Garland, E.L., Hanley, A.W., Nakamura, Y., Barrett, J.W., Baker, A.K., Reese, S.E., Riquino, M.R., Froeliger, B., & Donaldson, G.W. (2022). Mindfulness-Oriented Recovery Enhancement for co-occurring opioid misuse and chronic pain in primary care: A randomized clinical trial. JAMA Internal Medicine.
In this randomized clinical trial, among adult participants in a primary care setting, the MORE intervention led to sustained improvements in opioid misuse and chronic pain symptoms and reductions in opioid dosing, emotional distress, and opioid craving compared with supportive group psychotherapy. Despite attrition caused by the COVID-19 pandemic and the vulnerability of the sample, MORE appeared to be efficacious for reducing opioid misuse among adults with chronic pain.
Garland, E.L., Hudak, J., Hanley, A.W., & Nakamura, Y. (2020). Mindfulness-Oriented Recovery Enhancement reduces opioid dose in primary care by strengthening autonomic regulation during meditation. American Psychologist, 75(6), 840-852.
The current opioid crisis was fueled by escalation of opioid dosing among patients with chronic pain. Yet, there are few evidence-based psychological interventions for opioid dose reduction among chronic pain patients treated with long-term opioid analgesics. Mindfulness-Oriented Recovery Enhancement (MORE), which was designed to target mechanisms underpinning chronic pain and opioid misuse, has shown promising results in 2 randomized clinical trials (RCTs) and could facilitate opioid sparing and tapering by bolstering self-regulation.
Roberts, R.L., Ledermann, K., & Garland, E.L. (2021). Mindfulness-Oriented Recovery Enhancement improves negative emotion regulation among opioid-treated chronic pain patients by increasing interoceptive awareness. Journal of Psychosomatic Research, 152, 110677.
Long-term opioid therapy presents health risks for people with chronic pain. Some chronic pain patients escalate their opioid dose to regulate negative emotions. Therefore, emotion regulatory strategies like reappraisal are key treatment targets for this population. Mindfulness has been shown to enhance reappraisal, but the mechanisms of action are unknown. This study was a secondary analysis of data from a randomized, controlled trial of Mindfulness-Oriented Recovery Enhancement (MORE) to test a specific postulate of the Mindfulness-to-Meaning Theory: that mindfulness-based interventions promote reappraisal, via interoceptive self-regulation, as a means of decreasing emotional distress.
Cooperman, N., Hanley, A.W., Kline, A., Garland, E.L. (2021). A pilot randomized clinical trial of Mindfulness-Oriented Recovery Enhancement as an adjunct to methadone treatment for people with opioid use disorder and chronic pain: Impact on illicit drug use, health, and well-being. Journal of Substance Abuse Treatment, 127, 108468.
Chronic pain is highly prevalent among people in methadone maintenance treatment (MMT) for opioid use disorder and is known to be an important contributor to treatment discontinuation and opioid relapse. Mindfulness-Oriented Recovery Enhancement (MORE) is one of the few interventions developed and tested as an integrated treatment to simultaneously address both pain and illicit opioid use; however, this study is the first to evaluate MORE as an adjunct to MMT.
Hudak, J., Hanley, A.W., Marchand, W.R., Nakamura, Y., Yabko, B., Garland, E.L. (2021). Endogenous theta stimulation during meditation predicts reduced opioid dosing following treatment with Mindfulness-Oriented Recovery Enhancement. Neuropsychopharmacology, 46(4), 836–843.
Veterans experience chronic pain at greater rates than the rest of society and are more likely to receive long-term opioid therapy (LTOT), which, at high doses, is theorized to induce maladaptive neuroplastic changes that attenuate self-regulatory capacity and exacerbate opioid dose escalation. Mindfulness meditation has been shown to modulate frontal midline theta (FMT) and alpha oscillations that are linked with marked alterations in self-referential processing. These adaptive neural oscillatory changes may promote reduced opioid use and remediate the neural dysfunction occasioned by LTOT.
Hanley, A.W., & Garland, E.L. (2020). Salivary measurement and mindfulness-based modulation of prescription opioid cue-reactivity. Drug and Alcohol Dependence, 217(1), 108351.
Chronic pain patients on long-term opioid therapy (LTOT) may be at elevated risk for developing conditioned opioid cue-reactivity as their prescribed dosing schedules simultaneously function as fixed reinforcement schedules. Since opioids are typically consumed orally during LTOT, it stands to reason that opioid cue exposure might elicit conditioned salivary responses.
Hanley, A.W., & Garland, E.L. (2020). The Mindfulness-Oriented Recovery Enhancement Fidelity Measure (MORE-FM): Development and validation of a new tool to assess therapist adherence and competence. Journal of Evidence-Based Social Work, 18(3), 308-322.
Mindfulness-Oriented Recovery Enhancement (MORE) is a mind-body therapy that unites complementary aspects of mindfulness training, third-wave cognitive behavioral therapy (CBT), and principles from positive psychology into an integrative treatment for addiction and its comorbidities. As interest in MORE has grown among researchers and clinicians, there is an increasing need to provide quality assurance measures to ensure treatment integrity during implementation of MORE. Here, we describe the development and validation of the Mindfulness-Oriented Recovery Enhancement Fidelity Measure (MORE-FM).
Garland, E.L., Atchley, R.M., Hanley, A.W., Zubieta, J.K., & Froeliger, B. (2019). Mindfulness-Oriented Recovery Enhancement remediates hedonic dysregulation in opioid users: Neural and affective evidence of target engagement. Science Advances, 5(10), eaax1569.
Addiction neuroscience models posit that recurrent drug use increases reactivity to drug-related cues and blunts responsiveness to natural rewards, propelling a cycle of hedonic dysregulation that drives addictive behavior. Here, we assessed whether a cognitive intervention for addiction, Mindfulness-Oriented Recovery Enhancement (MORE), could restructure reward responsiveness from valuation of drug-related reward back to valuation of natural reward.
Garland, E.L., Hanley, A.W., Kline, A., & Cooperman, N.A. (2019). Mindfulness-Oriented Recovery Enhancement reduces opioid craving among individuals with opioid use disorder and chronic pain in medication assisted treatment: Ecological momentary assessments from a stage 1 randomized controlled trial. Drug and Alcohol Dependence, 201(1), 61-65.
Methadone maintenance therapy (MMT) is an efficacious form of medication assisted treatment for opioid use disorder (OUD), yet many individuals on MMT relapse. Chronic pain and deficits in positive affective response to natural rewards may result in dysphoria that fuels opioid craving and promotes relapse. As such, behavioral therapies that ameliorate chronic pain and enhance positive affect may serve as useful adjuncts to MMT. This analysis of ecological momentary assessment (EMA) data from a Stage 1 randomized clinical trial examined effects of Mindfulness-Oriented Recovery Enhancement (MORE) on opioid craving, pain, and positive affective state
Thomas, E.A., Mijangos, J., Walker, D., Reimers, C., Beck, A., Hansen, P., & Garland, E.L. (2019). Mindfulness-Oriented Recovery Enhancement restructures reward processing and promotes interoceptive awareness in overweight cancer survivors: Mechanistic results from a stage 1 RCT. Integrative Cancer Therapies, 18, 1534735419855138.
The primary aims of this Stage I pilot randomized controlled trial were to establish the feasibility of integrating exercise and nutrition counseling with Mindfulness-Oriented Recovery Enhancement (MORE), a novel intervention that unites training in mindfulness, reappraisal, and savoring skills to target mechanisms underpinning appetitive dysregulation a pathogenic process that contributes to obesity among cancer survivors; to identify potential therapeutic mechanisms of the MORE intervention; and to obtain effect sizes to power a subsequent Stage II trial.
Garland E.L., Bryan, M.A., Priddy, S.E., Riquino, M.R., Froeliger, B., & Howard, M.O. (2019). Effects of Mindfulness-Oriented Recovery Enhancement versus social support on negative affective interference during inhibitory control among opioid-treated chronic pain patients: A pilot mechanistic study. Annals of Behavioral Medicine, 53(10), 865-876.
Among opioid-treated chronic pain patients, deficient response inhibition in the context of emotional distress may contribute to maladaptive pain coping and prescription opioid misuse. Interventions that aim to bolster cognitive control and reduce emotional reactivity (e.g., mindfulness) may remediate response inhibition deficits, with consequent clinical benefits.
Garland, E.L. & Howard, M.O. (2018). Enhancing natural reward responsiveness among opioid users predicts relief from chronic pain: An analysis of EEG data from a trial of Mindfulness-Oriented Recovery Enhancement. Journal of the Society for Social Work and Research, 9(2), 2334-2315.
Although opioid-treated chronic pain patients evidence blunted responsiveness to natural rewards, focusing on naturally rewarding stimuli can produce analgesia in these patients. A prior randomized controlled trial (RCT) demonstrated that a social work intervention-Mindfulness-Oriented Recovery Enhancement (MORE)-enhanced natural reward processing as indicated by event-related brain potentials (ERPs). The aim of the present study was to perform a secondary data analysis on ERPs collected in this RCT to explore whether improvements in electrocortical response to natural reward predicted pain relief.
Li, W., Garland, E.L., & Howard, M.O. (2018). Therapeutic mechanisms of Mindfulness-Oriented Recovery Enhancement for internet gaming disorder: Reducing craving and addictive behavior by targeting cognitive processes. Journal of Addictive Diseases, 37(1-2), 5-13.
Internet gaming disorder (IGD) is characterized by signs and symptoms similar to substance use and gambling disorders, and associated with psychosocial impairments. Research suggests that maladaptive gaming-related cognitions and coping may be implicated in IGD; therefore, interventions for IGD need to target these underlying mechanisms. Mindfulness-based treatment is effective in changing maladaptive cognitive processes and increasing adaptive coping among people with addictions.
Garland, E.L., Howard, M.O., Zubieta, J., & Froeliger, B. (2017). Restructuring hedonic dysregulation in chronic pain and prescription opioid misuse: Effects of Mindfulness-Oriented Recovery Enhancement on responsiveness to drug cues and natural rewards. Psychotherapy and Psychosomatics, 86(2), 111-112.
We conducted a RCT of a Mindfulness-Oriented Recovery Enhancement (MORE) intervention for opioid misuse among chronic pain patients, which integrates skills to amplify natural reward processing with mindfulness and reappraisal techniques. In this RCT, relative to a support group (SG) control, MORE reduced opioid misuse and craving while decreasing pain symptoms. Given its focus on orienting attention away from drug-related cues and towards healthful and socially affiliative objects and events, it is possible that MORE may regulate attention to hedonically-relevant stimuli to shift the relative salience of drug and natural rewards and thereby ameliorate opioid misuse.
Garland, E.L., Baker, A.K., & Howard, M.O. (2017). Mindfulness-Oriented Recovery Enhancement reduces opioid attentional bias among prescription opioid-treated chronic pain patients. Journal of the Society for Social Work and Research, 8(4), 493-509.
Chronic pain involves hypervigilance for pain-related stimuli. Selective attention to pain-related stimuli, known as pain attentional bias (AB), can exacerbate chronic pain, prolong suffering, and undermine quality of life. The aim of this study was to determine if a multimodal mindfulness-oriented intervention could significantly reduce pain AB among chronic pain patients receiving opioid analgesics.
Garland, E.L., Bryan, C.J., Finan, P., Thomas, E.A., Priddy, S.E., Riquino, M., & Howard, M.O. (2017). Pain, hedonic regulation, and opioid misuse: Modulation of momentary experience by Mindfulness-Oriented Recovery Enhancement in opioid-treated chronic pain patients. Drug and Alcohol Dependence, 173, S65-S72.
Given the risk of opioid misuse among chronic pain patients being treated with long-term opioid pharmacotherapy, non-pharmacological treatments are needed. Further, in light of hedonic deficits in this population, therapies that enhance positive affect may be useful.
Garland, E.L., Baker, A.K., Riquino, M.R., & Priddy, S.E. (2017). Mindfulness-Oriented Recovery Enhancement: A review of its theoretical underpinnings, clinical application, and biobehavioral mechanisms. In Ivtzan, I. (ed.), Handbook of Mindfulness-Based Programs: Every Established Intervention, from Medicine to Education. Routledge Press.
Li, W., Garland, E.L., McGovern, P., O’Brien, J.E., Tronnier, C., & Howard, M.O. (2017). Mindfulness-Oriented Recovery Enhancement for internet gaming disorder in U.S. adults: A stage 1 randomized controlled trial. Psychology of Addictive Behaviors, 31, 393-402.
Empirical studies have identified increasing rates of Internet gaming disorder (IGD) and associated adverse consequences. However, very few evidence-based interventions have been evaluated for IGD or problematic video gaming behaviors. This study evaluated Mindfulness-Oriented Recovery Enhancement (MORE) as a treatment for IGD.
Froeliger, B., Mathew, A., McConnell, P., Eichberg, C., Saladin, M.E., Carpenter, M.J., & Garland, E.L. (2017). Restructuring reward mechanisms in nicotine addiction: A pilot fMRI study of Mindfulness-Oriented Recovery Enhancement for cigarette smokers. Evidence-Based Complementary and Alternative Medicine, Article ID 7018014.
The primary goal of this pilot feasibility study was to examine the effects of Mindfulness-Oriented Recovery Enhancement (MORE), a behavioral treatment grounded in dual-process models derived from cognitive science, on frontostriatal reward processes among cigarette smokers.
Li, W., Garland, E. L., O’Brien, J.E., Tronnier, C., McGovern, P., Howard, M. O. (2017). Mindfulness-Oriented Recovery Enhancement for video game addiction in emerging adults: Preliminary findings from case reports. International Journal of Mental Health and Addiction.
Garland E. L. (2016). Restructuring reward processing with Mindfulness-Oriented Recovery Enhancement: novel therapeutic mechanisms to remediate hedonic dysregulation in addiction, stress, and pain. Annals of the New York Academy of Sciences, 1373(1), 25–37
Though valuation processes are fundamental to survival of the human species, hedonic dysregulation is at the root of an array of maladies, including addiction, stress, and chronic pain, as evidenced by the allostatic shift in the relative salience of natural reward to drug reward observed among persons with severe substance use disorders. To address this crucial problem, novel interventions are needed to restore hedonic regulatory processes gone awry in persons exhibiting addictive behaviors. This article describes a theoretical rationale and empirical evidence for the effects of one such new intervention, Mindfulness-Oriented Recovery Enhancement (MORE), on top-down and bottom-up mechanisms implicated in cognitive control and hedonic regulation.
Garland, E.L., Roberts-Lewis, A., Tronnier, C., Kelley, K., & Graves, R. (2016). Mindfulness-Oriented Recovery Enhancement versus CBT for co-occurring substance dependence, traumatic stress, and psychiatric disorders: Proximal outcomes from a pragmatic randomized trial. Behaviour Research and Therapy, 77, 7-16.
In many clinical settings, there is a high comorbidity between substance use disorders, psychiatric disorders, and traumatic stress. Novel therapies are needed to address these co-occurring issues efficiently. The aim of the present study was to conduct a pragmatic randomized controlled trial comparing Mindfulness-Oriented Recovery Enhancement (MORE) to group Cognitive-Behavioral Therapy (CBT) and treatment-as-usual (TAU) for previously homeless men residing in a therapeutic community.
Garland, E.L., Froeliger, B.E., & Howard, M.O. (2015). Neurophysiological evidence for remediation of reward processing deficits in chronic pain and opioid misuse following treatment with Mindfulness-Oriented Recovery Enhancement: Exploratory ERP findings from a pilot RCT. Journal of Behavioral Medicine, 38(2), 327-336.
Dysregulated processing of natural rewards may be a central pathogenic process in the etiology and maintenance of prescription opioid misuse and addiction among chronic pain patients. This study examined whether a Mindfulness-Oriented Recovery Enhancement (MORE) intervention could augment natural reward processing through training in savoring as indicated by event-related brain potentials (ERPs).
Garland, E.L., Froeliger, B., & Howard, M.O. (2014). Effects of Mindfulness-Oriented Recovery Enhancement on reward responsiveness and opioid cue-reactivity. Psychopharmacology, 231(16), 3229-3238.
Dysregulated reward processing is a hallmark feature of drug addiction; however, scant research has evaluated restructuring reward processing in the context of addiction treatment. We examined effects of Mindfulness-Oriented Recovery Enhancement (MORE) on reward responsiveness (RR) and opioid cue-reactivity in a sample of chronic pain patients with opioid use problems. We previously reported that MORE decreased pain, opioid misuse, and craving relative to a social support control group (SG). Here, we examined whether these outcomes were linked to changes in RR in a subset of participants.
Garland, E.L., Manusov, E.G., Froeliger, B., Kelly, A., Williams, J., & Howard, M.O. (2014). Mindfulness-Oriented Recovery Enhancement for chronic pain and prescription opioid misuse: Results from an early stage randomized controlled trial. Journal of Consulting and Clinical Psychology, 82(3), 448-459.
Opioid pharmacotherapy is now the leading treatment for chronic pain, a problem that affects nearly one third of the U.S. population. Given the dramatic rise in prescription opioid misuse and opioid-related mortality, novel behavioral interventions are needed. The purpose of this study was to conduct an early-stage randomized controlled trial of Mindfulness-Oriented Recovery Enhancement (MORE), a multimodal intervention designed to simultaneously target mechanisms underpinning chronic pain and opioid misuse.
Garland, E.L., Thomas, E.A., & Howard, M.O. (2014). Mindfulness-Oriented Recovery Enhancement ameliorates the impact of pain on self-reported psychological and physical function among opioid-using chronic pain patients. Journal of Pain and Symptom Management, 48(6), 1091-1099.
Chronic pain impacts one-third of the U.S. population, and its effects are debilitating for individuals and costly to the medical system. Although opioids are commonly prescribed to address chronic pain, they confer risk for misuse and addiction in some patients and may not fully restore life function-particularly with regard to psychosocial factors. Because of the multiplicity of impacts that chronic pain may have on daily functioning, broad-spectrum behavioral interventions are needed.
Garland, E.L., & Howard, M.O. (2013). Mindfulness-Oriented Recovery Enhancement reduces pain attentional bias in chronic pain patients. Psychotherapy and Psychosomatics, 82, 311-318.
Chronic pain involves hypervigilance for pain-related stimuli. Selective attention to pain-related stimuli, known as pain attentional bias (AB), can exacerbate chronic pain, prolong suffering, and undermine quality of life. The aim of this study was to determine if a multimodal mindfulness-oriented intervention could significantly reduce pain AB among chronic pain patients receiving opioid analgesics.
Garland, E.L., Schwarz, N., Kelly, A., Whitt, A., & Howard, M.O. (2012). Mindfulness-Oriented Recovery Enhancement for alcohol dependence: Therapeutic mechanisms and intervention acceptability. Journal of Social Work Practice in the Addictions, 12, 242-263.
Mindfulness-based interventions may decrease addictive behaviors while promoting non-reactivity to stressors. This study employed qualitative methods to enhance understanding of mindfulness-related treatment effects. Study participants were eighteen alcohol dependent adults residing in a therapeutic community who had participated in a Mindfulness-Oriented Recovery Enhancement (MORE) intervention. Interviews were conducted to elicit participant narratives. Responses to open-ended questions were analyzed using a grounded theory approach and the method of constant comparison. Narrative accounts suggested that MORE enhanced self-awareness while helping clients to cope more effectively with emotional distress and addictive impulses. MORE appears to be acceptable to participants and feasible to implement within a residential treatment setting. Mindfulness training may assist marginalized persons recover from addiction.