Substance Use & Misuse, 49:608–611, 2014 C 2014 Informa Healthcare USA, Inc. Copyright ISSN: 1082-6084 print / 1532-2491 online DOI: 10.3109/10826084.2014.852801
APPENDIX
Mindfulness for Chronic Pain and Prescription Opioid Misuse: Novel Mechanisms and Unresolved Issues Eric L. Garland1 and David S. Black2 Subst Use Misuse Downloaded from informahealthcare.com by University of Newcastle on 09/29/14 For personal use only.
1
College of Social Work and Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA; 2 Department or Preventive Medicine, University of Southern California, Los Angeles, California, USA ther complicating this issue, those seeking treatment for chronic pain often respond poorly to existing addictions treatments.3 Conventional interventions for opioid misuse may have limited efficacy because they fail to directly target and durably alter dysregulated cognitive-affective neural circuits that govern appetitive responses elicited by pain, stress, and drug-related cues. The insidious downward spiral of chronic pain and opioid misuse involves a cycle of behavioral escalation in which nociception and stress elicit hypervigilance and catastrophizing, resulting in pain magnification and the perceived need to self-medicate with opioids (Garland, Froeliger, Zeidan, Partin, & Howard, in press). With repeated use of opioids, attention becomes biased toward opioid-related cues (e.g., the sight of a pill bottle; Garland, Froeliger, Passik, & Howard, 2012), which, through the process of conditioning, triggers the habit of opioid use despite increasing tolerance to the analgesic effects of the drug. Concurrently, chronic pain and prolonged opioid use undermines reward processing in the brain, depriving the individual of the ability to feel positive emotions and obtain a sense of meaning from healthful experiences (Koob & Le Moal, 2008). As this downward spiral
Keywords addiction, chronic pain, craving, drug seeking, mindfulness, Mindfulness-Oriented Recovery Enhancement (MORE), self-medication
Nearly one-third of individuals in the U.S. are affected by chronic pain at some point throughout their lifetime (Ospina & Harstall, 2002). Though opioid pharmacotherapy for chronic pain is often efficacious, and most patients take medicine as prescribed, more than 10% of chronic pain patients engage in opioid misuse behaviors, such as dose escalation or self-medication of negative emotions (Fishbain, Cole, Lewis, Rosomoff, & Rosomoff, 2007). Opioid misuse carries serious health and psychological risks, including overdose and development of opioid dependence. The magnitude of chronic pain in post-industrial societies coupled with the escalation in prescription opioid misuse presents a conundrum to the medical system and substance user treatment community alike. People experiencing prolonged pain should not be denied medical access to opioids, yet chronic opioid therapy bears significant risks for addiction. Fur-
3 Treatment can be usefully defined as a unique, planned, goal-directed, temporally structured, multi-dimensional change process, which may be phase-structured, of necessary quality, appropriateness and conditions (endogenous and exogenous), implemented under conditions of uncertainty, associated with a range of individual as well as systemic stakeholders, which is bounded (culture, place, time, etc.), which can be (un)successful (partially and/or totally), as well as being associated with iatrogenic harm and can be categorized into professional-based, tradition-based, mutual-help based (AA,NA, etc.) and self-help (“natural recovery”) models. Whether or not a treatment technique is indicated or contra-indicated, and its selection underpinnings (theory-based, empirically based, “principle of faith-based, tradition-based, budget-based, etc.) continues to be a generic and key treatment issue. In the West, with the relatively new ideology of “harm reduction” and the even newer quality of life (QOL) and “wellness” treatment-driven models there are now new sets of goals in addition to those derived from/associated with the older tradition of abstinence-driven models. Conflict-resolution models may stimulate an additional option for intervention. Treatment is implemented in a range of environments; ambulatory as well as within institutions which can also include controlled environments such as jails, prisons and military camps. Treatment includes a spectrum of clinician–caregiver–patient relationships representing various forms of decision-making traditions/models; (1) the hierarchical model in which the clinician-treatment agent makes the decision(s) and the recipient is compliant and relatively passive, (2) shared decision-making which facilitates the collaboration between clinician and client(s)/patient(s) in which both are active, and (3) the “informed model” in which the patient makes the decision(s). Within this planned change process, relatively recently in various parts of the world, active substance users who are not in “treatment,” as well as those users who are in treatment, have become social change agents, active advocates, and peer health counselors. . .which represent just a sampling of their new labels. There are no unique models or techniques used with substance users—of whatever types and heterogeneities—-people, patterns, manner of use, meanings attributed to use, functions of use, and life styles—which are not also used with nonsubstance users. Editor’s note. Address correspondence to Eric L. Garland, PhD, LCSW, College of Social Work and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT; E-mail: [email protected].
608
Subst Use Misuse Downloaded from informahealthcare.com by University of Newcastle on 09/29/14 For personal use only.
NOVEL MECHANISMS
perpetuates, the sense of self becomes entrapped by painladen narratives and driven by the insatiable compulsion to seek relief. In light of mounting evidence for the therapeutic effects of mindfulness on pain, stress, negative emotion, and addictive processes, mindfulness-based interventions (MBIs) target key components of the risk chain leading to opioid misuse and addiction in chronic pain patients. The original soteriological purpose of mindfulness practice in contemplative traditions was to gain insight into the true nature of the self as impermanent and interdependent, and, in so doing, liberate the individual from craving and attachment to a fixed and immutable sense of identity—held to be roots of pain and suffering. Mindfulness practice was viewed as an essential key to relinquish craving and attachment, offering a skillful means of transcending pain by embracing the nature of mind and life as flux. Complementing this contemplative epistemology, modern neuroscience and clinical research suggests that mindfulness training may: 1. reduce chronic pain by attenuating emotionally aversive appraisals of pain sensations while facilitating greater interoceptive awareness of those sensations (Garland, Gaylord, et al. 2012; Zeidan, Grant, Brown, McHaffie, & Coghill, 2012); 2. reduce attentional fixation on pain (Garland & Howard, 2013; Vago & Nakamura, 2011) and negative emotional reactivity (Froeliger, Garland, Modlin, & McClernon, 2012), thereby obviating the need to self-medicate stress and negative emotions with opioids; 3. lessen addiction attentional bias (Garland, Boettiger, Gaylord, Chanon, & Howard, 2012; Garland, Gaylord, Boettiger, & Howard, 2010), and thereby reduce biased processing of prescription opioid-related cues; 4. decrease craving (Bowen et al., 2009) by attenuating bottom-up reactivity to drug-related stimuli (Westbrook et al., 2013); 5. bolster positive emotion and facilitate savoring of natural rewards (Geschwind, Peeters, Drukker, van Os, & Wichers, 2011); 6. enhance cognitive control over habitual behavioral responses (Wenk-Sormaz, 2005), thereby strengthening self-regulation of compulsive and habitual opioid use. Though mindfulness has been applied as a means of targeting chronic pain (Kabat-Zinn, 1982) and addiction (Bowen et al., 2009) in isolation, Mindfulness-Oriented Recovery Enhancement (MORE; Garland, 2013) unites complementary aspects of mindfulness training, cognitive reappraisal skills, and principles from positive psychology into an integrative approach to treating co-occurring chronic pain and prescription opioid misuse. Recent findings from a randomized controlled trial demonstrate that MORE led to significant reductions in pain attentional
609
bias coupled with decreased emotional reactivity and increased perceived control over pain in a sample of chronic pain patients receiving long-term opioid therapy, most of whom were opioid misusers (Garland & Howard, 2013). New clinical outcome data from this trial suggest that MORE may significantly reduce pain severity and functional interference while decreasing opioid misuse and craving (Garland, Manusov, Froeliger, Williams, Kelly, & Howard, 2013). One pressing unresolved issue for the study of MBIs for co-occurring chronic pain and opioid misuse relates to the effects of MBIs on craving. The extant literature is divided as to whether mindfulness decreases craving in a bottom-up fashion, strengthens top-down control of craving, and/or increases awareness of craving (Garland & Froeliger, in press). However, theory and praxis may suggest a resolution. The practice of mindfulness often involves metacognitive awareness of the phenomenological constituents of aversive experience. This approach is evident in chronic pain treatment, where mindfulness training may alter the manner in which pain sensations are attended to and processed by providing instruction in breaking down the gestalt of an experience into its sensory components. For example, instead of confronting an anguishing experience of a “painful backache,” a chronic low back pain sufferer might learn to attend to the waxing and waning of sensations of heat and tension localized in the sacrum without identifying emotionally with these sensations—this process has been shown to mediate the pain-reductive effects of mindfulness (Garland et al., 2012). Similarly, mindful awareness can be used to decompose the experience of craving into its phenomenological components. Although the experience of craving in totality may be perceived as overwhelming, coping with each singular component of the craving experience may be perceived as being more manageable. For instance, although it may be difficult to resist an intense craving episode, it may be easier to tolerate subcomponent sensations of the craving (e.g., jitteriness in the stomach, a mental image of drug use). Moreover, by focusing mindful awareness on the sensations of craving, one can begin to notice the ephemeral nature of the craving experience, and in doing so, feel more capable of tolerating it. Mindful awareness of craving occurs at the metacognitive level whereby the cognitive, emotional, and somatic components of craving are witnessed as objects separate from the observer. Experienced from this vantage point, craving can lose its power to compel drug seeking. Hypothetically, mindfulness may exert U-shaped effects on craving by increasing awareness of craving followed by a decrease in craving intensity—yet the time course of these effects remains unknown. Because individuals with impaired insight into their addiction often underreport baseline levels of craving (Goldstein et al., 2009), this increased awareness may confound researchers’ attempts to measure the impact of mindfulness training on self-reported opioid urges, resulting in an apparent lack of change in craving
Subst Use Misuse Downloaded from informahealthcare.com by University of Newcastle on 09/29/14 For personal use only.
610
E. L. GARLAND AND D. S. BLACK
over time. These effects may account for the inconsistent findings regarding the effect of MBIs on craving reported in the literature. A second unresolved issue for the field of MBIs for chronic pain and opioid misuse relates to the role of positive psychological processes in ameliorating reward dysregulation. Although some recent theoretical conceptualizations of mindfulness for addiction eschew a focus on techniques designed to directly enhance positive affect and reward (Brewer et al., 2011), natural reward processing is a fundamental component of psychological well-being that is undermined both by addiction and chronic pain. Research reveals that as addictive use of opioids progresses, opioid cues captivate attentional brain resources to a greater extent than natural reward stimuli (Lubman et al., 2009) and consequently begin to supplant people, activities, experiences, or events that once held value for the individual. This process may increase dependence on opioids for reward and pleasure in lieu of the experience of positive life events. Savoring, or intentionally focusing on the beautiful and meaningful elements of life, is a powerful means of amplifying positive emotion (Quoidbach, Berry, Hansenne, & Mikolajczak, 2010) that may undo decreased sensitivity to natural reward experience. During savoring, one not only attends to a broadened diversity and range of sensations and perceptions, but also the positive emotions that unfold from such intimate, reflective engagement with life experience. By instructing clients to focus on and savor pleasurable objects and events (e.g., the sight of a beautiful sunset or the satisfying taste of a healthy meal), mindfulness training can increase the perceived value of natural rewards, and may thereby counter allostatic dysregulation of reward processing in opioid misuse and addiction. In support of this hypothesis, heart rate variability data from our lab indicates that the effect of MORE on reduced desire for opioids is statistically mediated by enhanced physiological responsiveness to natural reward stimuli (Garland, unpublished data). Thus, as chronic pain patients in the study savored and became more sensitive to natural rewards they experienced increasingly attenuated craving for opioids. In sum, MBIs appear to target key mechanisms implicated in prescription opioid misuse among chronic pain patients. Additional randomized clinical trials and functional neuroimaging studies are needed to further elucidate the effects of MBIs (such as MORE) on opioid craving and natural reward processing. Future studies should also employ multivariate autoregressive latent trajectory analysis of ecological momentary assessments to probe the interactive and cross-lagged effects of MBIs on natural reward experience and craving. It is our most sincere hope that with such methodologies, the next decade of clinical research and practice will illuminate these issues and, if warranted by the data, increase the wider dissemination and availability of MBIs for people suffering from chronic pain and the adverse effects of substance misuse.
THE AUTHORS Eric L. Garland, PhD, LCSW, is an Associate Professor at University of Utah College of Social Work and Associate Director of Integrative Medicine in the Supportive Oncology and Survivorship Program at Huntsman Cancer Institute. His biobehavioral research agenda is focused on translating findings from cognitive and affective neuroscience into treatments for stress-related conditions. Dr. Garland is the developer of Mindfulness-Oriented Recovery Enhancement (MORE), a multimodal intervention designed to ameliorate transdiagnostic mechanisms underpinning addiction, emotion dysregulation, and chronic pain. Dr. Garland has received funding from the National Institutes of Health to conduct clinical trials of MORE as a treatment for alcohol dependence and prescription opioid misuse.
David S. Black, PhD, MPH is an Assistant Professor in the Department of Preventive Medicine and member of the Norris Comprehensive Cancer Center at the University of Southern California. His research program focuses on the delivery and evaluation of mind–body therapeutic modalities, specifically mindfulness training, in order to modify mental and physical health symptoms and states. He is broadly interested in how integrative medicine approaches impact stress biology, specifically the interchange between neuroendocrine and immune system function. He is the Editor-in-Chief of Mindfulness Research Monthly, a web-based dissemination bulletin informing the latest advances in mindfulness research.
Declaration of Interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. REFERENCES Bowen, S., Chawla, N., Collins, S. E., Witkiewitz, K., Hsu, S., Grow, J., et al. (2009). Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial. Substance Abuse, 30, 295–305. Brewer, J. A., Mallik, S., Babuscio, T. A., Nich, C., Johnson, H. E., Deleone, C. M., et al. (2011). Mindfulness training for smoking cessation: Results from a randomized controlled trial. Drug and Alcohol Dependence, 119(1–2), 72–80. Fishbain, D. A., Cole, B., Lewis, J., Rosomoff, H. L., & Rosomoff, R. S. (2007). What Percentage of chronic nonmalignant pain
Subst Use Misuse Downloaded from informahealthcare.com by University of Newcastle on 09/29/14 For personal use only.
NOVEL MECHANISMS
patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain Medicine, 9(4), 444–459. Froeliger, B. E., Garland, E. L., Modin, L., & McClernon, F. J. (2012). Neurocognitive correlates of yoga meditation practice on emotion and cognition: A pilot study. Frontiers in Neuroscience, 6(48), 1–11. Garland, E. L. (2013). Mindfulness-oriented recovery enhancement for addiction, stress, and pain. Washington, DC: NASW Press. Garland, E. L., Boettiger, C. A., Gaylord, S. A., Chanon, V., & Howard, M. O. (2012). Mindfulness is inversely associated with alcohol attentional bias among recovering alcohol-dependent adults. Cognitive Therapy and Research, 36(5), 441–50. Garland, E. L., & Froeliger, B. E. (in press). Mindfulness training targets addiction at the attention-emotion interface: A neurocognitive framework. In E. Langer, A. Le, & C. Ngoumen (Eds.), Handbook of mindfulness. New York: Wiley-Blackwell. Garland, E. L., Froeliger, B., Passik, S., & Howard, M. (2012). Attentional bias for prescription opioid cues among opioid dependent chronic pain patients. Journal of Behavioral Medicine. doi: 10.1007/s10865-012-9455-8 Garland, E. L., Froeliger, B. E., Zeidan, F., Partin, K., & Howard, M. O. (in press). The downward spiral of chronic pain, prescription opioid misuse, and addiction: Cognitive, affective, and neuropsychopharmacologic pathways. Neuroscience & Biobehavioral Reviews. doi: 10.1016/j.neubiorev.2013.08.006 Garland, E.L., Gaylord, S. A., Boettiger, C. A., & Howard, M. O. (2010). Mindfulness training modifies cognitive, affective, and physiological mechanisms implicated in alcohol dependence: Results from a randomized controlled pilot trial. Journal of Psychoactive Drugs, 42, 177–192. Garland, E. L., Gaylord, S. A., Palsson, O., Faurot, K., Mann, J. D., & Whitehead, W. E. (2012). Therapeutic mechanisms of a mindfulness-based treatment for IBS: Effects on visceral sensitivity, catastrophizing, and affective processing of pain sensations. Journal of Behavioral Medicine, 35(6), 591–602. Garland, E. L., & Howard, M. O. (2013). Mindfulness-oriented recovery enhancement reduces pain attentional bias in chronic pain patients. Psychotherapy and Psychosomatics, 82(5), 311–318. Garland, E. L., Manusov, E. G., Froeliger, B. E., Kelly, A., Williams, J., & Howard, M. O. (2013). Mindfulness-Oriented Recovery Enhancement for chronic pain and prescription opi-
611
oid misuse: Results from an early stage randomized controlled trial. Manuscript Submitted for Publication. Geschwind, N., Peeters, F., Drukker, M., van Os, J., & Wichers, M. (2011). Mindfulness training increases momentary positive emotions and reward experience in adults vulnerable to depression: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 79(5), 618–628. Goldstein, R. Z., Craig, A. D., Bechara, A., Garavan, H., Childress, A. R., Paulus, M. P., et al. (2009). The neurocircuitry of impaired insight in drug addiction. Trends in Cognitive Sciences, 13, 372–380. Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General Hospital Psychiatry, 4, 33–47. Koob, G. F., & Le Moal, M. (2008). Addiction and the brain antireward system. Annual Review of Psychology, 59, 29–53. Lubman, D. I., Yucel, M., Kettle, J. W., Scaffidi, A., Mackenzie, T., Simmons, J. G., et al. (2009). Responsiveness to drug cues and natural rewards in opiate addiction: Associations with later heroin use. Archives of General Psychiatry, 66, 205–212. Ospina, M., & Harstall, C. (2002). Prevalence of chronic pain: An overview. Edmonton, Alberta, Canada: Alberta Heritage Foundation for Medical Research. Quoidbach, J., Berry, E. V., Hansenne, M., & Mikolajczak, M. (2010). Positive emotion regulation and well-being: Comparing the impact of eight savoring and dampening strategies. Personality and Individual Differences, 49(5), 368–373. Vago, D. R., & Nakamura, Y. (2011). Selective attentional bias towards pain-related threat in fibromyalgia: Preliminary evidence for effects of mindfulness meditation training. Cognitive Therapy and Research, 35(6), 581–594. Wenk-Sormaz, H. (2005). Meditation can reduce habitual responding. Alternative Therapies in Health and Medicine, 11(2), 42–58. Westbrook, C., Creswell, J. D., Tabibnia, G., Julson, E., Kober, H., & Tindle, H. A. (2013). Mindful attention reduces neural and self-reported cue-induced craving in smokers. Social Cognitive and Affective Neuroscience, 8(1), 73–84. Zeidan, F., Grant, J. A., Brown, C. A., McHaffie, J. G., & Coghill, R. C. (2012). Mindfulness meditation-related pain relief: Evidence for unique brain mechanisms in the regulation of pain. Neuroscience Letters, 520(2), 165–173.
APPENDIX
Mindfulness for Chronic Pain and Prescription Opioid Misuse: Novel Mechanisms and Unresolved Issues Eric L. Garland1 and David S. Black2 Subst Use Misuse Downloaded from informahealthcare.com by University of Newcastle on 09/29/14 For personal use only.
1
College of Social Work and Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA; 2 Department or Preventive Medicine, University of Southern California, Los Angeles, California, USA ther complicating this issue, those seeking treatment for chronic pain often respond poorly to existing addictions treatments.3 Conventional interventions for opioid misuse may have limited efficacy because they fail to directly target and durably alter dysregulated cognitive-affective neural circuits that govern appetitive responses elicited by pain, stress, and drug-related cues. The insidious downward spiral of chronic pain and opioid misuse involves a cycle of behavioral escalation in which nociception and stress elicit hypervigilance and catastrophizing, resulting in pain magnification and the perceived need to self-medicate with opioids (Garland, Froeliger, Zeidan, Partin, & Howard, in press). With repeated use of opioids, attention becomes biased toward opioid-related cues (e.g., the sight of a pill bottle; Garland, Froeliger, Passik, & Howard, 2012), which, through the process of conditioning, triggers the habit of opioid use despite increasing tolerance to the analgesic effects of the drug. Concurrently, chronic pain and prolonged opioid use undermines reward processing in the brain, depriving the individual of the ability to feel positive emotions and obtain a sense of meaning from healthful experiences (Koob & Le Moal, 2008). As this downward spiral
Keywords addiction, chronic pain, craving, drug seeking, mindfulness, Mindfulness-Oriented Recovery Enhancement (MORE), self-medication
Nearly one-third of individuals in the U.S. are affected by chronic pain at some point throughout their lifetime (Ospina & Harstall, 2002). Though opioid pharmacotherapy for chronic pain is often efficacious, and most patients take medicine as prescribed, more than 10% of chronic pain patients engage in opioid misuse behaviors, such as dose escalation or self-medication of negative emotions (Fishbain, Cole, Lewis, Rosomoff, & Rosomoff, 2007). Opioid misuse carries serious health and psychological risks, including overdose and development of opioid dependence. The magnitude of chronic pain in post-industrial societies coupled with the escalation in prescription opioid misuse presents a conundrum to the medical system and substance user treatment community alike. People experiencing prolonged pain should not be denied medical access to opioids, yet chronic opioid therapy bears significant risks for addiction. Fur-
3 Treatment can be usefully defined as a unique, planned, goal-directed, temporally structured, multi-dimensional change process, which may be phase-structured, of necessary quality, appropriateness and conditions (endogenous and exogenous), implemented under conditions of uncertainty, associated with a range of individual as well as systemic stakeholders, which is bounded (culture, place, time, etc.), which can be (un)successful (partially and/or totally), as well as being associated with iatrogenic harm and can be categorized into professional-based, tradition-based, mutual-help based (AA,NA, etc.) and self-help (“natural recovery”) models. Whether or not a treatment technique is indicated or contra-indicated, and its selection underpinnings (theory-based, empirically based, “principle of faith-based, tradition-based, budget-based, etc.) continues to be a generic and key treatment issue. In the West, with the relatively new ideology of “harm reduction” and the even newer quality of life (QOL) and “wellness” treatment-driven models there are now new sets of goals in addition to those derived from/associated with the older tradition of abstinence-driven models. Conflict-resolution models may stimulate an additional option for intervention. Treatment is implemented in a range of environments; ambulatory as well as within institutions which can also include controlled environments such as jails, prisons and military camps. Treatment includes a spectrum of clinician–caregiver–patient relationships representing various forms of decision-making traditions/models; (1) the hierarchical model in which the clinician-treatment agent makes the decision(s) and the recipient is compliant and relatively passive, (2) shared decision-making which facilitates the collaboration between clinician and client(s)/patient(s) in which both are active, and (3) the “informed model” in which the patient makes the decision(s). Within this planned change process, relatively recently in various parts of the world, active substance users who are not in “treatment,” as well as those users who are in treatment, have become social change agents, active advocates, and peer health counselors. . .which represent just a sampling of their new labels. There are no unique models or techniques used with substance users—of whatever types and heterogeneities—-people, patterns, manner of use, meanings attributed to use, functions of use, and life styles—which are not also used with nonsubstance users. Editor’s note. Address correspondence to Eric L. Garland, PhD, LCSW, College of Social Work and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT; E-mail: [email protected].
608
Subst Use Misuse Downloaded from informahealthcare.com by University of Newcastle on 09/29/14 For personal use only.
NOVEL MECHANISMS
perpetuates, the sense of self becomes entrapped by painladen narratives and driven by the insatiable compulsion to seek relief. In light of mounting evidence for the therapeutic effects of mindfulness on pain, stress, negative emotion, and addictive processes, mindfulness-based interventions (MBIs) target key components of the risk chain leading to opioid misuse and addiction in chronic pain patients. The original soteriological purpose of mindfulness practice in contemplative traditions was to gain insight into the true nature of the self as impermanent and interdependent, and, in so doing, liberate the individual from craving and attachment to a fixed and immutable sense of identity—held to be roots of pain and suffering. Mindfulness practice was viewed as an essential key to relinquish craving and attachment, offering a skillful means of transcending pain by embracing the nature of mind and life as flux. Complementing this contemplative epistemology, modern neuroscience and clinical research suggests that mindfulness training may: 1. reduce chronic pain by attenuating emotionally aversive appraisals of pain sensations while facilitating greater interoceptive awareness of those sensations (Garland, Gaylord, et al. 2012; Zeidan, Grant, Brown, McHaffie, & Coghill, 2012); 2. reduce attentional fixation on pain (Garland & Howard, 2013; Vago & Nakamura, 2011) and negative emotional reactivity (Froeliger, Garland, Modlin, & McClernon, 2012), thereby obviating the need to self-medicate stress and negative emotions with opioids; 3. lessen addiction attentional bias (Garland, Boettiger, Gaylord, Chanon, & Howard, 2012; Garland, Gaylord, Boettiger, & Howard, 2010), and thereby reduce biased processing of prescription opioid-related cues; 4. decrease craving (Bowen et al., 2009) by attenuating bottom-up reactivity to drug-related stimuli (Westbrook et al., 2013); 5. bolster positive emotion and facilitate savoring of natural rewards (Geschwind, Peeters, Drukker, van Os, & Wichers, 2011); 6. enhance cognitive control over habitual behavioral responses (Wenk-Sormaz, 2005), thereby strengthening self-regulation of compulsive and habitual opioid use. Though mindfulness has been applied as a means of targeting chronic pain (Kabat-Zinn, 1982) and addiction (Bowen et al., 2009) in isolation, Mindfulness-Oriented Recovery Enhancement (MORE; Garland, 2013) unites complementary aspects of mindfulness training, cognitive reappraisal skills, and principles from positive psychology into an integrative approach to treating co-occurring chronic pain and prescription opioid misuse. Recent findings from a randomized controlled trial demonstrate that MORE led to significant reductions in pain attentional
609
bias coupled with decreased emotional reactivity and increased perceived control over pain in a sample of chronic pain patients receiving long-term opioid therapy, most of whom were opioid misusers (Garland & Howard, 2013). New clinical outcome data from this trial suggest that MORE may significantly reduce pain severity and functional interference while decreasing opioid misuse and craving (Garland, Manusov, Froeliger, Williams, Kelly, & Howard, 2013). One pressing unresolved issue for the study of MBIs for co-occurring chronic pain and opioid misuse relates to the effects of MBIs on craving. The extant literature is divided as to whether mindfulness decreases craving in a bottom-up fashion, strengthens top-down control of craving, and/or increases awareness of craving (Garland & Froeliger, in press). However, theory and praxis may suggest a resolution. The practice of mindfulness often involves metacognitive awareness of the phenomenological constituents of aversive experience. This approach is evident in chronic pain treatment, where mindfulness training may alter the manner in which pain sensations are attended to and processed by providing instruction in breaking down the gestalt of an experience into its sensory components. For example, instead of confronting an anguishing experience of a “painful backache,” a chronic low back pain sufferer might learn to attend to the waxing and waning of sensations of heat and tension localized in the sacrum without identifying emotionally with these sensations—this process has been shown to mediate the pain-reductive effects of mindfulness (Garland et al., 2012). Similarly, mindful awareness can be used to decompose the experience of craving into its phenomenological components. Although the experience of craving in totality may be perceived as overwhelming, coping with each singular component of the craving experience may be perceived as being more manageable. For instance, although it may be difficult to resist an intense craving episode, it may be easier to tolerate subcomponent sensations of the craving (e.g., jitteriness in the stomach, a mental image of drug use). Moreover, by focusing mindful awareness on the sensations of craving, one can begin to notice the ephemeral nature of the craving experience, and in doing so, feel more capable of tolerating it. Mindful awareness of craving occurs at the metacognitive level whereby the cognitive, emotional, and somatic components of craving are witnessed as objects separate from the observer. Experienced from this vantage point, craving can lose its power to compel drug seeking. Hypothetically, mindfulness may exert U-shaped effects on craving by increasing awareness of craving followed by a decrease in craving intensity—yet the time course of these effects remains unknown. Because individuals with impaired insight into their addiction often underreport baseline levels of craving (Goldstein et al., 2009), this increased awareness may confound researchers’ attempts to measure the impact of mindfulness training on self-reported opioid urges, resulting in an apparent lack of change in craving
Subst Use Misuse Downloaded from informahealthcare.com by University of Newcastle on 09/29/14 For personal use only.
610
E. L. GARLAND AND D. S. BLACK
over time. These effects may account for the inconsistent findings regarding the effect of MBIs on craving reported in the literature. A second unresolved issue for the field of MBIs for chronic pain and opioid misuse relates to the role of positive psychological processes in ameliorating reward dysregulation. Although some recent theoretical conceptualizations of mindfulness for addiction eschew a focus on techniques designed to directly enhance positive affect and reward (Brewer et al., 2011), natural reward processing is a fundamental component of psychological well-being that is undermined both by addiction and chronic pain. Research reveals that as addictive use of opioids progresses, opioid cues captivate attentional brain resources to a greater extent than natural reward stimuli (Lubman et al., 2009) and consequently begin to supplant people, activities, experiences, or events that once held value for the individual. This process may increase dependence on opioids for reward and pleasure in lieu of the experience of positive life events. Savoring, or intentionally focusing on the beautiful and meaningful elements of life, is a powerful means of amplifying positive emotion (Quoidbach, Berry, Hansenne, & Mikolajczak, 2010) that may undo decreased sensitivity to natural reward experience. During savoring, one not only attends to a broadened diversity and range of sensations and perceptions, but also the positive emotions that unfold from such intimate, reflective engagement with life experience. By instructing clients to focus on and savor pleasurable objects and events (e.g., the sight of a beautiful sunset or the satisfying taste of a healthy meal), mindfulness training can increase the perceived value of natural rewards, and may thereby counter allostatic dysregulation of reward processing in opioid misuse and addiction. In support of this hypothesis, heart rate variability data from our lab indicates that the effect of MORE on reduced desire for opioids is statistically mediated by enhanced physiological responsiveness to natural reward stimuli (Garland, unpublished data). Thus, as chronic pain patients in the study savored and became more sensitive to natural rewards they experienced increasingly attenuated craving for opioids. In sum, MBIs appear to target key mechanisms implicated in prescription opioid misuse among chronic pain patients. Additional randomized clinical trials and functional neuroimaging studies are needed to further elucidate the effects of MBIs (such as MORE) on opioid craving and natural reward processing. Future studies should also employ multivariate autoregressive latent trajectory analysis of ecological momentary assessments to probe the interactive and cross-lagged effects of MBIs on natural reward experience and craving. It is our most sincere hope that with such methodologies, the next decade of clinical research and practice will illuminate these issues and, if warranted by the data, increase the wider dissemination and availability of MBIs for people suffering from chronic pain and the adverse effects of substance misuse.
THE AUTHORS Eric L. Garland, PhD, LCSW, is an Associate Professor at University of Utah College of Social Work and Associate Director of Integrative Medicine in the Supportive Oncology and Survivorship Program at Huntsman Cancer Institute. His biobehavioral research agenda is focused on translating findings from cognitive and affective neuroscience into treatments for stress-related conditions. Dr. Garland is the developer of Mindfulness-Oriented Recovery Enhancement (MORE), a multimodal intervention designed to ameliorate transdiagnostic mechanisms underpinning addiction, emotion dysregulation, and chronic pain. Dr. Garland has received funding from the National Institutes of Health to conduct clinical trials of MORE as a treatment for alcohol dependence and prescription opioid misuse.
David S. Black, PhD, MPH is an Assistant Professor in the Department of Preventive Medicine and member of the Norris Comprehensive Cancer Center at the University of Southern California. His research program focuses on the delivery and evaluation of mind–body therapeutic modalities, specifically mindfulness training, in order to modify mental and physical health symptoms and states. He is broadly interested in how integrative medicine approaches impact stress biology, specifically the interchange between neuroendocrine and immune system function. He is the Editor-in-Chief of Mindfulness Research Monthly, a web-based dissemination bulletin informing the latest advances in mindfulness research.
Declaration of Interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. REFERENCES Bowen, S., Chawla, N., Collins, S. E., Witkiewitz, K., Hsu, S., Grow, J., et al. (2009). Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial. Substance Abuse, 30, 295–305. Brewer, J. A., Mallik, S., Babuscio, T. A., Nich, C., Johnson, H. E., Deleone, C. M., et al. (2011). Mindfulness training for smoking cessation: Results from a randomized controlled trial. Drug and Alcohol Dependence, 119(1–2), 72–80. Fishbain, D. A., Cole, B., Lewis, J., Rosomoff, H. L., & Rosomoff, R. S. (2007). What Percentage of chronic nonmalignant pain
Subst Use Misuse Downloaded from informahealthcare.com by University of Newcastle on 09/29/14 For personal use only.
NOVEL MECHANISMS
patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain Medicine, 9(4), 444–459. Froeliger, B. E., Garland, E. L., Modin, L., & McClernon, F. J. (2012). Neurocognitive correlates of yoga meditation practice on emotion and cognition: A pilot study. Frontiers in Neuroscience, 6(48), 1–11. Garland, E. L. (2013). Mindfulness-oriented recovery enhancement for addiction, stress, and pain. Washington, DC: NASW Press. Garland, E. L., Boettiger, C. A., Gaylord, S. A., Chanon, V., & Howard, M. O. (2012). Mindfulness is inversely associated with alcohol attentional bias among recovering alcohol-dependent adults. Cognitive Therapy and Research, 36(5), 441–50. Garland, E. L., & Froeliger, B. E. (in press). Mindfulness training targets addiction at the attention-emotion interface: A neurocognitive framework. In E. Langer, A. Le, & C. Ngoumen (Eds.), Handbook of mindfulness. New York: Wiley-Blackwell. Garland, E. L., Froeliger, B., Passik, S., & Howard, M. (2012). Attentional bias for prescription opioid cues among opioid dependent chronic pain patients. Journal of Behavioral Medicine. doi: 10.1007/s10865-012-9455-8 Garland, E. L., Froeliger, B. E., Zeidan, F., Partin, K., & Howard, M. O. (in press). The downward spiral of chronic pain, prescription opioid misuse, and addiction: Cognitive, affective, and neuropsychopharmacologic pathways. Neuroscience & Biobehavioral Reviews. doi: 10.1016/j.neubiorev.2013.08.006 Garland, E.L., Gaylord, S. A., Boettiger, C. A., & Howard, M. O. (2010). Mindfulness training modifies cognitive, affective, and physiological mechanisms implicated in alcohol dependence: Results from a randomized controlled pilot trial. Journal of Psychoactive Drugs, 42, 177–192. Garland, E. L., Gaylord, S. A., Palsson, O., Faurot, K., Mann, J. D., & Whitehead, W. E. (2012). Therapeutic mechanisms of a mindfulness-based treatment for IBS: Effects on visceral sensitivity, catastrophizing, and affective processing of pain sensations. Journal of Behavioral Medicine, 35(6), 591–602. Garland, E. L., & Howard, M. O. (2013). Mindfulness-oriented recovery enhancement reduces pain attentional bias in chronic pain patients. Psychotherapy and Psychosomatics, 82(5), 311–318. Garland, E. L., Manusov, E. G., Froeliger, B. E., Kelly, A., Williams, J., & Howard, M. O. (2013). Mindfulness-Oriented Recovery Enhancement for chronic pain and prescription opi-
611
oid misuse: Results from an early stage randomized controlled trial. Manuscript Submitted for Publication. Geschwind, N., Peeters, F., Drukker, M., van Os, J., & Wichers, M. (2011). Mindfulness training increases momentary positive emotions and reward experience in adults vulnerable to depression: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 79(5), 618–628. Goldstein, R. Z., Craig, A. D., Bechara, A., Garavan, H., Childress, A. R., Paulus, M. P., et al. (2009). The neurocircuitry of impaired insight in drug addiction. Trends in Cognitive Sciences, 13, 372–380. Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General Hospital Psychiatry, 4, 33–47. Koob, G. F., & Le Moal, M. (2008). Addiction and the brain antireward system. Annual Review of Psychology, 59, 29–53. Lubman, D. I., Yucel, M., Kettle, J. W., Scaffidi, A., Mackenzie, T., Simmons, J. G., et al. (2009). Responsiveness to drug cues and natural rewards in opiate addiction: Associations with later heroin use. Archives of General Psychiatry, 66, 205–212. Ospina, M., & Harstall, C. (2002). Prevalence of chronic pain: An overview. Edmonton, Alberta, Canada: Alberta Heritage Foundation for Medical Research. Quoidbach, J., Berry, E. V., Hansenne, M., & Mikolajczak, M. (2010). Positive emotion regulation and well-being: Comparing the impact of eight savoring and dampening strategies. Personality and Individual Differences, 49(5), 368–373. Vago, D. R., & Nakamura, Y. (2011). Selective attentional bias towards pain-related threat in fibromyalgia: Preliminary evidence for effects of mindfulness meditation training. Cognitive Therapy and Research, 35(6), 581–594. Wenk-Sormaz, H. (2005). Meditation can reduce habitual responding. Alternative Therapies in Health and Medicine, 11(2), 42–58. Westbrook, C., Creswell, J. D., Tabibnia, G., Julson, E., Kober, H., & Tindle, H. A. (2013). Mindful attention reduces neural and self-reported cue-induced craving in smokers. Social Cognitive and Affective Neuroscience, 8(1), 73–84. Zeidan, F., Grant, J. A., Brown, C. A., McHaffie, J. G., & Coghill, R. C. (2012). Mindfulness meditation-related pain relief: Evidence for unique brain mechanisms in the regulation of pain. Neuroscience Letters, 520(2), 165–173.
