Psychosocial intervention and the reward system in pain and opioid misuse: new opportunities and directions

How Bud Craig's Insights Reshape the Research on Pain and Mind-Body Therapies

With his elegant studies, Bud Craig determined the structural neural basis for interoception and critically expanded our conceptual understanding of it. Importantly, he placed pain in the framework of interoception and redefined pain as a homeostatic emotion. Craig understood emotions and pain as experiences based on inferential brain processes within the theoretical model of prediction processing. This chapter aims to give a brief overview of relevant research. Mind-body therapies, such as meditation, mindfulness, yoga, Tai Chi, and others, are included as first-line non-pharmacological approaches in clinical guidelines for the management of chronic pain. Craig's groundbreaking work provided the background for our contemporary understanding of mind-body therapies and for the key role that interoceptive processes play in these therapies as they apply to a wide range of clinical conditions, including pain. This chapter reviews the tremendous influence that Craig's work had on the current state of research on mind-body therapies for managing chronic pain and how it led to new directions for cutting-edge clinical and neuroscientific research.

A Single-Session, 2-Hour Version of Mindfulness-Oriented Recovery Enhancement (One MORE) Improves Chronic Pain Patients' Pain-Related Outcomes Through 3-Month Follow-Up in a Randomized Controlled Trial

Introduction: Traditional, 8-week, mindfulness-based interventions can effectively treat chronic pain, but require a time and resource investment too burdensome for many patients and providers. The solution to this logistical challenge may be to distill the core, therapeutic elements of an efficacious 8-week, mindfulness-based intervention, Mindfulness-Oriented Recovery Enhancement (MORE), into a 2-h, single-session intervention. Methods: In this study, the authors conducted a waitlist-controlled, randomized clinical trial to assess the impact of a 2-h, single-session adaptation of MORE (i.e., One MORE) on chronic pain patients' (N = 40) pain-related outcomes through 3-month follow-up. Results: Results indicated that One MORE significantly improved chronic pain patients' pain catastrophizing (i.e., primary outcome; F = 9.97, p = 0.002), pain intensity (F = 26.58, p < 0.001), pain interference (F = 39.43, p < 0.001), physical function (F = 16.29, p < 0.001), sleep (F = 16.66, p < 0.001), anxiety (F = 12.54, p < 0.001), and depression (F = 17.48, p < 0.001). One MORE also significantly increased theoretically indicated therapeutic mechanisms through the 3-month follow-up: mindfulness, positive reappraisal, savoring, self-transcendence. Discussion: Study results are promising, and if replicated, would suggest that One MORE is a highly scalable, low-cost (e.g., sustainable), nonpharmacologic treatment for chronic pain. Clinical Trial Registration: NCT05194241.

Mindfulness-Oriented Recovery Enhancement: Implementing an evidence-based intervention for chronic pain, opioid use, and opioid addiction in clinical settings

The opioid crisis emerged in part due to the overprescribing of opioid analgesics for chronic pain. Although not the only source of the current epidemic of opioid use disorder (OUD), the prescription of opioids for chronic pain remains one vector for the development of opioid misuse and OUD. However, opioid tapering is not appropriate for all patients, and some patients may need to remain on opioid therapy for the long term. To reduce the risk of opioid-related harm among people with chronic pain and to treat incipient or entrenched addictive behaviours, new interventions are needed. This review discusses the clinical outcomes, biobehavioural mechanisms and implementation considerations for a novel, evidence-based intervention for chronic pain, opioid use and OUD called Mindfulness-Oriented Recovery Enhancement (MORE). MORE unites complementary aspects of mindfulness training, cognitive behavioural therapy and principles from positive psychology to simultaneously address addictive behaviour, emotion dysregulation and chronic pain by targeting brain reward and stress systems. MORE has been tested in 13 completed randomized clinical trials, including over 1300 patients, and has demonstrated efficacy against a range of active control conditions for reducing opioid dosing, opioid misuse, illicit drug use, depression, post-traumatic stress symptoms and chronic pain. Opportunities for implementing MORE include facilitating opioid tapering and promoting safe opioid use in primary care and specialty pain clinics, decreasing opioid misuse and enhancing medication-assisted treatment for OUD. Given evidence of MORE's efficacy, it is now time to consider disseminating this evidence-based treatment in the United States, the United Kingdom and worldwide.

Mindfulness-Based Interventions for Perioperative Pain Management and Opioid Risk Reduction Following Surgery: A Stepped Care Approach

Surgical procedures often improve health and function but can sometimes also result in iatrogenic effects, including chronic pain and opioid misuse. Due to the known risks of opioids and the physical, emotional, and financial suffering that often accompanies chronic pain, there has been a call for greater use of complementary non-pharmacological treatments like mindfulness-based interventions. Mindfulness can be broadly described as an attentional state involving moment-by-moment meta-awareness of thoughts, emotions, and body sensations. An expanding number of randomized clinical trials have found strong evidence for the value of mindfulness techniques in alleviating clinical symptomology relevant to surgical contexts. The purpose of this review is to examine the empirical evidence for the perioperative use of mindfulness interventions. We present a mindfulness-based stepped care approach that first involves brief mindfulness to treat preoperative pain and anxiety and prevent development of postoperative chronic pain or opioid misuse. More extensive mindfulness-based interventions are then provided to patients who continue to experience high pain levels or prolonged opioid use after surgery. Finally, we review psychophysiological mechanisms of action that may be integral to the analgesic and opioid sparing effects of mindfulness.

Development of two novel treatments to promote smoking cessation: Savor and retrieval-extinction training pilot clinical trial findings

Despite decades of progress, cigarette smoking remains a significant contributor to disease burden. This effect is especially pronounced for specific priority populations, such as individuals who live in rural communities, in that the burden of tobacco smoking is greater among these groups than in urban areas and the general population. The present study aims to evaluate the feasibility and acceptability of two novel tobacco treatment interventions delivered through remote telehealth procedures to individuals who smoke in the state of South Carolina. Results also include exploratory analyses of smoking cessation outcomes. Study I evaluated savoring, a strategy based on mindfulness practices, alongside nicotine replacement therapy (NRT). Study II evaluated retrieval-extinction training (RET), a memory-modification paradigm alongside NRT. In Study I (savoring), recruitment and retention data showed high interest and engagement in the intervention components, and participants who received this intervention decreased cigarette smoking throughout the course of the treatment (ps < .05). In Study II (RET), results showed high interest and moderate engagement in treatment, although exploratory outcome analyses did not demonstrate significant treatment effects on smoking behaviors. Overall, both studies showed promise in generating interest among individuals who smoke in participating in remotely delivered, telehealth smoking cessation interventions with novel therapeutic targets. A brief savoring intervention appeared to have effects on cigarette smoking throughout treatment, whereas RET did not. Gaining insight from the present pilot study, future studies may improve the efficacy of these procedures and incorporate the treatment components into more robust available treatments. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Stress Phenotyping Framework: A multidisciplinary biobehavioral approach for assessing and therapeutically targeting maladaptive stress physiology

Although dysregulated stress biology is becoming increasingly recognized as a key driver of lifelong disparities in chronic disease, we presently have no validated biomarkers of toxic stress physiology; no biological, behavioral, or cognitive treatments specifically focused on normalizing toxic stress processes; and no agreed-upon guidelines for treating stress in the clinic or evaluating the efficacy of interventions that seek to reduce toxic stress and improve human functioning. We address these critical issues by (a) systematically describing key systems and mechanisms that are dysregulated by stress; (b) summarizing indicators, biomarkers, and instruments for assessing stress response systems; and (c) highlighting therapeutic approaches that can be used to normalize stress-related biopsychosocial functioning. We also present a novel multidisciplinary Stress Phenotyping Framework that can bring stress researchers and clinicians one step closer to realizing the goal of using precision medicine-based approaches to prevent and treat stress-associated health problems.

Opioid analgesic effects on subjective well-being in the operating theatre

Exposure to opioid analgesics due to surgery increases the risk of new persistent opioid use. A mechanistic hypothesis for opioids' abuse liability rests on the belief that, in addition to pain relief, acute opioid treatment improves well-being (e.g. via euphoria) and relieves anxiety. However, opioids do not consistently improve mood in laboratory studies of healthy non-opioid users. This observational study determined how two commonly used opioid analgesics affected patients' subjective well-being in standard clinical practice. Day surgery patients rated how good and how anxious they felt before and after an open-label infusion of remifentanil (n = 159) or oxycodone (n = 110) in the operating theatre before general anaesthesia. One minute after drug injection, patients reported feeling intoxicated (> 6/10 points). Anxiety was reduced after opioids, but this anxiolytic effect was modest (remifentanil Cohen's d = 0.21; oxycodone d = 0.31). There was moderate to strong evidence against a concurrent improvement in well-being (Bayes factors > 6). After remifentanil, ratings of 'feeling good' were significantly reduced from pre-drug ratings (d = 0.28). After oxycodone, one in three participants felt better than pre-drug. Exploratory ordered logistic regressions revealed a link between previous opioid exposure and opioid effects on well-being, as only 14 of the 80 opioid-naïve patients reported feeling better after opioid injection. The odds of improved well-being ratings after opioids were higher in patients with previous opioid exposure and highest in patients with > 2 weeks previous opioid use (adjusted OR = 4.4). These data suggest that opioid-induced improvement of well-being is infrequent in opioid-naïve patients. We speculate that peri-operative exposure could increase risk of persistent use by rendering subsequent positive opioid effects on well-being more likely.

Shifting the perspective: how positive thinking can help diminish the negative effects of pain

OBJECTIVES

The field of pain psychology has taken significant steps forward during the last decades and the way we think about how to treat chronic pain has radically shifted from a biomedical perspective to a biopsychosocial model. This change in perspective has led to a surge of accumulating research showing the importance of psychological factors as determinants for debilitating pain. Vulnerability factors, such as pain-related fear, pain catastrophizing and escape/avoidant behaviours may increase the risk of disability. As a result, psychological treatment that has emerged from this line of thinking has mainly focused on preventing and decreasing the adverse impact of chronic pain by reducing these negative vulnerability factors. Recently, another shift in thinking has emerged due to the field of positive psychology, which aims to have a more complete and balanced scientific understanding of the human experience, by abandoning the exclusive focus on vulnerability factors towards including protective factors.

METHODS

The authors have summarised and reflected on the current state-of-the-art of pain psychology from a positive psychology perspective.

RESULTS

Optimism is an important factor that may in fact buffer and protect against pain chronicity and disability. Resulting treatment approaches from a positive psychology perspective are aimed at increasing protective factors, such as optimism, to increase resilience towards the negative effects of pain.

CONCLUSIONS

We propose that the way forward in pain research and treatment is the inclusion of both vulnerability and protective factors. Both have unique roles in modulating the experience of pain, a finding that had been neglected for too long. Positive thinking and pursuing valued goals can make one's life gratifying and fulfilling, despite experiencing chronic pain.

Mindfulness-Oriented Recovery Enhancement remediates anhedonia in chronic opioid use by enhancing neurophysiological responses during savoring of natural rewards

BACKGROUND

Neuropsychopharmacologic effects of long-term opioid therapy (LTOT) in the context of chronic pain may result in subjective anhedonia coupled with decreased attention to natural rewards. Yet, there are no known efficacious treatments for anhedonia and reward deficits associated with chronic opioid use. Mindfulness-Oriented Recovery Enhancement (MORE), a novel behavioral intervention combining training in mindfulness with savoring of natural rewards, may hold promise for treating anhedonia in LTOT.

METHODS

Veterans receiving LTOT (N = 63) for chronic pain were randomized to 8 weeks of MORE or a supportive group (SG) psychotherapy control. Before and after the 8-week treatment groups, we assessed the effects of MORE on the late positive potential (LPP) of the electroencephalogram and skin conductance level (SCL) during viewing and up-regulating responses (i.e. savoring) to natural reward cues. We then examined whether these neurophysiological effects were associated with reductions in subjective anhedonia by 4-month follow-up.

RESULTS

Patients treated with MORE demonstrated significantly increased LPP and SCL to natural reward cues and greater decreases in subjective anhedonia relative to those in the SG. The effect of MORE on reducing anhedonia was statistically mediated by increases in LPP response during savoring.

CONCLUSIONS

MORE enhances motivated attention to natural reward cues among chronic pain patients on LTOT, as evidenced by increased electrocortical and sympathetic nervous system responses. Given neurophysiological evidence of clinical target engagement, MORE may be an efficacious treatment for anhedonia among chronic opioid users, people with chronic pain, and those at risk for opioid use disorder.

The Mindful Reappraisal of Pain Scale (MRPS): Validation of a New Measure of Psychological Mechanisms of Mindfulness-Based Analgesia

Objectives

Mindfulness is theorized to decrease the affective amplification of chronic pain by facilitating a shift from emotionally-laden, catastrophic pain appraisals of nociceptive input to reappraising chronic pain as an innocuous sensory signal that does not signify harm. Understanding of these hypothetical psychological mechanisms of mindfulness-based analgesia has been limited by a lack of direct measures. We conducted a series of psychometric and experimental studies to develop and validate the Mindful Reappraisal of Pain Sensations Scale (MPRS).

Methods

After item generation, we conducted exploratory and confirmatory factor analyses of the MRPS in samples of opioid-treated chronic pain patients both before (n=450; n=90) and after (n=222) participating in Mindfulness-Oriented Recovery Enhancement (MORE). We then examined the convergent and divergent validity of the MRPS. Finally, in data from a randomized clinical trial (n=250), the MRPS was tested as a mediator of the effects of MORE on reducing chronic pain severity.

Results

Exploratory and confirmatory factor analyses demonstrated the single-factor structure of the MRPS. The MRPS also evidenced convergent and divergent validity. Mindfulness training through MORE significantly increased MRPS scores relative to supportive psychotherapy (F4,425.03 = 16.15, p < .001). Changes in MRPS scores statistically mediated the effect of MORE on reducing chronic pain severity through 9-month follow-up.

Conclusions

Taken together, these studies demonstrate that the MRPS is a psychometrically sound and valid measure of novel analgesic mechanisms of mindfulness including attentional disengagement from affective pain appraisals and interoceptive exposure to pain sensations.

Anhedonia in endometriosis: An unexplored symptom

Anhedonia is the diminished motivation and sensitivity to pleasurable stimuli. It has been reported to be more prevalent in patients with chronic pain as compared to healthy controls. Endometriosis is a chronic inflammatory systemic disease with a significant psychosocial impact that compromises wellbeing and the day-to-day life of patients. Women with endometriosis show significant psychological distress, even more pervasive when chronic pelvic pain is present. In the current review we will discuss the role of anhedonia in endometriotic chronic pelvic pain. We will also present new lines of research that could lead to more fully clarifying the psychological impact of endometriosis and its detrimental repercussions to quality of life and mental health.

Protocol for mindfulness-oriented recovery enhancement (MORE) in the management of lumbosacral radiculopathy/radiculitis symptoms: A randomized controlled trial

Introduction

Lumbosacral radiculopathy/radiculitis (LR) or "sciatica" is a commonly intractable sequelae of chronic low back pain (LBP), and challenges in the treatment of LR indicate that persistent pain may have both mechanical and neuropathic origins. Mindfulness-based interventions have been demonstrated to be effective tools in mitigating self-reported pain in LBP patients. This paper describes the protocol for a randomized controlled trial (RCT) evaluating the effects of the specific mindfulness-based intervention Mindfulness-Oriented Recovery Enhancement (MORE) on LR symptoms and sequelae, including mental health and physical function.

Methods

Participants recruited from the Portland, OR area are screened before completing a baseline visit that includes a series of self-report questionnaires and surface electromyography (sEMG) of the lower extremity. Upon enrollment, participants are randomly assigned to the MORE (experimental) group or treatment as usual (control) group for 8 weeks. Self-reported assessments and sEMG studies are repeated after the intervention is complete for pre/post-intervention comparisons. The outcome measures evaluate self-reported pain, physical function, quality of life, depression symptoms, trait mindfulness, and reinterpretation of pain, with surface electromyography (sEMG) findings evaluating objective physical function in patients with LR. To our knowledge, this is the first trial to date using an objective measure, sEMG, to evaluate the effects of a mindfulness-based intervention on LR symptoms.

Hypotheses

We hypothesize that MORE will be effective in improving self-reported pain, physical function, quality of life, depression symptoms, mindfulness, and reinterpretation of pain scores after 8 weeks of mindfulness training as compared to treatment as usual. Additionally, we hypothesize that individuals in the MORE group with abnormal sEMG findings at baseline will have improved sEMG findings at their 8-week follow-up visit.

Mindfulness-Oriented Recovery Enhancement vs Supportive Group Therapy for Co-occurring Opioid Misuse and Chronic Pain in Primary Care: A Randomized Clinical Trial

IMPORTANCE

Successful treatment of opioid misuse among people with chronic pain has proven elusive. Guidelines recommend nonopioid therapies, but the efficacy of mindfulness-based interventions for opioid misuse is uncertain.

OBJECTIVE

To evaluate the efficacy of Mindfulness-Oriented Recovery Enhancement (MORE) for the reduction of opioid misuse and chronic pain.

DESIGN, SETTING, AND PARTICIPANTS

This interviewer-blinded randomized clinical trial enrolled patients from primary care clinics in Utah between January 4, 2016, and January 16, 2020. The study included 250 adults with chronic pain receiving long-term opioid therapy who were misusing opioid medications.

INTERVENTIONS

Treatment with MORE (comprising training in mindfulness, reappraisal, and savoring positive experiences) or supportive group psychotherapy (control condition) across 8 weekly 2-hour group sessions.

MAIN OUTCOMES AND MEASURES

Primary outcomes were (1) opioid misuse assessed by the Drug Misuse Index (self-report, interview, and urine screen) and (2) pain severity and pain-related functional interference, assessed by subscale scores on the Brief Pain Inventory through 9 months of follow-up. Secondary outcomes were opioid dose, emotional distress, and ecological momentary assessments of opioid craving. The minimum intervention dose was defined as 4 or more completed sessions of MORE or supportive group psychotherapy.

RESULTS

Among 250 participants (159 women [63.6%]; mean [SD] age, 51.8 [11.9] years), 129 were randomized to the MORE group and 121 to the supportive psychotherapy group. Overall, 17 participants (6.8%) were Hispanic or Latino, 218 (87.2%) were White, and 15 (6.0%) were of other races and/or ethnicities (2 American Indian, 3 Asian, 1 Black, 2 Pacific Islander, and 7 did not specify). At baseline, the mean duration of pain was 14.7 years (range, 1-60 years), and the mean (SD) morphine-equivalent opioid dose was 101.0 (266.3) mg (IQR, 16.0-90.0 mg). A total of 203 participants (81.2%) received the minimum intervention dose (mean [SD], 5.7 [2.2] sessions); at 9 months, 92 of 250 participants (36.8%) discontinued the study. The overall odds ratio for reduction in opioid misuse through the 9-month follow-up period in the MORE group compared with the supportive psychotherapy group was 2.06 (95% CI, 1.17-3.61; P = .01). At 9 months, 36 of 80 participants (45.0%) in the MORE group were no longer misusing opioids compared with 19 of 78 participants (24.4%) in the supportive psychotherapy group. Mixed models demonstrated that MORE was superior to supportive psychotherapy through 9 months of follow-up for pain severity (between-group effect: 0.49; 95% CI, 0.17-0.81; P = .003) and pain-related functional interference (between-group effect: 1.07; 95% CI, 0.64-1.50; P < .001). Participants in the MORE group reduced their opioid dose to a greater extent than those in the supportive psychotherapy group. The MORE group also had lower emotional distress and opioid craving.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, among adult participants in a primary care setting, the MORE intervention led to sustained improvements in opioid misuse and chronic pain symptoms and reductions in opioid dosing, emotional distress, and opioid craving compared with supportive group psychotherapy. Despite attrition caused by the COVID-19 pandemic and the vulnerability of the sample, MORE appeared to be efficacious for reducing opioid misuse among adults with chronic pain.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02602535.

Diagnostic and Predictive Capacity of the Spanish Versions of the Opioid Risk Tool and the Screener and Opioid Assessment for Patients with Pain-Revised: A Preliminary Investigation in a Sample of People with Noncancer Chronic Pain

INTRODUCTION

Accurate assessment of the risk of opioid abuse and misuse in people with noncancer chronic pain is crucial for their prevention. This study aimed to provide preliminary evidence of the diagnostic and predictive capacity of the Spanish versions of the Opioid Risk Tool (ORT) and the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R).

METHODS

We used the Current Opioid Misuse Measure (COMM) as criterion measure to assess the capacity of each tool to identify patients misusing opioids at the time of the assessment. Eighteen months later, we used the COMM and the Drug Abuse Screening Test-10 (DAST-10) to assess their predictive capacity. In total, 147 people with noncancer chronic pain participated in the diagnostic study, and 42 in the predictive study.

RESULTS

Receiver operating curve analysis showed that the SOAPP-R had an excellent capacity to identify participants who were misusing opioids at the time of assessment (area under the curve [AUC] = 0.827). The diagnostic capacity of the ORT was close to acceptable (AUC = 0.649-0.669), whereas its predictive capacity was poor (AUC = 0.522-0.554). The predictive capacity of the SOAPP-R was close to acceptable regarding misuse (AUC = 0.672) and poor regarding abuse (AUC = 0.423).

CONCLUSION

In the setting of Spanish-speaking communities, clinicians should be cautious when using these instruments to make decisions on opioid administration. Further research is needed on the diagnostic and predictive capacity of the Spanish versions of both instruments.

Understanding and restoring dopaminergic function in fibromyalgia patients using a mindfulness-based psychological intervention: a [18F]-DOPA PET study. Study protocol for the FIBRODOPA study—a randomized controlled trial

Background

Fibromyalgia (FM) is a very prevalent and debilitating chronic pain disorder that is difficult to treat. Mindfulness-based techniques are regarded as a very promising approach for the treatment of chronic pain and in particular FM. The Mindfulness-Oriented Recovery Enhancement (MORE) intervention, a mindfulness-based group intervention, has shown beneficial effects in opioid-treated chronic pain patients, including reduced pain severity, functional interference, and opioid dosing, by restoring neurophysiological and behavioral responses to reward. The first evidence for a hypodopaminergic state and impaired reward processing in FM has been reported. However, little is known about its impact on dopamine (DA) function and in particular with regard to DA responses to monetary reward in FM. The aim of the present study protocol is to evaluate if MORE is able to restore the DA function in FM patients, in particular with regard to the DA responses to reward, and to reduce pain and mood complaints in FM.

Methods

The present study is a multi-center interventional RCT with 3 time points: before the intervention, after completion of the intervention, and 3 months after completion of the intervention. Sixty-four FM patients will be randomly assigned to either the MORE intervention (N = 32) or a non-intervention control group (N = 32). Additionally, a comparison group of healthy women (N = 20) for PET measures will be enrolled and another group of healthy women (N = 15) will do the ambulatory assessments only. The MORE intervention consists of eight 2-h-long group sessions administered weekly over a period of 8 weeks. Before and after the intervention, FM participants will undergo [18F] DOPA positron emission tomography (PET) and functional MR imaging while performing a reward task. The primary outcome will be endogeneous DA changes measured with [18F] DOPA PET at baseline, after the intervention (after 8 weeks for the non-intervention control group), and at 3 months’ follow-up. Secondary outcomes will be (1) clinical pain measures and FM symptoms using standardized clinical scales; (2) functional brain changes; (3) measures of negative and positive affect, stress, and reward experience in daily life using the ambulatory assessment method (AA); and (4) biological measures of stress including cortisol and alpha-amylase.

Discussion

If the findings of this study confirm the effectiveness of MORE in restoring DA function, reducing pain, and improving mood symptoms, MORE can be judged to be a promising means to improve the quality of life in FM patients. The findings of this trial may inform health care providers about the potential use of the MORE intervention as a possible non-pharmacological intervention for FM.

Trial registration

ClinicalTrials.govNCT 04451564. Registered on 3 July 2020. The trial was prospectively registered.

Mindfulness-oriented recovery enhancement improves negative emotion regulation among opioid-treated chronic pain patients by increasing interoceptive awareness

OBJECTIVE

Long-term opioid therapy presents health risks for people with chronic pain. Some chronic pain patients escalate their opioid dose to regulate negative emotions. Therefore, emotion regulatory strategies like reappraisal are key treatment targets for this population. Mindfulness has been shown to enhance reappraisal, but the mechanisms of action are unknown. This study was a secondary analysis of data from a randomized, controlled trial of Mindfulness-Oriented Recovery Enhancement (MORE) to test a specific postulate of the Mindfulness-to-Meaning Theory: that mindfulness-based interventions promote reappraisal, via interoceptive self-regulation, as a means of decreasing emotional distress.

METHODS

Ninety-five patients with opioid-treated chronic pain (age = 56.8 ± 11.7, 66% female) were randomized to 8 weeks of MORE or Support Group (SG) psychotherapy. An interoceptive awareness latent variable was constructed from the Multidimensional Assessment of Interoceptive Awareness (MAIA). Next, interoceptive self-regulation was assessed as a mediator of the effect of MORE on post-treatment reappraisal, and then reappraisal was examined as a mediator of change in distress through 3-month follow-up.

RESULTS

MORE participants had greater improvements in interoceptive awareness than the SG as measured by the interoceptive awareness latent variable (β = 0.310, p = 0.008) and by the self-regulation MAIA subscale (β = 0.335, p = 0.001). The effect of MORE on treatment-induced increases in reappraisal was mediated by increased interoceptive self-regulation (indirect effect: β = 0.110, p = 0.030). In turn, decreases in distress through 3-month follow-up were mediated by increases in reappraisal (indirect: β = -0.136, p = 0.031).

CONCLUSION

MORE facilitated reappraisal of distress by enhancing interoceptive self-regulation, supporting a central mechanistic causal pathway specified by the Mindfulness-to-Meaning Theory.

Effects of Acute Drug Administration on Emotion: A Review of Pharmacological MRI Studies

Purpose of review

Many drug users claim to use drugs to cope with negative emotions, which may, in turn, result in persistent emotional blunting or anhedonia even when they are not using drugs. The purpose of this review is to describe the ways acute administration of psychoactive drugs impacts brain regions during emotion-related tasks, as a first step in understanding how drugs influence emotion processing in the brain.

Recent findings

Drugs have varying effects on neural responses to emotional stimuli. In general, alcohol, analgesics, and psychedelics reduce neural reactivity to negative emotional stimuli in the amygdala and other brain regions. Other drugs produce mixed effects: Stimulants such as caffeine and modafinil increase brain activation while viewing emotional stimuli, whereas MDMA decreases activation during presentation of negative images. The effects of cannabinoids (cannabidiol and THC) are mixed. There are also inconsistent findings on the associations between neural responses to emotional stimuli and subjective drug effects.

Summary

Consistent with the notion that individuals might use drugs non-medically to diminish the experience of negative emotions, several drugs of abuse decrease neural responses to negative stimuli in limbic brain regions. These neural actions may underlie the reported 'emotional blunting' of drugs, which may contribute to drug-seeking behavior. Future work is needed to examine these limbic responses in relation to self-reports of changes in affect, both during acute administration and after extended drug use.

Mindfulness-based therapy compared to cognitive behavioral therapy for opioid-treated chronic low back pain: Protocol for a pragmatic randomized controlled trial

OBJECTIVE

Chronic low back pain (CLBP) is disabling and costly. Existing therapies have proven suboptimal, with many patients resorting to long-term opioid therapy, which can cause harms. Cognitive behavioral (CBT) and mindfulness-based (MBT) therapies can be effective and offer unique skills for safe pain coping. This article describes the protocol for a study evaluating comparative effectiveness of CBT and MBT in adults with opioid-treated CLBP.

DESIGN

Pragmatic, multi-center randomized controlled trial (RCT).

SETTINGS

Community and outpatient care.

PARTICIPANTS

Planned enrollment of 766 adults (383/group) with CLBP treated with long-term opioids (≥3 months; ≥15 mg/day morphine-equivalent dose).

INTERVENTIONS

CBT or MBT consisting of eight weekly therapist-led, two-hour group sessions, and home practice (≥30 min/day, 6 days/week) during the 12-month study.

MAIN OUTCOME MEASURES

Main outcome measures, collected by self-report at baseline, then three, six, nine and 12 months post-entry, include co-primary measures: pain intensity (Numeric Rating Scale) and function (Oswestry Disability Index), and secondary measures: quality of life (Medical Outcomes Study) and average daily opioid dose (Timeline Followback). Baseline scores of depression, anxiety, and opioid misuse questionnaires will be assessed as potential contributors to the heterogeneity of treatment response. Intention-to-treat, linear mixed-effects analysis will examine treatment effectiveness. Qualitative data will augment the quantitative measures.

CONCLUSIONS

This will be the largest RCT comparing CBT and MBT in opioid-treated CLBP. It will provide evidence on the impact of these interventions, informing clinical decisions about optimal therapy for safe, effective care, improving quality of life and decreasing opioid-related harm among adults with refractory CLBP.

Widespread Pressure Delivered by a Weighted Blanket Reduces Chronic Pain: A Randomized Controlled Trial

Pleasant sensation is an underexplored avenue for modulation of chronic pain. Deeper pressure is perceived as pleasant and calming, and can improve sleep. Although pressure can reduce acute pain, its effect on chronic pain is poorly characterized. The current remote, double-blind, randomized controlled trial tested the hypothesis that wearing a heavy weighted blanket - providing widespread pressure to the body - relative to a light weighted blanket would reduce ratings of chronic pain, mediated by improvements in anxiety and sleep. Ninety-four adults with chronic pain were randomized to wear a 15-lb. (heavy) or 5-lb. (light) weighted blanket during a brief trial and overnight for one week. Measures of anxiety and chronic pain were collected pre- and post-intervention, and ratings of pain intensity, anxiety, and sleep were collected daily. After controlling for expectations and trait anxiety, the heavy weighted blanket produced significantly greater reductions in broad perceptions of chronic pain than the light weighted blanket (Cohen's f = .19, CI [-1.97, -.91]). This effect was stronger in individuals with high trait anxiety (P = .02). However, weighted blankets did not alter pain intensity ratings. Pain reductions were not mediated by anxiety or sleep. Given that the heavy weighted blanket was associated with greater modulation of affective versus sensory aspects of chronic pain, we propose that the observed reductions are due to interoceptive and social/affective effects of deeper pressure. Overall, we demonstrate that widespread pressure from a weighted blanket can reduce the severity of chronic pain, offering an accessible, home-based tool for chronic pain. The study purpose, targeted condition, study design, and primary and secondary outcomes were pre-registered in ClinicalTrials.gov (NCT04447885: "Weighted Blankets and Chronic Pain"). Perspective: This randomized-controlled trial showed that a 15-lb weighted blanket produced significantly greater reductions in broad perceptions of chronic pain relative to a 5-lb weighted blanket, particularly in highly anxious individuals. These findings are relevant to patients and providers seeking home-based, nondrug therapies for chronic pain relief.

To be mindful of the breath or pain: Comparing two brief preoperative mindfulness techniques for total joint arthroplasty patients

OBJECTIVE

Total joint arthroplasty (TJA) often reduces pain and improves function, but it is also a risk factor for the development of chronic pain and postoperative opioid use. To protect against these untoward postsurgical outcomes, TJA patients need better, non-pharmacological pain management strategies. This study compared two, promising, mindfulness-based pain management techniques.

METHOD

We conducted a single-site, three-arm, parallel-group randomized controlled study conducted at an orthopedic clinic among patients undergoing TJA of the knee or hip. TJA patients (N = 118, M age = 65, female = 73, Caucasian = 110) were randomized to either a preoperative mindfulness of breath (MoB), mindfulness of pain (MoP), or cognitive-behavioral pain psychoeducation (CB) intervention, approximately 3 weeks before surgery. Each intervention was delivered in a single, 20-min session during a 2-hr, preoperative education program. Change in pain intensity was the sole preoperative outcome. The postoperative outcomes, pain intensity, pain interference, and opioid use were assessed on the 2nd, 3rd, 7th, 14th, 21st, and 28th postoperative days.

RESULTS

MoB was found to most effectively decrease preoperative pain scores, F(2, 89) = 5.28, p = .007, while MoP resulted in the least amount of postoperative pain intensity, F(8, 94) = 3.21, p = .003, and interference, F(8, 94) = 2.52, p = .016). Both MoB and MoP decreased postoperative opioid use relative to CB, F(8, 83) = 16.66, p < .001.

CONCLUSION

A brief preoperative MBI may be able to prevent both postoperative pain and opioid use. Moreover, the MBIs used in this study are highly feasible, capable of being delivered by nearly any healthcare provider, and requiring minimal clinic time given their brevity. As such, embedding MBIs in surgical care pathways has considerable potential. (PsycInfo Database Record (c) 2021 APA, all rights reserved).