Roxanne Nelson

November 05, 2013

VANCOUVER, British Columbia — An innovative intervention might help cancer survivors deal with chronic pain and reduce opioid misuse. In a pilot study, patients with chronic pain who used the Mindfulness-Oriented Recovery Enhancement (MORE) approach had significantly greater decreases in the severity of their pain than control subjects.

"A psychological intervention can be effective in reducing the way pain affects a person's functioning and even reducing pain severity itself," lead author Eric L. Garland, PhD, LCSW, associate professor at the University of Utah College of Social Work and associate director of integrative medicine in supportive oncology at the Huntsman Cancer Institute in Salt Lake City.

"It may even reduce pain severity itself," he told Medscape Medical News. "This intervention also reduces the craving for opioids and the misuse of opioids, which is a growing problem in this country."

The study results were presented here at the 10th International Conference of the Society for Integrative Oncology.

The study was conducted in patients with chronic pain that was unrelated to cancer. However, given that the intervention is effective in patients with chronic pain, it might have a therapeutic effect in cancer patients. "More research is needed to investigate that aspect, and to investigate the mechanisms of action," Dr. Garland said.

Reduce Opioid Misuse

MORE is a mental training program that unites complementary aspects of mindfulness training, cognitive-behavior therapy, and positive psychological principles into an integrative treatment strategy. Dr. Garland initially developed MORE as a treatment for alcohol dependence, and later adapted it to address substance dependence in general.

There are 2 main mechanistic findings behind MORE, Dr. Garland explained. "It reduces hypervigilance toward pain or difficulty disengaging from pain stimuli, which is very common in chronic pain patients who are distressed over their condition, and very common in cancer patients." It also increases sensitivity to pleasure. "The more patients experience natural pleasures, the less they desire their pain medication," he said.

Right now, Dr. Garland is using this intervention with individual cancer patients at his institution. He hopes in the future to deliver it in a group setting, emulating what was done in the study, "and then to actually do a study on it," he said.

Opioids are commonly used to treat nonterminal cancer pain, but for about 7.7% of patients, chronic long-term opioid use and the use of opioids to self-medicate can confer a risk for opioid misuse.

Integrative multimodal interventions are needed to target the transdiagnostic mechanisms, such as attentional and emotional reactivity, that are implicated in distress, pain, and maladaptive coping behaviors, noted Dr. Garland.

Reduced Pain and Opioid Craving

In their pilot study, Dr. Garland and colleagues assessed whether the MORE approach would improve well-being, pain, opioid craving, and opioid misuse behaviors in patients with chronic pain.

If MORE can reduce chronic pain and opioid misuse in general, the strategy could potentially be translated into supportive oncology and survivorship care, he noted.

The cohort involved 115 patients with chronic pain not related to cancer who had been taking opioid analgesics for more than 3 months. Patients had been experiencing pain for an average 10.4 years. Most were dealing with musculoskeletal pain (76%); the others were dealing with neuropathic pain (24%). In addition, there was a high degree of psychiatric comorbidity in the form of depression (67%) and generalized anxiety (30%).

The patients were randomized to either MORE (n = 57) or to a support group (n = 58). They were assessed before and after the intervention. At 3-month follow-up, a psychiatric interview was conducted, psychophysiologic measurements were taken, and self-report measures and cognitive tasks were assessed.

There were significantly greater decreases in pain severity (P = .04), functional interference (P < .001), and opioid craving (P = .005) in the MORE group than in the control group. These effects on pain severity and interference persisted for 3 months.

After treatment, more opioid misusers in the MORE group than in the control group no longer met the criteria for misuse (P = .05).

Increases in reinterpretation of pain sensations and nonreactivity were associated with decreases in pain severity. Heart rate variability responses to positive stimuli were associated with reduced opioid craving.

"As we know, chronic pain is a major issue in the United States, especially when we are talking about cancer survivors," said Jun J. Mao, MD, MSCE, director of integrative oncology initiative at the Abramson Cancer Center, Perelman School of Medicine, at the University of Pennsylvania in Philadelphia.

"They are now living for years to come, and this work can potentially help them minimize their need for opioid medications," said Dr. Mao, who was asked by Medscape Medical News for comment on the study.

"It has important implications for health and well-being," he added.

These results are preliminary. Larger studies with more follow-up are needed to better understand the underlying mechanisms. "Once we understand the mechanisms, we can target this type of therapy to patients with particular psychological comorbidities or types of chronic pain and distress."

The study was funded by the National Institutes of Health.

10th International Conference of the Society for Integrative Oncology (SIO): Abstract 84. Presented October 20, 2013.

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