Journal Article Annotations
2024, 1st Quarter


Annotations by Alissa Hutto, MD.
April, 2024

  1. Mindfulness-Oriented Recovery Enhancement for Veterans and Military Personnel on Long-Term Opioid Therapy for Chronic Pain: A Randomized Clinical Trial.


Mindfulness-Oriented Recovery Enhancement for Veterans and Military Personnel on Long-Term Opioid Therapy for Chronic Pain: A Randomized Clinical Trial.
Eric L Garland, Yoshio Nakamura, Craig J Bryan, Adam W Hanley, Anna Parisi, Brett Froeliger, William R Marchand, Gary W Donaldson


The finding:
This single-blind randomized control trial compared several opioid use, pain, and other psychological symptom outcomes for both veterans and active-duty military personnel who were treated with either Mindfulness-Oriented Recovery Enhancement (MORE) or supportive psychotherapy. The two primary outcomes are chronic pain (severity and interference) as measured by the Brief Pain Inventory (BPI), and opioid misuse as measured by the Current Opioid Misuse Measure (COMM). For primary outcomes, they found that MORE did reduce pain severity and interference significantly more than did supportive psychotherapy, but opioid misuse was not different between the groups. MORE did reduce MEDD (square root transformed data) by 21% as compared to 4% in the supportive psychotherapy group. For secondary outcomes, MORE reduced anhedonia, reduced pain catastrophizing, and improved positive affect significantly moreso than did supportive psychotherapy.

Strength and weaknesses:
A major caveat to these findings is a conflict of interest: MORE was developed by the first author of this study, who receives royalties from the sale of books related to MORE. This potential bias seems to be reflected in the glossing-over of several weaknesses. They do not mention the clinical relevance of the outcomes, which can be particularly questioned for the primary chronic pain outcomes, where the absolute change in the survey score is just one point. Their significant secondary outcomes (anhedonia, catastrophizing, and affect) are all <10% differences in scores on their respective scales. While the MEDD is perhaps the most impressive difference and most clinically meaningful, they do not fully explain the utility of using the square root of the MEDD instead of actual MEDD in their comparison. They did include patients with psychiatric disorders (though excluded those with psychosis and “elevated suicide risk”), and their population had a high average pain duration and an average MEDD above the CDC-recommended limit (90 MEDD). Both of these factors make this data more generalizable, especially in the psychiatric population. They do also note the potential effects of switching from an in-person to a virtual modality mid-study after COVID-19. Another interesting aspect of this paper is the inclusion of those meeting criteria for opioid use disorder (OUD), and it would have been very interesting to see how the MEDD reduction compared for the OUD and non-OUD subsets.

While this RCT does have some weaknesses and a major conflict of interest, it is another demonstration of how the pain management field may benefit not only from borrowing psychopharmacologic interventions, but non-medication psychiatric treatments as well. RCTs involving pain management that collect information about DSM diagnoses will continue to create a wealth of data about the pain-psychopathology overlap, which will benefit us as consult psychiatrists often called to see chronic pain patients both in and out of the hospital.