Mindfulness-oriented recovery enhancement for stress, pain, and addiction
The opioid crisis is the greatest threat to public health faced by this generation, said Eric Garland, PhD, LCSW, at the 2019 Institute for Functional Medicine Annual International Conference in San Antonio, Texas.
Opioid addiction and chronic pain have been empirically linked to the rise of morbidity and mortality observed among white U.S. adults, Garland said. The U.S. is the only wealthy country that has seen increases in the mortality rate in the past two decades. Addiction is a disease of despair, he said.
“Disease of despair is not a metaphor,” Garland said. “It gets right to the heart of the pathophysiology of addiction.”
Pleasure and pain have been considered opposites on a hedonic balance, Garland said. Hedonic dysregulation is marked by increased sensitivity to drug cues, increased sensitivity to stress and pain, and decreased sensitivity to natural reward. This dysregulation promotes comorbid addictive behaviors, affective disorders, and chronic pain disorders.
As the individual becomes more dependent on opioids just to feel okay, they become less able to extract a sense of healthy pleasure, joy, and meaning out of everyday life, Garland said. So why can some patients take opioids as prescribed, and others go on to misuse opioids or become addicted to them?
Garland and colleagues conducted a study, published in the journal Developmental Psychology, in which opioid-treated chronic pain patients were shown a series of 30 negative images for six seconds, and were asked to rate their opioid craving on a scale of 1-5 at baseline and after each image. The subjects were broken down by those who had experienced emotional abuse, physical abuse, and sexual abuse. They found adverse childhood experiences predicts significantly greater increases in opioid craving in response to viewing negative, emotional stimuli. Chronic pain patients with more extensive trauma histories report greater opioid craving when triggered by negative emotions, Garland said.
Garland has conducted several similar studies. Dot probe task studies published in 2013 and 2014 found opioid attentional bias significantly predicted opioid misuse 20 weeks following the end of treatment. A 2017 study by Garland published in the journal Psychopharmacology found that opioid misusers have a blunted capacity to increase healthy positive emotions, as revealed by neurophysiology.
To address this, Garland developed Mindfulness-Oriented Recovery Enhancement (MORE), an integrative therapy for addiction, stress, and chronic pain that unites mindfulness, or attentional control, reappraisal, or psychological flexibility, and savoring, or reward processing. This sequence-based therapeutic strategy targets attentional bias to pain and opioid cues, pain perception and interference, emotion regulation, and autonomic cue-reactivity and craving. The are intended to modulate several mechanisms, including attentional control over automaticity, shift from affective to sensory processing, cognitive change, and restructuring reward processing.
Mindfulness meditation is a form of mental exercise designed to strengthen attention and self-control. Garland’s MORE approach is an eight-week manualized group therapy program. MORE has been tested as a treatment for opioids, alcohol, illicit drugs, smoking, obesity, and internet addiction.
Group sessions are two hours long and include formal mindfulness meditation, debrief group process, psychoeducation and didactic material, experiential exercise, and homework of 15 minutes of mindfulness practice per day and three minutes of mindful breathing before taking medicine. Each week follows a different focus topic, including mindfulness of nociception, pain, and suffering; mindfulness of automatic habits, mindfulness reappraisal, mindful savoring, mindfulness of craving and opioid dependence, overcoming craving by coping with pain and stress, coping with acceptance instead of suppression, and mindful recovery plan.
The purpose of the MORE program is three-fold: to clarify whether opioid use is driven by a craving or legitimate need for pain relief, prevent unnecessary opioid dosing by providing a non-opioid means of pain relief, and synergistically increase the analgesic efficacy of opioid medications. MORE may shift valuation of drug reward to valuation of natural reward, Garland said.
Stress, pain, and addiction fuel a downward spiral of despair, Garland said. MORE is a promising treatment that has been shown to reduce prescription opioid misuse risk in two Stage 2 randomized controlled trials. A $25 million research program and four additional randomized controlled trials are currently underway involving more than 2,000 participants. MORE may counter the pathophysiology of addiction and other diseases of despair by reducing drug cue-reactivity, increasing hedonic function, and enhancing wellbeing, Garland said.
Teaching patients to “take in the good” and mindfully savor natural, healthy pleasures may provide the learning signal needed to restore adaptive hedonic regulation and ultimately, reverse addiction.
“We need bold strategies for this crisis,” said Garland. “Mindfulness can be a powerful tool that you can leverage in your practice.”
Editor’s note: This article is part of Integrative Practitioner’s live coverage of the 2019 Institute for Functional Medicine Annual International Conference. For a full list of coverage, click here.