Mindfulness-oriented recovery enhancement improves negative emotion regulation among opioid-treated chronic pain patients by increasing interoceptive awareness
Introduction
Chronic pain is a major public health problem, afflicting as many as 25.3 million adults in the United States alone [50]. Opioids are commonly prescribed to treat individuals with chronic pain. Although opioid analgesics rapidly relieve many types of acute pain and improve function, the benefits of long-term opioid therapy (LTOT) for chronic pain are limited, as LTOT presents risk of iatrogenic harms including opioid misuse, dependence, and opioid use disorder (OUD; [4]). Prevalence estimates suggest that approximately 25% of patients on LTOT engage in opioid misuse behaviors including opioid dose escalation and use of opioids to regulate negative emotions [56]. Additionally, several studies suggest bidirectional associations between chronic pain and emotion dysregulation [1,27]. As such, deficits in emotion regulation may be integral to the development and maintenance of opioid misuse and OUD among people with chronic pain.
Prominent theories of emotion state that perception of bodily sensations is crucial for mediating the emotional experience [7,34], suggesting that greater sensitivity for one's bodily state will facilitate the regulation of emotional responses. Interoception, defined as the representation of the body's internal state, involves central processing and perception of afferent signals – i.e., sensory information carried from the viscera (e.g., the heart) to the brain [6,8]. Interoception includes the processing of afferent stimulus perceptions conveyed from inside the body as well as the attention, emotional appraisal of, and inferences about these sensations [11]. Therefore, the ability to focus attention on bodily sensations may be key in emotion regulation, which involves deployment of antecedent and response-focused strategies to modulate emotional experience in the mind and body [26]. In fact, greater interoceptive facility is associated with the ability to downregulate negative emotions [13] and with the habitual use of regulatory strategies [36,53]. Moreover, there is evidence that individuals with chronic pain may have deficits in interoceptive capabilities [10], potentially reducing the ability to regulate emotion.
One important emotion regulation strategy is reappraisal, the reinterpretation of the meaning of an adverse stimulus or situation so as to reduce its negative emotional impact [27]. According to Gross' (2002, 2015) process model, cognitive reappraisal belongs to the family of antecedent-focused strategies, which aim to regulate emotions before they give rise to full-fledged emotional responses. This cognitive coping strategy has been shown to be associated with reduced distress and improved mental health outcomes and also appears to impact physiological parameters associated with stress by increasing parasympathetic nervous system activation and enhancing top-down, prefrontal cortical regulation of limbic circuitry subserving negative affect [52,[57], [58]].
People with chronic pain and those who misuse opioids may suffer from emotion regulation deficits, including deficient use of reappraisal. In that regard, among people with chronic pain being treated with LTOT, deficits in reappraisal have been shown to mediate the association between opioid misuse risk and emotional distress [19]. Similarly, chronic pain patients who misuse opioids show a blunted capacity to reappraise negative emotional stimuli, as indexed by autonomic and neurophysiological markers that are associated with heightened risk for opioid craving ([16,22,33], under review). This increased risk is consistent with more general theories of addiction, such as the self-medication hypothesis, which posits that individuals misuse substances as a way to cope with negative psychological states in the face of impairment in regulating those negative emotions [37]. Given that reduced capacity to reappraise negative emotions appears to be linked with risk of opioid misuse and craving among people receiving LTOT, there is a need for interventions to enhance reappraisal capacity.
Mindfulness may be one way of promoting reappraisal. Evidence for a positive association between mindfulness and reappraisal has been reported among different clinical and healthy populations [17,18,24,25,29,30,[35], [59], [60]], but the mechanism of action linking these two constructs is not yet known. Hypothetically, mindfulness may facilitate reappraisal by virtue of increasing interoceptive awareness of the impact of negative emotions on the physiological condition of the body. This hypothesis is plausible, given known linkages between interoception and reappraisal [13,36,53]. Indeed, interoceptive awareness has been suggested as a potential mechanism by which mindfulness interventions generate positive change [11,45,47]. In particular, the Mindfulness-to-Meaning Theory (MMT; [17]) posits that interoceptive awareness may be pivotal in the modulation of attention and facilitation of subsequent emotion regulation strategies.
In short, MMT provides a detailed process model of mindful emotion regulation that elucidates the downstream effects of mindfulness on salutary cognitive-affective processes, including reappraisal. In the MMT, mindfulness is proposed to introduce flexibility in the generation of cognitive reappraisals by enhancing interoceptive awareness, thereby expanding the scope of attention from a myopic focus on negative information to encompass previously unattended neutral and positive contextual information. Specifically, the MMT proposes that in the wake of a distressing experience, using mindfulness to cultivate interoceptive awareness on breath and body sensations down-regulates negative emotions and disrupts automatic deployment of negative cognitive appraisals, allowing for novel information processing. Integrating a widened array of positive, neutral, and negative features into the broadened scope of awareness fosters reappraisal of adversity as a source of psychological growth. By enhancing reappraisal, mindfulness is theorized to reduce emotional distress, facilitate savoring of positive emotions, and promote resilience and meaningful engagement with a valued and purposeful life (for more detail see [17]).
Founded on the MMT, Mindfulness Oriented Recovery Enhancement (MORE; [15]) unites training in mindfulness, reappraisal, and savoring skills into an integrative mind-body intervention for chronic pain and opioid misuse. A prior Stage 2 (i.e., a well-controlled efficacy trial) randomized controlled trial (RCT) found that, within a sample of people with chronic pain on LTOT, those treated with MORE had significantly reduced chronic pain symptoms and were significantly less likely than participants in an active control group to exhibit opioid misuse symptoms consistent with opioid use disorder [21]. Importantly, in this trial, MORE was also shown to significantly increase reappraisal. A second Stage 2 RCT of MORE in a sample of patients on LTOT replicated these results, by demonstrating significant effects of MORE on reducing chronic pain symptoms and opioid misuse [20].
To test whether MORE increases interoceptive awareness, and further, whether treatment-induced increases in interoceptive awareness mediate improvements in reappraisal, we conducted a secondary analysis of data obtained from this latter Stage 2 RCT ([20], NCT03298269). We assessed the effect of intervention group on interoceptive awareness, hypothesizing that 1) post-treatment improvements in interoceptive awareness would be associated with increased reappraisal. We additionally tested whether MORE led to reduced distress in this sample, hypothesizing that 2) improvements in reappraisal following the intervention would mediate the effect of MORE in decreasing emotional distress.
Section snippets
Participants
Ninety-five individuals with chronic, non-cancer pain who had been prescribed LTOT nearly every day or daily for at least the past 90 days were included in this study. Participants were recruited from primary care and pain clinics in Salt Lake City, Utah, USA through electronic health record review, opt-out letters, flyers, and radio advertisements. Exclusion criteria were active suicidality or psychosis, assessed with the Mini-International Neuropsychiatric Interview 6.0 (MINI; [55]), or
Participant characteristics
Pretreatment demographic and clinical characteristics were previously published [22]. There were no baseline differences between groups on relevant demographic or clinical information. Briefly, the mean age was 55.9 (SD = 11.5) for the MORE group and 57.6 (SD = 12.0) for the control group. The majority of participants in both groups racially identified as white. Of the 50 participants randomized to the MORE group, 27 (54%) were female, and of the 45 SG participants, 36 (80%) were female.
Discussion
This study tested a specific postulate of the Mindfulness-to-Meaning Theory (MMT): mindfulness-based interventions promote reappraisal of distressing life circumstances via interoceptive awareness of breath and body sensations as a means of self-regulating negative emotions. Here, we used path analysis to test this hypothesis in a sample of participants with chronic pain and opioid use, examining the function of MORE in increasing interoceptive awareness, enhancing reappraisal, and thereby
Disclosures
Eric Garland, PhD, LCSW is the Director of the Center on Mindfulness and Integrative Health Intervention Development. The Center provides Mindfulness-Oriented Recovery Enhancement (MORE), mindfulness-based therapy, and cognitive behavioral therapy in the context of research trials for no cost to research participants; however, Dr. Garland has received honoraria and payment for delivering seminars, lectures, and teaching engagements (related to training clinicians in mindfulness) sponsored by
Acknowledgements
This work was supported by a grant from the Fahs Beck Fund for Research and Experimentation (PI: Garland) and a gift from Stephanie Loker Harpst. E.L.G. was also supported by R01DA042033 (PI: Garland) from the National Institute on Drug Abuse during the preparation of this manuscript. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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