The potential role of mindfulness-based interventions in addiction medicine

Dr. Eric Garland is leading the field of mindfulness-based interventions for the treatment of opioid use disorder (OUD), which over 15 million Americans are estimated to meet the criteria for. His lab at the University of Utah has now conducted multiple randomized controlled trials (RCT) targeting patients with chronic pain and opioid misuse. They hypothesize that their mindfulness-based intervention, MORE (Mindfulness-Oriented Recovery Enhancement) bolsters self-regulation and in turn leads to greater success in reducing opioid doses and tapering amongst chronic pain patients who are at risk of opioid misuse. His group most recently published an additional publication supporting this hypothesis with the use of heart rate variability data. 

MORE is a mindfulness-based technique that was developed specifically to aid in the reduction of opioid dosing amongst individuals with chronic pain. Garland and his group have shown in previous work that MORE has significant effects on pain severity, stress arousal, desire for opioids, and opioid misuse risk as well as on positive psychological functioning when compared to control groups1

Heart rate variability (HRV) is the variation of time between each heartbeat. Greater HRV is considered a proxy for a healthy autonomic nervous system (ANS) function: the more variability there is in heart rate, the more the ANS is able to switch from one state to the other, showing resilience and flexibility. Importantly, chronic pain is thought to diminish self-regulation via autonomic dysregulation, which may escalate the opioid doses used by chronic pain patients. Mindfulness based techniques have been shown to increase self-regulation and in meta-analysis, HRV has been shown to be weakly related to self-regulation. So in turn, as a self-regulatory method, mindfulness-based interventions should increase HRV. 

Garland’s most recent study directly interrogated the impact of MORE on both opioid dosing and HRV during meditation amongst participants with chronic pain and being treated with opioids. MORE was shown to reduce pain and opioid-misuse risk at 3 months. MORE participants showed a significant decrease in opioid dosing when comparing pre- and post-intervention doses at 3-month follow-up whereas patients in the control group showed increased opioid dosing. Additionally, the effect of MORE on opioid dosing was mediated by increased HRV amongst participants who received the MORE intervention. It also seemed to have a dose-response relationship whereby longer meditation practices were positively associated with increases in HRV during meditation and inversely associated with subsequent opioid dose

This study not only suggests that mindfulness-based intervention may be important amongst chronic pain patients who are taking opioid analgesics to avoid high doses of opioids, but it also suggests a mechanism that may be mediating this observation. It would be wrong to conclude that mindfulness alone is responsible for these observations – the MORE program is multifaceted and includes much more than basic mindfulness practices. This study is also limited by a small sample size and recall bias, as participants were asked to self-report their opioid dosing. For now, there seems to be some signal that a mindfulness- based intervention may be useful in self-regulation amongst a population of chronic pain patients, but additional research that overcomes these limitations is needed to confidently determine causality.

Reference:
Garland, E. L., Hudak, J., Hanley, A. W., & Nakamura, Y. (2020). Mindfulness-oriented recovery enhancement reduces opioid dose in primary care by strengthening autonomic regulation during meditation. American Psychologist, 75(6), 840–852. https://doi.org/10.1037/amp0000638

This article was written by Zoe O’Neill, a medical student at McGill University and member of the Mindful Medical Learner Team.

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