid Misuse, and Addiction: Cognitive, Affective, and Neuropsychopharmacologic Pathways

My colleagues and I recently had a new paper accepted for publication in the highly esteemed, international journal Neuroscience and Biobehavioral Reviews. This paper draws upon current neuropsychopharmacologic research to provide a conceptual framework of the downward spiral leading to opioid misuse and addiction among chronic pain patients taking prescription opioids for pain relief. In brief, we theorize that addictive use of opioids is the outcome of a cycle initiated by chronic pain and negative emotions, leading to attentional hypervigilance for pain and drug cues, dysfunctional connectivity between self-referential and cognitive control networks in the brain, and allostatic dysregulation of stress and reward circuitry. We conclude the paper by introducing Mindfulness-Oriented Recovery Enhancement (MORE) as a potentially effective approach to disrupting the downward spiral. This is a particularly exciting publication for our research team, because it lays the theoretical groundwork for developing new and innovative efforts to help people recover from chronic pain and opioid addiction.

Mindfulness and Reappraisal

Inevitably, we encounter hardship in our lives. We become ill, fall into debt, are subject to criticism, harried by rumor and jealousy, and assailed by the many challenges and unrelenting demands of the world. Yet, individuals differ to the extent to which they remain resilient in the face of such stressors.  One key to resilience is positive reappraisal – the capacity to reframe or re-interpret difficult life experiences such that they become imbued with personal meaning. For instance, after facing a stressor, one might come to believe, “Dealing with this experience has made me a stronger person,” or, “I have grown and learned from adapting to this situation,” or even, “I would not be who I am today without this experience, no matter how difficult it has been.” Through positive reappraisal, we come to find meaning in the face of adversity.

Such positive reappraisals may be essential means of adapting to the rigors of life. People often believe that they have personally grown or learned from dealing with the stressful events of their lives. For example, over half of 2000 survivors of the devastating 2008 earthquake in Sichuan province, China, which reached 8.0 on the Richter scale, reported having experienced a form of meaningful growth in its wake, such as developing personal strength, a sense of appreciation of life, or an opening to new possibilities (Xiu & Liao, 2011). Similarly, after a deadly tornado struck Madison, Florida in 1998 and obliterated over 100 homes and business, 9 out of 10 survivors reported experiencing psychological benefits from the event, such as greater appreciation for others and a deepened sense of personal growth (McMillen, Smith, & Fisher, 1997). Innumerable examples may be found in the annals of history. Every time another tragedy is announced on the news, from devastating floods to acts of savage terrorism, positive reappraisals emerge during the interviews of survivors. The common theme echoed such tragic incidents is “This experience brought our community closer” and “This experience is a reminder of what is really important in life.”

At the same time, finding positive meaning in adversity does not only occur in the aftermath of large scale disasters; it is also commonly occurs in the face of daily stressors. For example, after being snubbed and disrespected by a work supervisor, one might reappraise the mistreatment into an opportunity to realize the importance of being sensitive to the opinions and viewpoints of others.  And after a long, exhausting day at the office, being treated rudely by the clerk at the grocery checkout line might be seen as an opportunity to feel empathy for the fact that she was probably standing on aching feet for more than eight hours. Similarly, a person stricken with a non-fatal heart attack might positively reappraise the event as a chance to change their diet and start exercising more. A person who has recovered from a vicious rape might view their survival of the assault as evidence of their strength and resilience, and they might decide to dedicate their life to helping others make similar recoveries. A person entangled in a fight with her spouse might initially villanize him and recoil from his attempts to resolve the conflict, and then, after recognizing his unwavering devotion to their relationship, redouble her efforts to understand his point of view.

Though reappraisal is well-known to enhance resilience and help individuals cope with stress, less is known about how this strategy works and how it can be strengthened. It is my contention that mindfulness promotes reappraisal. Mindfulness is a state of mind in which one observes his or her mental experiences without becoming “stuck in” or “trapped by” them. In the state of mindfulness, you become aware of thoughts, feelings, sensations, and perceptions without trying to hold on to them, and without trying to push them away. As the state mindfulness deepens, you not only become aware of where your mind is in the moment (i.e., on what content is it focused), you also become aware of the quality of that observing mind itself.  At the deepest levels of mindfulness practice, this metacognitive observation can be a bit like a mirror mirroring mirrors – being aware of being aware (and maybe, if you are really good, being aware of being aware of being aware!). Some neuroscientists suppose that the folds of the prefrontal cortex have evolved over millennia to allow for this metacognitive reflection.

So what do these abstract ideas have to do with reappraisal? Well, to make a positive reappraisal, one must first be aware of the initial negative or stressful appraisal (e.g., “This situation is horrible!”). Next, one must “step back” or disengage from that reappraisal. My colleagues and I (Garland, 2007; Garland, Gaylord, & Park, 2009) have argued that mindfulness affords that mental shifting function – allowing one to decenter from a given thought about one’s life, into the openly observing, metacognitive mode of awareness. Once the mind has stepped back from the stress appraisal into this state of mindfulness, attention broadens to encompass previously unattended details about one’s life circumstance – you begin to notice things about yourself and your situation that you had overlooked or ignored because you were so stressed and upset. For example, bad feedback from a boss might lead you to think, “I always screw up and my boss hates me.” However, if you were to engage mindfulness, you might be able to step back from this thought and then begin to notice the ways in which you have been successful at work and the recent times when your boss has given you praise. After which you might think, “Well, that’s not really true. Usually I do a good job at work and that’s why my boss is giving me this critical feedback – she believes that I can take my career to the next level!” This positive reappraisal might then motivate you to take constructive action at work. Thus, the metacognitive aspect of mindfulness allows us to see that our thoughts are not necessarily facts. By becoming aware of awareness, we come to realize that who we are is much bigger than any one thought, feeling, or stressful life event, and that ultimately, we are free to choose the meaning of our lives.

In these ways, mindfulness helps us to disrupt habits of negative thinking, allowing the mind to naturally expand to consider new possibilities and novel ways of seeing the world. When, through mindfulness, we suspend our preconceived notions and assumptions about the difficult aspects of our lives, we are able to bring increased awareness to the richly woven tapestry of life that unfolds all around us, allowing us to draw out innumerable golden threads. The smiling face of a passerby, the song of a bird perched in a nearby tree, the trill of insects on a warm summer evening, a tiny flower blossoming from a crack in a sidewalk, the laughter of children, or even the ever-constant companion of one’s own breath can become sources of wonder and delight to savor, in spite of and perhaps because of the stressors and challenges we face. Facing bitter hardship and adversity can help us to truly taste and appreciate the moments of sweetness that surround us. Through mindfulness and reappraisal we can learn to widen the scope of our awareness to encompass more of the meaningful and beautiful experiences in life, making the painful and dissatisfying ones smaller by comparison.

New Paper Accepted for Publication: Mindfulness-Oriented Recovery Enhancement Reduces Pain Attentional Bias in Chronic Pain Patients

My colleague Matthew Howard and I recently had a paper accepted for publication in the internationally-recognized journal, Psychotherapy and Psychosomatics. This paper describes a subset of findings from a randomized controlled trial (RCT) of Mindfulness-Oriented Recovery Enhancement for chronic pain patients who have been prescribed long-term opioid treatment (e.g., oxycontin, vicodin) for pain management. The study is the first in the scientific literature to demonstrate that a mindfulness-oriented intervention can reduce the pain attentional bias. In this study, 67 individuals suffering from low back pain, neck pain, arthritis, fibromyalgia, and other pain conditions were randomly assigned to participate in MORE or a support group and began treatment.

Participants in the MORE group received instruction in applying mindfulness and other psychological techniques to: discriminate between nociception (i.e., the signal that the body is being damaged), pain, and suffering; become aware of their automatic pain coping habits; disrupt the link between negative emotions, fear of pain, and catastrophizing; refocus attention from pain and stress to savor pleasant experiences; manage pain and opioid dependence; reduce stress; promote acceptance versus suppression of difficult experiences; and develop a mindful recovery plan. Mindfulness training involved meditation on breathing and body sensations, with an emphasis on metacognitive awareness and shifting from affective to sensory processing of pain sensations. In other words, participants learned to step back and observe their pain as innocuous sensory information rather than as an emotionally-anguishing event – e.g., seeing their pain as “sensations of heat, tightness, tingling, or coolness” rather than “terrible agony.”

reinterpreting_pain_sensations

Participants in the support group were led to disclose their feelings and thoughts about topics related to chronic pain and opioid-related problems, as well as to provide advice and emotional support for their peers. The format of the support group was similar to conventional support groups used in many medical and psychotherapy settings.

We hypothesized that MORE would help participants to fixate less on their pain – freeing them to refocus on the meaningful, beautiful, or rewarding aspects of their lives. To measure attentional fixation on pain, or pain attentional bias, we used a dot probe task. In this task, participants were presented with two images, side by side, on a computer screen. One of the images was a pain-related image – the other was a neutral image. The images were presented for either 2 seconds or 200 milliseconds, and then were replaced with a dot. Participants were asked to press a button to indicate location of the the dot. Previous research demonstrates that chronic pain patients are faster to respond to pain images than neutral images, indicating that they exhibit an attentional bias, or attentional fixation, on pain-related information. Hence, people in chronic pain tend to automatically focus their attention on pain and things related to pain. This attentional fixation might occur unconsciously, without a person intending to focus on pain or even realizing that it is happening.

pain_dotprobe

In summary of our study results, we found that MORE led to significant reductions in the pain attentional bias, whereas the support group did not have any effect on pain attentional bias. Importantly, participants in MORE who experienced the largest decreases in the pain attentional bias felt like they had greater control over their pain following treatment. In addition, those people who felt that MORE had helped them to become less reactive to negative thoughts and feelings also had less pain attentional bias following treatment.

MORE_reduces_pain_AB

In conclusion, MORE appears to help people suffering from chronic pain and opioid-related problems learn to free their minds from fixating on pain, and in so doing, empower them to regain control of their lives.