Nancy A. Melville

June 29, 2017

PITTSBURGH — An innovative psychotherapeutic intervention involving the deconstruction of the emotional response to pain and the use of mindfulness to gain more control shows some efficacy as a nonpharmacologic approach to not only manage of chronic pain but also  reduce misuse of opioids.

The intervention, called mindfulness-oriented recovery enhancement (MORE), integrates aspects of mindfulness with other facets of psychotherapy, said its developer, Eric Garland, PhD, associate dean for research in the College of Social Work at the University of Utah, Salt Lake City, in presenting the research here at the American Pain Society (APS) 2017 Annual Scientific Meeting.

"MORE unites complementary aspects of mindfulness training, third-wave cognitive-behavioral therapy (CBT), and principles of positive psychology," he said.

The therapy, detailed on Dr Garland's website, specifically targets the hedonic dysregulation that occurs with addiction, stress, and chronic pain and focuses on three components: mindfulness, involving attentional control; reappraisal, involving psychological flexibility; and savoring, with a focus on reward processing.

Aspects of the approach specifically strive to deconstruct the emotional responses that can perpetuate and worsen chronic pain and to use visualization tools to gain perspective, Dr Garland said.

"Some chronic pain patients experience pain emotionally as an unchanging entity over which they lay a layer suffering, saying things like 'Why me?' and 'This pain is ruining my life'."

"We teach patients skills to remove the emotional overlay and to decompose the experience into subcomponent sensory sensations," he said.

"For example, rather than experiencing the pain as this terrible anguish and emotional experience, we ask patients to focus on the pain as a cluster of sensations of heat, or tightness or tingling, as well as to pay attention to the spaces between such sensations, when there is no sensation at all.

"Coping with any one of the sensations may be more manageable than the monolithic experience of pain as a whole."

Another session of the intervention involves focusing mindfully on a bouquet of flowers to generate and shift emotional reward from a natural reward as opposed to a drug-related source.

In a randomized, controlled trial of the intervention published in 2014, 115 patients with chronic pain for a mean of 10.4 years were randomly assigned to the MORE intervention or a standard support group for 8 weeks. Those in the MORE group showed significant reductions in pain severity.

Several recent studies have further demonstrated significant improvements in chronic pain associated with the intervention, including an indirect effect of reinterpretation of pain sensations and nonreactivity to aversive experiences, Dr Garland said.

"The studies showed the effects of MORE were driven by the capacity to reinterpret pain as innocuous sensory information as well as having nonreactivity to stressful thoughts and emotions," he added

A subanalysis published this year in Drug and Alcohol Dependence using data from the study showed intriguing improvements in positive affect and reductions in misuse associated with the intervention.

The findings specifically showed greater improvements in measures of momentary pain (P = .01) and positive affect (P = .004) in the MORE group compared with the support group, and over the course of treatment, patients were significantly more likely to exhibit positive affect regulation (odds ratio, 2.75).

Additionally, improvements in positive affect (but not pain) during the intervention were associated with reduced risk of misusing opioids by post-treatment (P = .02).

Another analysis of the data, published in February in the Clinical Journal of Pain, showed a positive effect of MORE on deficits in hedonic capacity that can occur in chronic pain, characterized by increased sensitivity to aversive states and insensitivity to natural rewards.

In the analysis, dispositional mindfulness among those in the MORE group, assessed with the Five Facet Mindfulness Questionnaire, was associated with hedonic capacity scores, assessed on the Snaith-Hamilton Anhedonia and Pleasure Scale (P < .001).

"In light of this association, it is plausible that interventions that increase mindfulness may reduce pain-related impairment among opioid-using patients by enhancing hedonic capacity," the authors conclude.

Dr Garland concluded that the MORE approach could have highly powerful effects.

"Teaching patients to 'take in the good' and mindfully savor natural, healthy pleasures may provide the learning signal needed to restore adaptive hedonic regulation and, ultimately, reverse addiction," he said.

Dr Garland has disclosed no relevant financial relationships.

American Pain Society (APS) 2017 Annual Scientific Meeting.  Presented May 20, 2017.

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