Preventing Opioid Misuse through Ultra-Brief More Interventions Embedded into Surgical Care Pathways

Background: Mindfulness-Oriented Recovery Enhancement (MORE) have been shown to improve outcomes for people with chronic pain. But, the traditional 8-week version of MORE is not always accessible to those that need it. Furthermore, there are many different styles of mindfulness practice used in MORE. Thus, critical steps in improving pain-related outcomes include (1) improving MORE’s accessibility by developing briefer intervention models, and (2) identifying the most effective style of mindfulness practice for people with pain.

Methods: The primary aim of this randomized controlled trial was evaluate the effects of highly accessible, ultra-brief (i.e., 3-minute) mindfulness techniques extracted from the MORE intervention on preoperative pain and postoperative physical function in total joint arthroplasty patients. Patients (N=127) scheduled for knee or hip replacement at an academic orthopaedic center were eligible to participate. Participants were randomly assigned to one of three conditions: a standard, preoperative nurse consultation (N=43), a preoperative nurse consultation that included a 3-minute version of the MORE mindful breathing practice (N=42), and a preoperative nurse consultation that included a 3-minute version of the MORE mindfulness of pain practice (N=42). Preoperative outcomes included change in acute pain intensity (primary outcome), pain unpleasantness, and pain medication desire (secondary outcomes) during the preoperative consultation. Self-reported physical function at the 6-week postoperative appointment was an exploratory outcome.

Results: Pairwise contrasts following from significant condition by time effects in generalized linear models revealed patients randomized to a mindfulness of breath or pain consult reported significantly greater decreases in acute pain intensity (-0.77±.31, p=.015; -0.48±.15, p=.002, respectively) and pain unpleasantness (-0.90±.33, p=.008; -0.59±.14, p<.001, respectively) than those randomized to a standard consult. Additionally, patients randomized to a mindfulness of pain consult reported significantly greater decreases in acute pain medication desire than those randomized to a standard (-1.18±.31, p<.001) or mindfulness of breath (-0.86±.35, p<.001) consult. A significant condition by time interaction was also observed for physical function (F_2,91=11.64, p<.001), with pairwise contrasts revealing the mindfulness of pain consult significantly increased physical function scores from before to after surgery relative to the standard consult (3.61±1.52, p=.021). Additionally, the standard consult had significantly lower physical function scores relative to the mindfulness of breath consult (1.92±0.09, p=.029). Finally, change in intervention-related preoperative pain unpleasantness had a significant direct effect on physical function at the 6-week postoperative appointment (β=.34, p<.001).

Conclusions and Implications: Embedding an ultra-brief mindfulness technique from MORE in total joint arthroplasty patients’ surgical care pathways appears to be an effective nonpharmacological pain management strategy. Providing preoperative mindfulness interventions may contribute to better postoperative outcomes and help to prevent the downward spiral from prescribed opioid use to opioid misuse and OUD.