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

Development and initial testing of mindful journey: a digital mindfulness-based intervention for promoting recovery from Substance use disorder

BACKGROUND/OBJECTIVES

There is a great unmet need for accessible adjunctive interventions to promote long-term recovery from substance use disorder (SUD). This study aimed to iteratively develop and test the initial feasibility and acceptability of Mindful Journey, a novel digital mindfulness-based intervention for promoting recovery among individuals with SUD.

PATIENTS/MATERIALS

Ten adults receiving outpatient treatment for SUD.

METHODS

Phase 1 (n = 5) involved developing and testing a single introductory digital lesson. Phase 2 included a separate sample (n = 5) and involved testing all 15 digital lessons (each 30- to 45-minutes) over a 6-week period, while also receiving weekly brief phone coaching for motivational/technical support.

RESULTS

Across both phases, quantitative ratings (rated on a 5-point scale) were all at or above a 4 (corresponding with 'agree') for key acceptability dimensions, such as usability, understandability, appeal of visual content, how engaging the content was, and helpfulness for recovery. Additionally, in both phases, qualitative feedback indicated that participants particularly appreciated the BOAT (Breath, Observe, Accept, Take a Moment) tool for breaking down mindfulness into steps. Qualitative feedback was used to iteratively refine the intervention. For example, based on feedback, we added a second core mindfulness tool, the SOAK (Stop, Observe, Appreciate, Keep Curious), and we added more example clients and group therapy videos. In Phase 2, 4 out of 5 participants completed all 15 lessons, providing initial evidence of feasibility. Participants reported that the phone coaching motivated them to use the app. The final version of Mindful Journey was a smartphone app with additional features, including brief on-the-go audio exercises and a library of mindfulness practices. Although, participants used these additional features infrequently.

CONCLUSIONS

Based on promising initial findings, future acceptability and feasibility testing in a larger sample is warranted. Future versions might include push notifications to facilitate engagement in the additional app features.

Effects of Savoring Meditation on Positive Emotions and Pain-Related Brain Function: A Mechanistic Randomized Controlled Trial in People With Rheumatoid Arthritis

Positive emotions are a promising target for intervention in chronic pain, but mixed findings across trials to date suggest that existing interventions may not be optimized to efficiently engage the target. The aim of the current pilot mechanistic randomized controlled trial was to test the effects of a positive emotion-enhancing intervention called Savoring Meditation on pain-related neural and behavioral targets in patients with rheumatoid arthritis. Participants included 44 patients with a physician-confirmed diagnosis of rheumatoid arthritis (n = 29 included in functional magnetic resonance imaging (fMRI) analyses), who were randomized to either Savoring Meditation or a Slow Breathing control. Both meditation interventions were brief (four 20-minute sessions). Self-report measures were collected pre-and post-intervention. An fMRI task was conducted at post-intervention, during which participants practiced the meditation technique on which they had been trained while exposed to non-painful and painful thermal stimuli. Savoring significantly reduced experimental pain intensity ratings relative to rest (P < .001). Savoring also increased cerebral blood flow in the ventromedial prefrontal cortex and increased connectivity between the ventromedial prefrontal cortex and caudate during noxious thermal stimulation relative to Slow Breathing (z = 2.3 voxelwise, false discovery rate cluster corrected P = .05). Participants in the Savoring condition also reported significantly increased positive emotions (ps < .05) and reduced anhedonic symptoms (P < .01) from pre- to post-intervention. These findings suggest that Savoring recruits reward-enhancing corticostriatal circuits in the face of pain, and future work should extend these findings to evaluate if these mechanisms of Savoring are associated with improved clinical pain outcomes in diverse patient populations. PERSPECTIVE: Savoring Meditation is a novel positive emotion-enhancing intervention designed for patients with chronic pain. The present findings provide preliminary evidence that Savoring Meditation is acutely analgesic, and engages neural and subjective emotional targets that are relevant to pain self-management. Future work should evaluate the clinical translation of these findings.

Happy Hour: The association between trait hedonic capacity and motivation to drink alcohol

The (over)consumption of alcohol and other addictive substances is often conceptualized as a problem of low self-control (i.e., people's inability to inhibit unwanted impulses). According to that view, people drink because they cannot resist. In the present studies, we approached this from a different perspective and tested whether alcohol consumption might also be a problem of low hedonic capacity (i.e., people's inability to experience pleasure and relaxation, often due to intrusive thoughts). According to that view, people drink because it helps them enjoy or cope with negative thoughts or emotions. In two studies among individuals at low risk of harmful alcohol use (e.g., AUDIT < 7) we consistently found that trait hedonic capacity was unrelated to alcohol consumption but negatively related to coping motivation (drinking alcohol to cope with negative thoughts and feelings; Study 1: N = 348; Study 2: N = 302, preregistered). Exploratory analyses in study 2 (conducted during the COVID-19 pandemic) also showed that people with low, but not high, trait hedonic capacity drank more alcohol in response to stress. Our findings are in line with the notion that people's drinking motivation and behavior might not only be a problem of poor self-control but also of low trait hedonic capacity. They align with a new direction in addiction prevention and treatment research, which explores ways to help people to seek out and savor hedonic experiences from non-drug related reinforcers (e.g., engaging in leisure activities).

Neuroimaging of opioid effects in humans across conditions of acute administration, chronic pain therapy, and opioid use disorder

Evidence of central nervous system (CNS) exogenous opioid effects in humans has been primarily gained through neuroimaging of three participant populations: individuals after acute opioid administration, those with opioid use disorder (OUD), and those with chronic pain receiving opioid therapy. In both the brain and spinal cord, opioids alter processes of pain, cognition, and reward. Opioid-related CNS effects may persist and accumulate with longer opioid use duration. Meanwhile, opioid-induced benefits versus risks to brain health remain unclear. This review article highlights recent accumulating evidence for how exogenous opioids impact the CNS in humans. While investigation of CNS opioid effects has remained largely disparate across contexts of opioid acute administration, OUD, and chronic pain opioid therapy, integration across these contexts may enable advancement toward effective interventions.

Changes in peripheral oxytocin and vasopressin during a silent month-long Insight meditation retreat

Background

Given its putative roles in mediating prosocial behavior, attachment bonds, and stress physiology, oxytocin modulation has been hypothesized to be a biological correlate of the salubrious effects of meditation practice. Here we investigated the effects of a month-long silent meditation retreat on changes in oxytocin, and the related hormone and vasopressin, in relation to psychosocial changes in attachment style, anxiety, personality measures, and feelings of social connectedness with fellow meditators.

Methods

Plasma oxytocin and vasopressin and self-report questionnaires were measured in retreat participants (n = 28) at the beginning of, and 3 weeks into, a residential meditation retreat. Control participants (n = 34), who were similar in age, gender, and meditation experience, were also assessed across a 3-week interval. Linear mixed effects models were used to assess outcomes.

Results

The retreat group showed a small but significant decrease in oxytocin compared to controls who showed no change. In the retreat group, higher openness to experience at Time 1 predicted greater reductions in oxytocin during the retreat, and lower oxytocin at Time 2 was related to stronger feelings of personal connection with fellow meditators. The changes in oxytocin were not related to attachment style or anxiety. Vasopressin decreased over time across both groups, suggesting no specific effect of retreat.

Conclusion

These preliminary findings suggest that meditation training in the context of a silent residential retreat may reduce circulating levels of oxytocin. We interpret this finding from multiple theoretical perspectives, discussing key measurement limitations and proposing future study designs that may help to differentiate the effects of different meditation practices and contexts on oxytocin signaling.

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.

Naturalistic drug cue reactivity in heroin use disorder: orbitofrontal synchronization as a marker of craving and recovery

Movies captivate groups of individuals (the audience), especially if they contain themes of common motivational interest to the group. In drug addiction, a key mechanism is maladaptive motivational salience attribution whereby drug cues outcompete other reinforcers within the same environment or context. We predicted that while watching a drug-themed movie, where cues for drugs and other stimuli share a continuous narrative context, fMRI responses in individuals with heroin use disorder (iHUD) will preferentially synchronize during drug scenes. Results revealed such drug-biased synchronization in the orbitofrontal cortex (OFC), ventromedial and ventrolateral prefrontal cortex, and insula. After 15 weeks of inpatient treatment, there was a significant reduction in this drug-biased shared response in the OFC, which correlated with a concomitant reduction in dynamically-measured craving, suggesting synchronized OFC responses to a drug-themed movie as a neural marker of craving and recovery in iHUD.

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-induced self-transcendence promotes universal love with consequent effects on opioid misuse

In addition to its health benefits, mindfulness has been theorized in classical contemplative frameworks to elicit self-transcendent experiences as a means of promoting universal love and compassion. Increasing feelings of love may be especially clinically relevant for the treatment of opioid misuse, in that addictive use of opioids dysregulates neurobiological processes implicated in the experience of love. Here we tested these hypotheses in a secondary analysis (n = 187) of data from a randomized clinical trial of Mindfulness-Oriented Recovery Enhancement (MORE) versus supportive psychotherapy for comorbid opioid misuse and chronic pain. At pre- and post-treatment, participants completed a measure of state self-transcendence immediately following a laboratory-based mindfulness task. Through 9-month follow-up, we assessed changes in universal love and opioid misuse. Participants also completed ecological momentary assessments of opioid craving during the 8-week study interventions and for the following month. Compared to supportive psychotherapy, participants in MORE reported significantly greater increases in mindfulness-induced self-transcendence, which mediated the effect of MORE on increased feelings of universal love. In turn, increases in universal love significantly predicted decreased opioid craving and lower odds opioid misuse through 1- and 9-month follow-ups, respectively. Findings suggest mindfulness-induced self-transcendence may promote feelings of universal love, with possible downstream benefits on reducing addictive behavior.

Ultra-Brief Breath Counting (Mindfulness) Training Abolishes Negative Affect-Induced Alcohol Motivation in Hazardous Community Drinkers

Objectives

Mindfulness therapy improves drinking outcomes arguably by attenuating negative mood-induced drinking, but this mechanism has not been demonstrated in hazardous community drinkers. To address this, three studies tested whether a key ingredient of mindfulness, breath counting, would attenuate the increase in motivation for alcohol produced by experimentally induced negative mood, in hazardous community drinkers.

Method

In three studies, hazardous community drinkers were randomized to receive either a 6-min breath counting training or listen to a recited extract from a popular science book, before all participants received a negative mood induction. Motivation for alcohol was measured before and after listening to either the breath counting training or the control audio files, with a craving questionnaire in two online studies (n = 122 and n = 111), or an alcohol versus food picture choice task in a pub context in one in-person study (n = 62).

Results

In Study 1, breath counting reduced alcohol craving. However, since the mood induction protocol did not increase craving, the effect of breath counting in reversing such increase could not be demonstrated. Online breath counting eliminated the increase in alcohol craving induced by negative mood (Study 2) and eliminated the stress-induced increase in alcohol picture choice in the pub environment (Study 3).

Conclusions

Briefly trained breath counting attenuated negative mood-induced alcohol motivation in hazardous community drinkers. These results suggest that breath counting is a reliable and practical method for reducing the impact of negative emotional triggers on alcohol motivation.

Preregistration

These studies are not preregistered.

Cognitive Signatures of Depressive and Anhedonic Symptoms and Affective States Using Computational Modeling and Neurocognitive Testing

BACKGROUND

Deeper phenotyping may improve our understanding of depression. Because depression is heterogeneous, extracting cognitive signatures associated with severity of depressive symptoms, anhedonia, and affective states is a promising approach.

METHODS

Sequential sampling models decomposed behavior from an adaptive approach-avoidance conflict task into computational parameters quantifying latent cognitive signatures. Fifty unselected participants completed clinical scales and the approach-avoidance conflict task by either approaching or avoiding trials offering monetary rewards and electric shocks.

RESULTS

Decision dynamics were best captured by a sequential sampling model with linear collapsing boundaries varying by net offer values, and with drift rates varying by trial-specific reward and aversion, reflecting net evidence accumulation toward approach or avoidance. Unlike conventional behavioral measures, these computational parameters revealed distinct associations with self-reported symptoms. Specifically, passive avoidance tendencies, indexed by starting point biases, were associated with greater severity of depressive symptoms (R = 0.34, p = .019) and anhedonia (R = 0.49, p = .001). Depressive symptoms were also associated with slower encoding and response execution, indexed by nondecision time (R = 0.37, p = .011). Higher reward sensitivity for offers with negative net values, indexed by drift rates, was linked to more sadness (R = 0.29, p = .042) and lower positive affect (R = -0.33, p = .022). Conversely, higher aversion sensitivity was associated with more tension (R = 0.33, p = .025). Finally, less cautious response patterns, indexed by boundary separation, were linked to more negative affect (R = -0.40, p = .005).

CONCLUSIONS

We demonstrated the utility of multidimensional computational phenotyping, which could be applied to clinical samples to improve characterization and treatment selection.

Postoperative interictal epileptiform discharges predict seizure recurrence after antiepileptic drug withdrawal regardless of concordance with surgical site

Objective

The study aimed to explore the association between the site of interictal epileptic discharges (IEDs) on postoperative electroencephalogram (EEG) and seizure recurrence after antiepileptic drug (AED) withdrawal. The study hypothesizes that the concordance of IED sites with surgical sites indicates incomplete resection of epileptic focus, while non-concordance of IED sites with surgical sites indicates postoperative changes or cortical stimulation. The former has a higher risk of seizure recurrence.

Methods

We retrospectively analyzed the postoperative EEG pattern of 182 consecutive children who underwent resection surgery. To identify the risk factors for seizure recurrence, we compared the attributes of seizure recurred and seizure-free groups by univariate and multivariate analyses. AED tapering was standardized, involving a 25% reduction in the dose of a single type of AED every 2 weeks, independent of the presurgical AED load.

Results

We attempted AED withdrawal in 116 (63.7%) children. Twenty-eight (24.1%) children experienced seizure recurrence during or after AED withdrawal. A greater number of AEDs used at the time of surgery (p=0.005), incomplete resection (p=0.001), and presence of IED on postoperative EEG (p=0.011) are predictors of seizure recurrence. The completeness of resection and seizure recurrence after AED withdrawal were related to the presence of IED on the EEG, but not to the concordance of IED with surgical sites.

Conclusion

For children with abnormal EEG, the decision to discontinue AED should be made more cautiously, regardless of the relative location of the discharge site and the surgical site.

Development of two novel treatments to promote smoking cessation: Savor and retrieval-extinction training pilot clinical trial findings

Despite decades of progress, cigarette smoking remains a significant contributor to disease burden. This effect is especially pronounced for specific priority populations, such as individuals who live in rural communities, in that the burden of tobacco smoking is greater among these groups than in urban areas and the general population. The present study aims to evaluate the feasibility and acceptability of two novel tobacco treatment interventions delivered through remote telehealth procedures to individuals who smoke in the state of South Carolina. Results also include exploratory analyses of smoking cessation outcomes. Study I evaluated savoring, a strategy based on mindfulness practices, alongside nicotine replacement therapy (NRT). Study II evaluated retrieval-extinction training (RET), a memory-modification paradigm alongside NRT. In Study I (savoring), recruitment and retention data showed high interest and engagement in the intervention components, and participants who received this intervention decreased cigarette smoking throughout the course of the treatment (ps < .05). In Study II (RET), results showed high interest and moderate engagement in treatment, although exploratory outcome analyses did not demonstrate significant treatment effects on smoking behaviors. Overall, both studies showed promise in generating interest among individuals who smoke in participating in remotely delivered, telehealth smoking cessation interventions with novel therapeutic targets. A brief savoring intervention appeared to have effects on cigarette smoking throughout treatment, whereas RET did not. Gaining insight from the present pilot study, future studies may improve the efficacy of these procedures and incorporate the treatment components into more robust available treatments. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Mindfulness-based Interventions for Chronic Low Back Pain: A Systematic Review and Meta-analysis

OBJECTIVE

This systematic review aimed to compile existing evidence examining the effects of mindfulness-based interventions (MBIs) for chronic low back pain (CLBP). CLBP leads to millions of disabled individuals in the United States each year. Current pharmacologic treatments are only modestly effective and may present long-term safety issues. MBIs, which have an excellent safety profile, have been shown in prior studies to be effective in treating CLBP yet remained underutilized.

DESIGN

Ovid/Medline, PubMed, Embase, and the Cochrane Library were searched for randomized controlled trials (RCTs), pilot RCTs, and single-arm studies that explored the effectiveness of MBIs in CLBP.

METHODS

Separate searches were conducted to identify trials that evaluated MBIs in reducing pain intensity in individuals with CLBP. A meta-analysis was then performed using R v3.2.2, Metafor package v 1.9-7.

RESULTS

Eighteen studies used validated patient-reported pain outcome measures and were therefore included in the meta-analysis. The MBIs included mindfulness meditation, mindfulness-based stress reduction, mindfulness-based cognitive therapy, mindfulness-oriented recovery enhancement, acceptance and commitment therapy, dialectical behavioral therapy, meditation-cognitive behavioral therapy, mindfulness-based care for chronic pain, self-compassion course, and loving-kindness course. Pain intensity scores were reported using a numerical rating scale (0 to 10) or an equivalent scale. The meta-analysis revealed that MBIs have a beneficial effect on pain intensity with a large-sized effect in adults with CLBP.

CONCLUSIONS

MBIs seem to be beneficial in reducing pain intensity. Although these results were informative, findings should be carefully interpreted due to the limited data the high variability in study methodologies, small sample sizes, inclusion of studies with high risk of bias, and reliance on pre-post treatment differences with no attention to maintenance of effects. More large-scale RCTs are needed to provide reliable effect size estimates for MBIs in persons with CLBP.

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.

Association of Cortico-Striatal Engagement During Cue Reactivity, Reappraisal, and Savoring of Drug and Non-Drug Stimuli With Craving in Heroin Addiction

OBJECTIVE

The authors investigated cortico-striatal reactivity to drug cues (as compared with neutral and food cues), drug cue reappraisal, food cue savoring, and their correlations with heroin craving in individuals with heroin use disorder compared with healthy control subjects.

METHODS

Cross-sectional changes in functional MRI blood-oxygen-level-dependent signal during a novel cue reactivity task were assessed in 32 individuals with heroin use disorder (mean age, 40.3 years; seven women) and 21 age- and sex-matched healthy control subjects (mean age, 40.6 years; eight women).

RESULTS

Drug cue reactivity (vs. neutral cues) was significantly higher in the nucleus accumbens in the heroin use disorder group compared with the control group and nominally significantly higher in the orbitofrontal cortex (OFC); ventromedial prefrontal cortex (vmPFC) activity positively correlated with drug craving. Drug cue reactivity (vs. salient food cues) was also higher in the inferior frontal gyrus (IFG) in the heroin use disorder group compared with the control group. Drug reappraisal and food savoring (vs. passive viewing) showed increased IFG and supplementary motor area activity in all participants; in the heroin use disorder group, higher IFG/dorsolateral PFC (dlPFC) activity during drug reappraisal and rostral anterior cingulate cortex (ACC) activity during food savoring were associated with lower drug cue-induced craving and longer treatment, respectively. A direct comparison of regulation of reactivity to both salient cues revealed widespread group differences such that drug reappraisal activity was higher in the heroin use disorder group and food savoring activity was higher in the control group in both cortical (e.g., OFC, IFG, ACC, vmPFC, and insula) and subcortical (e.g., dorsal striatum and hippocampus) regions. Higher drug reappraisal versus food savoring in the dlPFC was associated with higher self-reported methadone dosage in the heroin use disorder group.

CONCLUSIONS

The results demonstrate cortico-striatal upregulation during drug cue exposure and impaired reactivity during processing of alternative non-drug rewards in the heroin use disorder group. Normalizing cortico-striatal function by reducing drug cue reactivity and enhancing natural reward valuation may inform therapeutic mechanisms for reducing drug craving and seeking in heroin addiction.

Be more mindful: Targeting addictive responses by integrating mindfulness with cognitive bias modification or cue exposure interventions

This review provides an overview of the most prominent neurocognitive effects of cognitive bias modification (CBM), cue-exposure therapy and mindfulness interventions for targeting addictive responses. It highlights the key insights that have stemmed from cognitive neuroscience and brain imaging research and combines these with insights from behavioural science in building a conceptual model integrating mindfulness with response-focused CBM or cue-exposure interventions. This furthers our understanding of whether and how mindfulness strategies may i) facilitate or add to the induced response-focused effects decreasing cue-induced craving, and ii) further weaken the link between craving and addictive responses. Specifically, awareness/monitoring may facilitate, and decentering may add to, response-focused effects. Combined awareness acceptance strategies may also diminish the craving-addiction link. The conceptual model presented in this review provides a specific theoretical framework to deepen our understanding of how mindfulness strategies and CBM or cue-exposure interventions can be combined to greatest effect. This is important in both suggesting a roadmap for future research, and for the further development of clinical interventions.

Effects of Savoring Meditation on Positive Emotions and Pain-Related Brain Function: A Mechanistic Randomized Controlled Trial in People With Rheumatoid Arthritis

Positive emotions are a promising target for intervention in chronic pain, but mixed findings across trials to date suggest that existing interventions may not be optimized to efficiently engage the target. The aim of the current mechanistic randomized controlled trial was to test the effects of a single skill positive emotion-enhancing intervention called Savoring Meditation on pain-related neural and behavioral targets in patients with rheumatoid arthritis (RA). Participants included 44 patients with a physician-confirmed diagnosis of RA (n=29 included in fMRI analyses), who were randomized to either Savoring Meditation or a Slow Breathing control. Both meditation interventions were brief (four 20-minute sessions). Self-report measures were collected pre- and post-intervention. An fMRI task was conducted at post-intervention, during which participants practiced the meditation technique on which they had been trained while exposed to non-painful and painful thermal stimuli. Relative to Slow Breathing, Savoring significantly reduced experimental pain intensity ratings relative to rest (p<.001), increased cerebral blood flow in the ventromedial prefrontal cortex (vmPFC) and increased connectivity between the vmPFC and caudate during noxious thermal stimulation (z=2.3 voxelwise, FDR cluster corrected p=0.05). Participants in the Savoring condition also reported significantly increased positive emotions (ps<.05) and reduced anhedonic symptoms (p<.01) from pre- to post-intervention. These findings suggest that that Savoring recruits reward-enhancing corticostriatal circuits in the face of pain, and future work should extend these findings to evaluate if these mechanisms of Savoring are associated with improved clinical pain outcomes in diverse patient populations.

Efficacy of mindfulness-based relapse prevention in a sample of veterans in a substance use disorder aftercare program: A randomized controlled trial

BACKGROUND

Complementary integrative medicine, such as mindfulness-based interventions, (MBI) have demonstrated efficacy in the treatment of depression, anxiety, substance use disorders (SUDs), and pain. Mindfulness-based relapse prevention (MBRP) is an aftercare intervention targeting SUD relapse that integrates cognitive-behavioral relapse prevention and mindfulness meditation practices, raising awareness of substance use triggers and reactive behavioral patterns. This study evaluated the efficacy of MBRP in reducing relapse in veterans following completion of an SUD treatment program.

METHODS

This study was a two-site, randomized controlled trial comparing MBRP to 12-step facilitation (TSF) aftercare in military veterans following completion of intensive treatment for SUDs. The 8 weeks of 90-minute, group-based MBRP or TSF sessions were followed by 3-, 6- and 10-month follow-up periods with assessments of alcohol/substance use and secondary outcomes of depression, anxiety, and mindfulness.

RESULTS

Forty-seven percent of veterans attended ≥75 % of sessions. Veterans in both the MBRP and TSF aftercare groups maintained reductions in alcohol and illicit substance use during the aftercare treatment. Nineteen participants (11 %; 19/174) reported returning to alcohol use during the study treatment period and the study found no difference between study groups [MBRP: 9 % vs. TSF 13 %; p = 0.42]. Thirteen participants (7.5 %; 13/174) reported a return to illicit substance use during study treatment [MBRP: 5.4 % vs. TSF 10.3 % p = 0.34]. The number of days of drinking and illicit substance use was not different between groups (alcohol, p = 0.53; illicit substance use, p = 0.28).

CONCLUSION

Although retention in treatment limits interpretation of the findings, both MBRP and TSF were effective in maintenance of treatment gains following an intensive treatment program for veterans with SUDs. Future studies should focus on strategies to improve treatment participation.

Patient Perceptions of Integrating Meditation-based Interventions in Office-based Opioid Treatment with Buprenorphine: A Mixed-methods Survey

INTRODUCTION

Recent findings support the provision of meditation-based interventions (MBIs) in primary care. However, the acceptability of MBI among patients prescribed medications for opioid use disorder (eg, buprenorphine) in primary care remains unclear. This study assessed experiences and preferences for adopting MBI among patients prescribed buprenorphine in office-based opioid treatment (OBOT).

METHODS

This 23-item, semistructured cross-sectional survey was administered by study staff to patients enrolled in OBOT (N = 72) and consisted of demographic and clinical characteristics, perceptions, experiences with MBI, and preferred strategies to access MBI to support their treatment on buprenorphine.

RESULTS

Most participants reported practicing at least 1 category of MBI (90.3%) on at least a daily (39.6%) or weekly (41.7%) basis including (1) spiritual meditation (eg, centering prayer; 67.7%); (2) nonmantra meditation (eg, comfortable posture; 61.3%); (3) mindfulness meditation (eg, mindfulness-based stress reduction; 54.8%); and (4) mantra meditation (eg, transcendental meditation; 29.0%). Interest in MBI was motivated by improving one's general health and well-being (73.4%), treatment outcomes with medications for OUD (eg, buprenorphine; 60.9%), and relationships with others (60.9%). Perceived clinical benefits of MBI included reduced anxiety or depression symptoms (70.3%), pain (62.5%), illicit substance or alcohol use (60.9%), cravings for illicit substances (57.8%), and opioid-related withdrawal symptoms (51.6%).

CONCLUSIONS

Findings from this study indicate high acceptability for adopting MBI among patients prescribed buprenorphine in OBOT. Further research is needed to assess the efficacy of MBI to improve clinical outcomes among patients initiating buprenorphine in OBOT.

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.

Restructuring reward: A pilot study to enhance natural reward response in adults with cannabis use disorder

BACKGROUND

Hedonic dysregulation is a core mechanism of addiction. There is a dearth of research on hedonic dysregulation in cannabis use disorder (CUD). The current study tested whether personalized scripted imagery may be an efficacious approach to remediate reward functioning in adults with CUD.

METHODS

Adults with CUD (n=10) and non-CUD controls (n=12) completed a single session personalized scripted imagery procedure. Non-drug (i.e. natural) reward and neutral scripts were transcribed and participants listened to the scripts in counterbalanced order. Primary outcomes included positive affect (PA), galvanic skin response (GSR), and cortisol and were assessed at four timepoints. Mixed effects models were used to compare between and within subject effects.

RESULTS

Mixed effects models revealed a Condition (reward vs. neutral) X Group (CUD vs. control) interaction (p=0.01) on PA response, indicating blunted PA response to the neutral script relative to the reward script in CUD participants. Likewise, GSR response in CUD participants was decreased in response to the neutral script relative to the reward script (p=0.034; interaction n.s.). An interaction effect of Group X PA on cortisol response was found (p=.036) indicating that cortisol was positively correlated with PA in healthy control participants, but not CUD participants.

CONCLUSIONS

Adults with CUD may demonstrate acute deficits in hedonic tone under neutral conditions relative to healthy controls. Personalized scripted imagery may be an efficacious tool to remediate hedonic dysregulation in CUD. Cortisol may play a role in healthy positive affect regulation warranting further investigation.

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).

Cognitive training and remediation interventions for substance use disorders: a Delphi consensus study

AIMS

Substance use disorders (SUD) are associated with cognitive deficits that are not always addressed in current treatments, and this hampers recovery. Cognitive training and remediation interventions are well suited to fill the gap for managing cognitive deficits in SUD. We aimed to reach consensus on recommendations for developing and applying these interventions.

DESIGN, SETTING AND PARTICIPANTS

We used a Delphi approach with two sequential phases: survey development and iterative surveying of experts. This was an on-line study. During survey development, we engaged a group of 15 experts from a working group of the International Society of Addiction Medicine (Steering Committee). During the surveying process, we engaged a larger pool of experts (n = 54) identified via recommendations from the Steering Committee and a systematic review.

MEASUREMENTS

Survey with 67 items covering four key areas of intervention development: targets, intervention approaches, active ingredients and modes of delivery.

FINDINGS

Across two iterative rounds (98% retention rate), the experts reached a consensus on 50 items including: (i) implicit biases, positive affect, arousal, executive functions and social processing as key targets of interventions; (ii) cognitive bias modification, contingency management, emotion regulation training and cognitive remediation as preferred approaches; (iii) practice, feedback, difficulty-titration, bias modification, goal-setting, strategy learning and meta-awareness as active ingredients; and (iv) both addiction treatment work-force and specialized neuropsychologists facilitating delivery, together with novel digital-based delivery modalities.

CONCLUSIONS

Expert recommendations on cognitive training and remediation for substance use disorders highlight the relevance of targeting implicit biases, reward, emotion regulation and higher-order cognitive skills via well-validated intervention approaches qualified with mechanistic techniques and flexible delivery options.

Disentangling the Effects of Mindfulness, Savoring, and Depressive Symptoms among Emerging Adults

The links between mindfulness, savoring positive experiences, and depressive symptoms have been well established in the literature. Nevertheless, little has been done to disentangle the prospective relations among these constructs. Clarifying the longitudinal relations is crucial, as it enables researchers and practitioners to discern potential trajectories of mental health interventions. In this study, 180 emerging adults between 18 and 27 years old were recruited twice at 3 months apart to complete self-reported measures including mindfulness, savoring positive experiences, and depressive symptoms. Cross-lagged path analysis indicated that savoring the moment was predictive of mindfulness three months later, whereas depressive symptoms were predictive of both mindfulness and savoring the moment three months later, above and beyond the effects of age, gender, and family income. Additionally, mindfulness, savoring positive experiences, and depressive symptoms were significantly correlated at baseline. The present study evidenced short-term inverse effects of depressive symptoms on mindfulness and savoring the moment, as well as a positive effect of savoring the moment on mindfulness. Hence, interventions geared towards reducing symptoms of depression are likely to carry concurrent and prospective benefits for psychological functioning, namely the ability to be present in the moment and to savor.

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 Treatment of Substance Use Disorders: Recent Developments and New Perspectives

Substance-related disorders are complex psychiatric disorders that are characterized by continued consumption in spite of harmful consequences. Addiction affects various brain networks critically involved in learning, reward, and motivation, as well as inhibitory control. Currently applied therapeutic approaches aim at modification of behavior that ultimately leads to decrease of consumption or abstinence in individuals with substance use disorders. However, traditional treatment methods might benefit from recent neurobiological and cognitive neuroscientific research findings. Novel cognitive-behavioral approaches in the treatment of addictive behavior aim at enhancement of strategies to cope with stressful conditions as well as craving-inducing cues and target erroneous learning mechanisms, including cognitive bias modification, reconsolidation-based interventions, mindfulness-based interventions, virtual-reality-based cue exposure therapy as well as pharmacological augmentation strategies. This review discusses therapeutic strategies that target dysregulated neurocognitive processes associated with the development and maintenance of disordered substance use and may hold promise as effective treatments for substance-related disorders.

Acute sensitization of the P3 event-related potential response to beverage images and the risk for alcohol use disorder

Previous research suggests the amplitude of the P3 event-related potential (ERP) response reflects the incentive value of the eliciting stimulus, and that individuals with trait-like lower sensitivity (LS) to the acute effects of alcohol, a potent risk factor for alcohol use disorder (AUD), tend to show exaggerated P3 ERP responses to alcohol beverage cues (compared to their peers with higher sensitivity; HS). No prior research has examined trajectories of the cue-elicited P3 response across repeated trials of nonreinforced cue presentations. Characterizing these trajectories can be informative as to potential mechanisms linking LS with increased AUD risk. Here, we tested whether individual differences in alcohol sensitivity are associated with different trial-by-trial trajectories of the P3 elicited by alcohol and nonalcohol reward cues (infrequent oddball/target stimuli) using a large sample of emerging adults (M _age = 19.53; N = 287; 55% female; 86% White; 90% right-handed) stratified for alcohol sensitivity. Multilevel models adjusted for age, sex, handedness, and alcohol use indicated that: (i) the P3 response to alcohol and nonalcohol reward cues alike sensitized (i.e., increased) across trials; (ii) across the task, the P3 response to alcohol cues was larger for the LS than the HS phenotype; and (iii) the P3 difference score (alcohol - nonalcohol) was larger for the LS than HS phenotype only across the first half of task. Findings suggest that whereas incentive value attribution may be a mechanism for alcohol cue-triggered attentional biases for both LS and HS individuals, LS individuals more consistently over-attribute incentive value to alcohol cues.

Learning from addiction: Craving of prescription opioids in chronic pain sufferers

Prescription opioids are a primary driver of opioid-related deaths. Although craving is a substantial component of OUD, the degree to which craving leads to misuse among chronic pain patients on long-term prescription opioids is unknown. A clear understanding of the factors that lead to misuse in this vulnerable population is needed for the development of safe and effective practices for opioid taper. This narrative review summarizes the relevant literature on the role of craving in addiction and chronic pain through epidemiological and behavioral studies. The first part of this review examines the role of craving in predicting opioid use/misuse in individuals with chronic pain with and without OUD. The second part covers methods on how craving is evaluated experimentally using both subjective and objective measures and provides related findings. The overall goal of this review is to facilitate the development of a population-specific description of craving in those who use opioids to control chronic pain and to describe how it may be mechanistically linked to patterns of opioid (mis)use.

Prefrontal cortical response to natural rewards and self-reported anhedonia are associated with greater craving among recently withdrawn patients in residential treatment for opioid use disorder

Both anhedonia and craving are common among patients with opioid use disorder (OUD), and are associated with vulnerability to relapse. Although these constructs are theoretically linked relatively few studies have examined them together. In the current study, recently withdrawn patients (N = 71) in residential treatment for prescription OUD underwent a cue reactivity paradigm while being monitored with functional near-infrared spectroscopy (fNIRS). Patients also self-reported symptoms of anhedonia via the Snaith-Hamilton Pleasure Scale (SHAPS), while smartphone-based ecological momentary assessments (EMA) were used to measure craving levels. On average, lower right prefrontal cortex (PFC) activity in response to positive social stimuli was associated with higher craving (β = - 2.87; S.E. = 1.23; p = 0.02). Self-reported anhedonia moderated the association between PFC activity and craving (β = - 1.02; S.E. = 0.48; p = 0.04), such that patients with two or more anhedonic symptoms had a significant and stronger negative association between PFC activation to hedonically positive images and craving, compared to patients with fewer than two anhedonic symptoms, among whom the association was not significant. This finding provides evidence that higher levels of anhedonia among patients in residential treatment for OUD are associated with a stronger link between lower PFC response to positive social experiences and higher levels of craving, potentially increasing overall vulnerability to relapse.

The impact of mindfulness meditation on social and moral behavior: Does mindfulness enhance other-oriented motivation or decrease monetary reward salience?

This perspective article provides an overview of the impact of mindfulness meditation (MM) on social and moral behavior. In mindfulness research, prosocial behavior has been operationalized as helping behavior, altruistic redistribution of funds, reparative behavior, or monetary donation. Studies concerning moral behavior are still scarce. Despite inconsistent evidence, several studies found a beneficial effect of mindfulness on prosocial outcomes (i.e., a higher propensity to spend or give away money for the sake of other individuals). However, since the employed tasks were reward-based, participants’ decisions also directly affected their own payoff by reducing it. Crucially, MM also affects self-control circuitry and reduces reward-seeking behaviors and reward salience by making rewards less tempting. We have discussed evidence suggesting how challenging it may be to dissociate the specific weight of enhanced other-oriented motivation from one of the decreased monetary reward salience in explaining meditators’ behavior. Future higher-quality studies are needed to address this open issue.

Simulated opioid choice linked to opioid use disorder severity among veterans with chronic pain: initial validation of a novel paradigm

Background: Modeling addictive behavior among individuals with, or at risk for, opioid use disorder (OUD) in a way that is accurate, ethical, and reproducible presents a pressing concern. OUD risk is elevated among people with chronic pain on long-term opioid therapy (LTOT).Objectives: To provide initial validation of a novel opioid preference task as an index of OUD and its symptomatology among veterans prescribed opioids for chronic pain, a population at high risk for poor opioid-related outcomes. The relative ease by which such a paradigm can be implemented and performed in clinical contexts, including enabling investigation of opioid reinforcement and drug-seeking behavior while avoiding ethical pitfalls associated with direct drug administration, could make this task an attractive approach for potentially tracking OUD symptoms.Methods: We studied 87 veterans (74 males, 13 females) on LTOT for chronic pain - 33 of whom had OUD diagnoses. Participants completed a picture-viewing choice task to assess preference for viewing opioid-related images in comparison with standardized pleasant, unpleasant, neutral, and blank images. Opioid-related choice, measured by vigor of button pressing, was tested for association with OUD severity (measured by symptom counts), as well as craving and anhedonia.Results: Choice for opioid-related images was positively correlated with OUD severity (i.e., number of DSM-5 measured OUD symptoms) (r = 0.38, p < .001), particularly among those meeting diagnostic criteria for OUD (r = 0.47, p = .006). Neither craving nor anhedonia correlated with opioid-related choice.Conclusions: Our results provide initial validation for a new opioid picture-choice paradigm in patients with chronic pain.

Startle-elicited Event-Related Potentials to Affective Stimuli are Associated with Recent Illicit Opioid use among Patients Receiving Opioid Agonist Treatment

Opioid use disorder (OUD) has been linked to exaggerated attentional, affective, and arousal responses to opioid-related stimuli, as well as altered responses to other affective (eg, naturally rewarding or aversive) stimuli, particularly blunted responses to pleasant/rewarding stimuli. Both exaggerated responses to drug-related stimuli and reduced response to pleasant stimuli may influence the course of OUD and its treatment, however interpretation of studies thus far is limited by methodological issues. In the present study, we examined subjective ratings, and attenuation of the P3 component of the acoustic startle-evoked event-related potential (as a measure of attention), while viewing neutral, pleasant, unpleasant, and drug-related images. Participants prescribed opioid agonist treatment (OAT) for OUD (n = 82) were compared to a carefully-matched control group (n = 33) and to recently-abstinent participants with OUD (n = 22). Relative to controls, participants prescribed OAT gave higher positive valence ratings of drug images, and blunted valence responses to other affective images, but groups did not differ in terms of arousal ratings or P3 amplitude. Within the OAT group, linear modeling of associations between frequency of recent illicit opioid use and startle P3 amplitude found an association between increased recent illicit opioid use and reduced attention to pleasant, relative to unpleasant, images. The latter finding may have implications for interventions targeting cognitive biases in people with substance use disorder. In particular, they suggest that enhancing attention to pleasant stimuli may be as, if not more important, than the typical approach of trying to reduce attentional bias to drug-related stimuli.

Neurophysiological Deficits During Reappraisal of Negative Emotional Stimuli in Opioid Misuse

BACKGROUND

Opioid misuse is hypothesized to compromise the ability to regulate negative emotions, as manifested through visceral and peripheral physiological signals. However, neurophysiological impairment of top-down cognitive emotion regulation in opioid misuse has not previously been shown.

METHODS

Patients with chronic pain who had been taking opioids for 90 days or longer (N = 149; female, n = 98) underwent a negative emotion regulation task with electroencephalography. Participants were instructed to view or reappraise negative images presented for 3 seconds. Using a validated cutoff score on the Current Opioid Misuse Measure, participants were classified as exhibiting aberrant drug-related behavior consistent with opioid misuse (MISUSE+) or as being low risk for opioid misuse (MISUSE-). Participants reported their craving in response to negative emotions over the past week.

RESULTS

We observed a group × condition interaction (p = .003) such that the MISUSE- group decreased the late positive potential of the electroencephalography during reappraisal, whereas the MISUSE+ group showed increased late positive potential during reappraisal. This deficit in negative emotion regulation remained significant after controlling for an array of potential confounding variables, including opioid dose, pain, and depression. Heightened late positive potential during reappraisal was associated with more severe opioid craving.

CONCLUSIONS

Opioid misuse may occasion top-down deficits in emotional regulation that begin as early as 400 ms after presentation of negative stimuli. It remains unknown whether emotion dysregulation is the cause, correlate, or consequence of opioid misuse. Nonetheless, targeting emotion dysregulation in opioid misuse with reappraisal-focused interventions may represent an important treatment approach.

Emotional distress and pain catastrophizing predict cue-elicited opioid craving among chronic pain patients on long-term opioid therapy

BACKGROUND

Individuals who use illicit substances exhibit cue-elicited craving and autonomic cue-reactivity when exposed to cues associated with past drug use. However, little is known about this phenomenon among chronic pain patients on long-term opioid therapy (LTOT). Negative cognitive-emotional reactivity in general (e.g., distress) and cognitive-emotional reactivity specific to pain (e.g., pain catastrophizing) might drive cue-reactivity independent of pain severity. Here we examined emotional distress and pain catastrophizing as predictors of cue-reactivity among a sample of chronic pain patients receiving LTOT. We also tested whether associations between distress, catastrophizing, and cue-reactivity differed as a function of opioid misuse status.

MATERIALS AND METHODS

Patients receiving LTOT (N = 243) were classified as exhibiting aberrant behavior consistent with opioid misuse (MISUSE+, n = 145) or as using opioids as prescribed (MISUSE-, n = 97). Participants completed assessments of pain catastrophizing and emotional distress and then participated in an opioid cue-reactivity task one week later. Cue-elicited opioid craving and autonomic cue-reactivity were measured with craving ratings and high-frequency heart rate variability (HRV), respectively.

RESULTS

Distress and catastrophizing predicted cue-elicited craving and HRV, whereas pain severity did not. Misuser status moderated the relationship between emotional distress and self-reported craving, such that higher levels of distress predicted craving among the MISUSE+ group, but not among the MISUSE- group. No moderating effects were found for catastrophizing.

CONCLUSIONS

Findings suggest that although opioids are prescribed for analgesia, the exacerbating influence of negative cognitive-emotional reactivity, both in general and specific to pain, on cue-elicited opioid craving extends beyond the effects of pain severity alone.

Mechanisms of Behavior Change in Substance Use Disorder With and Without Formal Treatment

This article provides a narrative review of studies that examined mechanisms of behavior change in substance use disorder. Several mechanisms have some support, including self-efficacy, craving, protective behavioral strategies, and increasing substance-free rewards, whereas others have minimal support (e.g., motivation, identity). The review provides recommendations for expanding the research agenda for studying mechanisms of change, including designs to manipulate putative change mechanisms, measurement approaches that expand the temporal units of analysis during change efforts, more studies of change outside of treatment, and analytic approaches that move beyond mediation tests. The dominant causal inference approach that focuses on treatment and individuals as change agents could be expanded to include a molar behavioral approach that focuses on patterns of behavior in temporally extended environmental contexts. Molar behavioral approaches may advance understanding of how recovery from substance use disorder is influenced by broader contextual features, community-level variables, and social determinants of health. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Internal consistency and test-retest reliability of the P3 event-related potential (ERP) elicited by alcoholic and non-alcoholic beverage pictures

Addiction researchers are interested in the ability of neural signals, like the P3 component of the ERP, to index individual differences in liability factors like motivational reactivity to alcohol/drug cues. The reliability of these measures directly impacts their ability to index individual differences, yet little attention has been paid to their psychometric properties. The present study fills this gap by examining within-session internal consistency reliability (ICR) and between-session test-retest reliability (TRR) of the P3 amplitude elicited by images of alcoholic beverages (Alcohol Cue P3) and non-alcoholic drinks (NADrink Cue P3) as well as the difference between them, which isolates alcohol cue-specific reactivity in the P3 (ACR-P3). Analyses drew on data from a large sample of alcohol-experienced emerging adults (session 1 N = 211, 55% female, aged 18-20 yr; session 2 N = 98, 66% female, aged 19-21 yr). Evaluated against domain-general thresholds, ICR was excellent (M ± SD; r= 0.902 ± 0.030) and TRR was fair (r = 0.706 ± 0.020) for Alcohol Cue P3 and NADrink Cue P3, whereas for ACR-P3, ICR and TRR were poor (r = 0.370 ± 0.071; r = 0.201 ± 0.042). These findings indicate that individual differences in the P3 elicited by cues for ingested liquid rewards are highly reliable and substantially stable over 8-10 months. Individual differences in alcohol cue-specific P3 reactivity were less reliable and less stable. The conditions under which alcohol/drug cue-specific reactivity in neural signals is adequately reliable and stable remain to be discovered.

Current Progress and Future Directions for Theory and Research on Savoring

As research on savoring has increased dramatically since publication of the book Savoring: A New Model of Positive Experience (Bryant and Veroff, 2007), savoring has gradually become a core concept in positive psychology. I begin by reviewing the evolution of this concept, the development of instruments for assessing savoring ability and savoring strategies, and the wide range of applications of savoring in the psychosocial and health sciences. I then consider important directions for future theory and research. To advance our understanding of how naturalistic savoring unfolds over time, future work should integrate the perceptual judgments involved in not only the later stages of attending to and regulating positive experience (where past research has concentrated), but also the initial stages of searching for and noticing positive stimuli. Whereas most research has investigated reactive savoring, which occurs spontaneously in response to positive events or feelings, future work is also needed on proactive savoring, which begins with the deliberate act of seeking out or creating positive stimuli. To advance the measurement of savoring-related constructs, I recommend future work move beyond retrospective self-report methods toward the assessment of savoring as it occurs in real-time. The development of new methods of measuring meta-awareness and the regulation of attentional focus are crucial to advancing our understanding of savoring processes. I review recent research on the neurobiological correlates of savoring and suggest future directions in which to expand such work. I highlight the need for research aimed at unraveling the developmental processes through which savoring skills and deficits evolve and the role that savoring impairments play in the etiology and maintenance of psychopathology. Research is also needed to learn more about what enhances savoring, and to disentangle how people regulate the intensity versus duration of positive emotions. Finally, I encourage future researchers to integrate the study of anticipation, savoring the moment, and reminiscence within individuals across time.

Understanding and restoring dopaminergic function in fibromyalgia patients using a mindfulness-based psychological intervention: a [18F]-DOPA PET study. Study protocol for the FIBRODOPA study—a randomized controlled trial

Background

Fibromyalgia (FM) is a very prevalent and debilitating chronic pain disorder that is difficult to treat. Mindfulness-based techniques are regarded as a very promising approach for the treatment of chronic pain and in particular FM. The Mindfulness-Oriented Recovery Enhancement (MORE) intervention, a mindfulness-based group intervention, has shown beneficial effects in opioid-treated chronic pain patients, including reduced pain severity, functional interference, and opioid dosing, by restoring neurophysiological and behavioral responses to reward. The first evidence for a hypodopaminergic state and impaired reward processing in FM has been reported. However, little is known about its impact on dopamine (DA) function and in particular with regard to DA responses to monetary reward in FM. The aim of the present study protocol is to evaluate if MORE is able to restore the DA function in FM patients, in particular with regard to the DA responses to reward, and to reduce pain and mood complaints in FM.

Methods

The present study is a multi-center interventional RCT with 3 time points: before the intervention, after completion of the intervention, and 3 months after completion of the intervention. Sixty-four FM patients will be randomly assigned to either the MORE intervention (N = 32) or a non-intervention control group (N = 32). Additionally, a comparison group of healthy women (N = 20) for PET measures will be enrolled and another group of healthy women (N = 15) will do the ambulatory assessments only. The MORE intervention consists of eight 2-h-long group sessions administered weekly over a period of 8 weeks. Before and after the intervention, FM participants will undergo [18F] DOPA positron emission tomography (PET) and functional MR imaging while performing a reward task. The primary outcome will be endogeneous DA changes measured with [18F] DOPA PET at baseline, after the intervention (after 8 weeks for the non-intervention control group), and at 3 months’ follow-up. Secondary outcomes will be (1) clinical pain measures and FM symptoms using standardized clinical scales; (2) functional brain changes; (3) measures of negative and positive affect, stress, and reward experience in daily life using the ambulatory assessment method (AA); and (4) biological measures of stress including cortisol and alpha-amylase.

Discussion

If the findings of this study confirm the effectiveness of MORE in restoring DA function, reducing pain, and improving mood symptoms, MORE can be judged to be a promising means to improve the quality of life in FM patients. The findings of this trial may inform health care providers about the potential use of the MORE intervention as a possible non-pharmacological intervention for FM.

Trial registration

ClinicalTrials.govNCT 04451564. Registered on 3 July 2020. The trial was prospectively registered.

An Integrated Mechanistic Model of Mindfulness-Oriented Recovery Enhancement for Opioid-Exposed Mother-Infant Dyads

A growing body of neurobiological and psychological research sheds light on the mechanisms underlying the development and maintenance of opioid use disorder and its relation to parenting behavior. Perinatal opioid use is associated with risks for women and children, including increased risk of child maltreatment. Drawing from extant data, here we provide an integrated mechanistic model of perinatal opioid use, parenting behavior, infant attachment, and child well-being to inform the development and adaptation of behavioral interventions for opioid-exposed mother-infant dyads. The model posits that recurrent perinatal opioid use may lead to increased stress sensitivity and reward dysregulation for some mothers, resulting in decreased perceived salience of infant cues, disengaged parenting behavior, disrupted infant attachment, and decreased child well-being. We conclude with a discussion of Mindfulness-Oriented Recovery Enhancement as a means of addressing mechanisms undergirding perinatal opioid use, parenting, and attachment, presenting evidence on the efficacy and therapeutic mechanisms of mindfulness. As perinatal opioid use increases in the United States, empirically informed models can be used to guide treatment development research and address this growing concern.

Mindfulness-based interventions for substance use disorders

BACKGROUND

Substance use disorders (SUDs) are highly prevalent and associated with a substantial public health burden. Although evidence-based interventions exist for treating SUDs, many individuals remain symptomatic despite treatment, and relapse is common.Mindfulness-based interventions (MBIs) have been examined for the treatment of SUDs, but available evidence is mixed.

OBJECTIVES

To determine the effects of MBIs for SUDs in terms of substance use outcomes, craving and adverse events compared to standard care, further psychotherapeutic, psychosocial or pharmacological interventions, or instructions, waiting list and no treatment.

SEARCH METHODS

We searched the following databases up to April 2021: Cochrane Drugs and Alcohol Specialised Register, CENTRAL, PubMed, Embase, Web of Science, CINAHL and PsycINFO. We searched two trial registries and checked the reference lists of included studies for relevant randomized controlled trials (RCTs).

SELECTION CRITERIA

RCTs testing a MBI versus no treatment or another treatment in individuals with SUDs. SUDs included alcohol and/or drug use disorders but excluded tobacco use disorders. MBIs were defined as interventions including training in mindfulness meditation with repeated meditation practice. Studies in which SUDs were formally diagnosed as well as those merely demonstrating elevated SUD risk were eligible.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Forty RCTs met our inclusion criteria, with 35 RCTs involving 2825 participants eligible for meta-analysis. All studies were at high risk of performance bias and most were at high risk of detection bias. Mindfulness-based interventions (MBIs) versus no treatment Twenty-four RCTs included a comparison between MBI and no treatment. The evidence was uncertain about the effects of MBIs relative to no treatment on all primary outcomes: continuous abstinence rate (post: risk ratio (RR) = 0.96, 95% CI 0.44 to 2.14, 1 RCT, 112 participants; follow-up: RR = 1.04, 95% CI 0.54 to 2.01, 1 RCT, 112 participants); percentage of days with substance use (post-treatment: standardized mean difference (SMD) = 0.05, 95% CI -0.37 to 0.47, 4 RCTs, 248 participants; follow-up: SMD = 0.21, 95% CI -0.12 to 0.54, 3 RCTs, 167 participants); and consumed amount (post-treatment: SMD = 0.10, 95% CI -0.31 to 0.52, 3 RCTs, 221 participants; follow-up: SMD = 0.33, 95% CI 0.00 to 0.66, 2 RCTs, 142 participants). Evidence was uncertain for craving intensity and serious adverse events. Analysis of treatment acceptability indicated MBIs result in little to no increase in study attrition relative to no treatment (RR = 1.04, 95% CI 0.77 to 1.40, 21 RCTs, 1087 participants). Certainty of evidence for all other outcomes was very low due to imprecision, risk of bias, and/or inconsistency. Data were unavailable to evaluate adverse events. Mindfulness-based interventions (MBIs) versus other treatments (standard of care, cognitive behavioral therapy, psychoeducation, support group, physical exercise, medication) Nineteen RCTs included a comparison between MBI and another treatment. The evidence was very uncertain about the effects of MBIs relative to other treatments on continuous abstinence rate at post-treatment (RR = 0.80, 95% CI 0.45 to 1.44, 1 RCT, 286 participants) and follow-up (RR = 0.57, 95% CI 0.28 to 1.16, 1 RCT, 286 participants), and on consumed amount at post-treatment (SMD = -0.42, 95% CI -1.23 to 0.39, 1 RCT, 25 participants) due to imprecision and risk of bias. The evidence suggests that MBIs reduce percentage of days with substance use slightly relative to other treatments at post-treatment (SMD = -0.21, 95% CI -0.45 to 0.03, 5 RCTs, 523 participants) and follow-up (SMD = -0.39, 95% CI -0.96 to 0.17, 3 RCTs, 409 participants). The evidence was very uncertain about the effects of MBIs relative to other treatments on craving intensity due to imprecision and inconsistency. Analysis of treatment acceptability indicated MBIs result in little to no increase in attrition relative to other treatments (RR = 1.06, 95% CI 0.89 to 1.26, 14 RCTs, 1531 participants). Data were unavailable to evaluate adverse events.

AUTHORS' CONCLUSIONS

In comparison with no treatment, the evidence is uncertain regarding the impact of MBIs on SUD-related outcomes. MBIs result in little to no higher attrition than no treatment. In comparison with other treatments, MBIs may slightly reduce days with substance use at post-treatment and follow-up (4 to 10 months). The evidence is uncertain regarding the impact of MBIs relative to other treatments on abstinence, consumed substance amount, or craving. MBIs result in little to no higher attrition than other treatments. Few studies reported adverse events.

Mindfulness and Behavior Change

Initiating and maintaining behavior change is key to the prevention and treatment of most preventable chronic medical and psychiatric illnesses. The cultivation of mindfulness, involving acceptance and nonjudgment of present-moment experience, often results in transformative health behavior change. Neural systems involved in motivation and learning have an important role to play. A theoretical model of mindfulness that integrates these mechanisms with the cognitive, emotional, and self-related processes commonly described, while applying an integrated model to health behavior change, is needed. This integrative review (1) defines mindfulness and describes the mindfulness-based intervention movement, (2) synthesizes the neuroscience of mindfulness and integrates motivation and learning mechanisms within a mindful self-regulation model for understanding the complex effects of mindfulness on behavior change, and (3) synthesizes current clinical research evaluating the effects of mindfulness-based interventions targeting health behaviors relevant to psychiatric care. The review provides insight into the limitations of current research and proposes potential mechanisms to be tested in future research and targeted in clinical practice to enhance the impact of mindfulness on behavior change.

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.

Day-to-day hedonic and calming effects of opioids, opioid craving, and opioid misuse among patients with chronic pain prescribed long-term opioid therapy

ABSTRACT

Concerns have been raised regarding the misuse of opioids among patients with chronic pain. Although a number of factors may contribute to opioid misuse, research has yet to examine if the hedonic and calming effects that can potentially accompany the use of opioids contribute to opioid misuse. The first objective of this study was to examine the degree to which the hedonic and calming effects of opioids contribute to opioid misuse in patients with chronic pain. We also examined whether the hedonic and calming effects of opioids contribute to patients' daily levels of opioid craving, and whether these associations were moderated by patients' daily levels of pain intensity, catastrophizing, negative affect, or positive affect. In this longitudinal diary study, patients (n = 103) prescribed opioid therapy completed daily diaries for 14 consecutive days. Diaries assessed a host of pain, psychological, and opioid-related variables. The hedonic and calming effects of opioids were not significantly associated with any type of opioid misuse behavior. However, greater hedonic and calming effects were associated with heightened reports of opioid craving (both P's < 0.005). Analyses revealed that these associations were moderated by patients' daily levels of pain intensity, catastrophizing, and negative affect (all P's < 0.001). Results from this study provide valuable new insights into our understanding of factors that may contribute to opioid craving among patients with chronic pain who are prescribed long-term opioid therapy. The implications of our findings for the management of patients with chronic pain are discussed.

Day-to-day opioid withdrawal symptoms, psychological distress, and opioid craving in patients with chronic pain prescribed opioid therapy

BACKGROUND

Research has shown that opioid craving is one of the strongest determinants of opioid misuse in patients with chronic pain. To date, however, little is known on the factors that contribute to opioid craving in these patients. It is possible that patients' physical dependence to opioids, manifested by opioid withdrawal symptoms in between daily opioid doses, contribute to opioid craving. Physical dependence symptoms might also lead to psychological distress, which in turn might contribute to opioid craving. The first objective of this study was to examine the day-to-day association between opioid withdrawal symptoms and opioid craving among patients with chronic pain. We also examined whether negative affect and catastrophic thinking mediated this association.

METHODS

In this longitudinal study, chronic pain patients (n = 79) prescribed short-acting opioids completed daily diaries for 14 consecutive days. Diaries assessed a host of pain, psychological, and opioid-related variables.

RESULTS

Day-to-day elevations in opioid withdrawal symptoms were associated with heightened opioid craving (p < .001). Results of a multilevel mediation analysis revealed that this association was mediated by patients' daily levels of negative affect and catastrophizing (p < .001).

CONCLUSIONS

Our study provides valuable new insights into our understanding of factors that may contribute to prescription opioid craving among patients with chronic pain.