A MORE Effective Treatment for Chronic Pain and Opioid Misuse?

                               

Opioid Misuse 

During a 12-month period ending in April 2021, 100,306 deaths in the United States were caused by drug overdose. This represents a 28.5% increase from the same period the year before. In the mid 1990s, healthcare providers were reassured that a new and less addictive opioid pain medication would not lead to addiction. This led to widespread prescribing practices over the next 2 decades that resulted in a large population of patients addicted to opioid pain medication. In October 2017, the Department of Health and Human Services declared a public health emergency in an effort to address the national opioid crisis. 

Approximately 25% of patients prescribed long-term opioids misuse them. Opioids block pain receptors in the brain and spinal cord, resulting in a feeling of euphoria. The chronic use of opioids lead to changes in the stress and reward systems in the brain, resulting in an increased sensitization to emotional distress and pain, and decreased sensitivity to pleasure derived from natural rewards. Opioid use disorder is defined in the DSM-5 as “a problematic pattern of opioid use leading to clinically significant impairment or distress”. Current treatment of opioid use disorder includes medication and cognitive behavioral therapy.

Cognitive Behavioral Therapy 

Cognitive behavioral therapy (CBT) helps patients manage their symptoms associated with chronic pain, while also treating underlying psychological disorders, such as anxiety or depression. Numerous large scale studies and quantitative reviews note the efficacy of CBT for the treatment of drug use disorders and chronic pain. CBT breaks the dependence on opioids by replacing the positive association of opioid use with a positive association with non-use, and builds skills to encourage patients to reduce or discontinue the use of opioids. CBT teaches that harmful actions and emotions are not logical, and helps patients reframe their feelings of pain and suffering. 

MORE 

A novel approach for the treatment of opioid use disorder is mindfulness-oriented recovery enhancement (MORE). MORE works by increasing a patient’s self-regulation capacity. It is a complement to mindfulness training and integrates the strengths of many different therapeutic techniques into one. It combines mindfulness training, cognitive behavioral therapy, and positive psychology in a group based setting to specifically target reward dysregulation, chronic pain, and opioid misuse. MORE is built on 3 key processes: mindfulness, reappraisal, and savoring. Mindfulness gives patients control over their thought processes, increasing awareness of addictive cues and physical or emotional pain. Reappraisal combines mindfulness skills with cognitive restructuring techniques in an effort to develop adaptive coping techniques when faced with negative emotions and addictive behaviors. Savoring teaches patients to have a sense of reward, and strengthens a positive emotional response to naturally rewarding experiences.

Is MORE More Effective for Opioid Misuse? 

A recent study published in the Journal of the American Medical Association in February 2022 evaluated the effect of MORE therapy vs supportive group therapy for the treatment of opioid use disorder and chronic pain. 

The study population of 250 adults with chronic pain and opioid misuse consisted of: 

●     63.6% women, 36.4% men,

●     Mean age of 51.8,

●     Mean pain duration of 14.7 years,

●     Patients with primarily lower back pain, though 76% of participants reported 2 or more pain conditions,

●     Mean severity of 5.5 on a 0-10 VAS scale,

●     Mean MED 101mg. 

Patients receiving cancer treatment, those with suicidal behavior, psychosis, and/or severe nonopioid substance use disorder were excluded from participation, as were people with previous mindfulness treatment. 

The participants were randomized into groups treated with either mindfulness or supportive group therapy, and the sessions consisted of 6-12 participants for 8 weekly 2-hour sessions. In addition to the group sessions, MORE participants engaged in daily 15 minute audio guided mindfulness, reappraisal, and savoring practices. They were instructed to practice 3 minutes of mindfulness before taking opioids to clarify if the use was due to craving, or pain relief. The supportive psychotherapy group participated in discussions about coping with pain, adverse effects of opioids, and use of opioids to alleviate negative emotions. Participants in this group were instructed to write for 15 minutes a day in a journal. 

Outcomes were collected at baseline, after treatment, and at 3 ,6, and 9 months following the end of the study. An initial pilot study revealed a 64% improvement among individuals receiving MORE vs 32% improvement among individuals receiving psychotherapy. The findings of the full study were similar. At 9 month follow up, 45% of participants receiving MORE were no longer misusing opioids, compared to 24.4% of participants receiving supportive group psychotherapy. Participants receiving MORE also reported improvement in chronic pain symptoms compared with those receiving supportive psychotherapy. In addition, at 9 month follow up, 35.5% of MORE participants were able to decrease their opioid dosage by at least 50%, compared with just 15.9% in the supportive psychotherapy group. Opioid craving ratings were decreased in the MORE group vs supportive psychotherapy group. While both groups noted a decrease in opioid misuse, the effects of MORE intervention were substantially greater than that noted in the control group. 

Is MORE the Right Choice for my Claims?

Given the recently released draft proposal of changes to opioid prescribing guidelines by the CDC eliminating the dosage ceiling for prescribed opioids, the onus of continuing to address the opioid epidemic falls on the hands of all involved in the healthcare system. While medication and cognitive behavioral therapy are proven therapies for opioid use disorder, more effective and enduring treatment options are needed to help wean patients with chronic pain and opioid use disorder off of chronic opioids. Mindfulness-oriented recovery enhancement is an effective method that should be considered for patients with chronic pain and a high MED, those on chronic opioids with continued elevated perceived pain scores, and for patients who require support during the opioid weaning process. 

By Aliza Krug, PA-C 

Aliza Krug is a Certified Physician Assistant and is the Clinical Director of Arbicare, a Utilization Management Organization focusing on improving the care of injured people. She has more than a decade of experience working with patients in both an urgent care and orthopedics setting, and has helped numerous injured workers in a clinical setting. 

Assistant Secretary of Public Affairs (ASPA). (n.d.). What is the U.S. opioid epidemic? HHS.gov. Retrieved March 17, 2022, from https://www.hhs.gov/opioids/about-the-epidemic/index.html

Centers for Disease Control and Prevention. (2021, November 17). Drug overdose deaths in the U.S. top 100,000 annually. Centers for Disease Control and Prevention. Retrieved March 17, 2022, from https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm

Centers for Disease Control and Prevention. (n.d.). Module 5: Assessing and addressing opioid use disorder (oud). Centers for Disease Control and Prevention. Retrieved March 17, 2022, from https://www.cdc.gov/drugoverdose/training/oud/accessible/index.html#:~:text=OUD%20Definition&text=About%202.1%20million%20Americans%20had,Opioid%20Dependence%20in%20DSM%2DIV.

Eric L. Garland, P. D. (2022, February 28). Mindfulness-Oriented Recovery Enhancement for co-occurring opioid misuse and chronic pain. JAMA Internal Medicine. Retrieved March 17, 2022, from https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2789279

McHugh, R. K., Hearon, B. A., & Otto, M. W. (2010, September). Cognitive behavioral therapy for Substance Use Disorders. The Psychiatric clinics of North America. Retrieved March 17, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2897895/

Opiod use disorder: Fact sheet - ABCT - association for behavioral and cognitive therapies. ABCT. (2021, April 8). Retrieved March 17, 2022, from https://www.abct.org/fact-sheets/opiod-use-disorder/


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