Results from a new clinical trial demonstrate that an eight-week mindfulness-based therapy—Mindfulness-Oriented Recovery Enhancement (MORE)—decreased opioid use and misuse while reducing chronic pain symptoms, with effects lasting as long as nine months. This is the first large-scale clinical trial to demonstrate that a psychological intervention can simultaneously reduce opioid misuse and chronic pain among people who were prescribed opioid pain relievers.
The study, published in the peer-reviewed journal JAMA Internal Medicine, followed 250 adults with chronic pain on long-term opioid therapy who met the criteria of misusing opioids. Most participants took oxycodone or hydrocodone, reported two or more painful conditions and met the clinical criteria for major depression. More than half of participants also had a diagnosable opioid use disorder.
Study participants were randomly assigned to either a standard supportive psychotherapy group, or a MORE group, both engaging in eight weekly two-hour group sessions, as well as 15 minutes of daily homework. The study treatment groups were delivered in doctor’s offices, in the same clinical care setting where patients received their opioid pain management. Researchers measured the participants’ opioid misuse behaviors; symptoms of pain; depression, anxiety and stress; and opioid dose through a nine-month follow-up. Opioid craving was measured at three random times a day, prompted by a text message sent to the participants’ smartphones.
Nine months after the treatment period ended, 45% of participants in the MORE group were no longer misusing opioids, and 36% had cut their opioid use in half or greater. Patients in MORE had more than twice the odds of those in standard psychotherapy to stop misusing opioids by the end of the study. Additionally, participants in the MORE group reported clinically significant improvements in chronic pain symptoms, decreased opioid craving and reduced symptoms of depression to levels below the threshold for major depressive disorder.
“MORE demonstrated one of the most powerful treatment effects I’ve seen,” said Eric Garland, lead author of the study, director of the Center on Mindfulness and Integrative Health Intervention Development at the University of Utah and the most prolific author of mindfulness research in the world. “There’s nothing else out there that works this well in alleviating pain and curbing opioid misuse.”
“Remarkably, the effects of MORE seem to get stronger over time,” said Garland, who developed MORE and has been studying it for over a decade. “One possible explanation is that these individuals are integrating the skills they’ve learned through MORE into their everyday lives.” Garland also hypothesized that, based on previous research, the sustained benefits might be related to MORE’s ability to restructure the way the brain processes rewards, helping the participants’ brains shift from valuing drug-related rewards to valuing natural, healthy rewards like a beautiful sunset, the bloom of springtime flowers or the smile on the face of a loved one.
MORE combines meditation, cognitive-behavioral therapy and principles from positive psychology into sequenced training in mindfulness, savoring and reappraisal skills.
Participants are taught to break down the experience of pain or opioid craving into their sensory components, “zooming in” on what they are feeling and breaking it down into different sensations like heat, tightness or tingling. They are trained to notice how those experiences change over time, and to adopt the perspective of an observer. They are also taught to savor pleasant, healthful and life-affirming experiences, amplifying the sense of joy, reward and meaning that can come from positive, everyday events. Finally, participants are taught to reframe stressful events to find a sense of meaning in the face of adversity, to recognize what can be learned from difficult events and how dealing with those experiences might make a person stronger.
Garland explained, “Rather than getting caught up in the pain or craving, we teach people how to step back and observe that experience from the perspective of an objective witness. When they can do that, people begin to recognize that who they truly are is bigger than any one thought or sensation. They are not defined by their experiences of pain or craving; their true nature is something more.”
People experiencing both chronic pain and opioid misuse present a significant treatment challenge, since opioid use disorder has been shown to increase pain sensitivity, which in turn promotes further opioid misuse. By simultaneously reducing pain and opioid use, MORE may offer an effective, economical and lifesaving intervention to help halt the ongoing opioid crisis.