Mindfulness-Oriented Recovery Enhancement for Veterans and Military Personnel on Long-Term Opioid Therapy for Chronic Pain: A Randomized Clinical Trial

Background and Purpose. Chronic pain and opioid misuse are threats to U.S. military personnel and Veterans, who may develop problematic opioid use coincident with long-term opioid therapy (LTOT) for painful conditions incurred during military service. To meet this need, we conducted a randomized clinical trial (RCT) of Mindfulness-Oriented Recovery Enhancement (MORE) in a sample of Veterans and military personnel receiving LTOT for chronic pain. MORE is an evidence-based social work intervention that unites complementary aspects of mindfulness training, cognitive-behavioral therapy, and principles from positive psychology to restructure dysregulated reward processes underpinning the cycle of behavioral escalation linking chronic pain to opioid misuse. In a recent meta-analysis, MORE was shown to produce statistically significant effects on addictive behavior, chronic pain, and psychiatric symptoms in civilians. Yet, MORE’s efficacy in Veterans and military personnel remains unknown. We hypothesized that MORE would outperform supportive group therapy for reducing chronic pain, opioid use and misuse, as well as psychiatric symptoms, reward-related processes, opioid craving, and cue-reactivity.

Methods. In a Department of Defense (DOD)-funded RCT, 230 past and current U.S. military personnel prescribed LTOT were randomized (1:1) to MORE or supportive psychotherapy (in-person and then online via Zoom after onset of COVID-19). Primary outcomes were 1) chronic pain measured by the Brief Pain Inventory (BPI) and 2) aberrant drug-related behaviors measured by the Current Opioid Misuse Measure (COMM) through 8-month follow-up. Opioid dose was a key secondary outcome. Other outcomes included psychiatric symptoms, catastrophizing, positive affect, ecological momentary assessments of opioid craving, and opioid attentional bias. Hypothesis were tested with constrained longitudinal data analysis (cLDA) via SAS 9.4 and MPlus. cLDA provides results similar to classic analysis of covariance (ANCOVA) when there is minimal missing data. Yet unlike ANCOVA, cLDA is a full information maximum-likelihood procedure that retains every observation and is hence more efficient and less prone to missing data biases.

Results. MORE was superior to supportive psychotherapy through 8-month follow-up in reducing pain-related functional interference (p=0.01), pain severity (p=0.048), and opioid dose (p=0.029). MORE reduced opioid dose by 20.7%, compared to 3.9% in supportive psychotherapy. Although there was no overall between-groups difference in opioid misuse (p=0.43), the in-person MORE cohorts outperformed supportive psychotherapy for reducing opioid misuse (p=0.047). MORE reduced anhedonia, pain catastrophizing, craving, and opioid attentional bias, while increasing positive affect to a greater extent than supportive psychotherapy. MORE also modulated therapeutic processes including mindful reinterpretation of pain sensations, nonreactivity, savoring, positive attention, and reappraisal.

Conclusions and Implications. For past and current U.S. military personnel, MORE led to sustained decreases in chronic pain, opioid use, craving, and opioid cue-reactivity. MORE facilitates opioid dose reduction while preserving adequate pain control and preventing mood decrements, suggesting MORE’s utility for safe opioid tapering. The DOD and Veterans Health Administration should train a cadre of clinical social workers to implement and disseminate MORE nationally to reduce opioid-related mortality and morbidity among Veterans and active duty military personnel.