In the midst of America’s opioid use disorder (OUD) epidemic, medication-assisted treatment is often viewed as the most effective intervention. However, nearly half of patients undergoing methadone maintenance treatment, the most common form of medication-assisted treatment, have a relapse within 6 months of starting treatment. Researchers argue that this is because medication-assisted treatments fail to address the changes in reward processing and emotional regulation seen in patients with OUD. A study recently published in the Drug and Alcohol Dependence journal examined the effectiveness of mindfulness-oriented recovery enhancement (MORE) on opioid-related outcomes and pain.
MORE uses the “restructuring reward hypothesis,” in which increasing positive affective responses to the socioenvironment are thought to decrease craving and addictive behaviors. Using ecologic momentary assessment data, the researchers gathered real-time reports of momentary experiences such as craving, pain, and affect. They hypothesized that MORE would provide improvements in craving, pain, affect, and stress. Participants included individuals receiving methadone maintenance treatment within the past year who were 18 years of age or older and had chronic noncancer pain. Patients received either treatment as usual (TAU) or had their treatment supplemented with MORE, which consisted of 8 2-hour weekly sessions of group therapy that emphasized mindfulness. After the therapy sessions, participants were instructed to practice mindfulness at home with audio guidance.
Participants received ecologic momentary assessments by smartphone prompts throughout the day. The assessments queried craving, level of pain, positive affect, and stress level using a 0 to 10 scale. A follow-up item developed specifically for the study assessed perceived level of control over one’s craving. The data were analyzed linearly using maximum likelihood estimation for missing data. The most common pain conditions experienced by participants were low back pain and arthritis. In terms of opioid and drug use, 67% reported heroin use in the past month, with others reporting use of cocaine (23%), marijuana (23%), and painkillers (16%).
Results showed a 44% decrease in craving intensity between MORE participants and TAU by the end of the 8-week intervention. Patients in the MORE group also showed a 13% decrease in pain unpleasantness and a 26% decrease in stress vs patients receiving TAU. The MORE treatment also increased positive affect of patients by 22% vs TAU. Although the MORE group reported much lower intensity of cravings, the rate of cravings was much greater. Overall, the MORE group had weaker urges for opioids and less severe wanting of opioids, as well as 129% greater perceived self-control when cravings struck. Among the MORE group, the correlation between increased positive affect and decreased opioid wanting was very strong.
These findings support the “restructuring reward hypothesis,” pointing to MORE’s improvements in natural reward processing. The researchers highlight MORE’s use of cognitive, affective, and sensorial components that allow participants to reshape the meaning of cravings by considering potential consequences.
Although the study was limited in its timeframe and inability to assess durability of changes in craving, pain, and affect adequately, the findings demonstrate the effectiveness of MORE compared with standard medication-assisted treatment. This evidence suggests that MORE could be appropriate in conjunction with medication-assisted treatment for people with chronic pain and OUD.
Garland EL Hanley AW, Kline A, Cooperman NA. Mindfulness-Oriented Recovery Enhancement reduces opioid craving among individuals with opioid use disorder and chronic pain in medication assisted treatment: ecological momentary assessments from a stage 1 randomized controlled trial. Drug Alcohol Depend. 2019;203:61-65.