A psychotherapeutic intervention that unites mindfulness training, “third wave” cognitive behavioral therapy (CBT), and positive psychology significantly reduces chronic pain and opioid misuse, new research suggests.
In a randomized clinical trial, 250 adults with both opioid misuse and chronic pain received either the intervention, called mindfulness-oriented recovery enhancement (MORE), or supportive psychotherapy.
Results showed the first group was twice as likely to reduce their opioid misuse after 9 months than the latter group.
The intervention was developed by Eric Garland, PhD, director of the Center on Mindfulness and Integrative Health Intervention Development (C-MIIND), University of Utah, Salt Lake City. “As the largest and longest-term clinical trial of MORE ever conducted, this study definitively establishes the efficacy of MORE as a treatment for chronic pain and opioid misuse,” he told Medscape Medical News.
The findings were published online February 28 in JAMA Internal Medicine.
Study participants included 250 adults (64% women; mean age, 51.8 years) with co-occurring opioid misuse and chronic pain who were randomly assigned to receive MORE or supportive psychotherapy, which served as a control group.
Both interventions were delivered by trained clinical social workers in six primary care clinics in Utah to groups of 6-12 participants across 8 weekly 2-hour sessions.
The MORE intervention, detailed on Garland’s website, provides sequenced training in mindfulness, reappraisal, and saving skills.
Mindfulness consisted of meditation on breathing and body sensations to strengthen self-regulation of compulsive opioid use and to mitigate pain and opioid craving by re-interpreting these experiences as innocuous sensory information.
Reappraisal consisted of reframing maladaptive thoughts to decrease negative emotions and engender meaning in life.
Savoring consisted of training in focusing awareness on pleasurable events and sensations to amplify positive emotions and reward.
Fewer Depressive Symptoms
Through 9 months of follow-up, the MORE group had about a twofold greater likelihood than the supportive psychotherapy group for reduction in opioid misuse (odds ratio [OR], 2.06; 95% CI, 1.17 – 3.61; P = .01)
“MORE reduced opioid misuse by 45% 9 months after the end of treatment, more than doubling the effect of standard supportive psychotherapy and exceeding the effect size of other therapies for opioid misuse among people with chronic pain,” Garland said.
Members of the MORE group also experienced greater reduction in pain and pain-related functional interference than members of the control group.
“MORE’s effect size on chronic pain symptoms was greater than that observed for CBT, the current gold-standard psychological treatment for chronic pain,” Garland noted.
Compared with supportive psychotherapy, MORE also decreased emotional distress, depressive symptoms, and real-time reports of opioid craving in daily life.
“Although nearly 70% of participants met criteria for depression at the beginning of the trial, on average, patients in MORE no longer exhibited consistent symptoms with major depressive disorder by the end of the study,” Garland said.
The current study builds on prior studies of MORE showing similar results, as previously reported by Medscape Medical News.
MORE can be successfully delivered in routine primary care, Garland noted. “In this trial, we delivered MORE in conference rooms, break rooms, and lunch rooms at community primary care clinics,” he added.
To date, Garland has trained more than 450 physicians, nurses, social workers, and psychologists in healthcare systems across the country to implement MORE as an insurance-reimbursable group visit for patients in need.
One of them is Nancy Sudak, MD, chief well-being officer and director of integrative health, Essentia Health, Duluth, Minnesota.
“MORE is a very powerful program that teaches patients how to turn down the volume of their pain. I’ve been quite impressed by the power of MORE,” Sudak told Medscape Medical News.
She noted that “buy-in” from patients is key — and the more a clinician knows a patient, the easier the buy-in.
“I recruited most of the patients in my groups from my own practice, so I already knew the patients quite well and there wasn’t really a need to sell it,” Sudak said.
“We have tried to operationalize it through our system and find that, as long as our recruitment techniques are robust enough, it’s not that hard to find patients to fill the groups, especially because chronic pain is just so common,” she added.
Sudak has also found that patients who participate in MORE “bond and learn with each other and support each other. Patients love it, providers love it, and it’s a way to address isolation and loneliness” that can come with certain conditions.
“There are really only upsides to the group visit model and I think we’ll be seeing quite a bit more of it in the future,” she added.
Anna Parisi, PhD, LCSW, is also delivering MORE to patients. She told Medscape Medical News, she was “really drawn” to the MORE program because oftentimes patients who require the most sophisticated therapies receive the ones with the least evidence.
This is often “what folks in the community are getting when they’re struggling with substance use,” added Parisi, a postdoctoral research associate working with Garland at the University of Utah. Parisi was not a co-author on the current study.
“With MORE, all of the strategies and techniques are tied to mechanistic studies of their efficacy, so you know that what you’re delivering has a rationale behind it,” she said.
Like Sudak, Parisi said her patients, for the most part, have also been receptive to the program. Although at first some were skeptical about mindfulness — with one patient using the term “tree-hugging” — they found immediate benefit even after the first session.
“That really helps them stay motivated to finish the program,” Parisi said.
This work was supported by a grant from the National Institute on Drug Abuse. Garland serves as d irector of the Center on Mindfulness and Integrative Health Intervention Development, which provides MORE, mindfulness-based therapy, and CBT in the context of research trials for no cost to research participants. He also received es honoraria and payment for delivering seminars, lectures, and teaching engagements related to training clinicians in MORE and mindfulness and reciv es royalties from BehaVR and from the sales of books related to MORE outside the submitted work. Sudak and Parisi have disclosed no relevant financial relationships.
JAMA Intern Med. Published online February 28, 2022. Abstract
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