By Ellen Feldman, MD
Altru Health System, Grand Forks, ND
SYNOPSIS: Among primary care patients diagnosed with comorbid chronic pain and opioid misuse, researchers found a specially designed, mindfulness-based group therapy showed superiority to generic supportive group therapy in reducing opioid use and controlling symptoms of chronic pain.
SOURCE: Garland EL, Hanley AW, Nakamura Y, et al. Mindfulness-oriented recovery enhancement vs. supportive group therapy for co-occurring opioid misuse and chronic pain in primary care: A randomized clinical trial. JAMA Intern Med 2022;182:407-417.
There is an inherent difficulty in treating primary care patients with chronic pain who are prescribed opioids but have misused these medications. While treatment guidelines from organizations such as the CDC recommend implementing nonpharmaceutical interventions, there are limited evidence-based studies regarding the efficacy of such treatments for opioid misuse for this population.1
Recognizing the need for such studies, Garland et al designed a randomized clinical trial to evaluate the clinical advantages of a specially designed mindfulness-based group therapy compared to supportive group therapy in reducing opioid misuse and improving pain-related interference in function. Mindfulness-oriented recovery enhancement (MORE) is designed to target the dysregulation of the reward center that is so prominent in patients with comorbid chronic pain and opioid misuse. The theory is prolonged opioid use increases neurobiological vulnerability to pain and emotional distress while decreasing perception of pleasure derived from natural stimuli.
Through a combination of mindfulness techniques and principles derived from cognitive behavioral therapy (CBT) and positive psychology, MORE has demonstrated efficacy in treating opioid overuse and/or chronic pain in short-term pilot studies.2 Garland et al designed their study to include long-term follow-up of nine months and to treat patients with comorbid chronic pain and opioid misuse in a primary care setting.
Subjects were recruited from January 2016 until January 2020 from six primary care clinics in Salt Lake City. Eligibility included a chronic pain diagnosis, opioid prescription for more than three months, and an opioid misuse diagnosis as measured on the Current Opioid Misuse Measure (COMM) — a validated scale measuring opioid misuse or disorder.3
MORE and the active control psychotherapy groups were delivered in primary care clinics in groups of six to 12 participants for two hours across eight weeks. One unique feature of MORE was the inclusion of techniques to not only decrease the effect of negative emotions, but also to increase and amplify awareness of positive emotions and events. Both MORE and the supportive psychotherapy interventions included a homework component. For the MORE group, this consisted of audio-guided mindfulness practice with daily electronic logging and using mindfulness before taking any opioid medication to help the participant bring to conscious awareness the reason for taking the medication (e.g., craving vs. pain relief).
Outcomes were measured periodically for nine months following recruitment. The authors employed the Drug Misuse Index, using a compilation of data from three sources (the self-reported COMM, clinician interviews, and urine toxicology screens) to measure opioid misuse.4 Researchers used two subscales from the Brief Pain Inventory to measure levels of chronic pain.5 Investigators used other validated scales to assess emotional distress and the level of opioid craving.
Results
Of the 250 patients enrolled in the study, just over 60% were women, and 87.2% self-identified as white. At baseline, most of this group was prescribed oxycodone or hydrocodone, with 10.8% on methadone or buprenorphine. Compliance was high, with 203 participants completing at least five of the eight groups, but participation fell off significantly during the COVID-19 pandemic, which coincided with the last year of the study.
At nine months of follow-up, the odds ratio (OR) for reduced misuse of opioids in the MORE arm vs. the supportive psychotherapy arm was 2.06 (95% CI, 1.17-3.61; P = 0.01). Specifically, at nine months, 36 of 80 participants in the MORE group no longer were misusing opioids, compared to 19 of 78 participants in the control group.
COMMENTARY
This trial provides valuable information to a field in need of evidence-based treatment. Long-term opioid treatment for chronic pain is not uncommon in primary care settings; however, there are few published studies of behavioral interventions for this population. With current studies estimating 25% of patients prescribed long-term opioids will misuse these agents, the need for validated treatment options for these individuals is increasingly urgent.6
Interestingly, opioid misuse decreased in participants in both the MORE group and those in the active control group (supportive psychotherapy.) However, the MORE intervention was associated with significantly greater increase in reduction of opioid misuse as well greater decreases in pain severity, functional impairment from pain, and emotional distress. These findings are clinically relevant, especially because the interventions were designed to be delivered in a primary care clinic. Notably, one of the few other studies of behavioral interventions for opioid misuse and chronic pain used CBT, which is a component of MORE. However, those authors found that while CBT seemed to alleviate pain, there was no associated reduction in opioid use or misuse.7 This finding may point to the efficacy of MORE residing in the combination of techniques that result in a restructuring of the reward processing center. Future studies of the specific components of MORE may shed further light on the mechanism of action.
This investigation entered the last year of recruitment and follow-up in early 2020. Given the onset of the pandemic in March 2020, it is not surprising participation fell at that point. Garland et al noted the withdrawal rates were similar in both arms of the study. It is important to replicate and expand studies like this one among individuals of various races, cultures, and socioeconomic backgrounds to be able to confidently generalize results. The type of pain and other specific characteristics of a patient also may be relevant in the potential to respond to MORE or other similar therapies; future studies in the field may uncover these nuances. Overall, it will be equally important to advocate for broad access to professionals trained to deliver therapeutic interventions such as MORE because regional accessibility of psychotherapists is quite variable.
However, with the information available, the primary care clinician is on firm ground looking toward behavioral and mindfulness interventions in the treatment of chronic pain and opioid misuse. The choice of intervention may be limited by local or regional availability, but knowing the type of intervention most likely is clinically relevant may assist with choice.
REFERENCES
- Centers for Disease Control and Prevention. Opioids: Healthcare professionals. Last reviewed Aug. 6, 2021.
- Parisi A, Roberts RL, Hanley AW, Garland EL. Mindfulness-oriented recovery enhancement for addictive behavior, psychiatric distress, and chronic pain: A multilevel meta-analysis of randomized controlled trials. Mindfulness (N Y) 2022;13:2396-2412.
- Butler SF, Budman SH, Fanciullo GJ, Jamison RN. Cross validation of the current opioid misuse measure to monitor chronic pain patients on opioid therapy. Clin J Pain 2010;26:770-776.
- Ducharme J, Moore S. Opioid use disorder assessment tools and drug screening. Mo Med 2019;116:318-324.
- Stanhope J. Brief Pain Inventory review. Occup Med (Lond) 2016;66:496-497.
- Chou R, Fanciullo GJ, Fine PG. Opioids for chronic noncancer pain: Prediction and identification of aberrant drug-related behaviors; A review of the evidence for an American pain society and American Academy of Pain Medicine clinical practice guideline. J Pain 2009;10:131-146.
- de C Williams AC, Fisher E, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev 2020;8:CD007407.
Among primary care patients diagnosed with comorbid chronic pain and opioid misuse, researchers found a specially designed, mindfulness-based group therapy showed superiority to generic supportive group therapy in reducing opioid use and controlling symptoms of chronic pain.
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