Treating Trauma in Primary Care through Mindfulness-Oriented Recovery Enhancement

Background: Chronic pain and posttraumatic stress disorder (PTSD) are commonly co-occurring conditions with deleterious effects on physical and emotional health. An estimated 20.5% of chronic pain patients meet criteria for PTSD, and this comorbidity has been shown to negatively impact the course of both disorders. The confluence of PTSD and chronic pain may be especially pernicious for chronic pain patients who exhibit opioid misusing behaviors, as trauma-related symptoms have been shown to exacerbate opioid use and misuse among this population. Despite the high incidence of PTSD among chronic pain patients, there has been a lag in research focusing on interventions that help manage concurrent opioid misuse and trauma-related symptoms. Further, access to PTSD treatments for people with chronic pain is limited by lack of trained providers in medical settings where pain is encountered (e.g., primary care). To this end, Mindfulness-Oriented Recovery Enhancement (MORE) is an integrative, mindfulness-based intervention designed to simultaneously address chronic pain, opioid misuse, and emotional distress underlying comorbid clinical conditions. In this secondary analysis of data from a NIH R01-funded clinical trial, we examined the effects of MORE on PTSD symptoms among chronic pain patients in primary care who exhibited signs of opioid misuse. We hypothesized that MORE result in significantly greater decreases in PTSD symptoms than a supportive psychotherapy group (SG), and that decreased PTSD would mediate the effect of MORE on reducing opioid misuse.

Methods: Chronic pain patients in primary care clinics (N = 250) were randomly assigned to receive 8 weeks of MORE (N = 129) or SG (N = 121). PTSD symptoms were measured using the PTSD Checklist (PCL) at baseline, after treatment, and at 3, 6, and 9 months. Opioid misuse was measured with an objective index triangulating self-report, blinded clinical interview, and drug urine screen. A validated cut-point on the PCL was used to identify participants with PTSD. Linear mixed ANCOVA models with an intent-to-treat approach and maximum likelihood estimation were used to examine the impact of MORE versus SG on PTSD symptoms

Results: Compared to SG, MORE led to significantly lower PTSD symptoms through 9 months of follow-up among the total sample (F[1, 192.3] = 3.9, p = .049). Likewise, MORE was associated with lower levels of PTSD symptoms among participants exceeding a validated cut-point on the PCL for PTSD (F[1, 74.6] = 5.0, p = .029). The effect of MORE on reducing opioid misuse was statistically mediated by decreasing PTSD symptoms, B = -.03, SE = .01, 95% CI = -.06, -.003.

Conclusions and Implications: Our finding demonstrate that MORE was superior to SG for PTSD symptoms among participants generally, as well as among those exceeding a validated cut-point for PTSD. Moreover, these effects mediated the effect of MORE on reducing opioid misuse, and were sustained through 9 months of follow-up. These results provide evidence for the value of MORE as an intervention for addressing PTSD symptomatology in the primary care setting among participants with co-occurring chronic pain and opioid misuse—a vulnerable and clinically complex population.