Mindfulness in the Clinic Waiting Room May Decrease Pain: Results from Three Pilot Randomized Controlled Trials

Introduction: Mindfulness interventions can improve a broad range of patient outcomes, but traditional mindfulness-based interventions are time and resource intensive. Emerging evidence indicates brief, single-session mindfulness interventions can also improve patient outcomes, and brief mindfulness interventions can be embedded into medical care pathways with minimal disruption. However, the direct impact of a brief mindfulness intervention on patients' pain while waiting in the clinic waiting room remains unexamined. Objective: A series of three, pilot, randomized controlled trials (RCTs) were conducted to examine the impact of a brief, audio-recorded, mindfulness intervention on patients' pain in the clinic waiting room. Method: Study 1 examined an 8-min mindfulness recording delivered before a provider visit; Study 2 examined a 5-min mindfulness recording after a provider visit; and Study 3 examined a 4-min mindfulness recording before a provider visit. Time- and attention-matched control conditions were used in each study. Studies 1 and 2 were conducted in an academic cancer hospital. Study 3 was conducted at a walk-in orthopedic clinic. Pain intensity was measured in each of the three studies. Anxiety and depression symptoms were measured in Studies 2 and 3. Pain unpleasantness was measured in Study 3. Results: A brief (i.e., 4- to 8-min), audio-recorded mindfulness intervention decreased patients' pain intensity in the clinic waiting room, whether delivered before (Study 1 Cohen's d=1.01, Study 3 Cohen's d=0.39) or after (Study 2 Cohen's d=0.89) a provider visit. Mindfulness had a significant effect on anxiety symptoms in both studies in which it was measured. No effect on depression symptoms was observed. Conclusions: Results from these three pilot RCTs indicate brief, audio-recorded, mindfulness interventions may be capable of quickly decreasing clinical symptoms. As such, embedding brief, audio-recorded, mindfulness interventions in clinic waiting rooms may have the potential to improve patient outcomes. The continued investigation of this intervention approach is needed. Clinical Trial Registrations: NCT04477278 and NCT06099964.

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.

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.

Telehealth Mindfulness-Oriented Recovery Enhancement vs Usual Care in Individuals With Opioid Use Disorder and Pain: A Randomized Clinical Trial

Importance

Methadone treatment (MT) fails to address the emotion dysregulation, pain, and reward processing deficits that often drive opioid use disorder (OUD). New interventions are needed to address these factors.

Objective

To evaluate the efficacy of MT as usual (usual care) vs telehealth Mindfulness-Oriented Recovery Enhancement (MORE) plus usual care among people with an OUD and pain.

Design, Setting, and Participants

This study was a randomized clinical trial conducted from August 2020 to June 2022. Participants receiving MT for OUD and experiencing chronic pain were recruited at 5 clinics in New Jersey.

Interventions

In usual care, participants received MT, including medication and counseling. Participants receiving MORE plus usual care attended 8 weekly, 2-hour telehealth groups that provided training in mindfulness, reappraisal, and savoring in addition to usual care.

Main Outcomes and Measure

Primary outcomes were return to drug use and MT dropout over 16 weeks. Secondary outcomes were days of drug use, methadone adherence, pain, depression, and anxiety. Analyses were based on an intention-to-treat approach.

Results

A total of 154 participants (mean [SD] age, 48.5 [11.8] years; 88 female [57%]) were included in the study. Participants receiving MORE plus usual care had significantly less return to drug use (hazard ratio [HR], 0.58; 95% CI, 0.37-0.90; P = .02) and MT dropout (HR, 0.41; 95% CI, 0.18-0.96; P = .04) than those receiving usual care only after adjusting for a priori-specified covariates (eg, methadone dose and recent drug use, at baseline). A total of 44 participants (57.1%) in usual care and 39 participants (50.6%) in MORE plus usual care returned to drug use. A total of 17 participants (22.1%) in usual care and 10 participants (13.0%) in MORE plus usual care dropped out of MT. In zero-inflated models, participants receiving MORE plus usual care had significantly fewer days of any drug use (ratio of means = 0.58; 95% CI, 0.53-0.63; P < .001) than those receiving usual care only through 16 weeks. A significantly greater percentage of participants receiving MORE plus usual care maintained methadone adherence (64 of 67 [95.5%]) at the 16-week follow-up than those receiving usual care only (56 of 67 [83.6%]; χ2 = 4.49; P = .04). MORE reduced depression scores and ecological momentary assessments of pain through the 16-week follow-up to a significantly greater extent than usual care (group × time F2,272 = 3.13; P = .05 and group × time F16,13000 = 6.44; P < .001, respectively). Within the MORE plus usual care group, EMA pain ratings decreased from a mean (SD) of 5.79 (0.29) at baseline to 5.17 (0.30) at week 16; for usual care only, pain decreased from 5.19 (0.28) at baseline to 4.96 (0.29) at week 16. Within the MORE plus usual care group, mean (SD) depression scores were 22.52 (1.32) at baseline and 18.98 (1.38) at 16 weeks. In the usual care-only group, mean (SD) depression scores were 22.65 (1.25) at baseline and 20.03 (1.27) at 16 weeks. Although anxiety scores increased in the usual care-only group and decreased in the MORE group, this difference between groups did not reach significance (group × time unadjusted F2,272 = 2.10; P= .12; Cohen d = .44; adjusted F2,268 = 2.33; P = .09). Within the MORE plus usual care group, mean (SD) anxiety scores were 25.5 (1.60) at baseline and 23.45 (1.73) at 16 weeks. In the usual care-only group, mean (SD) anxiety scores were 23.27 (1.75) at baseline and 24.07 (1.73) at 16 weeks.

Conclusions and Relevance

This randomized clinical trial demonstrated that telehealth MORE was a feasible adjunct to MT with significant effects on drug use, pain, depression, treatment retention, and adherence.

Trial Registration

ClinicalTrials.gov Identifier: NCT04491968.

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

OBJECTIVE

This randomized clinical trial evaluated the efficacy of Mindfulness-Oriented Recovery Enhancement (MORE) among past and present U.S. military personnel with prescriptions for long-term opioid therapy for chronic pain.

METHODS

In this clinical trial, 230 past and present military personnel with prescriptions for long-term opioid therapy were randomized in a 1:1 ratio to MORE or supportive psychotherapy (initially delivered in person and then via videoconferencing after the onset of the COVID-19 pandemic). Primary outcomes were chronic pain, measured by the Brief Pain Inventory, and aberrant drug-related behaviors, measured by the Current Opioid Misuse Measure, through 8 months of 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.

RESULTS

MORE was superior to supportive psychotherapy through the 8-month follow-up in reducing pain-related functional interference, pain severity, and opioid dose. MORE reduced daily opioid dose by 20.7%, compared with a dose reduction of 3.9% with supportive psychotherapy. Although there was no overall between-group difference in opioid misuse, the in-person MORE intervention outperformed supportive psychotherapy for reducing opioid misuse. MORE reduced anhedonia, pain catastrophizing, craving, and opioid attentional bias and increased 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

Among past and present U.S. military personnel, MORE led to sustained decreases in chronic pain, opioid use, craving, and opioid cue reactivity. MORE facilitated opioid dose reduction while preserving adequate pain control and preventing mood disturbances, suggesting its utility for safe opioid tapering.

The Effectiveness of a Mindfulness-Based Intervention Integrated with Physical Therapy (MIND-PT) for Postsurgical Rehabilitation After Lumbar Surgery: A Protocol for a Randomized Controlled Trial as Part of the Back Pain Consortium (BACPAC) Research Program

BACKGROUND

Improving pain management for persons with chronic low back pain (LBP) undergoing surgery is an important consideration in improving patient-centered outcomes and reducing the risk of persistent opioid use after surgery. Nonpharmacological treatments, including physical therapy and mindfulness, are beneficial for nonsurgical LBP through complementary biopsychosocial mechanisms, but their integration and application for persons undergoing surgery for LBP have not been examined. This study (MIND-PT) is a multisite randomized trial that compares an enriched pain management (EPM) pathway that integrates physical therapy and mindfulness vs usual-care pain management (UC) for persons undergoing surgery for LBP.

DESIGN

Participants from military treatment facilities will be enrolled before surgery and individually randomized to the EPM or UC pain management pathways. Participants assigned to EPM will receive presurgical biopsychosocial education and mindfulness instruction. After surgery, the EPM group will receive 10 sessions of physical therapy with integrated mindfulness techniques. Participants assigned to the UC group will receive usual pain management care after surgery. The primary outcome will be the pain impact, assessed with the Pain, Enjoyment, and General Activity (PEG) scale. Time to opioid discontinuation is the main secondary outcome.

SUMMARY

This trial is part of the National Institutes of Health Helping to End Addiction Long-term (HEAL) initiative, which is focused on providing scientific solutions to the opioid crisis. The MIND-PT study will examine an innovative program combining nonpharmacological treatments designed to improve outcomes and reduce opioid overreliance in persons undergoing lumbar surgery.

Zoom-Based Mindfulness-Oriented Recovery Enhancement Plus Just-in-Time Mindfulness Practice Triggered by Wearable Sensors for Opioid Craving and Chronic Pain

Objective

The opioid crisis in the USA remains severe during the COVID-19 pandemic, which has reduced access to evidence-based interventions. This Stage 1 randomized controlled trial (RCT) assessed the preliminary efficacy of Zoom-based Mindfulness-Oriented Recovery Enhancement (MORE) plus Just-in-Time Adaptive Intervention (JITAI) prompts to practice mindfulness triggered by wearable sensors (MORE + JITAI).

Method

Opioid-treated chronic pain patients (n = 63) were randomized to MORE + JITAI or a Zoom-based supportive group (SG) psychotherapy control. Participants completed ecological momentary assessments (EMA) of craving and pain (co-primary outcomes), as well as positive affect, and stress at one random probe per day for 90 days. EMA probes were also triggered when a wearable sensor detected the presence of physiological stress, as indicated by changes in heart rate variability (HRV), at which time participants in MORE + JITAI were prompted by an app to engage in audio-guided mindfulness practice.

Results

EMA showed significantly greater reductions in craving, pain, and stress, and increased positive affect over time for participants in MORE + JITAI than for participants in SG. JITAI-initiated mindfulness practice was associated with significant improvements in these variables, as well as increases in HRV. Machine learning predicted JITAI-initiated mindfulness practice effectiveness with reasonable sensitivity and specificity.

Conclusions

In this pilot trial, MORE + JITAI demonstrated preliminary efficacy for reducing opioid craving and pain, two factors implicated in opioid misuse. MORE + JITAI is a promising intervention that warrants investigation in a fully powered RCT.

Preregistration

This study is registered on ClinicalTrials.gov (NCT04567043).

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.

Mindfulness-induced endogenous theta stimulation occasions self-transcendence and inhibits addictive behavior

Self-regulation is instantiated by theta oscillations (4 to 8 Hz) in neurons of frontal midline brain regions. Frontal midline theta (FMΘ) is inversely associated with default mode network (DMN) activation, which subserves self-referential processing. Addiction involves impaired self-regulation and DMN dysfunction. Mindfulness is an efficacious self-regulatory practice for treating addiction, but little is known about the mechanisms by which mindfulness reduces addictive behavior. In this mechanistic study of long-term opioid users (N = 165), we assessed meditation-induced FMΘ as a mediator of changes in opioid misuse. Relative to a supportive psychotherapy control, participants treated with Mindfulness-Oriented Recovery Enhancement (MORE) exhibited increased FMΘ during a laboratory-based meditation session. FMΘ during meditation was associated with self-transcendent experiences characterized by ego dissolution, nondual awareness, and bliss. MORE's effects on decreasing opioid misuse were mediated by increased FMΘ. Given the role of aberrant self-referential processing in addiction, mindfulness-induced endogenous theta stimulation might "reset" DMN dysfunction to inhibit addictive behavior.

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.

Modeling the mindfulness-to-meaning theory's mindful reappraisal hypothesis: Replication with longitudinal data from a randomized controlled study

The Mindfulness to Meaning Theory provides a detailed process model of the mechanisms by which mindfulness may promote well-being. Central to the Mindfulness to Meaning Theory is the mindful reappraisal hypothesis (MRH), which suggests mindfulness training promotes well-being by facilitating positive reappraisal. Emerging evidence from interconnected domains of research supports the MRH. However, it remains unclear whether mindful reappraisal continues to develop after a mindfulness training course and whether this continued development encourages well-being over time. As such, this randomized controlled study compared participants receiving a mindfulness-based stress reduction (MBSR) course with participants receiving no mindfulness training on positive reappraisal use and well-being over the course of 6 years. Latent growth curve modeling revealed that mindfulness training increased well-being by significantly increasing the trajectory of positive reappraisal over time. The MRH was then unpacked by examining whether MBSR also stimulated decentering and broadened awareness, core components of the MRH. Multivariate path analysis revealed that mindfulness training increased decentering, which in turn broadened awareness, which was then associated with positive reappraisal, ultimately promoting well-being. Taken together, these findings suggest that MBSR cultivates a downstream cascade of adaptive psychological processes that continue to promote quality of life 6-years after mindfulness training.

Web- and Mindfulness-Based Intervention to Prevent Chronic Pain After Cardiac Surgery: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Cardiac surgery is a frequently performed procedure. However, pain after cardiac surgery may become chronic (lasting >3 months) in adults. Once discharged from the hospital, patients are at greater risk of developing chronic postsurgical pain (CPSP) and of prolonged opioid use, as they need to self-manage their pain. Psychological risk and protective factors such as pain-related catastrophic thoughts and pain acceptance determine their ability to cope and their use of opioids, which is crucial for self-management of pain. Studies on mindfulness-based cognitive therapy (MBCT) have multiplied their potential effects on pain acceptance and catastrophic thoughts. However, web-based MBCT for the prevention of CPSP has not yet been examined.

OBJECTIVE

The aim of this study is to pilot test a 4-week-long web-based MBCT intervention for adults following discharge from the hospital by assessing the acceptability or feasibility of the intervention and examining preliminary effects on pain intensity, pain interference with activities and opioid use, and pain acceptance and catastrophic thoughts in the 6 months following surgery.

METHODS

A double-blinded pilot randomized controlled trial will be used to assess a web-based MBCT intervention. Patients will be selected according to the following criteria: age ≥18 years; first-time elective cardiac surgery via a median sternotomy; worst pain in the past week score ≥4/10; ability to understand and complete questionnaires in English; and ability to use an electronic device such as a smartphone, computer, or tablet. After baseline measures, 32 participants will be randomized into two groups: one receiving both the brief, 4-week-long web-based MBCT intervention and usual care (experimental group) and the other receiving only one standardized, web-based educational session with weekly reminders and usual care (attention control group). Peer-reviewed competitive funding was received from Florida State University's Council on Research & Creativity in January 2021, as well as research ethics approval from Florida State University's institutional review board.

RESULTS

Recruitment began in June 2021. Unfortunately, because of the current COVID-19 pandemic, recruitment is not progressing as expected. Recruitment strategies are constantly monitored and updated according to latest data and restrictions surrounding the pandemic.

CONCLUSIONS

This research is significant because it targets the trajectory of CPSP, a leading cause of disability and opioid misuse. This is the first study to assess MBCT for the prevention of CPSP after cardiac surgery in the recovery phase. This approach is innovative because it promotes self-management of pain through the modulation of individual factors. If successful, the intervention could be expanded to numerous populations at risk of chronic pain.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/30951.

A pilot randomized clinical trial of mindfulness-oriented recovery enhancement as an adjunct to methadone treatment for people with opioid use disorder and chronic pain: Impact on illicit drug use, health, and well-being

BACKGROUND

Chronic pain is highly prevalent among people in methadone maintenance treatment (MMT) for opioid use disorder and is known to be an important contributor to treatment discontinuation and opioid relapse. Mindfulness-Oriented Recovery Enhancement (MORE) is one of the few interventions developed and tested as an integrated treatment to simultaneously address both pain and illicit opioid use; however, this study is the first to evaluate MORE as an adjunct to MMT.

METHODS

Randomized individuals in MMT (N = 30) received MORE plus methadone TAU (n = 15) or methadone TAU, only (n = 15). Participants in the MORE arm received their MMT, as usual, and attended eight, weekly, two-hour MORE groups at their MMT clinics. Participants in the TAU arm received their MMT, as usual, and group or individual counseling, as required by the clinic. TAU counseling consisted of relapse prevention, cognitive-behavioral therapy, and supportive treatment. TAU participants did not receive any mindfulness-based intervention. Participants completed assessments at baseline, post-treatment (i.e., 8-weeks post-baseline), and follow-up (i.e., 16-weeks post-baseline).

RESULTS

Participants in MORE evidenced significantly fewer baseline adjusted days of illicit drug use and significantly lower levels of craving through 16-week follow-up compared to TAU. Also, Participants in MORE reported significantly lower levels of pain, physical and emotional limitations, depression, and anxiety through 16-week follow-up compared to TAU. Conversely, participants in MORE reported significantly higher levels of well-being, vitality, and social functioning through 16-week follow-up compared to TAU.

CONCLUSION

MORE could be an effective adjunct to MMT, and larger trials are warranted.

Correction: Endogenous theta stimulation during meditation predicts reduced opioid dosing following treatment with Mindfulness Oriented Recovery Enhancement

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

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).

Effects of Video-Guided Group vs. Solitary Meditation on Mindfulness and Social Connectivity: A Pilot Study

Interest in mindfulness meditation continues to grow as accumulating evidence suggests mindfulness training encourages more positive functioning. However, basic questions about the conditions best suited for realizing mindful states remain unanswered. Prominent among these is whether a group mindfulness practice setting is more effective for novice meditators than a solitary practice setting. Answering this question has assumed new urgency due to the imposition of physical distancing measures designed to stop the spread of COVID-19. In a time of limited social contact, is a simulated group practice setting better than practicing alone? This preliminary study investigated whether environmental setting impacted mindfulness practice experience by examining the effects of three simulated meditation practice environments (1. group practice, 2. nature practice, and 3. solitary practice) on state mindfulness and perceived social connectivity in a sample of novice meditators. Significant differences emerged across the three simulated practice settings. Findings suggest watching others meditate while meditating appears to most effectively induce a state of mindfulness and strengthen feelings of social connectivity. This study supports traditional beliefs about the benefits of group mindfulness practice. These findings also have implications for social workers struggling to stretch limited resources to address growing mental health demands, especially during times of heightened social isolation due to COVID-19. If a simulated group practice confers the same cognitive benefits as solitary practice while also conferring social benefits, simulated group instruction may be preferable for therapeutic and economic reasons.

Brief preoperative mind-body therapies for total joint arthroplasty patients: a randomized controlled trial

ABSTRACT

Although knee and hip replacements are intended to relieve pain and improve function, up to 44% of knee replacement patients and 27% of hip replacement patients report persistent postoperative joint pain. Improving surgical pain management is essential. We conducted a single-site, 3-arm, parallel-group randomized clinical trial conducted at an orthopedic clinic, among patients undergoing total joint arthroplasty (TJA) of the hip or knee. Mindfulness meditation (MM), hypnotic suggestion (HS), and cognitive-behavioral pain psychoeducation (cognitive-behavioral pain psychoeducation) were each delivered in a single, 15-minute group session as part of a 2-hour, preoperative education program. Preoperative outcomes-pain intensity, pain unpleasantness, pain medication desire, and anxiety-were measured with numeric rating scales. Postoperative physical functioning at 6-week follow-up was assessed with the Patient-Reported Outcomes Measurement Information System Physical Function computer adaptive test. Total joint arthroplasty patients were randomized to preoperative MM, HS, or cognitive-behavioral pain psychoeducation (n = 285). Mindfulness meditation and HS led to significantly less preoperative pain intensity, pain unpleasantness, and anxiety. Mindfulness meditation also decreased preoperative pain medication desire relative to cognitive-behavioral pain psychoeducation and increased postoperative physical functioning at 6-week follow-up relative to HS and cognitive-behavioral pain psychoeducation. Moderation analysis revealed the surgery type did not differentially impact the 3 interventions. Thus, a single session of a simple, scripted MM intervention may be able to immediately decrease TJA patients' preoperative clinical symptomology and improve postoperative physical function. As such, embedding brief MM interventions in surgical care pathways has the potential to improve surgical outcomes for the millions of patients receiving TJA each year.

The Mindfulness-Oriented Recovery Enhancement Fidelity Measure (MORE-FM): Development and Validation of a New Tool to Assess Therapist Adherence and Competence

OBJECTIVE

Mindfulness-Oriented Recovery Enhancement (MORE) is a mind-body therapy that unites complementary aspects of mindfulness training, third-wave cognitive behavioral therapy (CBT), and principles from positive psychology into an integrative treatment for addiction and its comorbidities. As interest in MORE has grown among researchers and clinicians, there is an increasing need to provide quality assurance measures to ensure treatment integrity during implementation of MORE. Here, we describe the development and validation of the Mindfulness-Oriented Recovery Enhancement Fidelity Measure (MORE-FM).

METHOD

We developed a 17-item scale assessing therapist competence and adherence to the MORE treatment manual, which was then used for fidelity monitoring of 40 MORE treatment sessions across two Stage 2 and two Stage 1 RCT for addictive behaviors (e.g., opioid misuse, obesity) involving a total N = 295.

RESULTS

Internal consistency for the Adherence (α =.89) and Competence subscales (α =.92) was high, and interrater reliability was adequate (Adherence subscale ICC =.77; Competence subscale ICC =.51), with therapists exhibiting good-to-excellent levels of fidelity across all trials. Importantly, linear mixed modeling indicated that higher levels of overall fidelity were associated with greater reductions in opioid misuse across two Stage 2 RCTs (F_1,48.00 = 7.38, p=.009), indicating that the MORE-FM is a valid measure of treatment fidelity that can predict clinical outcomes.

CONCLUSIONS

Findings from this study yielded insights for future iterations of the MORE-FM. In sum, the MORE-FM is a valuable tool for assessing and enhancing the integrity of MORE in future research trials and clinical applications.

Endogenous theta stimulation during meditation predicts reduced opioid dosing following treatment with Mindfulness-Oriented Recovery Enhancement

Veterans experience chronic pain at greater rates than the rest of society and are more likely to receive long-term opioid therapy (LTOT), which, at high doses, is theorized to induce maladaptive neuroplastic changes that attenuate self-regulatory capacity and exacerbate opioid dose escalation. Mindfulness meditation has been shown to modulate frontal midline theta (FMT) and alpha oscillations that are linked with marked alterations in self-referential processing. These adaptive neural oscillatory changes may promote reduced opioid use and remediate the neural dysfunction occasioned by LTOT. In this study, we used electroencephalography (EEG) to assess the effects of a mindfulness-based, cognitive training intervention for opioid misuse, Mindfulness-Oriented Recovery Enhancement (MORE), on alpha and theta power and FMT coherence during meditation. We then examined whether these neural effects were associated with reduced opioid dosing and changes in self-referential processing. Before and after 8 weeks of MORE or a supportive psychotherapy control, veterans receiving LTOT (N = 62) practiced mindfulness meditation while EEG was recorded. Participants treated with MORE demonstrated significantly increased alpha and theta power (with larger theta power effect sizes) as well as increased FMT coherence relative to those in the control condition-neural changes that were associated with altered self-referential processing. Crucially, MORE significantly reduced opioid dose over time, and this dose reduction was partially statistically mediated by changes in frontal theta power. Study results suggest that mindfulness meditation practice may produce endogenous theta stimulation in the prefrontal cortex, thereby enhancing inhibitory control over opioid dose escalation behaviors.

Mindfulness-based waiting room intervention for osteopathic manipulation patients: a pilot randomized controlled trial

CONTEXT

Osteopathic manipulative treatment (OMT) and mindfulness-based interventions are both efficacious pain management strategies. Combining these two therapeutic approaches may offer added benefits to pain patients.

OBJECTIVES

To determine whether engaging in a mindfulness-based intervention before an OMT session improved OMT session outcomes.

METHODS

Patients seeking OMT care from a single osteopathic physician at an integrative health clinic were recruited for this pilot randomized, controlled trial at an academic hospital. All patients scheduled for osteopathic structural evaluation and treatment with the provider from March 2019 to September 2019 were eligible and invited to participate during the reminder call before their visit. Participants were randomly assigned to listen to one of two audio recordings matched for length: (1) the history of osteopathic medicine, or (2) a guided mindfulness meditation practice. Patients completed surveys including numeric rating scales to measure mindfulness and embodied safety (a self-reported feeling that the patient's body was in a safe place) immediately before and after listening to the audio recording. A global pain rating report along with a sensation manikin (a digital human figure silhouette overlaid with a grid of 786 "sensation" pixels) capturing both pleasant and unpleasant sensation were collected before and after the OMT session. Session satisfaction was also assessed with a single survey item.

RESULTS

A total of 57 participants were enrolled in the study; however, 18 were unable to listen to the full audio recording and were excluded from further analysis. The final study sample consisted of 39 patients, with 19 (48.7%) randomized to the history audio recording and 20 (51.3%) randomized to the mindfulness recording. The mean age of patients was 57 years (standard deviation, 11.75 years); 25 (64.1%) were women and 14 (35.9%) were men. The most common primary pain location was the neck (16; 41.0%), followed by back (12; 30.8%) and joint (5; 12.8%). Twenty (51.3%) participants were cancer patients; 19 (48.8%) did not have a cancer diagnosis. Practicing mindfulness before OMT increased patients' sense of mindful connection to (p=0.036) and safety within (p=0.026) their bodies as well as their overall session satisfaction (p=0.037). Additionally, OMT paired with either study condition (mindfulness vs. history) decreased pain (p<0.001) and increased the ratio of pleasant to unpleasant sensations reported by patients (p<0.001). Finally, regardless of experimental condition (mindfulness vs. history), increased safety within the body predicted greater pain relief (β=-0.33, p=0.035) and larger sensation ratio changes (β=0.37, p=0.030) at the OMT session's end. Additionally, increased mindful connection to the body predicted less pain (β=-0.41, p=0.005) at the session's end.

CONCLUSIONS

This study demonstrated the feasibility of integrating a mindfulness-based intervention with OMT and results suggest that having patients listen to an audio-guided mindfulness practice while waiting for their OMT session may increase their mindful connection to and safety within their bodies as well as their session satisfaction. This study also provides empirical evidence that OMT may increase the distribution of pleasant sensations reported by pain patients while decreasing the distribution of unpleasant sensations reported.

The temporal dynamics of emotion dysregulation in prescription opioid misuse

BACKGROUND

Opioid misuse is theorized to compromise the capacity to regulate positive and negative emotions. Yet, the temporal dynamics of emotion dysregulation in opioid misuse remain unclear.

METHODS

Patients with chronic pain on long-term opioid therapy (N = 71) participated in an experiment in which they completed an event-related emotion regulation task while heart rate (HR) and galvanic skin responses (GSR) were recorded over a 5 s emotional picture viewing period. Participants were asked to passively view the images or to proactively regulate their emotional responses via reappraisal (i.e., negative emotion regulation) and savoring (i.e., positive emotion regulation) strategies. Using a validated cutpoint on the Current Opioid Misuse Measure, participants were classified as medication-adherent or opioid misusers.

RESULTS

Medication-adherent patients were able to significantly decrease GSR and HR during negative emotion regulation, whereas opioid misusers exhibited contradictory increases in these autonomic parameters during negative emotion regulation. Furthermore, GSR during positive emotion regulation increased for non-misusers, whereas GSR during positive emotion regulation did not increase for misusers. These autonomic differences, which remained significant even after controlling for a range of covariates, were evident within 1 s of emotional stimulus presentation but reached their maxima 3-4 s later.

CONCLUSIONS

Opioid misuse among people with chronic pain is associated with emotion dysregulation that occurs within the first few seconds of an emotional provocation. Treatments for opioid misuse should aim to remediate these deficits in emotion regulation.

The Metacognitive Processes of Decentering Scale: Development and initial validation of trait and state versions

The ability to decenter from internal experiences is important for mental health. Consequently, improving decentering is a common therapeutic target, particularly for mindfulness-based interventions. However, extant decentering measures are limited as they fail to directly assess all 3 metacognitive processes recently theorized to subserve decentering. We thus conducted 4 studies to develop and test the Metacognitive Processes of Decentering-Trait (MPoD-t) and State (MPoD-s) scales. Consistent with the metacognitive processes model, exploratory factor analysis (N = 355) and then bifactor exploratory structural equation modeling (N = 275) indicated the MPoD-t was composed of three independent yet interrelated lower-order factors, metaawareness, (dis)identification with internal experience, and (non)reactivity to internal experience, which subserved an emergent, higher-order, decentering factor. We next found evidence of the MPoD-t's convergent validity; as well as known-groups criterion validity, wherein mindfulness practitioners reported higher MPoD-t scores than nonpractitioners. Item response theory analyses were then used to identify a subset of 3 MPoD-t items for the MPoD-s. Finally, we found evidence that the MPoD-s was sensitive to changes in state decentering following a brief mindfulness induction relative to an active control condition; and that MPoD-s changes mediated the effect of mindfulness on levels of pain and related outcomes among a sample of preoperative surgery patients (N = 82). These studies indicate the trait and state versions of the MPoD may prove useful for the study of decentering and its constituent metacognitive processes. As such, the MPoD may help advance our understanding of how the metacognitive processes of decentering support mental health and well-being. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Mindfulness-oriented recovery enhancement reduces opioid dose in primary care by strengthening autonomic regulation during meditation

The current opioid crisis was fueled by escalation of opioid dosing among patients with chronic pain. Yet, there are few evidence-based psychological interventions for opioid dose reduction among chronic pain patients treated with long-term opioid analgesics. Mindfulness-Oriented Recovery Enhancement (MORE), which was designed to target mechanisms underpinning chronic pain and opioid misuse, has shown promising results in 2 randomized clinical trials (RCTs) and could facilitate opioid sparing and tapering by bolstering self-regulation. Here we tested this hypothesis with secondary analyses of data from a Stage 2 RCT. Chronic pain patients (N = 95) on long-term opioid therapy were randomized to 8 weeks of MORE or a support group (SG) control delivered in primary care. Opioid dose was assessed with the Timeline Followback through 3-month follow-up. Heart rate variability (HRV) during mindfulness meditation was quantified as an indicator of self-regulatory capacity. Participants in MORE evidenced a greater decrease in opioid dosing (a 32% decrease) by follow-up than did the SG, F(2, 129.77) = 5.35, p = .006, d = 1.07. MORE was associated with a significantly greater increase in HRV during meditation than was the SG. Meditation-induced change in HRV partially mediated the effect of MORE on opioid dose reduction (p = .034). MORE may boost self-regulatory strength via mindfulness and thereby facilitate self-control over opioid use, leading to opioid dose reduction in people with chronic pain. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The OPTIMIZE study: protocol of a pragmatic sequential multiple assessment randomized trial of nonpharmacologic treatment for chronic, nonspecific low back pain

BACKGROUND

Low back pain is a prevalent condition that causes a substantial health burden. Despite intensive and expensive clinical efforts, its prevalence is growing. Nonpharmacologic treatments are effective at improving pain-related outcomes; however, treatment effect sizes are often modest. Physical therapy (PT) and cognitive behavioral therapy (CBT) have the most consistent evidence of effectiveness. Growing evidence also supports mindfulness-based approaches. Discussions with providers and patients highlight the importance of discussing and trying options to find the treatment that works for them and determining what to do when initial treatment is not successful. Herein, we present the protocol for a study that will evaluate evidence-based, protocol-driven treatments using PT, CBT, or mindfulness to examine comparative effectiveness and optimal sequencing for patients with chronic low back pain.

METHODS

The Optimized Multidisciplinary Treatment Programs for Nonspecific Chronic Low Back Pain (OPTIMIZE) Study will be a multisite, comparative effectiveness trial using a sequential multiple assessment randomized trial design enrolling 945 individuals with chronic low back pain. The co-primary outcomes will be disability (measured using the Oswestry Disability Index) and pain intensity (measured using the Numerical Pain Rating Scale). After baseline assessment, participants will be randomly assigned to PT or CBT. At week 10, participants who have not experienced at least 50% improvement in disability will be randomized to cross-over phase-1 treatments (e.g., PT to CBT) or to Mindfulness-Oriented Recovery Enhancement (MORE). Treatment will consist of 8 weekly sessions. Long-term outcome assessments will be performed at weeks 26 and 52.

DISCUSSION

Results of this study may inform referring providers and patients about the most effective nonoperative treatment and/or sequence of nonoperative treatments to treat chronic low back pain.

TRIAL REGISTRATION

This study was prospectively registered on March 1, 2019, with Clinicaltrials.gov under the registration number NCT03859713 (https://clinicaltrials.gov/ct2/show/NCT03859713).

Does mindfulness practice promote psychological functioning or is it the other way around? A daily diary study

Mindfulness-based interventions are commonly used to reduce psychological symptoms and enhance positive qualities of human functioning. However, the influence of mindfulness practice dosage remains poorly understood, limiting dissemination and implementation efforts. The current study examined the association between practice dosage and several constructs related to psychological functioning (positive and negative affect, state mindfulness) over the course of a standardized mindfulness-based intervention (Mindfulness-Oriented Recovery Enhancement). Twenty-five participants completed daily diary assessments for 12 weeks. Two-part gamma regression models examined the dichotomous (did practice occur?) and continuous (how much practice?) components of practice minutes. Practice time and outcomes showed same-day relationships in the expected directions. Lagged models, however, showed no evidence that current day practice time predicts subsequent day outcomes. In contrast, higher current day negative affect predicted less subsequent day practice time, and higher current day mindfulness predicted more subsequent day practice time. In a post hoc analysis, practice time moderated the link between day-to-day affect, strengthening the link for positive affect and weakening the link for negative affect. Collectively, these findings suggest that the causal direction linking practice time and outcome may flow from outcome to practice time, rather than the reverse-with potential recursive relationships between these factors. Further examination of lagged relationships between practice time and outcome as well as random assignment of participants to varying practice dosages (e.g., in within-person microrandomized trials) may help clarify the influence of this central treatment ingredient within mindfulness-based interventions. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Behavioral preference for viewing drug v. pleasant images predicts current and future opioid misuse among chronic pain patients

BACKGROUND

The USA is currently enduring an opioid crisis. Identifying cost-effective, easy-to-implement behavioral measures that predict treatment outcomes in opioid misusers is a crucial scientific, therapeutic, and epidemiological goal.

METHODS

The current study used a mixed cross-sectional and longitudinal design to test whether a behavioral choice task, previously validated in stimulant users, was associated with increased opioid misuse severity at baseline, and whether it predicted change in opioid misuse severity at follow-up. At baseline, data from 100 prescription opioid-treated chronic pain patients were analyzed; at follow-up, data were analyzed in 34 of these participants who were non-misusers at baseline. During the choice task, participants chose under probabilistic contingencies whether to view opioid-related images in comparison with affectively pleasant, unpleasant, and neutral images. Following previous procedures, we also assessed insight into choice behavior, operationalized as whether (yes/no) participants correctly self-reported the image category they chose most often.

RESULTS

At baseline, the higher choice for viewing opioid images in direct comparison with pleasant images was associated with opioid misuse and impaired insight into choice behavior; the combination of these produced especially elevated opioid-related choice behavior. In longitudinal analyses of individuals who were initially non-misusers, higher baseline opioid v. pleasant choice behavior predicted more opioid misuse behaviors at follow-up.

CONCLUSIONS

These results indicate that greater relative allocation of behavior toward opioid stimuli and away from stimuli depicting natural reinforcement is associated with concurrent opioid misuse and portends vulnerability toward future misuse. The choice task may provide important medical information to guide opioid-prescribing practices.

Effects of Mindfulness Meditation on Self-Transcendent States: Perceived Body Boundaries and Spatial Frames of Reference

Objectives

Mindfulness training is believed to encourage self-transcendent states, but little research has examined this hypothesis. This study examined the effects of mindfulness training on two phenomenological features of self-transcendence: 1) perceived body boundary dissolution, and 2) more allocentric spatial frames of reference.

Methods

A sample of healthy, young adults (n=45) were randomized to five sessions of mindfulness training or an active listening control condition.

Results

Results indicated mindfulness training decreased perceived body boundaries (F _4,172=6.010, p<.001, η ²=.12) and encouraged more allocentric frames of reference (F _4,168=2.586, p=.039, η ²=.06). The expected inverse relationship was observed between perceived body boundaries and allocentric frames of reference ((β=-.58, p=.001)), and path analysis revealed the effect of mindfulness training on allocentric frames of reference was mediated by decreased perceived body boundaries (β=.24, se=.17, CI: 0.11 to 0.78).

Conclusions

Taken together, study results suggest that mindfulness training alters practitioners' experience of self, relaxing the boundaries of the self and extending the spatial frame of reference further beyond the physical body. Future studies are needed to explore the psychophysiological changes that co-occur with phenomenological reports of self-transcendence and the behavioral consequences following self-transcendent experiences.

Mind-Body Therapies for Opioid-Treated Pain: A Systematic Review and Meta-analysis

Importance

Mind-body therapies (MBTs) are emerging as potential tools for addressing the opioid crisis. Knowing whether mind-body therapies may benefit patients treated with opioids for acute, procedural, and chronic pain conditions may be useful for prescribers, payers, policy makers, and patients.

Objective

To evaluate the association of MBTs with pain and opioid dose reduction in a diverse adult population with clinical pain.

Data Sources

For this systematic review and meta-analysis, the MEDLINE, Embase, Emcare, CINAHL, PsycINFO, and Cochrane Library databases were searched for English-language randomized clinical trials and systematic reviews from date of inception to March 2018. Search logic included (pain OR analgesia OR opioids) AND mind-body therapies. The gray literature, ClinicalTrials.gov, and relevant bibliographies were also searched.

Study Selection

Randomized clinical trials that evaluated the use of MBTs for symptom management in adults also prescribed opioids for clinical pain.

Data Extraction and Synthesis

Independent reviewers screened citations, extracted data, and assessed risk of bias. Meta-analyses were conducted using standardized mean differences in pain and opioid dose to obtain aggregate estimates of effect size with 95% CIs.

Main Outcomes and Measures

The primary outcome was pain intensity. The secondary outcomes were opioid dose, opioid misuse, opioid craving, disability, or function.

Results

Of 4212 citations reviewed, 60 reports with 6404 participants were included in the meta-analysis. Overall, MBTs were associated with pain reduction (Cohen d = -0.51; 95% CI, -0.76 to -0.26) and reduced opioid dose (Cohen d = -0.26; 95% CI, -0.44 to -0.08). Studies tested meditation (n = 5), hypnosis (n = 25), relaxation (n = 14), guided imagery (n = 7), therapeutic suggestion (n = 6), and cognitive behavioral therapy (n = 7) interventions. Moderate to large effect size improvements in pain outcomes were found for meditation (Cohen d = -0.70), hypnosis (Cohen d = -0.54), suggestion (Cohen d = -0.68), and cognitive behavioral therapy (Cohen d = -0.43) but not for other MBTs. Although most meditation (n = 4 [80%]), cognitive-behavioral therapy (n = 4 [57%]), and hypnosis (n = 12 [63%]) studies found improved opioid-related outcomes, fewer studies of suggestion, guided imagery, and relaxation reported such improvements. Most MBT studies used active or placebo controls and were judged to be at low risk of bias.

Conclusions and Relevance

The findings suggest that MBTs are associated with moderate improvements in pain and small reductions in opioid dose and may be associated with therapeutic benefits for opioid-related problems, such as opioid craving and misuse. Future studies should carefully quantify opioid dosing variables to determine the association of mind-body therapies with opioid-related outcomes.

Mindfulness-oriented recovery enhancement reduces opioid misuse risk via analgesic and positive psychological mechanisms: A randomized controlled trial

OBJECTIVE

Despite the heightened urgency of the current prescription opioid crisis, few psychotherapies have been evaluated for chronic pain patients receiving long-term opioid analgesics. Current psychological pain treatments focus primarily on ameliorating negative affective processes, yet basic science suggests that risk for opioid misuse is linked with a dearth of positive affect. Interventions that modulate positive psychological processes may produce therapeutic benefits among patients with opioid-treated chronic pain. The aim of this study was to conduct a theory-driven mechanistic analysis of proximal outcome data from a Stage 2 randomized controlled trial of Mindfulness-Oriented Recovery Enhancement (MORE), an integrative intervention designed to promote positive psychological health.

METHOD

Patients with opioid-treated chronic pain (N = 95; age = 56.8 ± 11.7; 66% female) were randomized to 8 weeks of therapist-led MORE or support group (SG) interventions. A latent positive psychological health variable comprised of positive affect, meaning in life, and self-transcendence measures was examined as a mediator of the effect of MORE on changes in pain severity at posttreatment and opioid misuse risk by 3-month follow-up.

RESULTS

Participants in MORE reported significantly greater reductions in pain severity by posttreatment (p = .03) and opioid misuse risk by 3-month follow-up (p = .03) and significantly greater increases in positive psychological health (p < .001) than SG participants. Increases in positive psychological health mediated the effect of MORE on pain severity by posttreatment (p = .048), which in turn predicted decreases in opioid misuse risk by follow-up (p = .02).

CONCLUSIONS

Targeting positive psychological mechanisms via MORE and other psychological interventions may reduce opioid misuse risk among chronic pain patients receiving long-term opioid therapy. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Mindfulness-Oriented Recovery Enhancement remediates hedonic dysregulation in opioid users: Neural and affective evidence of target engagement

Addiction neuroscience models posit that recurrent drug use increases reactivity to drug-related cues and blunts responsiveness to natural rewards, propelling a cycle of hedonic dysregulation that drives addictive behavior. Here, we assessed whether a cognitive intervention for addiction, Mindfulness-Oriented Recovery Enhancement (MORE), could restructure reward responsiveness from valuation of drug-related reward back to valuation of natural reward. Before and after 8 weeks of MORE or a support group control, prescription opioid users (N = 135) viewed opioid and natural reward cues while an electroencephalogram biomarker of target engagement was assessed. MORE was associated with decreased opioid cue-reactivity and enhanced capacity to regulate responses to opioid and natural reward cues. Increased positive affective responses to natural reward cues were associated with decreased craving and mediated MORE's therapeutic effects on opioid misuse. This series of randomized experiments provide the first neurophysiological evidence that an integrative behavioral treatment can remediate hedonic dysregulation among chronic opioid users.

Mindfulness meditation in the treatment of substance use disorders and preventing future relapse: neurocognitive mechanisms and clinical implications

Substance use disorders (SUDs) are a pervasive public health problem with deleterious consequences for individuals, families, and society. Furthermore, SUD intervention is complicated by the continuous possibility of relapse. Despite decades of research, SUD relapse rates remain high, underscoring the need for more effective treatments. Scientific findings indicate that SUDs are driven by dysregulation of neural processes underlying reward learning and executive functioning. Emerging evidence suggests that mindfulness training can target these neurocognitive mechanisms to produce significant therapeutic effects on SUDs and prevent relapse. The purpose of this manuscript is to review the cognitive, affective, and neural mechanisms underlying the effects of mindfulness-based interventions (MBIs) on SUDs. We discuss the etiology of addiction and neurocognitive processes related to the development and maintenance of SUDs. We then explore evidence supporting use of MBIs for intervening in SUDs and preventing relapse. Finally, we provide clinical recommendations about how these therapeutic mechanisms might be applied to intervening in SUDs and preventing relapse.

The Nondual Awareness Dimensional Assessment (NADA): New tools to assess nondual traits and states of consciousness occurring within and beyond the context of meditation

This article details the development of two measures of nondual awareness, the Nondual Awareness Dimensional Assessment-Trait (NADA-T) and the Nondual Awareness Dimensional Assessment-State (NADA-S). Principal component analysis (N = 528) revealed two, interpretable dimensions of the NADA-T: self-transcendence and bliss. Bifactor exploratory structural equation modeling, conducted in three independent samples (N = 338, N = 221, N = 166), indicated that both NADA-T dimensions were components of a second-order nondual awareness construct. Convergent validity was observed between the NADA-T and theoretically aligned constructs, including interdependent self-construals and dispositional mindfulness. Given theoretical and observed relationships between nondual awareness and mindfulness, additional analyses examined the relationship between mindfulness practice and nondual awareness. Results indicated that mindfulness practitioners reported higher NADA-T scores than nonpractitioners, and mindfulness practice frequency was positively associated with nondual awareness. To assess the immediate effect of meditation practice on nondual awareness, items retained in the final version of the NADA-T were modified to create the NADA-S. A randomized controlled experiment (N = 53) comparing participants receiving a mindfulness induction (i.e., body scan) with those in an attention control group revealed state effects of mindfulness on nondual awareness using two, alternate forms of the NADA-S. Thus, the NADA-T appears to be psychometrically sound, representing a novel, standardized instrument capable of facilitating quantitative investigation of nondual awareness. Furthermore, the NADA-S may be useful for measuring fluctuations in nondual states of awareness evoked during mindfulness meditation practice and other contemplative techniques designed to transform consciousness. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Dispositional mindfulness and prescription opioid misuse among chronic pain patients: Craving and attention to positive information as mediating mechanisms

OBJECTIVES

Opioid-treated chronic pain patients may be at risk for prescription opioid misuse due to heightened opioid craving coupled with deficits in attention to naturally rewarding, positive stimuli. Conversely, dispositional mindfulness, which is associated with reduced craving and increased responsiveness to natural rewards, may serve as a protective factor and buffer opioid misuse risk. The current investigation aimed to examine the association between mindfulness and opioid misuse, and to test opioid craving and attention to positive information as mediators of this relationship.

METHODS

This cross-sectional analysis examined data obtained from a sample of civilian opioid-treated chronic pain patients in the Southeastern U.S. (Sample 1: N = 115), as well as civilian (Sample 2: N = 141) and military samples in the Intermountain West (Sample 3: N = 44). Pearson correlations and path analyses were employed to test relations among participant self-reports on the Current Opioid Misuse Measure (COMM), the Five Facet Mindfulness Questionnaire (FFMQ), two measures of opioid craving, and the Attention to Positive and Negative Information Scale (APNIS).

RESULTS

Across all three samples, dispositional mindfulness was significantly inversely associated with opioid misuse (N = 300, r = -0.36, p < .001). Reduced opioid craving and increased attention to positive information mediated the association between dispositional mindfulness and opioid misuse.

DISCUSSION

Dispositional mindfulness may buffer opioid misuse risk by attenuating opioid craving and enhancing attention to naturally rewarding stimuli.

The Mindful Personality II: Exploring the Metatraits from a Cybernetic Perspective

Relationships between dispositional mindfulness and the personality metatraits, stability and plasticity, remain unexplored despite continued efforts to more accurately characterize associations between dispositional mindfulness and personality. The metatraits are theorized to constitute basic requirements for biological survival and their expression is believed to be a strong determinant of well-being. As such, this study used path analysis to explore associations between dispositional mindfulness, the metatraits and psychological well-being in a sample of 403 American adults. Results indicate that dispositional mindfulness is principally associated with stability, or the capacity to sustain currently operative schemas and goals. Results further suggest a positive relationship between dispositional mindfulness and plasticity, or the tendency to flexibly adapt to changing circumstances. A more granular investigation of these associations demonstrated that the facets of dispositional mindfulness are differentially related with the metatraits. Ultimately, the metatraits were found to fully mediate the relationship between dispositional mindfulness and psychological well-being.

Reappraisal deficits promote craving and emotional distress among chronic pain patients at risk for prescription opioid misuse

Background: A subset of chronic pain patients misuse prescription opioids as a means of regulating negative emotions. However, opioid misuse may result in deficits in emotion regulation strategies like reappraisal by virtue of the deleterious effects of chronic opioid exposure. Aims: The aim of this study was to characterize differences in reappraisal use among chronic pain patients at risk for opioid misuse and those who report taking opioids as prescribed. Methods: A sample of 127 pain patients receiving chronic opioid analgesic pharmacotherapy were classified as at risk for opioid misuse (n = 62) or taking opioids as prescribed (n = 65) using the Current Opioid Misuse Measure (COMM). The Emotion Regulation Questionnaire (ERQ) characterized use of emotion regulation strategies including reappraisal and expressive suppression. Participants also reported levels of opioid craving, emotional distress, and pain severity. Results: Patients at risk for opioid misuse reported significantly less reappraisal use (M = 25.31, SD = 7.33) than those who reportedly took opioids as prescribed (M = 30.28, SD = 7.50), p<.001, but did differ with regard to suppression strategies. Reduced reappraisal use was associated with higher opioid craving and emotional distress that mediated the association between reappraisal deficits and opioid misuse risk. Further, there was a significant indirect effect of opioid misuse on emotional distress via reappraisal use. Discussion: Opioid misuse risk was associated with reduced use of reappraisal, which in turn was associated with dysregulated negative emotions and increased appetitive drive towards consuming opioids. Studying individual differences in emotion regulation may yield efficacious intervention and prevention approaches to stem the rising tide of the prescription opioid crisis.

Testing the mindfulness-to-meaning theory: Evidence for mindful positive emotion regulation from a reanalysis of longitudinal data

Background and objective

The Mindfulness to Meaning Theory (MMT) provides a detailed process model of mindful positive emotion regulation.

Design

We conducted a post-hoc reanalysis of longitudinal data (N = 107) derived from a RCT of mindfulness-based stress reduction (MBSR) versus cognitive-behavioral therapy (CBT) for social anxiety disorder to model the core constructs of the MMT (attentional control, decentering, broadened awareness, reappraisal, and positive affect) in a multivariate path analysis.

Results

Findings indicated that increases in attentional control from baseline to post-training predicted increases in decentering by 3 months post-treatment (p<.01) that in turn predicted increases in broadened awareness of interoceptive and exteroceptive data by 6 months post-treatment (p<.001). In turn, broadened awareness predicted increases in the use of reappraisal by 9 months post-treatment (p<.01), which culminated in greater positive affect at 12 months post-treatment (p<.001). MBSR led to significantly greater increases in decentering (p<.05) and broadened awareness than CBT (p<.05). Significant indirect effects indicated that increases in decentering mediated the effect of mindfulness training on broadening awareness, which in turn mediated enhanced reappraisal efficacy.

Conclusion

Results suggest that the mechanisms of change identified by the MMT form an iterative chain that promotes long-term increases in positive affectivity. Though these mechanisms may reflect common therapeutic factors that cut across mindfulness-based and cognitive-behavioral interventions, MBSR specifically boosts the MMT cycle by producing significantly greater increases in decentering and broadened awareness than CBT, providing support for the foundational assumption in the MMT that mindfulness training may be a key means of stimulating downstream positive psychological processes.

The mindful personality: A meta-analysis from a cybernetic perspective

Dispositional mindfulness (DM), or the tendency to attend to present moment experience, may have important implications for the structure of human personality. However, relationships between DM and the Big Five Model of Personality (BF) have not been definitively established. Therefore, the purpose of this meta-analysis was to extend previous investigations of the relationship between DM and the BF, utilizing a larger sample of studies, attending to relational inconsistencies potentially associated with alternative methods of operationalizing DM, conducting the first meta-analysis of the DM subdomains in relation to the BF, and situating the results in a cybernetic model. Results indicate that neuroticism evidenced the strongest, negative relationship with DM and conscientiousness evidenced the strongest, positive relationship with DM, suggesting the mindful personality may be characterized principally by emotional stability and conscientious self-regulation - potentially reflective of an inclination towards the personality metatrait stability. Measurement differences were also observed, with the mindful personality arrived at through the FFMQ differing to some extent from the mindful personality emerging from the MAAS. Broadly, the mindful personality associated with the FFMQ appears to reflect greater personality complexity, with the FFMQ evidencing associations with all five personality factors while the MAAS appears primarily linked with only three personality factors (Neuroticism, Conscientiousness and Agreeableness). Examination of the relationships between the BF and DM at the facet level also suggest unique patterns of association between the DM facets and each of the personality factors.

Randomized Controlled Trial of Brief Mindfulness Training and Hypnotic Suggestion for Acute Pain Relief in the Hospital Setting

BACKGROUND

Medical management of acute pain among hospital inpatients may be enhanced by mind-body interventions.

OBJECTIVE

We hypothesized that a single, scripted session of mindfulness training focused on acceptance of pain or hypnotic suggestion focused on changing pain sensations through imagery would significantly reduce acute pain intensity and unpleasantness compared to a psychoeducation pain coping control. We also hypothesized that mindfulness and suggestion would produce significant improvements in secondary outcomes including relaxation, pleasant body sensations, anxiety, and desire for opioids, compared to the control condition.

METHODS

This three-arm, parallel-group randomized controlled trial conducted at a university-based hospital examined the acute effects of 15-min psychosocial interventions (mindfulness, hypnotic suggestion, psychoeducation) on adult inpatients reporting "intolerable pain" or "inadequate pain control." Participants (N = 244) were assigned to one of three intervention conditions: mindfulness (n = 86), suggestion (n = 73), or psychoeducation (n = 85).

KEY RESULTS

Participants in the mind-body interventions reported significantly lower baseline-adjusted pain intensity post-intervention than those assigned to psychoeducation (p < 0.001, percentage pain reduction: mindfulness = 23%, suggestion = 29%, education = 9%), and lower baseline-adjusted pain unpleasantness (p < 0.001). Intervention conditions differed significantly with regard to relaxation (p < 0.001), pleasurable body sensations (p = 0.001), and desire for opioids (p = 0.015), but all three interventions were associated with a significant reduction in anxiety (p < 0.001).

CONCLUSIONS

Brief, single-session mind-body interventions delivered by hospital social workers led to clinically significant improvements in pain and related outcomes, suggesting that such interventions may be useful adjuncts to medical pain management.

TRIAL REGISTRATION

Trial Registry: ClinicalTrials.gov ; registration ID number: NCT02590029 URL: https://clinicaltrials.gov/ct2/show/NCT02590029.

Biobehavioral Mechanisms of Mindfulness as a Treatment for Chronic Stress: An RDoC Perspective

Mindfulness-based interventions have been heralded as promising means of alleviating chronic stress. While meta-analyses indicate that mindfulness-based interventions significantly reduce global measures of stress, how mindfulness-based interventions modulate the specific mechanisms underpinning chronic stress as operationalized by the National Institute of Mental Health research domain criteria (RDoC) of sustained threat has not yet been detailed in the literature. To address this knowledge gap, this article aims to (1) review evidence that mindfulness-based interventions ameliorate each of the 10 elements of behavioral dysregulation characterizing sustained threat via an array of mindful counter-regulatory strategies; (2) review evidence that mindfulness-based interventions modify biological domains implicated in sustained threat, such as the hypothalamic–pituitary–adrenal axis, as well as brain circuits involved in attentional function, limbic reactivity, habit behavior, and the default mode network; and (3) integrate these findings into a novel conceptual framework of mindful self-regulation in the face of stress—the Mindfulness-to-Meaning Theory. Taken together, the extant body of scientific evidence suggests that the practice of mindfulness enhances a range biobehavioral factors implicated in adaptive stress coping and induces self-referential plasticity, leading to the ability to find meaning in adversity. These mechanistic findings can inform the treatment development process to optimize the next generation of mindfulness-based interventions for greater therapeutic efficacy.

Self-interest may not be entirely in the interest of the self: Association between selflessness, dispositional mindfulness and psychological well-being

The association between mindfulness and selflessness is firmly grounded in classical Indo-Sino-Tibetan contemplative traditions, but has received limited empirical attention from Western researchers. In Buddhism, the relationship between mindfulness and the self is of central concern to the cultivation of well-being. Mindfulness is believed to encourage insight into the truly insubstantial nature of the self, an understanding that is thought to encourage well-being. The present study explores these relationships, attending to dispositional mindfulness, the self as it exists on a continuum from self-centered to selfless, and psychological well-being. Results indicate a positive relationship between selflessness, dispositional mindfulness, and psychological well-being. It appears that construing the self as interdependent and interconnected with a broader social, natural, and cosmic context is linked with greater psychological well-being and dispositional mindfulness. Path analyses revealed that selflessness mediated the relationship between dispositional mindfulness and psychological well-being.