Disrupting The Downward Spiral of Chronic Pain and Opioid Addiction With Mindfulness-oriented Recovery Enhancement: A Review of Clinical Outcomes and Neurocognitive Targets

New Study (1)Abstract

Prescription opioid misuse and addiction among chronic pain patients are problems of growing medical and social significance. Chronic pain patients often require intervention to improve their well-being and functioning, and yet, the most commonly available form of pharmacotherapy for chronic pain is centered on opioid analgesics–drugs that have high abuse liability. Consequently, health care and legal systems are often stymied in their attempts to intervene with individuals who suffer from both pain and addiction. As such, novel, nonpharmacologic interventions are needed to complement pharmacotherapy and interrupt the cycle of behavioral escalation. The purpose of this paper is to describe how the downward spiral of chronic pain and prescription opioid misuse may be targeted by one such intervention, Mindfulness-Oriented Recovery Enhancement (MORE), a new behavioral treatment that integrates elements from mindfulness training, cognitive-behavioral therapy, and positive psychology. The clinical outcomes and neurocognitive mechanisms of this intervention are reviewed with respect to their effects on the risk chain linking chronic pain and prescription opioid misuse. Future directions for clinical and pharmacologic research are discussed.


Garland, E.L. (2014). Disrupting the downward spiral of chronic pain and opioid addiction with mindfulness-oriented recovery enhancement: a review of clinical outcomes and neurocognitive targets. Journal of Pain and Palliative Care Pharmacotherapy, 28(2), 122-129. doi: 10.3109/15360288.2014.911791.

Telephone-Delivered CBT for Pain Management among Older Military Veterans

This study investigated the effectiveness of telephone-delivered cognitive-behavioral therapy (T-CBT) in the management of chronic pain with older military veterans enrolled in VA primary-care clinics. We conducted a randomized clinical trial comparing T-CBT with telephone-delivered pain education (T-EDU). A total of 98 military veterans with chronic pain were enrolled in the study and randomized into one of two treatment conditions. Study participants were recruited from primary-care clinics at an urban VA medical center and affiliated VA community-based outpatient clinics (CBOCs). Pain management outcomes were measured at mid-treatment (10 weeks), post-treatment (20 weeks), 3-month follow-up (32 weeks), and 6-month follow-up (46 weeks). No significant differences were found between the two treatment groups on any of the outcome measures. Both treatment groups reported small but significant increases in level of physical and mental health, and reductions in pain and depressive symptoms. Improvements in all primary outcome measures were mediated by reductions in catastrophizing. Telephone-delivered CBT and EDU warrant further study as easily accessible interventions for rural-living older individuals with chronic pain.

Carmody, T. P., Duncan, C. L., Huggins, J., Solkowitz, S. N., Lee, S. K., Reyes, N., Mozgai, S., … Simon, J. A. (January 01, 2013). Telephone-delivered cognitive-behavioral therapy for pain management among older military veterans: A randomized trial. Psychological Services, 10(3), 265-275.


Physical Therapist-Delivered Cognitive Behavioral Therapy

The importance of the bio-psychosocial model in assessment and management of chronic musculoskeletal conditions is recognized. Physical therapists have been encouraged to develop psychologically informed practice. Little is known about the process of physical therapists’ learning and delivering of psychological interventions within the practice context. The aim of this study was to investigate physical therapists’ experiences and perspectives of a cognitive-behavioral-informed training and intervention process as part of a randomized controlled trial (RCT) involving adults with painful knee osteoarthritis. A qualitative design was used. Participants were physical therapists trained to deliver pain coping skills training (PCST). Eight physical therapists trained to deliver PCST were interviewed by telephone at 4 time points during the 12-month RCT period. Interviews were audio recorded, transcribed verbatim into computer-readable files, and analyzed using Framework Analysis. Thematic categories identified were: training, experience delivering PCST, impact on general clinical practice, and perspectives on PCST and physical therapist practice. Physical therapists reported positive experiences with PCST and program delivery. They thought that their participation in the RCT had enhanced their general practice. Although some components of the PCST program were familiar, the therapists found delivering the program was quite different from regular practice. Physical therapists believed the PCST program, a 3- to 4-day workshop followed by formal mentoring and performance feedback from a psychologist for 3 to 6 months and during the RCT, was critical to their ability to effectively deliver the PCST intervention. They identified a number of challenges in delivering PCST in their normal practice. Physical therapists can be trained to confidently deliver a PCST program. The physical therapists in this study believed that training enhanced their clinical practice. Comprehensive training and mentoring by psychologists was crucial to ensure treatment fidelity.

Nielsen, M., Keefe, F. J., Bennell, K., & Jull, G. A. (January 01, 2014). Physical Therapist-Delivered Cognitive-Behavioral Therapy: A Qualitative Study of Physical Therapists’ Perceptions and Experiences. Physical Therapy, 94, 2, 197-209.

Using CBT and Smart Phones for the Self-Management of Chronic Pain

In this age of technology, internet interventions are becoming more common in the practice of Cognitive Behavioral Therapy (CBT).  Chronic Widespread Pain (CWP) causes patients to live in constant pain, as well as fear of that pain, which can lead to avoidant behavior and depression.  Kristjansdottir et al (2011) hope to develop an intervention program that will help patients with CWP to self-manage their pain.  Using CBT with a focus on mindfulness and the acceptance of pain, researchers developed a four week intervention that is administered to the patients via Web-enabled smart phones.  In the present study, the researchers look into the feasibility of the intervention.

Six women with CWP were recruited to participate in the intervention.  Each participant first met one-on-one with a therapist where she was asked about her condition, informed of the intervention, and lent a web-enabled phone.  For the next four weeks, the participants received an SMS text message three times a day (morning, evening, and a random time between 11:30 am and 2 pm) reminding the participants to fill out an online diary.  This diary included a set of questions asking about current thoughts and pain awareness.  Within 90 minutes, each participant received online feedback from a therapist, who was supervised by two other professionals of mindfulness meditation and CBT.

Each online diary included questions regarding the usefulness of the previous diary’s feedback.  The effects of the intervention were quantified by use of the Chronic Pain Acceptance Questionnaire (CPAQ) and the Pain Catastrophizing Scale (PSC), given to participants before and after the intervention.  Half-way through the intervention, and after completion, researchers met with participants to ask them about their experiences and opinions.

Kristjansdottir et al found that the participants were responsive to the intervention and saw it as supportive and useful.  Despite minimal technical difficulties, the program was found to be user-friendly and feasible.  Future randomized studies can adapt the program and explore its effects on CWP.

Kristjansdottir, O. B., Fors, E. A., Eide, E., Finset, A., van Dulmen, S., Wigers, S. H., & Eide, H. (2011).  Written online situational feedback via mobile phone to support self-management of chronic widespread pain: A usability study of web-based intervention.  BMC Musculosketital Disorders, 12(51).

CBT Relieves Chronic Back Pain

NewStudy-Graphic-72x72_edited-3In a recent study, published in the February 26, 2010 issue of The Lancet, 701 patients with chronic back pain were treated with either standard treatment alone or standard treatment supplemented with Cognitive Behavior Therapy (CBT). The intervention helped participants identify cycles of negative thinking that lead to their inactivity and thus perpetuated their pain. Specifically, CBT played an important role in helping patients to resume activities they had been avoiding based on distorted thoughts and beliefs about the pain they experienced (e.g., “I should avoid all activities that cause me pain.”). At one year follow-up, the participants who received CBT showed greater improvement on disability tests than their non-CBT counterparts.

Because CBT is cost-effective and does not expose patients to additional risks like so many other treatment options, the researchers hope that this study will raise awareness, among health insurance providers and physicians, of the important role CBT may play in clinical practice.



Lamb, S.E., Hansen, Z., Lall, R., Castelnuovo, E., Withers, E.J., Nichols, V., et al. (2010). Group cognitive behavioural treatment for low-back pain in primary care: A randomised controlled trial and cost-effectiveness analysis. The Lancet, 375(9718), 916-923.