Chronic Pain Treatment, Neuroscience, and Genetics – Mindfulness-Oriented Recovery Enhancement on the Radio

Today I had the opportunity to speak about the treatment, neuroscience, and genetics of chronic pain with Dr. Dan Gottlieb, host of Voices in the Family, and Dr. Jeffrey Mogil, head of the Pain Genetics Lab at McGill University, on radio station WHYY in Philadelphia (a local NPR station). I spoke about how negative emotions and stress can influence pain processing in the brain, and about how Mindfulness-Oriented Recovery Enhancement can reduce the harmful impact of negative emotions on pain by teaching people to change the way they focus their attention and to reinterpret chronic pain as innocuous sensory signals from the body. 

The entire interview can be found here:

New Paper Accepted for Publication: Mindfulness Training Targets Neurocognitive Mechanisms of Addiction at the Attention-Appraisal-Emotion Interface

mindfulness centered regulation
Neurocognitive Model of Mindfulness-Centereted Regulation (Garland, Froeliger, & Howard, 2014)

My colleagues Brett Froeliger, Matthew Howard, and I recently authored an invited conceptual review paper (FREE TO DOWNLOAD) for a special issue of Frontiers in Psychiatry: Addictive Disorders and Behavioral Dyscontrol. Prominent neuroscience models suggest that addictive behavior occurs when environmental stressors and drug-relevant cues activate a cycle of cognitive, affective, and psychophysiological mechanisms, including dysregulated interactions between bottom-up and top-down neural processes, that compel the user to seek out and use drugs. Mindfulness-based interventions (MBIs) target pathogenic mechanisms of the risk chain linking stress and addiction. This review describes how MBIs may target neurocognitive mechanisms of addiction at the attention-appraisal-emotion interface. Empirical evidence is presented suggesting that MBIs ameliorate addiction by enhancing cognitive regulation of a number of key processes, including: clarifying cognitive appraisal and modulating negative emotions to reduce perseverative cognition and emotional arousal; enhancing metacognitive awareness to regulate drug-use action schema and decrease addiction attentional bias; promoting extinction learning to uncouple drug-use triggers from conditioned appetitive responses; reducing cue-reactivity and increasing cognitive control over craving; attenuating physiological stress reactivity through parasympathetic activation; and increasing savoring to restore natural reward processing. Treatment and research implications of our neurocognitive framework are presented. We conclude by offering a temporally sequenced description of neurocognitive processes targeted by MBIs through a hypothetical case study. Our neurocognitive framework has implications for the optimization of addiction treatment with MBIs.

The conceptual framework outlined in this paper clarifies and contextualizes the recent results from our randomized controlled trial of Mindfulness-Oriented Recovery Enhancement as a treatment for prescription opioid misuse and 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 Accepted for Publication: Mindfulness-Oriented Recovery Enhancement Reduces Pain Attentional Bias in Chronic Pain Patients

My colleague Matthew Howard and I recently had a paper accepted for publication in the internationally-recognized journal, Psychotherapy and Psychosomatics. This paper describes a subset of findings from a randomized controlled trial (RCT) of Mindfulness-Oriented Recovery Enhancement for chronic pain patients who have been prescribed long-term opioid treatment (e.g., oxycontin, vicodin) for pain management. The study is the first in the scientific literature to demonstrate that a mindfulness-oriented intervention can reduce the pain attentional bias. In this study, 67 individuals suffering from low back pain, neck pain, arthritis, fibromyalgia, and other pain conditions were randomly assigned to participate in MORE or a support group and began treatment.

Participants in the MORE group received instruction in applying mindfulness and other psychological techniques to: discriminate between nociception (i.e., the signal that the body is being damaged), pain, and suffering; become aware of their automatic pain coping habits; disrupt the link between negative emotions, fear of pain, and catastrophizing; refocus attention from pain and stress to savor pleasant experiences; manage pain and opioid dependence; reduce stress; promote acceptance versus suppression of difficult experiences; and develop a mindful recovery plan. Mindfulness training involved meditation on breathing and body sensations, with an emphasis on metacognitive awareness and shifting from affective to sensory processing of pain sensations. In other words, participants learned to step back and observe their pain as innocuous sensory information rather than as an emotionally-anguishing event – e.g., seeing their pain as “sensations of heat, tightness, tingling, or coolness” rather than “terrible agony.”

reinterpreting_pain_sensations

Participants in the support group were led to disclose their feelings and thoughts about topics related to chronic pain and opioid-related problems, as well as to provide advice and emotional support for their peers. The format of the support group was similar to conventional support groups used in many medical and psychotherapy settings.

We hypothesized that MORE would help participants to fixate less on their pain – freeing them to refocus on the meaningful, beautiful, or rewarding aspects of their lives. To measure attentional fixation on pain, or pain attentional bias, we used a dot probe task. In this task, participants were presented with two images, side by side, on a computer screen. One of the images was a pain-related image – the other was a neutral image. The images were presented for either 2 seconds or 200 milliseconds, and then were replaced with a dot. Participants were asked to press a button to indicate location of the the dot. Previous research demonstrates that chronic pain patients are faster to respond to pain images than neutral images, indicating that they exhibit an attentional bias, or attentional fixation, on pain-related information. Hence, people in chronic pain tend to automatically focus their attention on pain and things related to pain. This attentional fixation might occur unconsciously, without a person intending to focus on pain or even realizing that it is happening.

pain_dotprobe

In summary of our study results, we found that MORE led to significant reductions in the pain attentional bias, whereas the support group did not have any effect on pain attentional bias. Importantly, participants in MORE who experienced the largest decreases in the pain attentional bias felt like they had greater control over their pain following treatment. In addition, those people who felt that MORE had helped them to become less reactive to negative thoughts and feelings also had less pain attentional bias following treatment.

MORE_reduces_pain_AB

In conclusion, MORE appears to help people suffering from chronic pain and opioid-related problems learn to free their minds from fixating on pain, and in so doing, empower them to regain control of their lives.

Leading-Edge Science Supports the Notion of Recovery

Image By Sandy Burns

Over the past several decades there has been an explosion of research demonstrating that our feelings and thoughts are closely tied to the function of our brains, so much so that the 1990s were heralded as the “Decade of the Brain” by the Library of Congress and the National Institutes of Health. Neuroscience has come to have a powerful influence on our concepts of mental health, leading many people to believe that forms of psychological suffering like depression, anxiety, and addiction are caused by “biochemical brain imbalances.” While this view has removed a great deal of the stigma that was once associated with chronic mental health problems, it also may send the implicit and unfortunate message that change and recovery is not possible. If depression, anxiety, and addiction are diseases of the brain, how can anyone possibly change their brain? Isn’t the function and structure of the brain, like any other organ, determined by genes and fixed from birth?

The answer emerging from neuroscience research of the past decade is an unequivocal “NO!” We now know that the brain grows and changes throughout childhood, adolescence, and even into adulthood and old age! A number of factors can stimulate changes in the brain, known as neuroplasticity, including stress, diet, exercise, and even learning experiences. So, if chronic states of depression, anxiety, and addiction are partially the result of brain dysfunction (and, to be clear, a number of scholars have raised serious and important challenges to the neurobiological model of mental illness), many scientific studies demonstrate that learning and practicing new ways of thinking, acting, and responding to the challenges in our lives can change the way our brains function! Research is beginning to demonstrate that the very structure of our brains can be modified by mental training, not unlike the way people lift weights to build the size and strength of their muscles through physical training.

So what does all this groundbreaking and fascinating science mean for the idea of recovery from mental health and substance abuse problems? It explains how addiction treatment and mental health services can help people who have been diagnosed with a mental and/or substance use disorder to transcend their challenges to live a healthy and meaningful life. Innovative ways of helping people recover are continually being developed and tested, with promising results. The Trinity Institute for the Addictions at the FSU College of Social Work is dedicated to advancing new methods of promoting recovery.  Through my work at Trinity and through my prior work at the University of North Carolina at Chapel Hill, I have developed a new type of mental training program for people struggling with addiction, mental health problems, and chronic pain called Mindfulness-Oriented Recovery Enhancement, or MORE. MORE combines mindfulness training, cognitive-behavior therapy, and positive psychological principles into an integrative treatment strategy designed to help people increase self-control over their unhealthy habits and/or addictive behaviors, reduce their negative emotions (like feelings of anxiety, anger, and hopelessness), and improve their psychological well-being. I am currently conducting a clinical trial to test MORE as a way to combat chronic pain and problems related to prescription painkiller use – a growing epidemic in the U.S. and a frequent headliner in Florida’s news media.

Although this study is still in process, other studies suggest that mental training programs can be very helpful. For example, in previous research my colleagues and I found that mindfulness training reduced chronic pain symptoms by 38 percent and psychological stress by 31 percent! Another one of our studies indicated that mindfulness training helped people struggling with alcoholism to recover after being exposed to addictive triggers by calming their nervous system reactivity back towards baseline levels.  Other research suggests that mental training programs including cognitive-behavior therapy and mindfulness training can alter brain function and significantly reduce the symptoms of depression and anxiety, often with lasting positive effects.

The Substance Abuse and Mental Health Services Administration defines recovery as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential” (SAMHSA, 2011). The latest neuroscience findings on neuroplasticity and results from clinical research on psychological therapies like mindfulness training and cognitive-behavior therapy provide strong evidence for the notion that recovery from mental health problems and substance abuse is possible. Time and time again, cutting-edge science and clinical findings reveal a simple, hopeful, and powerful truth: treatment is effective, and people do recover.

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!

Recovery from Addiction, Stress, and Pain through Mindfulness and Social Support

I am honored to have the opportunity to discover new ways of helping people heal and recover from the challenges in their lives. For the past several years, I have been busily engaged in developing a new therapy for people struggling with chronic pain and problems with prescription opioid painkillers through a study funded by the National Institute on Drug Abuse. I first developed this new therapeutic approach, which I call Mindfulness-Oriented Recovery Enhancement, for an earlier study I conducted on alcoholism that was funded by a Francisco Varela Award from Mind and Life Institute. Mindfulness is an expansive and fundamental concept that has been pursued for millennia as a means of ameliorating suffering – look for more posts here soon about it. I am studying how this new treatment compares to a conventional support group. Support groups are a widely-used form of psychological support for people dealing with health and mental health issues that can be extremely helpful.

My approach to helping people is focused on promoting the basic goodness and inherent capacity for growth that lies within each person. I have a lot to say on this topic, but my latest thoughts can be summed up with an image:

In a way, this upward spiral of mindfulness, meaning, and positive emotion may be viewed as the converse of the downward spirals of addiction, stress, and pain that have become a modern day epidemic.

Downward Spiral of Pain and Prescription Opioid Misuse, Abuse, Dependence, and Addiction