A mindfulness-based addiction therapy appears to reduce cravings in chronic prescription opioid users, according to a new study published in the October 18 issue of Science Advances.
The study provides the first neurophysiological evidence that Mindfulness-Oriented Recovery Enhancement (MORE) therapy changes brain activity in people with opioid addictions in just eight weeks, suggesting the approach can increase responsiveness to healthy, non-drug-related rewards.
In the United States, opioid medications prescribed for pain management have resulted in an epidemic, with a reported 11.5 million Americans misusing the drugs in 2016 and 191 million opioid prescriptions distributed in the U.S. in 2017. Previous research has shown that chronic drug use alters the brain such that, over time, the user experiences stronger reactions to drug-related cues like the sight of a pill bottle while becoming less sensitive to the healthy experiences they previously enjoyed, like spending time with loved ones.
"This blunted ability to experience natural positive feelings leads people to take higher and higher doses of opioids just to feel okay, and ultimately propels a downward spiral of opioid dependence and misuse," said Eric Garland, director of the Center on Mindfulness and Integrative Health Intervention Development at the University of Utah and the first author of the study. "Current addiction treatment approaches tend to focus on reducing craving or decreasing stress as a way of preventing drug use, but they do not provide training in skills to help regain the ability to savor natural pleasure and meaning from healthful objects and events in everyday life."
In an effort to fill this gap, Garland developed MORE by combining aspects of mindfulness training, cognitive behavioral therapy and positive psychology that focuses on the study of factors that enable people to thrive.
"MORE was designed to enhance positive emotion and meaning in life by instructing clients to mindfully focus attention on and savor naturally rewarding experiences, such as enjoying the pleasant colors, textures and scents of a beautiful flower, while cultivating metacognitive awareness to appreciate and amplify any positive emotions and pleasant body sensations arising in response to the experience," said Garland.
While MORE was originally developed to treat alcohol and drug addictions, some research also suggests it may be effective for smoking cessation, obesity among cancer patients and video game addiction.
In the current study, Garland and colleagues investigated the treatment's ability to influence responses to drug and non-drug reward stimuli in 135 patients from the Salt Lake Valley area seeking to address problems with prescription pain medication use. Patients were recruited using a combination of electronic health record data, letters, physician referrals and print and television advertisements.
Participants underwent eight weeks of MORE sessions, which cultivated their ability to focus on and enjoy naturally rewarding experiences and taught them to redirect attention to their breathing when they experienced the compulsive desire to use opioids. To overcome cravings, they were instructed to cognitively and emotionally deconstruct the impulse from a distance, contemplate the consequences of indulging, and finally to redirect their attention to healthy rewards.
Before and after the training period, participants were connected to an electroencephalogram (EEG), which detects electrical activity in the brain via electrodes attached to the scalp, to measure brain activity theorized to reflect sustained attention to emotional stimuli. They then took part in experiments in which they viewed combinations of opioid-related images (opioid pills, pill bottles and people taking pills), non-drug reward-related images (smiling babies, beautiful sunsets and lovers holding hands), and neutral images (marbles, napkins and neutral facial expressions). In some experiments, participants were instructed to consciously down-regulate their reactions to opioid cues.
While participants who did not receive the mindfulness training continued to exhibit greater responses to the opioid images than the neutral or non-drug reward images after eight weeks, those who completed the MORE sessions no longer showed significantly different EEG responses to opioid and neutral images.
"I was skeptical that eight weeks of MORE could produce significant changes in brain activity in a sample of people who had used opioids chronically for many years," said Garland. "We were very surprised to see such robust effects."
In addition to the EEG measures, participants themselves reported feeling happier after the treatment, saying it helped them "savor the good" and find a sense of meaning in life. The researchers also assessed participants three months after the MORE treatment ended using a validated measure of opioid misuse risk, finding that the participants continued to show significantly reduced risk of addictive behavior.
To determine the treatment's long-term efficacy, Garland is leading a large-scale five-year clinical trial funded by the National Institute on Drug Abuse with a nine-month follow-up and another five-year clinical trial funded by the Department of Defense with a six-month follow-up. He is also co-investigator on three other large clinical trials of MORE's applications for opioids and for managing pain.
"When the studies are completed in approximately two years from now, we will be able to definitively assess the efficacy of the MORE intervention for reducing opioid misuse and chronic pain and will also acquire additional data to help us understand the effects of MORE on opioid cue-reactivity and natural reward responsiveness," said Garland.