My new paper published in the prestigious journal Science Advances reporting effects of Mindfulness-Oriented Recovery Enhancement on brain reward responses among chronic opioid users has been covered by multiple news outlets, including the Los Angeles Times, the Durham Herald-Sun, the Fort Worth Star Telegram, Science Daily, and the American Association for the Advancement of Science, among others. The paper can be downloaded for free here.
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.
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.
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 recently learned that my research on Mindfulness-Oriented Recovery Enhancement (MORE) was highlighted on the National Institute on Drug Abuse website. The NIDA news story, entitled “Mindfulness training may reduce deficits in natural reward processing during chronic pain or drug addiction” details a study I conducted with my colleagues Brett Froeliger (Neuroscience, Medical University of South Carolina) and Matthew Howard (Social Work, University of North Carolina at Chapel Hill) that was published in April in the Journal of Behavioral Medicine. According to the excellent summary of this research on the NIDA website,
“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.
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.
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.
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.
An article written by my colleagues Charlotte Boettiger, Susan Gaylord, Vicki West Chanon, and Matthew Howard and I was recently published in the journal Cognitive Therapy and Research. This article describes the relationship between the tendency to be mindful in everyday life and the alcohol attentional bias among people in recovery from alcoholism. As described in the post below, attentional bias is the phenomena in which a person’s attention may be automatically captured by or fixated on an emotionally-significant object or event. Among alcoholics, cues associated with drinking tend to have a strong emotional importance – the sight of a bottle of liquor, an old drinking buddy, or familiar bar can automatically grab their attention and trigger the urge or craving to drink. This alcohol attentional bias can be measured in the laboratory using a dot probe task very similar to the one pictured in the post below, by asking participants to press a button to indicate the location of a target that replaces either an alcohol-related or neutral photo.
In the study described in our paper, we tested 58 people in long-term treatment for alcoholism with a dot probe task to measure their alcohol attentional bias. We also gave them questionnaires assessing their former drinking behavior, their level of craving, and the extent to which they reported to be mindful. These people had never received formal mindfulness training, but instead had received standard substance abuse treatment services. We found that individuals who classified themselves as having higher mindfulness actually had less attentional bias towards alcohol cues than people who classified themselves as being less mindful, regardless of how much they drank in the past or how much they craved alcohol.
Why is this important? The trait of mindfulness, that is, the tendency to be mindful in everyday life, is thought to involve being less reactive to difficult thoughts and feelings, less judgmental of yourself and others, more in touch with your emotions, more observant of sensory experiences (like the feeling of the wind in your hair or the sun on your face), and being aware of when you are acting out of habit or on “auto-pilot.” What makes the study findings so compelling is that the recovering alcoholics who thought they were more mindful (i.e., more aware of their habitual responses and less reactive to strong emotions) were the ones who were best able to shift their attention away from alcohol cues. In other words, they were better able to “disengage” their attention from addictive temptations and refocus on other things.
If people in recovery who are more mindful are less perturbed by addictive triggers, would explicit mindfulness training help them to overcome addiction? It’s not a wild stretch of the imagination to make this supposition. Indeed, my research on Mindfulness-Oriented Recovery Enhancement shows that mindfulness has great promise as a treatment for alcoholism and other forms of addiction. But more research is needed!