Mindfulness Therapy Can Reduce Chronic Pain and Opioid Misuse

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Approximately 25% of individuals receiving long-term opioid therapy (opioid use for more than 90 days) misuse opioids[1]—defined as drug-related behaviors inconsistent with prescription directions,[2] such as taking opioids to facilitate feeling euphoric or to alleviate negative emotions.

Escalation from chronic pain to opioid misuse and Opioid Use Disorder (OUD) is thought to be propelled by the effects of prolonged opioid use on stress and reward circuitry in the brain.[3] These neurobiological changes increase sensitization to emotional distress and pain and decrease sensitivity to pleasure derived from natural rewards,[4] promoting opioid dose escalation as a means of preserving a dwindling sense of well-being.[5]

The challenge of treating co-occurring opioid misuse and chronic pain

Opioid misuse and addiction have been major public health issues in the U.S. for 15 years. Throughout this time, the successful treatment of opioid misuse among people with chronic pain has proven elusive. The efficacy of mindfulness-based interventions for opioid misuse, though promising, hadn’t been subjected to the scrutiny of a randomized clinical trial—until now.

The results of such a study recently published in JAMA Internal Medicine demonstrated that an 8-week mindfulness-based therapy—Mindfulness-Oriented Recovery Enhancement (MORE)—decreased opioid use and misuse while reducing chronic pain symptoms.[6] Moreover, these effects lasted up to nine months post-intervention. This is the first large-scale clinical trial to demonstrate that psychological intervention can simultaneously reduce opioid misuse and chronic pain among people who were prescribed opioid pain medications.

The study involved 250 adults with chronic pain on long-term opioid therapy who met the criteria for 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 8 weekly 2-hour group sessions, as well as 15 minutes of daily homework. Sessions in both study treatment groups provided psychoeducation to address opioid misuse and chronic pain and both were delivered in doctor’s offices, in the same setting where patients received their opioid pain management. Researchers measured participants’ opioid misuse behaviors; symptoms of pain; levels of depression, anxiety, and stress; and opioid dose through a 9-month follow-up. Opioid craving was measured at three random times each day, prompted by a text message sent to the participants’ smartphones.

Mindfulness, reappraisal, and savoring

The manualized MORE intervention provided sequenced training in mindfulness, reappraisal, and savoring skills. In this approach, mindfulness practice consists of meditation on breathing and body sensations to strengthen self-regulation of obsessive/compulsive opioid use, and to mitigate pain and opioid craving by reinterpreting these experiences as benign/neutral sensory information. Participants are taught to break down the experience of pain or opioid craving into their sensory components, tuning in to 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.

Reappraisal focuses on reframing 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. This perspective shift modifies event-associated maladaptive thoughts and decreases negative emotions. Savoring consists of training attention to focus on pleasurable events, healthful and life-affirming experiences, amplifying positive emotions and sensations related to the sense of joy, reward, and meaning that can come from everyday events.

Primary outcomes and measures were (1) opioid misuse assessed by the Drug Misuse Index (self-report, interview, and urine screen) and (2) pain severity and pain-related functional interference, assessed by subscale scores on the Brief Pain Inventory through nine months of follow-up. Secondary outcomes were opioid dose, emotional distress, and ecological momentary assessments of opioid craving. The minimum intervention dose was defined as four or more completed sessions of MORE or supportive group psychotherapy.

At 9 months post-treatment, 45% of participants in the MORE group were no longer misusing opioids, and 36% had cut their opioid use in half or greater. Those receiving MORE had more than twice the odds of those in standard supportive psychotherapy to stop misusing opioids by the end of the study. Additionally, participants receiving MORE also reported significant improvements in chronic pain symptoms compared with those receiving supportive psychotherapy, as well as decreased opioid cravings, and reduced symptoms of depression to levels below the threshold for major depressive disorder.

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How MORE appears to work

The primary mechanisms of action in the MORE approach are training people how to step back and observe their experiences of pain and opioid craving from the perspective of an objective observer, rather than getting caught up in and becoming attached to and becoming effectively controlled by the pain or craving. When people can do that, their perspective shifts substantially and they need not be held hostage nor defined by their experiences of pain or craving, or any particular thought or sensation.

This, in combination with the practices specific to savoring, may help to restructure the way the brain processes rewards, supporting a change from valuing drug-related rewards toward valuing rewards that are natural and healthy—like being out in nature, seeing live music, enjoying a nice meal, or being with beloved family or friends.

People experiencing both chronic pain and opioid misuse present a significant treatment challenge, particularly since opioid use disorder has been shown to increase pain sensitivity (a phenomenon known as opioid-induced hyperalgesia), which in turn promotes further opioid misuse. By simultaneously reducing pain and opioid use, MORE appears to provide an especially effective and promising intervention that can help people struggling with these life-altering co-occurring challenges to significantly improve the quality of their lives.

Copyright 2022 Dan Mager, MSW