Largest Neuroscience Study of Mindfulness as a Treatment for Addiction Published in Science Advances

The largest neuroscience study to date of mindfulness as a treatment for addiction shows that Mindfulness-Oriented Recovery Enhancement (MORE) can decrease opioid misuse by changing the brain.

Mindfulness-Oriented Recovery Enhancement Amplified Frontal Midline Theta EEG Power During Meditation

The study, published in the top journal Science Advances, provides new insight into the neurobiological mechanisms by which mindfulness treats addiction. Study findings provide a promising, safe and accessible treatment option for the more than 9 million Americans misusing opioids. Eric Garland is the lead author on the paper and is a distinguished professor, and associate dean for research at the University of Utah College of Social Work. He also directs the University of Utah’s Center on Mindfulness and Integrative Health Intervention Development

Garland’s study builds on previous research measuring the positive effects of theta waves in the human brain. Researchers have found that individuals with low theta waves tend to experience a wandering mind, trouble concentrating or they ruminate on thoughts about themselves. Theta waves can best be viewed on electroencephalogram, or EEG scans of the frontal midline regions of their brains. Low theta waves result in a loss of self-control as the brain slips into its default mode of automatic habits. In contrast, when a person is focused, present and fully absorbed in a task, EEG scans will show increased frontal midline theta wave activity.

“With high theta activity, your mind becomes very quiet, you focus less on yourself and become so deeply absorbed in what you are doing that the boundary between yourself and the thing you are focusing on starts to fade away. You lose yourself in what you are doing,” said Garland.

Garland’s new study showed it is in this mindful, theta wave state that people begin to experience feelings of self-transcendence and bliss, and the brain changes in ways that actually reduce one’s addictive behaviors. 

ABOUT THE STUDY

Garland’s research team recruited 165 adults with long-term opioid use for study. Participants were randomly placed into either the control group that participated in supportive group psychotherapy, or the experimental group taught to incorporate Mindfulness-Oriented Recovery Enhancement (MORE) into their daily lives. Before and after the eight weeks of study treatment, all participants were brought into the research lab and had their brain waves measured with EEG while they were asked to try to practice mindfulness meditation. Participants were assessed for opioid misuse for nine months after the treatment ended.

MORE is an eight-week, mindfulness-based therapy created by Garland to treat addiction, pain and emotional distress by promoting self-awareness and self-regulation of automatic and addictive habits. In a large clinical trial recently published in JAMA Internal Medicine, MORE was shown to reduce opioid misuse by 45%, more than doubling the effect of standard therapy.

Study participants in the MORE group learned to practice mindfulness meditation by focusing their attention on their breath or body sensations for sustained periods of time, and to refocus their attention when their minds began to wander into obsessive thinking about drugs or life stressors. 

STUDY FINDINGS

Participants showed more than twice as much frontal midline theta brain activity following treatment with MORE, whereas those in supportive therapy showed no increase in theta. Participants in MORE who showed the biggest increases in theta waves reported more intense experiences of self-transcendence during meditation, including the sense of one’s ego fading away, a sense of oneness with the universe or feelings of blissful energy and love.

Mindfulness-Oriented Recovery Enhancement Significantly Increased Self-Transcendent Experiences
The Effect of MORE on Reducing Opioid Misuse was Mediated by Increased Frontal Midline Theta

MORE also led to significant decreases in opioid misuse through the nine-month follow-up. These reductions in opioid misuse were caused in part by the increases in frontal midline theta brain waves. Garland explained that by achieving “tastes of self-transcendence” through meditation, the mindfulness therapy boosted theta waves in the frontal lobes of the brain to help participants gain self-control over their addictive behaviors.  

“Mindfulness can create a pathway for us to transcend our limited sense of self,” said Garland. “Civilizations have known for thousands of years that self-transcendence, the experience of being connected to something greater than ourselves, has powerful therapeutic benefits.”

This, he explained, is a part of why some cultures engage in spiritual practices, practice deep meditation or use psychedelic substances like psilocybin mushrooms. Even in the popular 12-step addiction treatment program, the 11th step—seeking conscious contact with a higher power through prayer or meditation—taps into this same mechanism to promote recovery from addiction.

The state of transcendence can be like a blissful, natural high. Garland stated, “Rather than seeking a high from something outside of yourself like a drug, meditation can help you to find an even greater sense of pleasure, peace and fulfillment from within.”

Credit: https://attheu.utah.edu/research/mindfulness-training-provides-a-natural-high-study-finds/

MORE’s Efficacy for Opioid Misuse and Chronic Pain Shown in JAMA

The largest trial of Mindfulness-Oriented Recovery Enhancement (MORE) ever conducted “Mindfulness-Oriented Recovery Enhancement vs Supportive Group Therapy for Co-occurring Opioid Misuse and Chronic Pain in Primary Care: A Randomized Clinical Trial” was just published in JAMA Internal Medicine! The results of this $2.8 million NIH-funded clinical trial (N=250) for people with chronic pain and opioid misuse were outstanding: MORE reduced opioid misuse by 45%, more than doubling the effect of standard supportive therapy.This is one of the strongest effect sizes ever shown for a treatment for opioid misuse among people with chronic pain. MORE also reduced opioid use; 36% of patients treated with MORE were able to reduce their opioid dose in half or greater. At the same time, 50% of patients treated with MORE experienced clinically significant reductions in pain severity. And, although nearly 70% of patients met criteria for major depressive disorder (MDD) at the beginning of the trial, the mean depression symptom severity score for patients treated with MORE no longer surpassed the threshold for MDD by the end of the study. These therapeutic effects lasted for 9 months after the end of treatment, demonstrating the sustained efficacy of MORE. We followed patients for almost a year after they enrolled in the study, representing the longest follow-up ever conducted for the MORE intervention.

MORE resulted in long-term reductions in chronic pain and emotional distress.

The timing of this publication is highly serendipitous, given that the opioid pharmaceutical settlements are just now reaching the states. My hope is that governors and legislators will consider using MORE as part of the solution to help stem the tide of the opioid crisis. Please help me get the word out! #MOREworks!

Mindful positive emotion regulation as a treatment for addiction: from hedonic pleasure to self-transcendent meaning

My new theory paper was just published online in Current Opinion in Behavioral Sciences. This paper outlines my recent ideas about how an addictions treatment approach based on mindfulness can enhance healthy pleasure, joy, and meaning in life. Most addictions treatments are focused on decreasing negative psychological experiences (e.g., stress, craving) and unhealthy behaviors. Few have focused on increasing positive psychological experiences as a core treatment approach. This oversight ignores fundamental discoveries from addiction neuroscience that demonstrate the plasticity of the brain reward circuitry underlying addiction. Therapies that use mindfulness techniques to savor natural rewarding objects and events, self-generate internal reward responses, and access self-transcendence may remediate the dysfunction in the reward system and thereby reduce addictive behavior.

The abstract is below:

Chronic drug use is theorized to induce cortico-striatal neuroplasticity, driving an allostatic process marked by increased sensitivity to drug-related cues and decreased sensitivity to natural rewards that results in anhedonia and a dearth of positive affect. As such, positive emotion regulation represents a key mechanistic target for addictions treatment. This paper provides a conceptual model detailing how mindfulness may synergize a range of positive affective mechanisms to reduce addictive behavior, from savoring the hedonic pleasure derived from natural rewards, to self-generating interoceptive reward responses, and ultimately to cultivating self-transcendent meaning. These therapeutic processes may restructure reward processing from overvaluation of drug-related rewards back to valuation of natural rewards, and hypothetically, ‘reset’ the default mode network dysfunction that undergirds addiction.

New Science Advances Publication on the Neuroscience of MORE Covered by News Outlets

Effect of MORE on Neural Indices of Opioid Cue-Reactivity Revealed by EEG

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.

Mindfulness-Oriented Recovery Enhancement Covered on NPR

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.

The NPR story can be found here.

 

 

New R01 Grant from the National Institute on Drug Abuse: Targeting Chronic Pain and Prescription Opioid Misuse in Primary Care with Mindfulness-Oriented Recovery Enhancement

nidaRecently, 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.

New Research Funding: Neuroimaging Research on the Effects of Mindfulness-Oriented Recovery Enhancement on Hedonic Regulation

mindfulness-centered-regulation-in-brainChronic 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.

more-conceptual-framework-opioid

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.

 

 

News: Dr. Garland’s Biobehavioral Research on MORE and Mindful Savoring Highlighted by the National Institute on Drug Abuse

MORE Reward ERPI 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 tetonsRecovery 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.

New Paper Accepted for Publication – Opioid Attentional Bias and Cue-Elicited Craving Predict Future Risk of Prescription Opioid Misuse

opioid_probe 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.

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! 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.

New Paper Published! “Mindfulness Is Inversely Associated with Alcohol Attentional Bias Among Recovering Alcohol Dependent Adults”

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!