Controlling Pain Without Medication: Mindfulness-Oriented Recovery Enhancement (MORE)
July 7, 2017   

A recently published study examined the associations between dispositional mindfulness, hedonic capacity, and pain related interference. Researchers analyzed data of 115 chronic-pain suffers who were taking opioids for analgesia at least 5 days/week for the past >90 days. From the sample group, 56.5% participants had a primary pain condition of low back pain (n=65), 20% had fibromyalgia (n=23), 7% had joint pain (n=8), 6% had upper back/neck pain (n=7), and 10.4% had ‘other’ pain conditions (n=12). Participants completed the Snaith-Hamilton Anhedonia and Pleasure Scale (SHAPS) which measures hedonic capacity with 14-items. Pain severity and interference was assessed with the Brief Pain Inventory (BPI), and mindfulness was measured with the 39-item Five Facet Mindfulness Questionnaire (FMMQ). A total of 69 participants (60%) from the sample met the diagnostic criteria for major depressive disorder through Mini-International Neuropsychiatric Interview (MINI). Compared to those without depression, this group reported lower dispositional mindfulness scores (t = 3.49, P = 0.001) and hedonic capacity scores (t = 3.49, P = 0.001; t = 20.33, P = 0.02, respectively), while reporting significantly high pain interference scores. After controlling for clinically relevant confounders such as depression, analysis showed a positive correlation between dispositional mindfulness and hedonic capacity scores (r = 0.33, P < 0.001). The association between dispositional mindfulness and pain interference was mediated by hedonic capacity (b = -0.011, SE = 0.005; 95% CI, -0.004 to -0.024, full model R-squared = 0.39). This suggests that interventions that increase mindfulness may reduce pain-related impairment among opioid-using patients by enhancing hedonic capacity.1

One intervention that integrates mindfulness and specifically targets hedonic dysregulation is Mindfulness-Oriented Recovery Enhancement (MORE). MORE is being investigated by Dr. Eric Garland, director at the Center on Mindfulness and Integrative Health Intervention Development (C-MIIND) at the University of Utah. This multimodal intervention is designed to simultaneously target mechanisms underpinning chronic pain and opioid misuse. MORE integrates mindfulness training with techniques from cognitive behavioral therapy CBT and positive psychology designed to restructure reward processing and boost positive affect

A randomized controlled trial published in 2014 showed, relative to a support group active control, MORE was shown to significantly reduce pain severity and functional interference, as well as opioid craving and misuse.2 A more recently published secondary analysis of the data, demonstrated improvements in positive affect and reductions in misuse associated with MORE. In the analysis, findings specifically showed greater improvements in measures of momentary pain (P=0.01) and positive affect (P=0.004) in the MORE group compared with the support group. Over the course of treatment, patients were significantly more likely to exhibit positive affect regulation (OR=2.75). Additionally, improvements in positive affect (but not pain) during the intervention were associated with reduced risk of misusing opioids by post-treatment (P = 0.02).3

Mindfulness training may be an important target of interventions aimed at reducing both anhedonia and pain-related interference among individuals suffering from chronic pain.


1. Thomas EA, Garland EL. Mindfulness is Associated With Increased Hedonic Capacity Among Chronic Pain Patients Receiving Extended Opioid Pharmacotherapy. Clin J Pain. 2017;33(2):166-173.

2. Garland EL, Manusov EG, Froeliger B, Kelly A, Williams JM, Howard MO. Mindfulness-oriented recovery enhancement for chronic pain and prescription opioid misuse: results from an early-stage randomized controlled trial. J Consult Clin Psychol. 2014;82(3):448-59.

3. Garland EL, Bryan CJ, Finan PH, et al. Pain, hedonic regulation, and opioid misuse: Modulation of momentary experience by Mindfulness-Oriented Recovery Enhancement in opioid-treated chronic pain patients. Drug Alcohol Depend. 2017;173 Suppl 1:S65-S72.