Mindfulness-Oriented Recovery Enhancement Modifies Dynamic Change Trajectories of Opioid Craving: Ecological Momentary Assessment of a Randomized Controlled Trial of Opioid-Treated Chronic Pain Patients

BACKGROUND AND PURPOSE: The opioid crisis confronting the United States has been driven by the prescription of analgesic medications like oxycodone and fentanyl as frontline treatments for chronic pain. Although these medications can temporarily suppress pain experience, they simultaneously activate mesocorticolimbic brain reward circuits underlying a broad range of addictive behaviors. Consequently, chronic opioid use and misuse can lead to cravings that drive opioid dose escalation irrespective of the need to obtain pain relief, ultimately resulting in the loss of control over opioid use that is characteristic of addiction. A novel social work intervention called Mindfulness-Oriented Recovery Enhancement (MORE) aims to address prescription opioid craving among chronic pain patients by increasing the capacity to mindfully disengage from addictive urges (i.e., decentering) and by boosting positive affect and reward via mindfully engaging with healthful objects and events in the social environment (i.e., savoring). The present study evaluated the effects and therapeutic mechanisms of MORE on reducing ecological momentary assessments (EMA) of opioid craving. EMA overcomes retrospective reporting biases by gathering data through real-time assays of momentary experiences in everyday life.  Due to the longitudinal density of its sampling structure, EMA facilitates a temporally-dynamic analysis of interrelationships between therapeutic processes and clinical outcomes. Relative to an active control condition, we hypothesized that MORE would result in significantly greater decreases in EMA measures of craving over time, and that higher levels of decentering and savoring would predict lower levels of craving.

METHODS: In a NIH-funded randomized controlled trial (RCT), 117 opioid-treated chronic pain patients were allocated to 8 weeks of MORE or a social support group (SG) control condition. Participants completed up to 270 EMAs of craving randomly presented by smartphone up to three times a day during and one month following treatment. EMA data were analyzed via multilevel models with an autoregressive (AR1) repeated measures structure.

RESULTS: Participants in the MORE group reported significantly greater decreases over time in opioid craving than the SG, F(1, 2081.23) = 31.12, p = .00000003. Overall, participants in MORE reported a 23% greater decrease in craving than the control condition. Moreover, participants in the MORE group reported significantly greater increases in mindful decentering than the SG, F(1, 2104.84) = 37.27, p = .000000001. In cross-lagged analyses focused on therapeutic mechanism, higher levels of mindful decentering predicted lower levels of opioid urge in the next moment, B = -.06, SE = .01, p = .00007. Greater duration of savoring practice among MORE participants was associated with lower levels of opioid urge, B = -.01, SE = .004, p = .029, and higher levels of positive affect, B = .02, SE = .004, p = .001, that in turn predicted decreases in opioid urge in successive moments, B = -.04, SE = .02, p = .01.

CONCLUSIONS: MORE appears to ameliorate prescription opioid craving by targeting the therapeutic processes of decentering and savoring. By leveraging these salutogenic mechanisms, MORE holds great promise for helping to address one of the greatest public health crises of the modern era.