Impact of Mindfulness-Oriented Recovery Enhancement on Craving Among Opioid Addicted Individuals with Chronic Pain in Community-Based Methadone Maintenance Therapy

Background: Medication assisted treatment is the most effective intervention for opioid use disorder (OUD), and methadone maintenance treatment (MMT) is the most commonly used MAT; however, 50% of people retained in MMT continue to use opioids or relapse within six months. Chronic pain, which affects more than half of people receiving MMT, is thought to contribute to continued opioid use, relapse, and MMT dropout. Despite its efficacy for OUD, MMT can paradoxically increase pain sensitivity, and may fail to address the emotion regulation deficits that amplify craving in OUD. Novel psychosocial interventions are needed as adjuncts to MMT to address the chronic pain, emotion dysregulation, and craving associated with relapse. In that regard, we conducted a R21 funded by the NIH HEAL initiative to test Mindfulness-Oriented Recovery Enhancement (MORE) as an adjunct to MMT for people with OUD and pain. We hypothesized that MORE would significantly decrease the strength of momentary opioid cravings and increase the sense of control over cravings.

Methods: To test these hypotheses, an urban, low-income, predominately minority (53% black, 23% Hispanic/latino) sample of patients with OUD and chronic pain receiving community-based MMT (N=30; age=48.8±9.9; 50% female) were randomized to 8 weeks of MORE or treatment as usual (TAU). Intervention fidelity was monitored throughout the trial. Over the 8-week intervention period, participants to were instructed self-initiate event-contingent ecological momentary assessments (EMA) via smartphone whenever they experienced an opioid craving. Participants rated the intensity of the craving and the degree of self-control the experienced over the craving.

Results:  Across 8 weeks of treatment, participants in MORE reported 252 cravings, whereas participants in TAU reported 62 cravings. Although participants in MORE reported a greater number of cravings than those in TAU (χ²=14.23, p<.001) their cravings were significantly less intense than those in TAU (F=7.20, p=.008) – on average, cravings were 37% weaker among participants in MORE. Crucially, participants in MORE reported having significantly greater self-control over their cravings than individuals in TAU (F=16.65, p<.001).

Conclusions and Implications: MORE appears to facilitate self-control over craving and decrease craving intensity among individuals with OUD and chronic pain in community-based MMT. The comparatively greater number of craving reports suggests that MORE increases awareness of craving – an explicit therapeutic goal of the intervention. By boosting self-efficacy over cravings through mindfulness skills, MORE may reduce opioid relapse – a hypothesis to be tested in longer-term results of self-reported assessments and urine screen data our ongoing NIH-funded clinical trial.