Mindfulness-Oriented Recovery Enhancement Reduces Opioid Use By Strengthening Brain Function

Background: Veterans are more vulnerable to develop chronic pain than the general population, and Veterans with chronic pain are at heightened risk for progressing to opioid misuse and opioid use disorder as a consequence of long-term opioid therapy (LTOT). In that regard, prolonged, high-dose opioid use may dysregulate brain activity, causing a functional decoupling between frontal and striatal brain regions that reduces capacity to engage in adaptive self-regulation and leading to opioid dose escalation. To mitigate opioid-related harms, the U.S. Department of Veterans Affairs (VA) launched Opioid Safety Initiatives that have increased use of non-opioid pain treatment across the VA healthcare system, including the use of psychosocial and complementary and integrative health interventions. Among these modalities, interest in mindfulness-based interventions is growing among Veterans. The goal of this randomized controlled study (RCT) was to assess the effects of a MBI, Mindfulness-Oriented Recovery Enhancement (MORE), on brain function as measured by electroencephalographic (EEG) spectral power analyses during a lab-based mindfulness meditation practice session. We hypothesized that participation in MORE would boost alpha and theta spectral power that would in turn predict decreased opioid dosing following treatment with MORE.

Methods: In this RCT, a sample of Veterans receiving LTOT (N=62, mean age=59.3±9.9 years) were recruited from primary care and pain clinics, and met study inclusion criteria if they reported chronic non-cancer pain on more days than not and had taken opioid analgesics daily or nearly every day for at least the past 90 days (mean duration of opioid use =9.1±8.1 years). Participants were randomized to MORE or a supportive group (SG) psychotherapy control. At pre- and post-treatment assessments, participants completed a laboratory-based mindfulness meditation practice session while EEG was recorded; EEG was assessed with repeated measures ANOVA. Opioid use was assessed with the Timeline Followback interview and assessed via intention-to-treat analyses conducted via linear mixed modeling. Path analyses examined changes in EEG spectral power as a mediator.

Results: Relative to the SG, participation in MORE was associated with significantly greater increases in frontal alpha [F(1,60)=5.01, p=.029] and theta power [F(1,60)=6.45, p=.014] during mindfulness meditation. In a linear mixed model controlling for pre-treatment differences in opioid dose, the treatment X time interaction was significant, [F(1,110.27) =5.50, p=.02], indicating that participants in MORE exhibited a greater decrease in opioid dose over time than those in the SG. Sobel test results indicated that the indirect effect of MORE on reducing opioid dose by increasing frontal theta power was statistically significant, z=1.97, p=.048.

Conclusions and Implications: In this mechanistic study of Veterans with chronic pain receiving LTOT, we found that a novel mindfulness-based intervention, Mindfulness-Oriented Recovery Enhancement (MORE), increased alpha and theta activation during mindfulness meditation – neural oscillatory changes that mediated the effects of MORE on reductions in opioid dosing. Thus, increasing neural function in prefrontal brain regions through mindfulness-based interventions may have important clinical consequences for patients on LTOT.