Can mindfulness treat opioid misuse and chronic pain?
“Mindfulness is a mental training approach of focusing attention in the present moment, to become aware of thoughts, emotions, body sensations, perceptions, without holding on to experience, but just watching it. Like an observer, or a witness."
That’s professor Eric Garland, the director of the Center on Mindfulness and Integrative Health Intervention Development at the University of Utah.
To some, ‘mindfulness’ is just buzzword, or a relaxation tool, that lacks real medical substance. But using the gold standard in medical research; the randomized clinical trial, Garland and his colleagues have shown that Mindfulness Oriented Recovery Enhancement (M.O.R.E.) is effective in treating patients with chronic pain and opioid misuse.
“Mindfulness Oriented Recovery Enhancement is an 8-week therapy. We delivered it as a group therapy. Each session begins with a formal mindful breathing practice. We actually teach people how to use mindfulness to zoom into pain, and to break it down. Getting people to cultivate this kind of awareness of the pain itself, it sounds paradoxical, but it actually reduced the intensity of the pain,” said Garland.
Garland said that unbeknownst to many patients, they were turning to opioids for reasons other than pain. He said mindfulness allowed them to realize when they needed opioids to manage their physical pain and when they were misusing them to self-medicate stress, depression, emotional pain or anger.
“When they would go take their opioid, instead of just popping the pill without thinking about it, we'd ask them to sit with the pill bottle, and actually practice mindfulness and become aware of whatever thoughts were coming up in their mind. And many folks discovered that doing this practice, they actually didn't need to take as much opioids,” Garland said.
According to Garland, chronic use of addictive drugs, like opioids, alters the brain’s wiring in ways that reduce the pleasure of everyday experiences; like sunsets, birds singing, the warmth of a loved one’s hand, become less pleasurable. Simultaneously, the brain becomes hypersensitive to drug-related cues such as the presence of an opioid pill bottle. This imbalance in the brain’s reward system is a main driver in the cycle of addiction. To combat this, Garland says patients were taught what’s called 'savoring.'
“We bring in a bouquet of roses. The patients pull out a rose, and we asked them to focus mindful attention on the rose and to appreciate the pleasant colors, and textures, and scent of the flower, as well as the touch of the petals against their skin,” said Garland.
In 2019, Garland and his colleagues showed that M.O.R.E. reduces the brain’s sensitivity to drug-related cues and increases its sensitivity to natural healthy pleasures.
However, it wasn’t until February 2022 when the results of the most recent large-scale randomized trial were published in the Journal of American Medical Associations Internal Medicine. In this trial M.O.R.E. was shown to be clinically effective in treating opioid misuse.
“M.O.R.E. reduced opioid misuse by 45%, so it was more than twice as powerful as standard supportive psychotherapy. Thirty-six percent of the patients were able to cut their opioid dose in half or greater. And at the same time, M.O.R.E. significantly reduced physical pain. Almost 70% of the patients met criteria for major depressive disorder at the beginning of the study. On average patients in M.O.R.E. reported depression symptom levels below the threshold for major depression,” said Garland.
Dr. Zev Schuman-Olivier is an assistant professor in psychiatry at Harvard Medical School. He is also the Director of Addictions Research and the Director of the Center for Mindfulness and Compassion at Cambridge Health Alliance.
“What stood out to me was the reductions in opioid misuse, as well as the reductions in the percentage of people that continue to misuse opioids despite being on opioid therapy for chronic pain. For a lot of people, especially middle and older adults, the pathway to opioid use disorder starts with chronic pain. So being able to have an intervention that can specifically target folks who are in pain and have chronic pain, and to prevent that transition to opioid use disorder, it’s particularly important,” Schuman-Olivier said.
Dr. Schuman-Olivier is currently conducting a national clinical trial using a mindfulness-based approach in patients who are taking the medication for opioid use disorder called buprenorphine, often known as suboxone.
“And one of the things that we actually built into that intervention. Was this mindful savoring, based on Eric's pioneering work,” said Schuman-Olivier.
Utah resident, Jon Spencer, has had back pain for over a decade. In 2018 he underwent major back surgery that resulted in pain manageable only by daily hydrocodone use. He didn’t like the way opioids affected his memory and made him feel, but he couldn’t manage the pain without them. So when he heard about Garland’s mindfulness clinical trial, he enrolled.
“Basically, there's two parts to pain. There’s the place where the pain originates. It’s not pain at that point, it’s just a stimulus. And it gets to the brain and the brain interprets it as, “that hurts”. But there’s not much you can do at the site of the pain. So the only other way to deal with it is in the brain. It’s mindfulness, is what they call it. What it is, is it's giving you techniques to control what's happening in your brain. And that sounds weird. And it sounds a little new agey to me, but it worked,” said Spencer.
Though he still experiences pain, Spencer said his mindfulness training has allowed him to find a different way to control it.
“Since the last two weeks of the study to this day, I haven't taken a single opioid. My goal is to never take an opioid pill again for the rest of my life. That's my goal and I know I can do it. I know I can do it,” Spencer said.
According to Dr. Schuman-Olivier it has taken a decade and a half for researchers to lay the groundwork for mindfulness-based therapies to be scientifically tested as psychological interventions, as Garland’s study has done. And to Garland’s knowledge its the largest clinical trial to date to show that a psychological intervention can reduce opioid misuse and chronic pain.