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Published Online: 1 February 2024

MORE Is Less Pain and Less Opioid Misuse: A Mindful Remedy

Publication: American Journal of Psychiatry
The opioid epidemic has triggered a need for more interventions for individuals with chronic pain receiving long-term opioid therapy. On the basis of CDC guidelines published in 2016 (1), opioid prescribers changed their prescribing practices for patients on long-term opioid therapy. Many patients were left to manage chronic pain with either lower doses of opioids or alternative ways of managing pain that can put them at high risk for detrimental consequences. Several studies have shown that individuals on long-term opioid therapy who discontinued opioids, either abruptly or following a dose reduction, had significantly higher odds of suicide and overdose than individuals who remained on opioids (2, 3). Furthermore, increased dosage and longer duration of opioid therapy has been associated with development of an opioid use disorder (4). The more recent 2022 guidelines emphasize that patients and prescribers should collaboratively explore both pharmacological and nonpharmacological approaches to treatment and discuss multimodal options for the management of pain that are acceptable, available, and accessible (5).
Chronic pain, substance misuse and substance use disorder, and other stress-related comorbid psychiatric disorders commonly occur together in a complex combination that is difficult to treat. Negative affect and cognitions, anxiety sensitivity, distress tolerance, and emotion regulation difficulties are common transdiagnostic factors in all these disorders. Novel interventions to address factors that intersect these disorders are urgently needed.
A higher percentage of U.S. veterans report experiencing chronic pain than nonveterans (32% and 20%, respectively) (6). Veterans are also more likely than nonveterans to report poor health, disability, and co-occurring mental health problems, all of which are risk factors for opioid or other substance use disorders and subsequently higher overdose rates (7, 8).
In this issue of the Journal, Garland et al. (9) present a timely and relevant study targeting veterans and active-duty military personnel with chronic pain who were receiving opioid medications. This randomized controlled trial compared two psychosocial therapies, Mindfulness-Oriented Recovery Enhancement (MORE) and supportive group psychotherapy, adjunctive with opioid medication for chronic pain. This was a well-designed study with a number of strengths, including an ample sample size, a good comparator intervention, assessments conducted by staff blinded to the interventions, state-of-the-art assessments including ecological momentary assessment for opioid craving, intervention fidelity monitoring, and a relatively long follow-up of 8 months. The study has important implications for the use of this intervention with veterans with chronic pain who may be trying to reduce their use of medication without increasing pain severity. In this study, 34% of the enrolled veterans receiving long-term opioid therapy for chronic pain were diagnosed with an opioid use disorder. Veterans in this study had been receiving long-term opioid therapy for an average duration of 10–11 years and received average daily morphine equivalent doses over 100 mg, both of which are indictive of increased risk of opioid misuse or opioid use disorder. Session attendance (participants attended a mean of 5.5 MORE sessions and 5.7 supportive therapy sessions) for the two groups were similar and in line with group attendance in other mindfulness programs delivered remotely (10). In this study, results showed that MORE outperformed supportive therapy, with statistically significant reductions in pain interference, pain severity, and opioid use. A recent meta-analysis of randomized controlled trials exploring the efficacy of MORE found small to moderate effect sizes favoring MORE in relation to addictive behaviors, craving, opioid dose reduction, chronic pain, and psychiatric symptoms (11).
Negative emotional states and stressors can adversely affect pain perception, and individuals experiencing chronic pain have difficulty regulating emotional states, possibly because of a lack of interoceptive awareness capabilities. Individuals practicing mindfulness can enhance awareness of bodily sensations and stimuli through a process of reappraisal. Reappraisal and reinterpreting painful stimuli, stress, and craving through mindfulness practice result in improved self-regulatory processes and less emotional reactivity, while savoring natural positive rewarding experiences (12). Interoceptive awareness, self-regulation, and adaptive reappraisal result in experiencing pain perception and stress in a more meaningful way. In another study comparing MORE to supportive therapy in a group of individuals with chronic pain receiving long-term opioid therapy, Roberts and colleagues (13) found that improvements in reappraisal are mediated by interoceptive self-regulation and improvements in distress tolerance. The process variables explored in the Garland et al. study replicated the reappraisal and distress tolerance findings associated with MORE, which produced significant increases in mindful reinterpretation of pain sensations, nonreactivity to distressing thoughts and emotions, cognitive reappraisal, savoring or attending to pleasant natural reward stimuli, and attention to positive information. A subsample of veterans in the study participated in a natural reward stimuli task, before and after the intervention, in which physiological measurements were collected. Changes in EEG and skin conductance level measurements revealed that there was a greater positive response to natural reward stimuli in the MORE condition than in the supportive therapy condition. Furthermore, increased late positive potential on the EEG was associated with greater attention to savoring and decreased anhedonia (14). It is not uncommon for veterans with chronic pain and mental health conditions, such as depression and posttraumatic stress disorder (PTSD), to be preoccupied with pain, depression, and traumatic experiences. Attention and focus on present-moment experiences and developing skills to reappraise pain sensory stimuli can raise pain tolerance and decrease pain perception, thereby reducing opioid use. As the authors state, veterans practicing mindfulness can reinstate natural reward circuits that have been adversely affected by long-term opioid therapy. This conclusion was validated by greater improvements in the secondary outcome factors (positive affect, anhedonia, savoring, and attention to positive information) that identify pathways to better clinical outcomes in veterans receiving MORE compared with those receiving supportive therapy. An earlier study comparing MORE to supportive therapy conducted in a primary care population of civilians (15) validated the outcome variables studied by Garland et al. Considering that veterans often have clinically complex profiles, this finding has important implications for implementation in veterans and military populations who suffer from chronic pain and stress-related disorders. Mindfulness-based interventions similar to MORE are increasingly being integrated into the care of individuals with these disorders (16). From 2012 to 2017, meditation practice among U.S. adults increased from 1.4% to 14.2% (17).
Mindfulness interventions such as MORE, which are rooted in cognitive and behavioral psychology, use a present-moment, nonjudgmental approach that fosters awareness of both pleasant and unpleasant triggers, observing them for what they are and making well-informed responses. Mindfulness interventions are delivered in a group format with group members engaging in mindfulness meditation exercises, thereby experiencing and practicing the skill within the session, rather than being advised what skill may be helpful in a given triggering situation. In the context of mental health treatment, patients view mindfulness practice as useful and less stigmatizing than traditional therapies (18). Mindfulness has also been shown to reduce self-stigma and shame, which are commonly experienced in veteran populations. A recent meta-analysis found that compassion-focused mindfulness interventions outperformed standard treatment and some active control interventions in reducing self-stigma (19). In another study, mindfulness was shown to be negatively associated with self-stigma via reductions in PTSD symptom severity in a sample of U.S. veterans (20). Moreover, self-compassion is also associated with reductions in functional disability (21). Mindfulness meditation, a practice that promotes well-being and health, is appropriate for all individuals, but it can be particularly useful in patients with chronic pain on long-term opioid therapy and other stress-related disorders.
The authors have accumulated sufficient research findings favoring MORE that have implications for dissemination of this intervention into chronic pain clinics, opioid use disorder clinics, other substance use disorder treatment programs, and mental health programs where veterans commonly seek treatment. The scope of opioid misuse, opioid use disorder, and opioid overdose warrants novel effective treatments that can be delivered adjunctively with long-term opioid therapy. The addition or inclusion of mindfulness practices to various forms of psychotherapy, for example, dialectical behavior therapy and mindfulness-based cognitive therapy, have become established evidence-based interventions for a host of psychiatric disorders, and MORE promises to be a powerful tool in the fight against opioid misuse, opioid use disorder, and associated chronic pain.

References

1.
Dowell D, Haegerich TM, Chou R: CDC guideline for prescribing opioids for chronic pain: United States, 2016. JAMA 2016; 315:1624–1645
2.
DiPrete BL, Ranapurwala SI, Maierhofer CN, et al: Association of opioid dose reduction with opioid overdose and opioid use disorder among patients receiving high-dose, long-term opioid therapy in North Carolina. JAMA Netw Open 2022; 5:e229191
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Hallvik SE, El Ibrahimi S, Johnston K, et al: Patient outcomes after opioid dose reduction among patients with chronic opioid therapy. Pain 2022; 163:83–90
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Baumann L, Bello C, Georg FM, et al: Acute pain and development of opioid use disorder: patient risk factors. Curr Pain Headache Rep 2023; 27:437–444
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Dowell D, Ragan KR, Jones CM, et al: CDC clinical practice guideline for prescribing opioids for pain: United States, 2022. MMWR Recomm Rep 2022; 71:1–95
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Rikard SM, Strahan AE, Schmit KM, et al: Chronic pain among adults: United States, 2019-2021. MMWR Morb Mortal Wkly Rep 2023; 72:379–385
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Bennett AS, Watford JA, Elliott L, et al: Military veterans’ overdose risk behavior: demographic and biopsychosocial influences. Addict Behav 2019; 99:106036
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Perry C, Liberto J, Milliken C, et al: The management of substance use disorders: synopsis of the 2021 US Department of Veterans Affairs and US Department of Defense clinical practice guideline. Ann Intern Med 2022; 175:720–731
9.
Garland EL, Nakamura Y, Bryan CJ, et al: Mindfulness-Oriented Recovery Enhancement for veterans and military personnel on long-term opioid therapy for chronic pain: a randomized clinical trial. Am J Psychiatry 2024; 181:125–134
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Winter N, Russell L, Ugalde A, et al: Engagement strategies to improve adherence and retention in web-based mindfulness programs: systematic review. J Med Internet Res 2022; 24:e30026
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Parisi A, Roberts RL, Hanley AW, et al: Mindfulness-Oriented Recovery Enhancement for addictive behavior, psychiatric distress, and chronic pain: a multilevel meta-analysis of randomized controlled trials. Mindfulness (NY) 2022; 13:2396–2412
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Garland EL: Restructuring reward processing with Mindfulness-Oriented Recovery Enhancement: novel therapeutic mechanisms to remediate hedonic dysregulation in addiction, stress, and pain. Ann N Y Acad Sci 2016; 1373:25–37
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Roberts RL, Ledermann K, Garland EL: Mindfulness-Oriented Recovery Enhancement improves negative emotion regulation among opioid-treated chronic pain patients by increasing interoceptive awareness. J Psychosom Res 2021; 152:110677
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Garland EL, Fix ST, Hudak JP, et al: Mindfulness-Oriented Recovery Enhancement remediates anhedonia in chronic opioid use by enhancing neurophysiological responses during savoring of natural rewards. Psychol Med 2023; 53:2085–2094
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Garland EL, Hanley AW, Nakamura Y, et al: Mindfulness-Oriented Recovery Enhancement vs supportive group therapy for co-occurring opioid misuse and chronic pain in primary care: a randomized clinical trial. JAMA Intern Med 2022; 182:407–417
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Shapero BG, Greenberg J, Pedrelli P, et al: Mindfulness-based interventions in psychiatry. Focus (Am Psychiatr Publ) 2018; 16:32–39
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Clarke TC, Barnes PM, Black LI, et al: Use of yoga, meditation, and chiropractors among US adults aged 18 and over. NCHS Data Brief 2018:1–8
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Tofighi B, Marini C, Lee JD, et al: Patient perceptions of integrating meditation-based interventions in office-based opioid treatment with buprenorphine: a mixed-methods survey. J Addict Med 2023; 17:517–520
19.
Stynes G, Leão CS, McHugh L: Exploring the effectiveness of mindfulness-based and third wave interventions in addressing self-stigma, shame and their impacts on psychosocial functioning: a systematic review. J Contextual Behav Sci 2022; 23:174–189
20.
Barr N, Davis JP, Diguiseppi G, et al: Direct and indirect effects of mindfulness, PTSD, and depression on self-stigma of mental illness in OEF/OIF veterans. Psychol Trauma 2022; 14:1026–1034
21.
Dahm KA, Meyer EC, Neff KD, et al: Mindfulness, self-compassion, posttraumatic stress disorder symptoms, and functional disability in US Iraq and Afghanistan war veterans. J Trauma Stress 2015; 28:460–464

Information & Authors

Information

Published In

Go to American Journal of Psychiatry
Go to American Journal of Psychiatry
American Journal of Psychiatry
Pages: 89 - 91

History

Accepted: 5 December 2023
Published online: 1 February 2024
Published in print: February 01, 2024

Keywords

  1. Mindfulness
  2. Mindfulness-Oriented Recovery Enhancement
  3. Opioid Misuse
  4. Psychotherapy
  5. Recovery
  6. Substance Use Disorder

Authors

Details

Therese K. Killeen, Ph.D., A.P.R.N. [email protected]
Addiction Science Division, Department of Psychiatry and Behavioral Sciences (Killeen), and Department of Psychiatry and Behavioral Sciences (Brewerton), Medical University of South Carolina, Charleston.
Timothy D. Brewerton, M.D.
Addiction Science Division, Department of Psychiatry and Behavioral Sciences (Killeen), and Department of Psychiatry and Behavioral Sciences (Brewerton), Medical University of South Carolina, Charleston.

Notes

Send correspondence to Dr. Killeen ([email protected]).

Competing Interests

Dr. Killeen receives royalties from Oxford University Press. Dr. Brewerton reports no financial relationships with commercial interests.

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