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 ventral 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. Though this study had a number of limitations, including the small sample size and lack of a randomized design, 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.
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.
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.