Mindfulness-Oriented Recovery Enhancement Restructures Reward Processing Mechanisms Among Opioid Misusers: Results from a Randomized Controlled Trial

Background: Addiction involves a process of hedonic dysregulation, in which the motivation to obtain natural rewards is re-organized around seeking drug-induced reward, resulting in increased sensitivity to drug-related cues coupled with decreased sensitivity to natural rewards like social affiliation, natural beauty, and other healthful experiences. The downward shift in salience of natural reward relative to drug reward may represent a crucial tipping point leading to the loss of control over drug use that is characteristic of addiction. Among chronic pain patients receiving extended opioid pharmacotherapy, such hedonic dysregulation may drive the development of prescription opioid misuse, a significant public health threat that is being addressed with urgency at clinical and policy levels. This NIH-funded randomized controlled trial sought to test the mechanistic hypothesis that a novel, mindfulness-based social work intervention, Mindfulness-Oriented Recovery Enhancement (MORE), might reduce prescription opioid misuse by restructuring reward responsiveness from valuation of drug reward to valuation of natural reward.

Methods: To test this hypothesis, we examined data from a NIDA-funded randomized controlled trial of MORE vs. a support group (SG) control condition (N=115) for chronic pain and prescription opioid misuse. Chronic pain patients on long-term opioid analgesics were randomly assigned into one of the two 8-week long interventions. The MORE intervention provided training in mindfulness and reappraisal skills to strengthen self-control over addictive behaviors and training in savoring skills to amplify responsiveness to natural rewards. Pre- and post-treatment, participants completed a biobehavioral research protocol, including validated assessments of opioid misuse and a cue-reactivity paradigm in which participants viewed a series of opioid, pain, neutral, and natural reward-related images (e.g., smiling babies, beautiful landscapes, intimate couples) while heart rate variability was assessed. Repeated measures ANOVA examined between-groups changes in self-reported arousal ratings and heart rate reactions to these clinically-relevant stimuli, with a specific focus on changes in the relative ratio of responses to natural reward cues and drug cues. This relative responsiveness measure was then used to predict changes in opioid misuse by 3-month follow-up.

Results: Compared with the SG, the MORE group experienced significantly greater increases in heart rate responsiveness to natural reward cues relative to drug cues from pre- to post-treatment, F(1,49) = 7.61, p = .008, η²_partial = .13, Further, the MORE group reported significantly greater increases in arousal ratings to natural reward images compared to the SG, F(1,49) = 9.30, p = .004, η²_partial = .21. Increases in relative responsiveness of natural to drug reward significantly predicted decreased opioid misuse at 3-month follow-up, B = -.32, p <.05 (model R²=.32).

Implications: Taken together, study findings provide evidence that restructuring reward processing mechanisms through MORE may reverse the downward shift in salience of natural reward relative to drug reward, and thereby disrupt the downward spiral to opioid misuse and addiction. By targeting key cognitive, affective, and psychophysiological processes, MORE appears to be a promising means of enhancing therapeutic outcomes among vulnerable persons suffering from chronic pain and prescription opioid misuse.