For those struggling with opioid use disorder, the medication buprenorphine is often prescribed as a first-line treatment, but patients may still struggle with a host of debilitating symptoms including drug craving and anxiety. A recent randomized clinical trial evaluated the effectiveness of a mindfulness-based intervention for patients prescribed buprenorphine for opioid use disorder.
Dr. Schuman-Olivier, an Addiction Psychiatrist at Cambridge Health Alliance and Associate professor at Harvard Medical School, is the lead author on a paper published last month in the Journal of American Medical Association Network Journal, which reported the results of the trial. He said the mindfulness treatment intervention was developed by his team at the Center for Mindfulness and Compassion in the Boston area and was designed to be safe and effective for a population with a history of trauma, psychiatric disorders, and addiction. The intervention utilizes a variety of techniques that are targeted towards catalyzing behavior change and sustaining addiction recovery.
“The goal was to create a third-generation mindfulness-based intervention that would specifically target successful behavior change using principles of behavior change from the mindfulness literature,” Schuman-Olivier said.
Patients either received a 24-week mindfulness-based group treatment or the standard treatment: a recovery support group with a curriculum of evidence-based skills and best practices for substance use treatment. The study was originally intended to be in person, in Massachusetts, but because of the COVID-19 pandemic it had to be conducted online. 196 patients from 16 states were randomized in the study.
“One of the things that was unique about this study was that we brought people together from all over the country, from every region. So it was a geographically diverse sample, which I'm proud that we were able to do,” Schuman-Olivier said.
Schuman-Olivier said the study found no difference between the two treatments in opioid abstinence, and they showed a similar large reduction in anxiety suggesting an equivalent level of effectiveness. However, the mindfulness treatment outperformed standard treatment on measures of opioid craving. The mindfulness group showed a 67% reduction in opioid craving, compared to a 44% reduction in the standard therapy after 24 weeks of treatment.
“We do see that the craving in particular is more specific to mindfulness as something that's getting reduced. So I think one of the questions we had is what are the potential practices that might be linked to this reduction in craving," Schuman-Olivier said.
Schuman-Olivier, said one of the largest reductions in cravings occurred after a session when patients learned about auto pilot behaviors, which are actions that happen out of habit and are difficult to recognize and stop.
“We all have it. But it gets super-charged in addiction. What happens with opioids is a lot of these other types of automatic processing all get channeled into one thing. So you know, you're actually feeling hungry, the autopilot might be to eat, but if you are an opioid user, it might actually feel like withdrawal. If you're feeling mad or angry, it might actually lead to craving. Everything starts to get, get wired up into this automatic response of 'opioids will solve it.' We want people to become aware of all the different autopilots they have,” Schuman-Olivier said.
The intervention also includes mindful savoring, a technique for focusing attention on pleasant experiences, which researchers at the University of Utah have previously shown to reduce craving among people with opioid misuse during chronic pain treatment. The treatment also included several techniques aimed at increasing patient’s interoceptive awareness, the sense of one’s own body and internal body sensations and the ability to regulate them. Interoceptive dysfunction has previously been found to be involved in disorders like depression, anxiety, and drug craving.
“With opioids, if you see your pill bottle and there's a little bit of pain, you already know what to do. If you can target the interoceptive sensations, the body signals and the feeling tone of the body, you can start to be able to break these automatic cycles at its most sensitive point,” Schuman-Olivier said.
Schuman-Olivier said that participants in the mindfulness group were asked to start small with 5 minutes of mindfulness a day and work their way up to 20 minutes a day by 8 weeks. He calls this the ascending practice dose ladder of mindfulness, which he believed made this approach to mindfulness training more accessible and doable, even to people with shorter attention spans and those caught in the grip of addiction.
While this study suggests mindfulness-based therapies are effective for this patient population, Schuman-Olivier says the intervention would work best with patients who are interested in pursuing a mindfulness-based approach to recovery and should not be required or forced, but rather offered as an option available for those receiving medication for opioid use disorder treatment.
