Mindfulness-Oriented Recovery Enhancement Reduces Craving and Post-Traumatic Stress Among Heroin Users: A Secondary Analysis of Data from a Pragmatic, Community-Based Randomized Controlled Trial

BACKGROUND AND PURPOSE: Use of prescription opioids has skyrocketed over the past two decades. While opiates and their synthetic analogs have a long history of use in pain management, the substantial increase in accessibility of these drugs has contributed to frequent diversion and misuse, and increased rates of opioid use disorders. Whereas recent efforts to curtail prescription opioid availability have reduced the frequency of opioid-related mortality, rates of heroin use have continued to rise. Exposure to trauma plays an important role in determining one’s propensity to engage in heroin use and develop addiction. Mindfulness Oriented Recovery Enhancement (MORE) is an integrative, mindfulness-based intervention with the capacity to treat not only addiction but also comorbid trauma symptoms by targeting transdiagnostic mechanisms implicated in stress and addictive behavior. Specifically, MORE aims to reduce drug craving and emotional reactivity by enhancing emotion regulation and restructuring reward processes, dampening addictive urges and the trauma symptoms that exacerbate them. This secondary data analysis examined the effects of MORE on craving and PTSD symptoms among heroin users with lifetime histories of trauma exposure participating in a pragmatic randomized controlled trial involving a large, heterogeneous sample of individuals with a wide array of substance use disorders and psychiatric conditions. We hypothesized that participation in MORE, relative to cognitive-behavioral therapy (CBT) and treatment as usual (TAU), would be associated with significantly greater decreases in craving and PTSD symptoms.

METHODS: Data were analyzed from a subsample of trauma-exposed heroin users (N = 63) residing in a long-term therapeutic community who had participated in a previously published RCT (Garland et al., 2016). All participants had been formerly homeless and many had histories of incarceration. These participants were randomly assigned to 10 weeks of MORE (n = 18), CBT (n = 33), or TAU (n = 12). Pre- and post-treatment, participants completed measures of craving, PTSD symptoms, and mindfulness. Linear mixed modeling was used to test study hypotheses with an intention-to-treat framework, after covarying individual differences in readiness to change. In analysis models, we dummy coded treatment condition into two planned custom contrasts of MORE vs. CBT and MORE vs. TAU.

RESULTS: Craving and PTSD symptoms were significantly positively associated, r = .62, p <.001, such that heroin users with higher levels of PTSD symptoms reported more severe craving. Significant treatment X time interactions were observed for craving, such that MORE resulted in greater decreases in craving than CBT [F(1,28.26) = 4.63, p = .04] and TAU [F(1,26.73) = 5.33, p = .03]. Similarly, significant treatment X time interactions were observed for PTSD symptoms, such that MORE resulted in greater decreases in PTSD symptoms than CBT [F(1,26.21) = 13.12, p = .001] and TAU [F(1,25.64) = 7.66, p = .01].

CONCLUSIONS: MORE produced significantly greater improvements in craving and PTSD symptoms than CBT and TAU in this subsample of heroin users with lifetime trauma histories. Given this demonstration of preliminary efficacy, MORE should now be tested in a future, large-scale RCT as a treatment for opiate (heroin) use disorder.