Mindfulness-Oriented Recovery Enhancement Decreases Opioid Dose Escalation and Opioid Misuse Via Positive Psychological Processes: A Randomized Controlled Trial

Background: Despite the heightened urgency of the current prescription opioid crisis, few psychosocial interventions have been evaluated for chronic pain patients receiving long-term opioid analgesics. Current psychosocial pain treatments focus primarily on ameliorating negative affective processes, yet basic science suggests that risk for opioid misuse is linked with a dearth of positive affect. Interventions that boost positive psychological processes may produce therapeutic benefits among patients with opioid-treated chronic pain. The aim of this study was to conduct a theory-driven mechanistic analysis of proximal outcome data from a Stage 2 randomized controlled trial (RCT) of Mindfulness-Oriented Recovery Enhancement (MORE), an integrative social work intervention designed to promote positive psychological health. We hypothesized that MORE would reduce opioid misuse risk by reducing pain and enhancing positive psychological processes. Furthermore, we hypothesized that MORE would reduce opioid dosing by increasing heart rate variability (HRV) – a positive physiological process involved in adaptive stress coping.

Methods: To test these hypotheses, patients with opioid-treated chronic pain (N=95; age=56.8±11.7; 66% female) were randomized to 8 weeks of a primary care-based MORE or Support Group (SG) control intervention led by a clinical social worker. Outcomes assessors were blinded to treatment condition. Intervention fidelity was monitored throughout the trial. Multivariate path analyses examined a latent positive psychological health variable comprised of positive affect, meaning in life, and self-transcendence measures as a mediator of the effect of MORE on changes in pain severity and opioid misuse risk by 3 month follow-up. In a psychophysiological protocol, participants were asked to practice mindfulness meditation while heart rate variability (a parasympathetic marker) was assessed. Latent growth curve analysis assessed HRV as a mediator of the effects of MORE on changes in the trajectory of opioid dosing over time.

Results:  MORE participants reported significantly greater reductions in pain severity by post-treatment (p=.03) and opioid misuse risk by 3-month follow-up (p=.03) than SG participants, and significantly greater increases in the latent positive psychological health variable (p<.001). Increases in positive psychological health mediated the effect of MORE on pain severity by post-treatment (p=.048), which in turn predicted decreases in opioid misuse risk by follow-up (p=.02). Analysis of the latent slope factor indicated that MORE prevented opioid dose escalation, B = -.28, p =.004. The effects of MORE on opioid dose by 3-month follow-up were mediated by significant increases in HRV during meditation (p=.04).

Conclusions and Implications: MORE appears to prevent escalation of opioid misuse risk and opioid dose by augmenting salutogenic processes, including meaning-in-life and adaptive mindfulness-induced physiological responses. By targeting key cognitive, affective, and psychophysiological mechanisms, MORE is a promising means of enhancing therapeutic outcomes among vulnerable persons suffering from chronic pain who are at risk for prescription opioid misuse. Given that this is the second Stage 2 RCT to demonstrate the efficacy of MORE on proximal outcomes related to opioid misuse, it may now be an opportune time to disseminate the intervention to social workers providing integrative behavioral health services at community-based primary care clinics.