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 ventral 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. Though this study had a number of limitations, including the small sample size and lack of a randomized design, 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.
Chronic pain is often treated with extended use of opioid analgesics, yet these drugs can alter the brain in ways that may make it difficult to cope with pain and may reduce the experience pleasure in life. Mindfulness-based interventions appear to be a promising means of addressing these issues, but research is needed to understand how such interventions change the brain to reduce suffering.
To that end, in September, 2016, I was recently awarded a five-year phased innovation grant from the National Institutes of Health’s (NIH) National Center for Complementary and Integrative Health entitled Effects of Mindfulness-Oriented Intervention on Endogenous Opioid Mechanisms of Hedonic Regulation in Chronic Pain (R61AT009296). The objective of the project is to study the effects of an innovative mindfulness-based intervention on brain mechanisms linked with pain and pleasure.
In the first two-year phase of the study ($800,000), I (Principal Investigator), along with my Co-Principal Investigator Jon-Kar Zubieta (Co-Principal Investigator), chair of the University of Utah’s Department of Psychiatry, will use positron emission tomography (PET) neuroimaging to assess the effects of Mindfulness-Oriented Recovery Enhancement (MORE) on restoring brain levels of endorphins in patients with chronic back pain who are being treated with prescription opioids.
This study represents the first use of PET in the history of science to quantify the effects of a mindfulness-based therapy on levels of endogenous opioids in the brain.
We will also use functional magnetic resonance imaging (fMRI) methods to assess how mindfulness training through MORE may increase people’s capacity to savor natural pleasure from positive and meaningful events in everyday life – a capacity that becomes diminished over time through the deleterious effects of chronic pain and prolonged opioid use on the brain. We will use a fMRI paradigm developed by my Co-Investigator Brett Froeliger, Assistant Professor of Neuroscience at the Medical University of South Carolina.
This study aims to test whether MORE might reverse this insensitivity to natural reward by targeting the endogenous opioid system and brain reward functions.
Following a successful first phase of the project, a three-year second phase ($2.2 million) will investigate whether patients with a particular genetic makeup that affects the expression of opioid receptors in the brain might benefit more from the mindfulness-based treatment. The second phase of the project will also assess the dose of mindfulness skill practice as a predictor of changes in endogenous opioid function and clinical correlates.
Based on the results of previous research, we hypothesize that mindfulness meditation training through MORE will restore proper function to the brain’s opioid receptors. We will be able to measure how MORE changes the brain’s ability to regulate pain and respond to natural rewards, as well as deepen our understanding of exactly how these changes in neural mechanisms happen.
Overall, this project will unite expertise in mindfulness-based interventions with expertise in neurogenetics and the use of PET and fMRI to probe the neurobiological mechanisms of pain and emotional experience. By elucidating a key mechanism of meditation-based therapies, this program of translational research will further the emerging field of social work neuroscience and enable us to rapidly optimize MORE to increase the effectiveness of the intervention as it is rolled out in clinical practice.
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.