Mindfulness and Prescription Opioid Misuse: The Mediational Roles of Craving and Hedonic Capacity

Objectives:  Prescription opioid addiction is a pernicious public health threat of epidemic proportions, particularly among individuals with chronic pain. Data indicate that long-term opioid analgesic use can erode the capacity to experience natural pleasure from healthful objects and events in the social environment (i.e., hedonic capacity) coupled with craving for opioids as a means of countering dysphoria and maintaining hedonic equilibrium, irrespective of the need to achieve pain relief. These factors are theorized to drive a downward spiral of behavioral escalation toward opioid misuse and addiction. Recent prevalence estimates suggest that 25% of opioid-treated pain patients engage in opioid misuse. Yet, little is known about the protective factors that reduce opioid misuse risk among chronic pain patients. Mindfulness, the propensity to engage in nonreactive awareness and acceptance of present-moment experience, is a likely protective factor, in light of prior studies demonstrating associations between mindfulness, decreased craving, and improved hedonic capacity in other substance misusing populations. The present study aimed to examine the relationship between dispositional mindfulness and opioid misuse among two separate samples of chronic pain patients. We hypothesized that this association would be mediated by reduced opioid craving and enhanced hedonic capacity.

Methods: This cross-sectional analysis examined data obtained from two different samples. The first sample of 115 chronic pain patients receiving long-term opioid analgesic therapy completed measures of mindfulness (Five Facet Mindfulness Questionnaire), opioid craving (Obsessive Compulsive Drug Use Scale), and opioid misuse (Current Opioid Misuse Measure). The second sample of 85 chronic pain patients also prescribed long-term opioid therapy completed the same measures of mindfulness and opioid misuse, as well as a measure of hedonic capacity (the Snaith-Hamilton Anhedonia and Pleasure Scale). The zero-order correlation between mindfulness and opioid misuse was computed. Separate path analyses examined opioid craving (Sample 1) and hedonic capacity (Sample 2) as mediators of the association between mindfulness and opioid misuse.

Results:  In our first sample (N=115), we found that attenuated opioid craving mediates the association between dispositional mindfulness and opioid misuse (b= -.08, SE= .03; 95% CI=[-.16, -.02]), such that relative to patients with lower levels of mindfulness, patients with higher levels of mindfulness reported less opioid craving, which partially accounted for their comparatively lower levels of opioid misuse.  In our second sample (N=85), we found that heightened hedonic capacity mediates the association between dispositional mindfulness and opioid misuse (b= -.04, SE=.02; 95% CI= [-.09, -.002]), such that relative to patients with lower levels of mindfulness, patients with higher levels of mindfulness reported more hedonic capacity, which partially accounted for their comparatively lower levels of opioid misuse. Across the combined samples (N=200), dispositional mindfulness was significantly inversely associated with opioid misuse, r = -.23, p<.001.

Conclusions and Implications:  Findings suggest that social work interventions aimed at increasing mindfulness may reduce opioid misuse risk among chronic pain patients by decreasing opioid craving and enhancing the capacity to feel natural pleasure from healthful, positive, everyday experiences. Randomized controlled trials are now needed to test these hypotheses.