Mindfulness-oriented recovery enhancement for chronic pain and prescription opioid misuse: Results from an early-stage randomized controlled trial.
Open accessAbstract
OBJECTIVE: Opioid pharmacotherapy is now the leading treatment for chronic pain, a problem that affects nearly one third of the U.S. population. Given the dramatic rise in prescription opioid misuse and opioid-related mortality, novel behavioral interventions are needed. The purpose of this study was to conduct an early-stage randomized controlled trial of Mindfulness-Oriented Recovery Enhancement (MORE), a multimodal intervention designed to simultaneously target mechanisms underpinning chronic pain and opioid misuse. METHOD: Chronic pain patients (N = 115; mean age = 48 ± 14 years; 68% female) were randomized to 8 weeks of MORE or a support group (SG). Outcomes were measured at pre- and posttreatment, and at 3-month follow-up. The Brief Pain Inventory was used to assess changes in pain severity and interference. Changes in opioid use disorder status were measured by the Current Opioid Misuse Measure. Desire for opioids, stress, nonreactivity, reinterpretation of pain sensations, and reappraisal were also evaluated. RESULTS: MORE participants reported significantly greater reductions in pain severity (p = .038) and interference (p = .003) than SG participants, which were maintained by 3-month follow-up and mediated by increased nonreactivity and reinterpretation of pain sensations. Compared with SG participants, participants in MORE evidenced significantly less stress arousal (p = .034) and desire for opioids (p = .027), and were significantly more likely to no longer meet criteria for opioid use disorder immediately following treatment (p = .05); however, these effects were not sustained at follow-up. CONCLUSIONS: Findings demonstrate preliminary feasibility and efficacy of MORE as a treatment for co-occurring prescription opioid misuse and chronic pain. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
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MORE did not significantly increase self-reported mindfulness, nor did it result in significant decrements in craving, but it significantly reduced symptoms associated with chronic pain and prescription opioid misuse.
“Contrary to their hypotheses, MORE did not significantly increase self-reported mindfulness, nor did it result in significant decrements in craving, but significantly reduced symptoms associated with chronic pain and prescription opioid misuse.”
From Mindfulness-Based Interventions for the Treatment of Substance and Behavioral Addictions: A Systematic Review (2018) · cites this paper as [56]
The Results (Pre-post treatment analyses; Therapeutic mechanisms; page unavailable) support reductions in pain and opioid-use-disorder symptoms, but report a significant increase in nonreactivity, measured with a self-report mindfulness subscale. They also report significantly less desire for opioids after MORE; the Methods (Measures; page unavailable) identify that measure as a proxy for craving. Thus, the claim’s assertions of no significant mindfulness increase or craving-related decrease are not supported, although the paper cautions that the desire-for-opioids effect was not sustained at follow-up. (LLM, conf=0.90)
Experimental — accuracy not yet measuredEvidence indicates that mindfulness interventions work through reducing stress and craving and improving mindfulness and interoceptive awareness.
“Evidence indicates that mindfulness interventions work through reducing stress and craving and improving mindfulness and interoceptive awareness [15,19,20,28–32].”
From Mindful moms: acceptability and impact of co-designed and digitally delivered video meditations for pregnant and parenting women with opioid use disorder (2025) · cites this paper as [15]
The Results (page unavailable) report lower sympathetic stress arousal and desire for opioids after MORE than after support-group treatment. The Discussion (page unavailable) links treatment effects to increased nonreactivity and attending to interoceptive information with less affective bias. These findings support much of the claim, but they concern MORE in patients with chronic pain and prescription opioid misuse; the paper does not establish that reduced stress and craving are themselves the mechanisms through which mindfulness interventions generally work. (LLM, conf=0.84)
Experimental — accuracy not yet measuredOther studies find moderate effect sizes on reducing craving and opioid use.
“Other studies find moderate effect sizes on reducing craving and opioid use (Cooperman et al., 2021; Garland et al., 2014, 2016).”
From Mindfulness-based cognitive therapy for chronic noncancer pain and prescription opioid use disorder: A qualitative pilot study of its feasibility and the perceived process of change (2023) · cites this paper as Garland et al., 2014
The Results (Pre-post treatment analyses; page unavailable) report a moderate effect on desire for opioids, used as a proxy for craving (d = .50). They also report fewer patients meeting opioid use disorder criteria after treatment, but the Discussion says the study could not quantify opioid dosing. It therefore does not establish a moderate effect size for reduced opioid use. (LLM, conf=0.88)
Experimental — accuracy not yet measuredThere is a dearth of research investigating the efficacy of psychosocial treatments in reducing opioid use among people living with chronic pain.
“There is a dearth of research investigating the efficacy of psychosocial treatments in reducing opioid use among people living with chronic pain.42,43”
From Acceptance and Commitment Therapy to manage pain and opioid use after major surgery: Preliminary outcomes from the Toronto General Hospital Transitional Pain Service (2017) · cites this paper as [42]
The passage under Abstract > Conclusions says there is scant research on psychological treatments that simultaneously address chronic pain and prescription opioid misuse. The claim broadens this to reducing opioid use generally, rather than misuse. The Discussion also says this trial did not quantify changes in opioid dosing. (LLM, conf=0.87)
Experimental — accuracy not yet measuredMindfulness-based interventions have demonstrated promise for supporting recovery and improving mental health for persons with substance use conditions.
“Mindfulness-based interventions have demonstrated promise for supporting recovery and improving mental health for persons with substance use conditions (e.g. Refs. [11–21]).”
From Mindful moms: acceptability and impact of co-designed and digitally delivered video meditations for pregnant and parenting women with opioid use disorder (2025) · cites this paper as [15]
The findings are consistent with other studies that have demonstrated the positive impact of mindfulness interventions on stress and mindfulness constructs.
“Our findings are consistent with other studies that have demonstrated the positive impact of mindfulness interventions on stress and mindfulness constructs [12,15,16,19,20,25–27,30,32].”
From Mindful moms: acceptability and impact of co-designed and digitally delivered video meditations for pregnant and parenting women with opioid use disorder (2025) · cites this paper as [15]
MORE has been shown to produce clinically significant improvements in chronic pain symptoms and prescription opioid misuse.
“Within a behavioral medicine context, MORE has been shown to produce clinically significant improvements in chronic pain symptoms and prescription opioid misuse [80].”
From Testing the mindfulness-to-meaning theory: Evidence for mindful positive emotion regulation from a reanalysis of longitudinal data (2017) · cites this paper as [80]
MORE significantly increased the mindfulness facet of nonreactivity which, in turn, predicted decreases in prescription opioid misuse.
“MORE significantly increased the mindfulness facet of nonreactivity which, in turn, predicted decreases in prescription opioid misuse [41].”
From Mindfulness-based treatment of addiction: current state of the field and envisioning the next wave of research (2018) · cites this paper as [41]
MBRP significantly reduced the association between postintervention depressive symptoms and craving 2 months following treatment, which in turn predicted reduced substance use at 4-months follow-up.
“MBRP significantly reduced the association between postintervention depressive symptoms and craving 2 months following treatment, which in turn predicted reduced substance use at 4-months follow-up [41, 56].”
From Mindfulness-based treatment of addiction: current state of the field and envisioning the next wave of research (2018) · cites this paper as [41]
In individual studies, MBIs produced significant increases in emotion regulation, substance-related self-efficacy, and positive emotions.
“In individual studies, MBIs produced a host of other significant salutary effects including increases in emotion regulation [41, 54], substance-related self-efficacy [65, 66], and positive emotions [33]”
From Mindfulness-based treatment of addiction: current state of the field and envisioning the next wave of research (2018) · cites this paper as [41]
In chronic pain patients with prescription opioid misuse on long-term opioids, MORE participants were more likely to no longer meet criteria for opioid use disorder at post-treatment than support-group control.
“and were more likely to no longer meet criteria for opioid use disorder at post-treatment.40”
MORE seemed to weaken the link between drug craving and addictive behavior.
“decreasing the correlation strength between drug craving and addictive behavior,40”
Earlier randomized controlled trials of MORE used active control conditions intended to control for nonspecific therapeutic factors that could otherwise confound efficacy evaluations.
“prior RCTs of MORE have employed active control conditions39,40 in an attempt to control for nonspecific therapeutic factors (e.g., social support, attention by a caring professional, expectation of benefit) that might otherwise confound evaluations of intervention efficacy”
In chronic pain patients with prescription opioid misuse on long-term opioids, MORE produced greater reductions in pain, stress arousal, and opioid craving than a support-group control.
“In a second trial, a modified version of MORE was tested as a treatment for prescription opioid misuse among chronic pain patients prescribed long-term opioid analgesics (n = 115). Compared with a support-group control condition (n = 58), participants in MORE (n = 57) evidenced greater reductions in pain, stress arousal, and opioid craving, and were more likely to no longer meet criteria for”
In a few studies in patients receiving opioid treatment for chronic pain, mindfulness has been significantly inversely correlated with opioid craving.
“In a few studies in patients receiving opioid treatment for chronic pain, mindfulness has been significantly inversely correlated with opioid craving (134–136).”
From Craving in Opioid Use Disorder: From Neurobiology to Clinical Practice (2019) · cites this paper as [136]
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References 64 · Cited by 431
Research works printed but not linked: 7
- Chu LF Angst MS Clark D 2008 Opioid-induced hyperalgesia in humans: molecular mechanisms and clinical considerations Clinical Journal of Pain 24 6 479 496 18574358
- Garland EL 2012 Pain processing in the human nervous system: A selective review of nociceptive and biobehavioral pathways Primary Care: Clinics in Office Practice 39 3 561 571 PMC3438523 22958566
- Garland EL 2013 Mindfulness-Oriented Recovery Enhancement for addiction, stress, and pain NASW Press Washington, DC
- Garland EL Froeliger B Howard MO (under review) Mindfulness-Oriented Recovery Enhancement reduces opioid craving by restructuring reward responsiveness
- Garnefski N Kraaij V 2007 The cognitive emotion regulation questionnaire: Psychometric features and prospective relationships with depression and anxiety in adults European Journal of Psychological Assessment 23 9 141 149
- Kelley A Garland EL LeCrory CW (in press) Treatment of depression and coping with chronic pain through Mindfulness-Oriented Recovery Enhancement Case Studies in Social Work Practice Wiley New York
- Ling W Charuvastra C Collins JF Batki S Brown LS Kintaudi P Wesson DR McNicholas L Tusel DJ Malkerneker U Renner JA Santos E Casadonte P Fye C Stine S Wang RI Segal D 2002 Buprenorphine maintenance treatment of opiate dependence: a multicenter, randomized clinical trial Addiction 93 4 475 486 9684386
- Authors
- Garland, E. L., Manusov, E. G., Froeliger, B., Kelly, A., Williams, J. M., & Howard, M. O.
- Affiliations
- Southern Regional Area Health Education Centers (US)
- Medical University of South Carolina (US)
- Smith College (US)
- Florida State University (US)
- University of North Carolina at Chapel Hill (US)
- ORCID
- Venue
- Journal of Consulting and Clinical Psychology
- Published
- 2014-06
- Volume
- 82
- Issue
- 3
- Pages
- 448-459
- ISSN
- 0022-006X (ISSN-L)
- 1939-2117
- PMC
- PMC4076008
- OpenAlex
- W1994291283
- Cited by
- 431
- References
- 64
- Citations by year
- 2026: 29 · 2025: 24 · 2024: 26 · 2023: 28 · 2022: 40 · 2021: 37 · 2020: 80 · 2019: 50 · 2018: 29 · 2017: 26 · 2016: 24 · 2015: 22 · 2014: 14 · 2013: 1
- FWCI
- 28.53
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Journal of Consulting and Clinical Psychology (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- ScholarWorks @ UTRGV (The University of Texas Rio Grande Valley) (submittedVersion)
- Funders
- National Institute on Drug Abuse (R03DA032517; R34DA037005)
- Fahs–Beck Fund for Research and Experimentation
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Opioid Use Disorder Treatment
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Keywords
- Mindfulness-Oriented Recovery Enhancement, chronic pain, prescription opioid misuse, opioid use disorder, mindfulness-based interventions, pain intensity, pain interference, stress arousal, support groups
- MeSH terms
- Adult, Aged, Analgesics, Opioid, Arousal, Combined Modality Therapy, Feasibility Studies, Female, Humans, Male, Middle Aged, Opioid-Related Disorders, United States, Veterans, Treatment Outcome, Chronic Pain, Mindfulness
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