Fighting opioid abuse with mindfulness — and M.O.R.E.
The CDC statistic is hard to fathom — about 30,000 Americans died of opioid overdoses in 2014 alone. Addiction to heroin or the likes of oxycodone or fentanyl is rampant across the country, which is part of the reason public health officials are now urging doctors to steer more patients toward non-drug interventions.
Could mindfulness be part of the solution?
Dr. Eric L. Garland, creator of a program called Mindfulness-Oriented Recovery Enhancement (MORE), is on the front lines of research into this question. He’s the associate dean for research at the University of Utah College of Social Work and also serves as an associate director at the Hunstman Cancer Institute, in Salt Lake City.
Garland, who was named a fellow of the Mind and Life Institute in 2012, developed the MORE program based on insights derived from cognitive, affective and neurobiological science. While effective for patients coping with stress or chronic pain, MORE targets a particularly challenging hallmark of long-term opioid addiction — the tendency for addicts to become more sensitive to stress and pain (hyperalgesia) and less able to feel joy or reward from life (hedonic dysregulation).
“When you look mechanistically at how chronic pain and prescribed opioid use devolves into opioid misuse and addiction, one of the key factors that needs to be considered is this concept of hedonic dysregulation,” Garland said. “Essentially, the brain maintains a hedonic balance by minimizing pain and maximizing pleasure as we adapt to challenges from the environment. This is a basic, evolutionarily conserved function that has helped keep us alive and preserve the species.”
Prolonged exposure to opioids and other powerfully rewarding substances can upend this natural hedonic balance, explains Garland, a licensed psychotherapist with more than a decade of clinical experience. “The opioids might initially provide relief from chronic pain, but over time, due to physiological dependence and an increasing tolerance to the effects of the drug, they no longer work,” he said. “The individual might try to escalate the dose, but it’s a losing battle.”
Due in part to neuroplasticity in a brain structure called the extended amygdala, chronic opioid users may become less sensitive to natural pleasure even as they grow more sensitive to stress and negative emotions, Garland explains. “They stop being able to experience the same level of joy and reward from everyday, healthy sorts of objects and events — appreciating the beauty of a sunset, getting a sense of warm connection from holding the hand of a loved one, or enjoying the taste of a healthy meal,” he said. “Typically, they will then ramp up opioid consumption even further just to feel OK.”
To arrest this downward spiral, patients in Garland’s MORE program undergo conventional mindfulness training along with two additional steps: reappraisal and savoring. Reappraisal is about reinterpreting stressful or adverse life events and starting to see them as opportunities to grow and learn, Garland explains. In mindful savoring, practitioners work to rewire their brains to be sensitive once again to the pleasures of life.
“Mindful savoring involves focusing attention on the sensory qualities of pleasant, daily experiences like feeling the warmth of the sun on your skin, or enjoying the movement of the leaves on a tree in a breeze,” Garland said. “Not only that, but individuals focus on both their emotional and cognitive responses to those pleasant experiences as well.” After all, he says, these higher-order experiences are important to savor, too. “You could learn to savor the feeling of connection to your husband or wife, the sense of warmth and love you feel toward your children or the sense of accomplishment after completing a difficult task at work,” he said. “So we are no longer focusing just on the breath. We’re using mindful awareness to focus on and appreciate what’s good in life.”
The savoring practice makes use of discursive thought — “story,” in other words — in ways that might run counter to traditional meditation instructions. “The mind might begin to wander to positive associations and helpful thoughts, helpful beliefs or a deeper sense of meaning or purpose,” Garland explained. “In the context of savoring, we would actually encourage that and allow the mind to elaborate on the positive aspects of that experience. This basic human capacity for meaning-making and for experiencing deep pleasure and contentment in life is actually something that we want to harness.”
Over the past few years, Garland has received grants from federal agencies such as the National Institutes of Health to conduct various randomized, controlled trials of MORE as a treatment for alcohol dependence, prescription opioid misuse and chronic pain. Positive results from this research have appeared in publications such as the Journal of Clinical and Consulting Psychology; Psychotherapy and Psychosomatics; Behaviour Research and Therapy; Psychopharmacology, and the Journal of Behavioral Medicine. Ongoing research includes a pilot study with chronic pain sufferers who are practicing MORE in their doctors’ offices as part of their treatment, as well as a study on the efficacy of MORE in preventing opioid addiction among soldiers with histories of chronic pain and opioid misuse. Funded by the National Institute on Drug Abuse, the latter research takes place at the U.S. Army pain clinic in Fort Carson, Colo.
The work on MORE is still in an early phase and needs to be confirmed with additional and larger scale studies, but the data seem to be telling a remarkable story, Garland said. “When people learn how to savor effectively, they become more sensitive to natural pleasure,” he said. “The more sensitive to natural pleasure they become, the less craving they feel for the drug. That’s revolutionary.”
For those of us who teach mindfulness or otherwise work to promote meditation, Garland’s work hints at the importance of acknowledging the particular needs of meditation students who are in recovery or at risk of opioid misuse. Mindfulness of breathing or a mantra, in other words, might not be enough to maximize their chances of getting better. “As a mindfulness therapist and researcher, clearly I believe that mindful awareness of the breath is therapeutic,” Garland said. “However, I don’t think it goes far enough to address the specific mechanisms that undergird chronic pain and opioid misuse. It’s a complex problem.”
For information on MORE (including a manual for therapists as well as classes on the program), visit drericgarland.com.