Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Article
  • Published:

Mindfulness-Oriented Recovery Enhancement reduces post-traumatic stress via reappraisal among patients with chronic pain and co-occurring opioid misuse

Nature Mental Health volume 1, pages 489–500 (2023)Cite this article

Subjects

Abstract

Chronic pain and post-traumatic stress disorder (PTSD) are co-occurring conditions that exacerbate the risk of opioid misuse. In this secondary analysis of a randomized clinical trial (NCT02602535), we examined the efficacy of Mindfulness-Oriented Recovery Enhancement (MORE) for reducing PTSD symptoms in patients with chronic pain who misused opioids (N = 241) and who were randomized to MORE or supportive group psychotherapy. Self-reported cognitive reappraisal and skin conductance during an emotion regulation task were tested as mediators of the effect of MORE on changes in PTSD symptoms, and changes in PTSD symptoms were tested as a mediator of the effect of MORE on opioid misuse. MORE led to larger improvements in PTSD symptoms than supportive group psychotherapy across 9 months of follow-up, with 59% of those meeting criteria for a PTSD diagnosis showing clinically significant reductions in PTSD symptoms following treatment with MORE. Changes in reappraisal mediated the effect of MORE on PTSD symptoms, which in turn mediated reduced opioid misuse following MORE. Enhancing reappraisal through MORE may be efficacious for reducing PTSD in opioid-treated chronic pain.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: The Consolidated Standards of Reporting Trials (CONSORT) diagram of participant recruitment and retention.
Fig. 2: Post-traumatic stress symptoms on the PCL-C through the 9 month follow-up period for participants randomized to MORE and SG who were diagnosed with PTSD as determined by the symptom cluster scoring method (N = 104).
Fig. 3: Pre- to- post-treatment change in SCL during negative emotion regulation (view negative–reappraise negative) for participants assigned to MORE and SG.
Fig. 4: Path analysis using structural equation modeling to examine the effects of MORE versus SG on PTSD symptoms as mediated by treatment-induced changes in self-reported reappraisal.
Fig. 5: Path analysis using structural equation modeling to examine the effects of MORE versus SG on opioid misuse outcomes as mediated by PTSD symptoms.

Similar content being viewed by others

Data availability

Data are available from the corresponding author upon reasonable request with an approved data sharing agreement. Requests will be responded to in 30 days. Data will be restricted to de-identified participant data (demographics, summary outcome variables).

Code availability

Coding used for analyses will be shared upon reasonable request. Code will be made available upon publication of this manuscript.

References

  1. Moeller-Bertram, T., Keltner, J. & Strigo, I. A. Pain and post traumatic stress disorder—review of clinical and experimental evidence. Neuropharmacology 62, 586–597 (2012).

    Article  PubMed  Google Scholar 

  2. Fishbain, D. A., Pulikal, A., Lewis, J. E. & Gao, J. Chronic pain types differ in their reported prevalence of post-traumatic stress disorder (PTSD) and there is consistent evidence that chronic pain is associated with PTSD: an evidence-based structured systematic review. Pain Med. 18, 711–735 (2017).

    PubMed  Google Scholar 

  3. Åkerblom, S., Perrin, S., Rivano Fischer, M. & McCracken, L. M. The Impact of PTSD on functioning in patients seeking treatment for chronic pain and validation of the posttraumatic diagnostic scale. Int. J. Behav. Med. 24, 249–259 (2017).

    Article  PubMed  PubMed Central  Google Scholar 

  4. Bair, M. J., Outcalt, S. D., Ang, D., Wu, J. & Yu, Z. Pain and psychological outcomes among Iraq and Afghanistan veterans with chronic pain and PTSD: ESCAPE trial longitudinal results. Pain Med. 21, 1369–1376 (2020).

    Article  PubMed  Google Scholar 

  5. Benedict, T. M., Keenan, P. G., Nitz, A. J. & Moeller-Bertram, T. Post-traumatic stress disorder symptoms contribute to worse pain and health outcomes in veterans with PTSD compared to those without: a systematic review with meta-analysis. Mil. Med. 185, e1481–e1491 (2020).

    Article  PubMed  Google Scholar 

  6. Langford, D. J. et al. Number and type of post-traumatic stress disorder symptom domains are associated with patient-reported outcomes in patients with chronic pain. J. Pain 19, 506–514 (2018).

    Article  PubMed  PubMed Central  Google Scholar 

  7. Li, H. et al. Relationship between post-traumatic stress disorder symptoms and chronic pain-related symptom domains among military active duty service members. Pain Med. 22, 2876–2883 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  8. Outcalt, S. D. et al. Chronic pain and comorbid mental health conditions: independent associations of posttraumatic stress disorder and depression with pain, disability, and quality of life. J. Behav. Med. 38, 535–543 (2015).

    Article  PubMed  Google Scholar 

  9. Ruiz-Párraga, G. T. & López-Martínez, A. E. The contribution of posttraumatic stress symptoms to chronic pain adjustment. Health Psychol. 33, 958–967 (2014).

    Article  PubMed  Google Scholar 

  10. López-Martínez, A. E., Reyes-Pérez, Á., Serrano-Ibáñez, E. R., Esteve, R. & Ramírez-Maestre, C. Chronic pain, posttraumatic stress disorder, and opioid intake: a systematic review. World J. Clin. Cases 7, 4254–4269 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  11. Vowles, K. E. et al. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain 156, 569–576 (2015).

    Article  PubMed  Google Scholar 

  12. McCance-Katz, E. F. The National Survey on Drug Use and Health (NSDUH): 2020 (Substance Abuse and Mental Health Service Administration, 2020).

  13. Badour, C. L. & Feldner, M. T. Trauma-related reactivity and regulation of emotion: associations with posttraumatic stress symptoms. J. Behav. Ther. Exp. Psychiatry 44, 69–76 (2013).

    Article  PubMed  Google Scholar 

  14. Chesney, S. A. & Gordon, N. S. Profiles of emotion regulation: understanding regulatory patterns and the implications for posttraumatic stress. Cogn. Emot. 31, 598–606 (2017).

    Article  PubMed  Google Scholar 

  15. Seligowski, A. V., Lee, D. J., Bardeen, J. R. & Orcutt, H. K. Emotion regulation and posttraumatic stress symptoms: a meta-analysis. Cogn. Behav. Ther. 44, 87–102 (2015).

    Article  PubMed  Google Scholar 

  16. Tull, M. T., Barrett, H. M., McMillan, E. S. & Roemer, L. A preliminary investigation of the relationship between emotion regulation difficulties and posttraumatic stress symptoms. Behav. Ther. 38, 303–313 (2007).

    Article  PubMed  Google Scholar 

  17. Wolkenstein, L., Sommerhoff, A. & Voss, M. Positive emotion dysregulation in posttraumatic stress disorder. J. Anxiety Disord. 86, 102534 (2022).

    Article  PubMed  Google Scholar 

  18. Asmundson, G. J., Coons, M. J., Taylor, S. & Katz, J. PTSD and the experience of pain: research and clinical implications of shared vulnerability and mutual maintenance models. Can. J. Psychiatry 47, 930–937 (2002).

    Article  PubMed  Google Scholar 

  19. Bedford, C. E., Nakamura, Y., Marchand, W. R. & Garland, E. L. Heightened autonomic reactivity to negative affective stimuli among active duty soldiers with PTSD and opioid-treated chronic pain. Psychiatry Res. 309, 114394 (2022).

    Article  PubMed  PubMed Central  Google Scholar 

  20. Bosco, M. A., Gallinati, J. L. & Clark, M. E. Conceptualizing and treating comorbid chronic pain and PTSD. Pain Res. Treat. 2013, 174728 (2013).

    PubMed  PubMed Central  Google Scholar 

  21. Jenewein, J., Wittmann, L., Moergeli, H., Creutzig, J. & Schnyder, U. Mutual influence of posttraumatic stress disorder symptoms and chronic pain among injured accident survivors: a longitudinal study. J. Trauma. Stress 22, 540–548 (2009).

    PubMed  Google Scholar 

  22. Sharp, T. J. & Harvey, A. G. Chronic pain and posttraumatic stress disorder: mutual maintenance? Clin. Psychol. Rev. 21, 857–877 (2001).

    Article  PubMed  Google Scholar 

  23. Ehlers, A. et al. The nature of intrusive memories after trauma: the warning signal hypothesis. Behav. Res. Ther. 40, 995–1002 (2002).

    Article  PubMed  Google Scholar 

  24. Franke, L. K. et al. Neuroscientific evidence for pain being a classically conditioned response to trauma- and pain-related cues in humans. Pain 163, 2118–2137 (2022).

    Article  PubMed  Google Scholar 

  25. Macdonald, B., Salomons, T. V., Meteyard, L. & Whalley, M. G. Prevalence of pain flashbacks in posttraumatic stress disorder arising from exposure to multiple traumas or childhood traumatization. Can. J. Pain 2, 48–56 (2018).

    Article  PubMed  PubMed Central  Google Scholar 

  26. Khantzian, E. J. The self-medication hypothesis of substance use disorders: a reconsideration and recent applications. Harv. Rev. Psychiatry 4, 231–244 (1997).

    Article  PubMed  Google Scholar 

  27. Leeies, M., Pagura, J., Sareen, J. & Bolton, J. M. The use of alcohol and drugs to self-medicate symptoms of posttraumatic stress disorder. Depress. Anxiety 27, 731–736 (2010).

    Article  PubMed  Google Scholar 

  28. Garland, E. L., Hanley, A. W., Thomas, E. A., Knoll, P. & Ferraro, J. Low dispositional mindfulness predicts self-medication of negative emotion with prescription opioids. J. Addict. Med. 9, 61–67 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  29. Groenewald, C. B., Law, E. F., Fisher, E. Beals-Erickson, S. E. & Palermo, T. M. Associations between adolescent chronic pain and prescription opioid misuse in adulthood. J. Pain 20, 28–37 (2019).

    Article  PubMed  Google Scholar 

  30. Zvolensky, M. J., Rogers, A. H., Shepherd, J. M., Vujanovic, A. A. & Bakhshaie, J. Anxiety sensitivity and opioid misuse and dependence among trauma-exposed adults with chronic pain. J. Behav. Med. 43, 174–184 (2020).

    Article  PubMed  Google Scholar 

  31. Bilevicius, E., Sommer, J. L., Asmundson, G. J. G. & El-Gabalawy, R. Posttraumatic stress disorder and chronic pain are associated with opioid use disorder: results from a 2012–2013 American nationally representative survey. Drug Alcohol Depend. 188, 119–125 (2018).

  32. Baker, T. B., Piper, M. E., McCarthy, D. E., Majeskie, M. R. & Fiore, M. C. Addiction motivation reformulated: an affective processing model of negative reinforcement. Psychol. Rev. 111, 33–51 (2004).

    Article  PubMed  Google Scholar 

  33. Garland, E. L., Froeliger, B., Zeidan, F., Partin, K. & Howard, M. O. The downward spiral of chronic pain, prescription opioid misuse, and addiction: cognitive, affective, and neuropsychopharmacologic pathways. Neurosci. Biobehav. Rev. 37, 2597–2607 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  34. Koob, G. F. Neurobiology of opioid addiction: opponent process, hyperkatifeia, and negative reinforcement. Biol. Psychiatry 87, 44–53 (2020).

    Article  PubMed  Google Scholar 

  35. Koob, G. F., Powell, P. & White, A. Addiction as a coping response: hyperkatifeia, deaths of despair, and COVID-19. Am. J. Psychiatry 177, 1031–1037 (2020).

    Article  PubMed  Google Scholar 

  36. Elman, I. & Borsook, D. Common brain mechanisms of chronic pain and addiction. Neuron 89, 11–36 (2016).

    Article  PubMed  Google Scholar 

  37. Elman, I. & Borsook, D. The failing cascade: comorbid post traumatic stress- and opioid use disorders. Neurosci. Biobehav. Rev. 103, 374–383 (2019).

    Article  PubMed  Google Scholar 

  38. Baldacchino, A., Balfour, D. J. K., Passetti, F., Humphris, G. & Matthews, K. Neuropsychological consequences of chronic opioid use: a quantitative review and meta-analysis. Neurosci. Biobehav. Rev. 36, 2056–2068 (2012).

    Article  PubMed  Google Scholar 

  39. Hudak, J. et al. Neurophysiological deficits during reappraisal of negative emotional stimuli in opioid misuse. Biol. Psychiatry. 91, 1070–1078 (2022).

    Article  PubMed  PubMed Central  Google Scholar 

  40. Garland, E. L., Bryan, C. J., Nakamura, Y., Froeliger, B. & Howard, M. O. Deficits in autonomic indices of emotion regulation and reward processing associated with prescription opioid use and misuse. Psychopharmacology 234, 621–629 (2017).

    Article  PubMed  Google Scholar 

  41. Hudak, J. et al. The temporal dynamics of emotion dysregulation in prescription opioid misuse. Prog. Neuropsychopharmacol. Biol. Psychiatry 104, 110024 (2021).

    Article  PubMed  Google Scholar 

  42. Baker, K. S., Gibson, S., Georgiou-Karistianis, N., Roth, R. M. & Giummarra, M. J. Everyday executive functioning in chronic pain: specific deficits in working memory and emotion control, predicted by mood, medications, and pain interference. Clin. J. Pain 32, 673–680 (2016).

    Article  PubMed  Google Scholar 

  43. Ng, S. K. et al. Neural activity during cognitive reappraisal in chronic low back pain: a preliminary study. Scand. J. Pain 21, 586–596 (2021).

    Article  PubMed  Google Scholar 

  44. Fitzgerald, J. M. et al. An electrocortical investigation of voluntary emotion regulation in combat-related posttraumatic stress disorder. Psychiatry Res. Neuroimaging 249, 113–121 (2016).

    Article  PubMed  Google Scholar 

  45. Fitzgerald, J. M., DiGangi, J. A. & Phan, K. L. Functional neuroanatomy of emotion and its regulation in PTSD. Harv. Rev. Psychiatry 26, 116–128 (2018).

    Article  PubMed  PubMed Central  Google Scholar 

  46. Rabinak, C. A. et al. Focal and aberrant prefrontal engagement during emotion regulation in veterans with posttraumatic stress disorder. Depress. Anxiety 31, 851–861 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  47. Pole, N. The psychophysiology of posttraumatic stress disorder: a meta-analysis. Psychol. Bull. 133, 725–746 (2007).

    Article  PubMed  Google Scholar 

  48. Hopwood, T. L. & Schutte, N. S. A meta-analytic investigation of the impact of mindfulness-based interventions on post traumatic stress. Clin. Psychol. Rev. 57, 12–20 (2017).

    Article  PubMed  Google Scholar 

  49. Polusny, M. A. et al. Mindfulness-based stress reduction for posttraumatic stress disorder among veterans: a randomized clinical trial. JAMA 314, 456–465 (2015).

    Article  PubMed  Google Scholar 

  50. Cherkin, D. C. et al. Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial. JAMA 315, 1240–1249 (2016).

    Article  PubMed  PubMed Central  Google Scholar 

  51. Hilton, L. et al. Mindfulness meditation for chronic pain: systematic review and meta-analysis. Ann. Behav. Med. 51, 199–213 (2017).

    Article  PubMed  Google Scholar 

  52. Garland, E. L. et al. Mind-body therapies for opioid-treated pain: a systematic review and meta-analysis. JAMA Intern. Med. 180, 91–105 (2020).

    Article  PubMed  Google Scholar 

  53. Goldberg, S. et al. Mindfulness-based interventions for substance use disorders. Cochrane Database Syst. Rev. 10, CD011723 (2021).

    PubMed  Google Scholar 

  54. Li, W., Howard, M. O., Garland, E. L., McGovern, P. & Lazar, M. Mindfulness treatment for substance misuse: a systematic review and meta-analysis. J. Subst. Abuse Treat. 75, 62–96 (2017).

    Article  PubMed  Google Scholar 

  55. Garland, E. L. Mindfulness-Oriented Recovery Enhancement for Addiction, Stress, and Pain (National Association of Social Workers, 2013).

  56. Gross, J. J. & John, O. P. Individual differences in two emotion regulation processes: implications for affect, relationships, and well-being. J. Pers. Soc. Psychol. 85, 348–362 (2003).

    Article  PubMed  Google Scholar 

  57. Kangaslampi, S. & Peltonen, K. Mechanisms of change in psychological interventions for posttraumatic stress symptoms: a systematic review with recommendations. Curr. Psychol. 41, 258–275 (2022).

    Article  Google Scholar 

  58. Boden, M. T., Bonn-Miller, M. O., Kashdan, T. B., Alvarez, J. & Gross, J. J. The interactive effects of emotional clarity and cognitive reappraisal in posttraumatic stress disorder. J. Anxiety Disord. 26, 233–238 (2012).

    Article  PubMed  Google Scholar 

  59. Boden, M. T. et al. Emotion regulation and posttraumatic stress disorder: a prospective investigation. J. Soc. Clin. Psychol. 32, 296–314 (2013).

    Article  Google Scholar 

  60. Garland, E., Hanley, A., Goldin, P. & Gross, J. Testing the mindfulness-to-meaning theory: evidence for mindful positive emotion regulation from a reanalysis of longitudinal data. PLoS ONE 12, e0187727 (2017).

    Article  PubMed  PubMed Central  Google Scholar 

  61. Garland, E., Kiken, L., Faurot, K., Palsson, O. & Gaylord, S. Upward spirals of mindfulness and reappraisal: testing the mindfulness-to-meaning theory with autoregressive latent trajectory modeling. Cogn. Ther. Res. 41, 381–392 (2017).

    Article  Google Scholar 

  62. Hanley, A. W. et al. Modeling the mindfulness-to-meaning theory’s mindful reappraisal hypothesis: replication with longitudinal data from a randomized controlled study. Stress Health. 37, 778–779 (2021).

    Article  PubMed  Google Scholar 

  63. Garland, E. L. et al. Mindfulness-oriented recovery enhancement for chronic pain and prescription opioid misuse: results from an early-stage randomized controlled trial. J. Consult. Clin. Psychol. 82, 448–459 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  64. Roberts, R. L., Ledermann, K. & Garland, E. L. Mindfulness-oriented recovery enhancement improves negative emotion regulation among opioid-treated chronic pain patients by increasing interoceptive awareness. J. Psychosom. Res. 152, 110677 (2022).

    Article  Google Scholar 

  65. Parisi, A., Roberts, R. L., Hanley, A. W. & Garland, E. L. Mindfulness-Oriented Recovery Enhancement for addictive behavior, psychiatric distress, and chronic pain: a multilevel meta-analysis of randomized controlled trials. Mindfulness 13, 2396–2412 (2022).

    Article  PubMed  PubMed Central  Google Scholar 

  66. Garland, E. L. et al. Mind-body therapies for opioid-treated pain: a systematic review and meta-analysis. JAMA Intern. Med. 180, 91–105 (2020).

    Article  PubMed  Google Scholar 

  67. Garland, E. L. et al. Mindfulness-oriented recovery enhancement reduces opioid misuse risk via analgesic and positive psychological mechanisms: a randomized controlled trial. J. Consult. Clin. Psychol. 87, 927–940 (2019).

    Article  PubMed  PubMed Central  Google Scholar 

  68. Garland, E. L. et al. Mindfulness-Oriented Recovery Enhancement vs supportive group therapy for co-occurring opioid misuse and chronic pain in primary care: a randomized clinical trial. JAMA Intern. Med. 182, 407–417 (2022).

    Article  PubMed  PubMed Central  Google Scholar 

  69. Garland, E. L., Roberts-Lewis, A., Tronnier, C. D., Graves, R. & Kelley, K. Mindfulness-Oriented Recovery Enhancement versus CBT for co-occurring substance dependence, traumatic stress, and psychiatric disorders: proximal outcomes from a pragmatic randomized trial. Behav. Res. Ther. 77, 7–16 (2016).

    Article  PubMed  Google Scholar 

  70. Cicchetti, D. & Dawson, G. Multiple levels of analysis. Dev. Psychopathol. 14, 417–420 (2002).

    Article  PubMed  Google Scholar 

  71. Weathers, F. W. et al. The PTSD Checklist (PCL): reliability, validity, and diagnostic utility. In Annual Meeting of the International Society for Traumatic Stress Studies, San Antonio, TX (1993).

  72. Weathers, F. W., Huska, J. A., & Keane, T. M. PCL-C for DSM-IV (National Center for PTSD-Behavioral Science Division, 1994).

  73. Butler, S. F., Fernandez, K., Benoit, C., Budman, S. H. & Jamison, R. N. Validation of the revised Screener and Opioid Assessment Measure for Patients with Pain (SOAPP-R). J. Pain 9, 360–372 (2008).

  74. Harrington, T. & Newman, E. The psychometric utility of two self-report measures of PTSD among women substance users. Addict. Behav. 32, 2788–2798 (2007).

    Article  PubMed  Google Scholar 

  75. Kuyken, W. et al. Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial. Lancet 386, 63–73 (2015).

    Article  PubMed  Google Scholar 

  76. Teasdale, J. D. et al. Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. J. Consult. Clin. Psychol. 68, 615–23 (2000).

    Article  PubMed  Google Scholar 

  77. Monson, C. M. et al. Change in posttraumatic stress disorder symptoms: do clinicians and patients agree? Psychol. Assess. 20, 131–138 (2008).

    Article  PubMed  Google Scholar 

  78. Jamison, R. N. et al. Substance misuse treatment for high-risk chronic pain patients on opioid therapy: a randomized trial. Pain 150, 390–400 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  79. Lawrence, R., Mogford, D. & Colvin, L. Systematic review to determine which validated measurement tools can be used to assess risk of problematic analgesic use in patients with chronic pain. Br. J. Anaesth. 119, 1092–1109 (2017).

    Article  PubMed  Google Scholar 

  80. Garland, E. L., Farb, N. A., Goldin, P. R. & Fredrickson, B. L. Mindfulness broadens awareness and builds eudaimonic meaning: a process model of mindful positive emotion regulation. Psychol. Inq. 26, 293–314 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  81. Cuthbert, B. N., Schupp, H. T., Bradley, M. M., Birbaumer, N. & Lang, P. J. Brain potentials in affective picture processing: covariation with autonomic arousal and affective report. Biol. Psychol. 52, 95–111 (2000).

    Article  PubMed  Google Scholar 

  82. Kreibig, S. D. Autonomic nervous system activity in emotion: a review. Biol. Psychol. 84, 394–421 (2010).

    Article  PubMed  Google Scholar 

  83. McRae, K., Ciesielski, B. & Gross, J. J. Unpacking cognitive reappraisal: goals, tactics, and outcomes. Emotion 12, 250–255 (2012).

    Article  PubMed  Google Scholar 

  84. Delgado, M. R., Nearing, K. I., LeDoux, J. E. & Phelps, E. A. Neural circuitry underlying the regulation of conditioned fear and its relation to extinction. Neuron 59, 829–838 (2008).

    Article  PubMed  PubMed Central  Google Scholar 

  85. Zhang, S. et al. Ventromedial prefrontal cortex and the regulation of physiological arousal. Soc. Cogn. Affect. Neurosci. 9, 900–908 (2014).

    Article  PubMed  Google Scholar 

  86. Hinrichs, R. et al. Mobile assessment of heightened skin conductance in posttraumatic stress disorder. Depress. Anxiety 34, 502–507 (2017).

    Article  PubMed  PubMed Central  Google Scholar 

  87. Hinrichs, R. et al. Increased skin conductance response in the immediate aftermath of trauma predicts PTSD risk. Chronic Stress 3, 247054701984444 (2019).

    Article  Google Scholar 

  88. Back, S. E., Brady, K. T., Sonne, S. C. & Verduin, M. L. Symptom improvement in co-occurring ptsd and alcohol dependence. J. Nerv. Ment. Dis. 194, 690–696 (2006).

    Article  PubMed  Google Scholar 

  89. McLean, C. P., Su, Y.-J. & Foa, E. B. Mechanisms of symptom reduction in a combined treatment for comorbid posttraumatic stress disorder and alcohol dependence. J. Consult. Clin. Psychol. 83, 655–661 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  90. Hien, D. A. et al. Do treatment improvements in PTSD severity affect substance use outcomes? A secondary analysis from a randomized clinical trial in NIDA’s clinical trials network. Am. J. Psychiatry 167, 95–101 (2010).

    Article  PubMed  Google Scholar 

  91. Davis, T. A. et al. Substance use attenuates physiological responses associated with PTSD among individuals with co-morbid PTSD and SUDs. J. Psychol. Psychother. https://doi.org/10.4172/2161-0487.S7-006 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  92. Hawn, S. E., Cusack, S. E. & Amstadter, A. B. A systematic review of the self-medication hypothesis in the context of posttraumatic stress disorder and comorbid problematic alcohol use. J. Trauma. Stress 33, 699–708 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  93. Lane, A. R., Waters, A. J. & Black, A. C. Ecological momentary assessment studies of comorbid PTSD and alcohol use: a narrative review. Addict. Behav. Rep. 10, 100205 (2019).

    PubMed  PubMed Central  Google Scholar 

  94. Roberts, N. P., Roberts, P. A., Jones, N. & Bisson, J. I. Psychological interventions for post-traumatic stress disorder and comorbid substance use disorder: a systematic review and meta-analysis. Clin. Psychol. Rev. 38, 25–38 (2015).

    Article  PubMed  Google Scholar 

  95. Simpson, T. L. et al. Efficacy and acceptability of interventions for co-occurring PTSD and SUD: a meta-analysis. J. Anxiety Disord. 84, 102490 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  96. McDonald, S. D. & Calhoun, P. S. The diagnostic accuracy of the PTSD checklist: a critical review. Clin. Psychol. Rev. 30, 976–987 (2010).

    Article  PubMed  Google Scholar 

  97. van Rooij, S. J. H. et al. Impaired right inferior frontal gyrus response to contextual cues in male veterans with PTSD during response inhibition. J. Psychiatry Neurosci. 39, 330–338 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  98. Zweerings, J. et al. Rt-fMRI neurofeedback-guided cognitive reappraisal training modulates amygdala responsivity in posttraumatic stress disorder. NeuroImage Clin. 28, 102483 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  99. Jackson, D. C., Malmstadt, J. R., Larson, C. L. & Davidson, R. J. Suppression and enhancement of emotional responses to unpleasant pictures. Psychophysiology 37, 515–522 (2000).

    Article  PubMed  Google Scholar 

  100. Ochsner, K. N. & Gross, J. J. The cognitive control of emotion. Trends Cogn. Sci. 9, 242–249 (2005).

    Article  PubMed  Google Scholar 

  101. Wolf, E. J., Miller, M. W. & McKinney, A. E. Emotional processing in PTSD: heightened negative emotionality to unpleasant photographic stimuli. J. Nerv. Ment. Dis. 197, 419–426 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  102. Hanley, A. W., Garland, E. L. & Tedeschi, R. G. Relating dispositional mindfulness, contemplative practice, and positive reappraisal with posttraumatic cognitive coping, stress, and growth. Psychol. Trauma 9, 526–536 (2017).

    Article  PubMed  Google Scholar 

  103. Tedeschi, R. G. & Calhoun, L. G. Posttraumatic growth: conceptual foundations and empirical Evidence. Psychol. Inq. https://doi.org/10.1207/s15327965pli1501_01 (2004).

  104. Garland, E. L. Restructuring reward processing with Mindfulness-Oriented Recovery Enhancement: novel therapeutic mechanisms to remediate hedonic dysregulation in addiction, stress, and pain. Ann. N. Y. Acad. Sci. 1373, 25–37 (2016).

    Article  PubMed  PubMed Central  Google Scholar 

  105. Garland, E. L. et al. Mindfulness-oriented recovery enhancement remediates anhedonia in chronic opioid use by enhancing neurophysiological responses during savoring of natural rewards. Psychol. Med. 53, 2085–2094 (2023).

    Article  PubMed  Google Scholar 

  106. Elman, I. et al. Functional neuroimaging of reward circuitry responsivity to monetary gains and losses in posttraumatic stress disorder. Biol. Psychiatry 66, 1083–1090 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  107. Elman, I. et al. Reward and aversion processing in patients with post-traumatic stress disorder: functional neuroimaging with visual and thermal stimuli. Transl. Psychiatry 8, 240 (2018).

    Article  PubMed  PubMed Central  Google Scholar 

  108. Nawijn, L. et al. Reward functioning in PTSD: a systematic review exploring the mechanisms underlying anhedonia. Neurosci. Biobehav. Rev. 51, 189–204 (2015).

    Article  PubMed  Google Scholar 

  109. Boyd, J. E., Lanius, R. A. & McKinnon, M. C. Mindfulness-based treatments for posttraumatic stress disorder: a review of the treatment literature and neurobiological evidence. J. Psychiatry Neurosci. 43, 7–25 (2018).

    Article  PubMed  Google Scholar 

  110. King, A. P. et al. A pilot study of group mindfulness-based cognitive therapy (MBCT) for combat veterans with posttraumatic stress disorder (PTSD). Depress. Anxiety 30, 638–645 (2013).

    Article  PubMed  PubMed Central  Google Scholar 

  111. Sheehan, D. The MINI International Neuropsychiatric Interview, (Version 7.0. 2) for DSM-5 (Harm Research Institute, 2016).

  112. Gaylord, S. A. et al. Mindfulness training reduces the severity of irritable bowel syndrome in women: results of a randomized controlled trial. Am. J. Gastroenterol 106, 1678–1688 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  113. Weathers, F. W., Huska, J. A., & Keane, T. M. PCL-C for DSM-IV (National Center for PTSD-Behavioral Science Division, 1991).

  114. Wu, S. M. et al. The addiction behaviors checklist: validation of a new clinician-based measure of inappropriate opioid use in chronic pain. J. Pain Symptom Manag. 32, 342–351 (2006).

    Article  Google Scholar 

  115. Benedek, M. & Kaernbach, C. A continuous measure of phasic electrodermal activity. J. Neurosci. Methods 190, 80–91 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  116. Critchley, H. D., Elliott, R., Mathias, C. J. & Dolan, R. J. Neural activity relating to generation and representation of galvanic skin conductance responses: a functional magnetic resonance imaging study. J. Neurosci. 20, 3033–3040 (2000).

    Article  PubMed  PubMed Central  Google Scholar 

  117. Lang, P., Bradley, M. & Cuthbert, B. International Affective Picture System (IAPS): Technical Manual and Affective Ratings (NIMH Center for the Study of Emotion and Attention, 1997).

  118. Hanley, A. W. & Garland, E. L. The Mindfulness-Oriented Recovery Enhancement Fidelity Measure (MORE-FM): development and validation of a new tool to assess therapist adherence and competence. J. Evid. Based J. Evid. Based 18, 308–322 (2021).

    Google Scholar 

  119. IBM SPSS Statistics for Windows (IBM, 2020).

  120. Little, R. J. A. A test of missing completely at random for multivariate data with missing values. J. Am. Stat. Assoc. 83, 1198–1202 (1988).

    Article  Google Scholar 

  121. Newman, D. A. Longitudinal modeling with randomly and systematically missing data: a simulation of ad hoc, maximum likelihood, and multiple imputation techniques. Organ. Res. Methods 6, 328–362 (2003).

    Article  Google Scholar 

  122. Kline, R. B. Principles and Practice of Structural Equation Modeling (Guilford, 2005).

  123. Hayes, A. F. Introduction to Mediation, Moderation, and Conditional Process Analysis: a Regression-Based Approach (Guilford, 2013).

  124. Felder, J. N. et al. Neural mechanisms of subclinical depressive symptoms in women: a pilot functional brain imaging study. BMC Psychiatry 12, 152 (2012).

    Article  PubMed  PubMed Central  Google Scholar 

  125. Danielsen, A. et al. Effects of diazepam and ethanol on heart rate and galvanic skin responses. Acta Pharmacol. Toxicol. 36, 113–122 (1975).

    Article  Google Scholar 

  126. Mahmud, M. S., Fang, H., Wang, H., Carreiro, S. & Boyer, E. Automatic detection of opioid intake using wearable biosensor. In 2018 International Conference on Computing, Networking and Communications (ICNC) 784–788 (IEEE, 2018); https://doi.org/10.1109/ICCNC.2018.8390334

  127. Wade, D. et al. Gender difference in outcomes following trauma-focused interventions for posttraumatic stress disorder: systematic review and meta-analysis. Psychol. Trauma Theory Res. Pract. Policy 8, 356–364 (2016).

    Article  Google Scholar 

  128. West, S. G., Taylor, A. B. & Wu, W. in Handbook of Structural Equation Modeling (ed Hoyle, R. H.) 209–231 (Guilford, 2012).

  129. Lee, T. & Shi, D. A comparison of full information maximum likelihood and multiple imputation in structural equation modeling with missing data. Psychol. Methods 26, 466–485 (2021).

    Article  PubMed  Google Scholar 

  130. Rosseel, Y. Lavaan: an R package for structural equation modeling and more. Version 0.5–12 (BETA). J. Stat. Softw. 48, 1–36 (2012).

    Article  Google Scholar 

  131. Preacher, K. J., Zyphur, M. J. & Zhang, Z. A general multilevel SEM framework for assessing multilevel mediation. Psychol. Methods 15, 209–233 (2010).

    Article  PubMed  Google Scholar 

  132. Muthén, L. K. & Muthén, B. O. Mplus User’s Guide 8th edn (Muthén & Muthén, 1998).

  133. Asparouhov, T. & Muthén, B. Advances in Bayesian model fit evaluation for structural equation models. Struct. Equ. Model. https://doi.org/10.1080/10705511.2020.1764360 (2021).

Download references

Acknowledgements

Research reported in this article was supported by the National Institute on Drug Abuse of the National Institutes of Health under award number R01DA042033 (principal investigator: E.L.G.). E.L.G. was also supported by R01AT011772, R01DA056537 and R01DA057631 during the preparation of this article. The National Institute on Drug Abuse had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; or decision to submit the manuscript for publication.

Author information

Authors and Affiliations

  1. Center on Mindfulness and Integrative Health Intervention Development, University of Utah, Salt Lake City, UT, USA

    Anna Parisi, Justin Hudak & Eric L. Garland

  2. Department of Psychology, University of Missouri, Columbia, MO, USA

    Brett Froeliger

  3. Veterans Health Care Administration VISN 19 Whole Health Flagship site located at the VA Salt Lake City Health Care System, Salt Lake City, UT, USA

    Eric L. Garland

Authors
  1. Anna Parisi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Justin Hudak
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Brett Froeliger
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Eric L. Garland
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

E.L.G. conceived and designed the study and acquired funding. E.L.G., as principal investigator, had overall responsibility for the management of the study. B.F. developed the emotion regulation task, and J.H. processed the psychophysiological data. A.P. conducted the data analyses. A.P. and E.L.G. wrote the first draft of the report with input from J.H. and B.F. E.L.G. had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Corresponding author

Correspondence to Eric L. Garland.

Ethics declarations

Competing interests

E.L.G. is the director of the Center on Mindfulness and Integrative Health Intervention Development. The center provides MORE, mindfulness-based therapy and CBT in the context of research trials at no cost to research participants. However, E.L.G. has received honoraria and payment for delivering seminars, lectures and teaching engagements (related to training clinicians in mindfulness) sponsored by institutions of higher education, government agencies, academic teaching hospitals and medical centers. E.L.G. also receives royalties from the sale of books related to MORE. E.L.G. has also been a consultant and licensor to BehaVR. The other authors declare no competing interests.

Peer review

Peer review information

Nature Mental Health thanks Alicja Binkowska, Annett Lotzin and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Parisi, A., Hudak, J., Froeliger, B. et al. Mindfulness-Oriented Recovery Enhancement reduces post-traumatic stress via reappraisal among patients with chronic pain and co-occurring opioid misuse. Nat. Mental Health 1, 489–500 (2023). https://doi.org/10.1038/s44220-023-00084-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s44220-023-00084-2

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing