My colleagues and I had a new paper published in the top scientific journal Nature Mental Health showing that Mindfulness-Oriented Recovery Enhancement (MORE) led to clinically significant reductions in post-traumatic stress symptoms in 59% of patients with comorbid PTSD, chronic pain, and opioid misuse. In this NIH-funded study involving 241 patients, MORE significantly reduced PTSD symptoms by increasing the capacity to regulate negative emotions through reappraisal. In turn, the effects of MORE on reducing opioid misuse were statistically mediated by decreases in PTSD symptoms. This study is important because PTSD is highly prevalent among people with chronic pain and addiction, yet there are no evidence-based treatments for this complex comorbidity. These data suggest that MORE is a highly effective therapy that can simultaneously treat traumatic stress, chronic pain, and addictive behavior.
Mindfulness-Oriented Recovery Enhancement (MORE) reduced PTSD symptoms to a significantly greater extent than supportive group (SG) psychotherapy.
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.
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 ExperiencesThe 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.”
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!
On May 4, I had the honor of giving an invited lecture for the National Center for Complementary and Integrative Health (NCCIH) of the National Institutes of Health, entitled “Healing the Opioid Crisis with Mindfulness-Oriented Recovery Enhancement: Clinical Efficacy and Neurophysiological Mechanisms.” The full video of this lecture can be found here. In this lecture, I described my decade-long research program focused on developing and testing MORE as a treatment for chronic pain, opioid misuse, and addiction, and reported results from the largest clinical trial of MORE to date.
Dr. Garland presents his research on Mindfulness-Oriented Recovery Enhancement to NIH Leadership
I began the talk discussing the destructive processes that unwittingly propel a person suffering from prolonged pain down the path toward an eventual loss of control over opioid use. I have been studying these risk mechanisms undergirding opioid misuse and OUD in people with chronic pain for more than a decade, and the discoveries I have made, along with great science from the field, informed the development of MORE. Then I described the Mindfulness-to-Meaning Theory, a key theoretical framework underlying MORE, as well as MORE’s treatment components, including mindfulness meditation, reappraisal, and savoring. Finally, I detailed MORE’s clinical outcomes and mechanisms of action across four randomized controlled trials involving nearly 500 patients. MORE works by strengthening self-control, reducing the brain’s reactivity to drug cues, increasing the brain’s response to natural, healthy rewards, enhancing meaning in life, and eliciting experiences of self-transcendence.
Following the lecture, I had a fascinating dialogue with the Director of NCCIH, Dr. Helene Langevin, and the Deputy Director of NCCIH, Dr. David Shurtleff about the emergence of self-transcendence in biological systems and its impact on health, and the use of mindfulness as a prevention and treatment strategy. This dialogue then opened up into a fantastic question and answer period. After the talk, I had the honor of discussing my research with multiple program directors and branch chiefs at NIH. If you didn’t have a chance to listen in, you can still watch the videocast here!
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.
I was recently interviewed by renowned psychotherapist Lisa Dale Miller for her Groundless Ground Podcast about a range of topics. It was definitely my favorite interview I’ve had to date. Lisa and I had a really fun conversation ranging from the treatment of chronic pain and addiction with mindfulness, to the neuroscience of reward, to Buddhist philosophy, to self-transcendence, and finally, to the arcane Tantric notion that the dynamic Primordial Bliss of Consciousness lies at the heart of all experience.
Eric Garland Interviewed on Groundless Ground Podcast by Lisa Dale Miller
Using my research on Mindfulness-Oriented Recovery Enhancement (MORE) as a launchpad, Lisa and I delve into specific clinical issues around the use of meditation as a means of alleviating physical pain and drug craving, providing mindfulness instruction to people suffering trauma, and how to enhance the sense of meaning and joy in life through reappraisal and savoring. We dig deep into the science of restructuring reward processes in the brain as novel approach to addictions treatment. Finally, we give a brief history of the science of mindfulness and how it developed from a core of mechanistic cognitive psychology to begin to explore the outer edge of meditative states of consciousness – including the study of how people can transcend their limited sense of self and come to feel intimately interconnected with the world around them.
We let it all hang out! Come check it out! The podcast is also available on Spotify.
Along with my colleagues Drs. Brett Froeliger and Michael Saladin (Medical University of South Carolina), I was recently awarded a 5-year, $2.3 million grant from the National Institute on Drug Abuse to study the neural mechanisms of Mindfulness-Oriented Recovery Enhancement (MORE) as a smoking cessation intervention. In this study, 100 smokers will be randomly assigned to receive eight sessions of MORE or eight sessions of cognitive-behavioral therapy (CBT) to assist them in quitting smoking. Before and after the eight session intervention, participants will complete a task while their brain activity is being recorded in a fMRI scanner to measure their neural response natural rewards and cigarette cues. According to the allostatic model of addiction, as addiction progresses, the brain becomes hypersensitive to drug-related cues and triggers, and insensitive to natural, healthy rewards and pleasures, resulting in a lack of hedonic pleasure and dysphoria that pushes the individual to take higher and higher doses of the drug just to feel okay. This study is designed to test my restructuring reward hypothesis, which states that mindful savoring can reduce addictive behaviors by causing a shift in brain reward circuitry from valuing of drug-related rewards back to valuing natural rewards – reversing the allostatic process of addiction. This new research grant builds upon our earlier published proof-of-concept study showing that MORE increases savoring-related neural activation in the medial prefrontal cortex and ventral striatum – key reward-related brain areas. This increase in brain activity was associated with significant reductions in cigarette smoking. Here we will seek to replicate this finding using a rigorous, randomized clinical trial design. It is my sincere hope that this work will help to free people from smoking – the leading cause of preventable death in the United States.
Results from this study, conducted in 95 people with chronic pain who had been prescribed long-term opioid therapy, demonstrate that MORE significantly decreased chronic pain intensity and significantly decreased the risk of future opioid misuse. Further, MORE boosted a range of positive psychological functions, including positive emotions, savoring, meaning in life, and the sense of self-transcendence. Importantly, the MORE’s effects on reducing pain and opioid misuse were linked with these increases in positive psychological functioning, suggesting that teaching people to “savor the good” and increase the sense of joy, meaningfulness, and natural healthy pleasure in life may be an antidote to the current pain and opioid crises in America – modern epidemics that have been termed “diseases of despair.”
This is the second randomized controlled trial to demonstrate therapeutic effects of MORE on chronic pain symptoms and opioid misuse, providing compelling evidence of MORE’s efficacy as a means of alleviating the suffering caused by the opioid crisis.
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.
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 ventromedial 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. 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 hypothesiswhich 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.
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.
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.
Michael Saladin (Medical University of South Carolina), I was recently awarded a 5-year, $2.3 million grant from the National Institute on Drug Abuse to study the neural mechanisms of 
medial prefrontal cortex and ventral striatum – key reward-related brain areas
Recently, I was awarded a R01 grant from the 
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.