Mindfulness-Oriented Recovery Enhancement for Opioid Misuse and Chronic Pain: Neurocognitive and Neuroaffective Findings from a Biobehavioral Clinical Trial

Background and Purpose: Mindfulness-Oriented Recovery Enhancement (MORE) is a novel, integrative, social work intervention designed to target neurocognitive and neuroaffective mechanisms undergirding prescription opioid misuse among chronic pain patients - a social problem of increasing prevalence and public health impact. From a neuroscience perspective, the comorbidity of chronic pain and opioid misuse stems from an allostatic process whereby individuals become hypersensitized to pain- and drug-related cues over time, while becoming insensitive to natural pleasure and reward; this dysregulation of brain stress and reward systems is thought to drive a downward spiral of behavioral escalation, leading to opioid addiction. With training in mind-body interventions like MORE, social work practitioners may be uniquely suited to address these comorbid issues. The current presentation will describe findings from a NIH-funded, randomized controlled trial of MORE as a treatment for chronic pain and opioid misuse, with a specific focus on the biobehavioral mechanistic targets of the intervention. We hypothesized that MORE would reverse this downward spiral by strengthening attentional control over pain- and drug-related reactivity, while enhancing sensitivity to natural reward to a significantly greater extent than a conventional support group (SG).

Methods: Chronic pain patients (N = 115) were randomized to 8 weeks of either a MSW-led MORE group (n = 57) or a SG (n = 58). The MORE intervention sessions involved training in mindfulness, cognitive reappraisal, and techniques for positive emotion regulation (i.e., finding meaning in adversity, savoring pleasant events). In addition to self-report measures of clinical outcome, tasks from cognitive neuroscience were administered pre- and post-treatment to assess attentional and psychophysiological responses to pain-, drug-, and natural reward cues. Psychophysiological analyses focused on heart rate (HR) variability, an index of autonomic nervous system function, and electroencephalography (EEG), an index of central nervous system function.

Results: In addition to clinically-significant improvements in opioid misuse, craving, and pain symptoms, MORE led to significantly greater reductions in attentional reactivity to pain-related (p = .005) and opioid-related cues (p = .04) than the SG. MORE also significantly improved HR responses to pain-related (p = .02), opioid-related (p = .004), and natural reward cues (p = .003); increases in HR response to natural reward cues statistically mediated the craving reducing effect of MORE (Sobel test p = .01).  In parallel, MORE led to significantly greater increases in EEG brain responses to natural reward cues than the SG (p = .04), and increased brain response to natural reward cues significantly predicted reductions in opioid craving (B = -.42, p =.03).

Conclusions and Implications: Findings indicate that MORE may modulate brain and body responses integral to the comorbidity of chronic pain and addiction, and provide evidence that social work interventions can feasibly influence biobehavioral mechanisms to ameliorate physical as well as psychological health conditions. Trained in empirically-supported mind-body interventions like MORE, in the coming decade of the 21^st century social workers will play key roles on multidisciplinary teams of health care providers working in integrative primary care settings.