Mind Over Matter: Beating Pain and Painkillers


Findings were recently published on a study of a mindfulness based intervention for chronic pain and opioid misuse.

To test the treatment, 115 chronic pain patients were randomly assigned to eight weeks of either MORE or conventional support group therapy, and outcomes were measured through questionnaires at pre- and post-treatment, and again at a three-month follow-up. Nearly three-quarters of the group misused opioid painkillers before starting the program by taking higher doses than prescribed, using opioids to alleviate stress and anxiety or another method of unauthorized self-medication with opioids.

Among the skills taught by MORE were a daily 15-minute mindfulness practice

“People who are in chronic pain need relief, and opioids are medically appropriate for many individuals,” Garland said. “However, a new option is needed because existing treatments may not adequately alleviate pain while avoiding the problems that stem from chronic opioid use.”session guided by a CD and three minutes of mindful breathing prior to taking opioid medication. This practice was intended to increase awareness of opioid craving—helping participants clarify whether opioid use was driven by urges versus a legitimate need for pain relief.

It’s important to note that this may be a very useful option for non-addicted opioid misusers with chronic pain.

They are also trying the model for smoking cessation. It’ll be interesting to see their outcomes.

It’ll also be interesting to see if more non-pharmacological treatments for pain, either as adjuncts to medication or as stand-alone treatments. Facing chronic pain is a concern for most recovering people I know, especially recovering opiate addicts.


via Mind Over Matter: Beating Pain and Painkillers | University of Utah News.

no hint of opinion here


To me, the most important line in the NY Times Suboxone series was this one, “[Dr. Sullivan] considered opioid addiction “a hopeless disease'”.

We believe that maintenance approaches are rooted in the belief that most opiate addicts are not capable of recovering in the same manner that doctors recover.

Most of the arguments for maintenance treatments focus on reduced harm and its relative risks, very few focus on quality of life or achieving full recovery.

It’s also worth remembering that Suboxone compliance rates aren’t what they used to be.

The post below was originally published on 6/26/13. I decided to repost it to accompany the posts from the last few days.

*   *   *

From an article about a new report on medications for opiate treatment:

The report also examined studies that evaluated buprenorphine, methadone, injectable naltrexone, and oral naltrexone and concluded a benefit in patient outcomes as well as costs.

“I can say with no hint of opinion here, it’s simple fact, they are all effective,” McLellan said. “They’re effective not just in reducing opioid use, they’re effective in so many other ways that are important to societies and families.”

Effective. It’s a fact. No opinion here. Hmmm.

Effective at what? These drugs are effective at reducing opiate use. If that outcome is all one wants, they may be a good option.

The problem is that it’s a palliative response, when we know that full recovery is possible if the right resources are made available. (Of course these treatment approaches are not the ones physicians choose for themselves and their peers.)

Let’s see what the report says about another outcome that might speak more directly to quality of life, say, employment [emphasis mine]:

These studies have also measured various types of related outcomes such as reductions non-opioid drug use, employment and criminal activity. Here the literature is quite mixed and appears to be a result of the particular patient population, the clinical approach of the methadone maintenance program and the available counseling and social services provided.


As with methadone, the literature is quite mixed with regard to reducing non-opioid drug use, improving employment and reducing crime.


He also found improvements within the methadone maintenance group across various time periods on HIV risk behaviors, employment and criminal justice involvement. [My note: In this study, employment increased from approximately 21% to approximately 31%.]

So…while there’s little doubt that these medications reduce opiate use and overdose deaths, the quality of life evidence is considerably weaker.

With the increases in opiate ODs, I understand families and individuals struggling with these decisions. I struggle to come up with the best analogy for informed consent. Maybe something like this?

Maybe the choice is something like a person having incapacitating (socially, emotionally, occupationally, spiritually, etc.) and life-threatening but treatable cardiac disease. There are 2 treatments:

  1. A pill that will reduce death and symptoms, but will have marginal impact on QoL (quality of life). Relatively little is known about long term (years) compliance rates for this option, but we do know that discontinuation of the medication leads to “near universal relapse“, so getting off it is extremely difficult. The drug has some cognitive side-effects and may also have some emotional side effects. It is known to reduce risk of death, but not eliminate it.
  2. Diet and exercise can arrest all symptoms, prevent death and provide full recovery, returning the patient to a normal QoL. This is the option we use for medical professionals and they have great outcomes. Long-term compliance is the challenge and failure to comply is likely to result in relapse and may lead to death. However, we have lots of strategies and social support for making and maintaining these changes.

The catch is that you can’t do both because option 1 appears to interfere with the benefits of option 2.

Methadone with and without counseling

by Fearless Tall Dude Killer
by Fearless Tall Dude Killer

Drug and Alcohol Findings reviews research on the impact of counseling for methadone patients.

While across the board there was significant improvement, being assigned to standard/enhanced versus interim (no counseling) programmes did not further improve retention, illicit drug use and related problems, or make much difference to criminal activity. There was no evidence that interim patients has been substantially disadvantaged by the four-month period during which only emergency counselling was available and during which they could not ‘earn’ take-home doses by providing ‘clean’ urine tests.

The findings are consistent with other studies at typical US methadone clinics. They strongly suggest that rather than making such services obligatory, opioid agonist treatment regulations should allow for additional services where these are both helpful to and wanted by patients. As well as increasing costs by imposing services that may or may not be needed, mandating these services has the unintended consequence of denying access to more basic treatment which is demonstrably of value to patients and to society. The findings also raise questions over discharging patients simply because they have not attended the required number of counselling sessions.

Some of the obvious possible explanations are:

  • Counseling is not effective or necessary with opiate addicts. [But, we know it’s effective with doctors.]
  • Methadone interferes with counseling, possibly leaving patients unavailable for counseling. [There’s some evidence for this with MAT. Here, here, here, here, here and here.]
  • That the dose of counseling methadone patients receive is ineffective. [It seems pretty intuitive that once-a-month counseling is likely to be a sub-therapeutic dose.]

Suboxone diversion?

Ah subutex!
Ah subutex! (Photo credit: nicolasnova)

A recent study looking at diversion of buprenorphine finds that:

While 9% reported recent street-obtained buprenorphine use, only a small minority reported using buprenorphine to get high, with the majority reporting use to manage withdrawal symptoms.

The use of street-obtained buprenorphine primarily to avoid withdrawal fits with Dawn Farm’s experience, though the percentage would be much higher than 9%.

We know that the experience in Europe has been different. For example, a 5 year study there found:

In 2007, 60.2% of the respondents claimed heroin or morphine as their first injected drug. This percentage had declined to 51.3% in 2010, but in contrast the incidence of buprenorphine as the first injected or abused drug by the study population increased from 30.5% (2007) to 44.4% (2010).

Why the difference? Well, a few possibilities come to mind:

  • That Europe adopted the drug earlier than the US.
  • That the brand most widely used in the U.S. includes naloxone, which is less desirable as a street-obtained drug.
  • That the American study was done in 2008, and things have changed rapidly since then.

The big question is whether we’ll see the kind of misuse that Europe has seen.

[Hat tip: Substance Matters]

Buprenorphine compliance rates

Choose you evidence carefully by rocket ship
Choose you evidence carefully by rocket ship

The following abstract popped up today.

The purpose of the study was to look at factors associated with completion of the 6 month, primary care based program.

What struck me was the completion rate–35.7%. For all the crowing about ORT, this seems really low. (And, they said this completion rate is consistent with prior studies.) This is particularly underwhelming when the researchers identify physical injury as a predictor of completions and speculate that this is related to chronic pain. These subjects constitute 71.7% of completers. So…when you omit those with injuries, the completion rate drops to 24%.

Primary care patient characteristics associated with completion of 6-month buprenorphine treatment

BACKGROUND: Opioid addiction is prevalent in the United States. Detoxification followed by behavioral counseling (abstinence-only approach) leads to relapse to opioids in most patients. An alternative approach is substitution therapy with the partial opioid receptor agonist buprenorphine, which is used for opioid maintenance in the primary care setting. This study investigated the patient characteristics associated with completion of 6-month buprenorphine/naloxone treatment in an ambulatory primary care office.
METHODS: A retrospective chart review of 356 patients who received buprenorphine for treatment of opioid addiction was conducted. Patient characteristics were compared among completers and non-completers of 6-month buprenorphine treatment.
RESULTS: Of the 356 patients, 127 (35.7%) completed 6-month buprenorphine treatment. Completion of treatment was associated with counseling attendance and having had a past injury.
CONCLUSIONS: Future research needs to investigate the factors associated with counseling that influenced this improved outcome. Patients with a past injury might suffer from chronic pain, suggesting that buprenorphine might produce analgesia in addition to improving addiction outcome in these patients, rendering them more likely to complete 6-month buprenorphine treatment. Further research is required to test this hypothesis. Combination of behavioral and medical treatment needs to be investigated for primary care patients with opioid addiction and chronic pain.

“It works!”, Ctd

This is "effective"?
This is “effective”?

A new study of buprenorphine implants find that implants work as well as oral dosing and outperform placebo.

What does that mean?

If I’m reading it correctly, it means that the average subject receiving the implant tested positive for opioids 68.8% of the time compared to 86.6% for the placebo subjects. (If I’m misreading it, set me straight.)

I don’t know about you, but that not how I’d define success for myself or a family member.

This speaks directly to the importance of asking, “what does ‘effective’ mean?”

Another article argues for morphine maintenance for opioid addiction.

If ORT is the direction the field is heading, why not? If questioning the assertion that ORT is the most effective treatment based on quality of life differences is a bogus argument*, why not morphine maintenance or heroin maintenance?

*  Note that I’ve argued that physicians health programs are the gold standard and that they should replicated and offered to all opioid addicts. I did not say that they standard abstinence-based treatment was superior or should be imposed on anyone. In fact, I’ve repeatedly argued that the standard abstinence-based treatment offered opioid addicts does not provide the appropriate quality, duration, intensity or dose.

Buprenorphine and emotional reactivity

The following article was shared with me by a reader. Not surprisingly, the emphasized portion below caught my eye. [emphasis mine]


Addictions to illicit drugs are among the nation’s most critical public health and societal problems. The current opioid prescription epidemic and the need for buprenorphine/naloxone (Suboxone®; SUBX) as an opioid maintenance substance, and its growing street diversion provided impetus to determine affective states (“true ground emotionality”) in long-term SUBX patients. Toward the goal of effective monitoring, we utilized emotion-detection in speech as a measure of “true” emotionality in 36 SUBX patients compared to 44 individuals from the general population (GP) and 33 members of Alcoholics Anonymous (AA). Other less objective studies have investigated emotional reactivity of heroin, methadone and opioid abstinent patients. These studies indicate that current opioid users have abnormal emotional experience, characterized by heightened response to unpleasant stimuli and blunted response to pleasant stimuli. However, this is the first study to our knowledge to evaluate “true ground” emotionality in long-term buprenorphine/naloxone combination (Suboxone™). We found in long-term SUBX patients a significantly flat affect (p<0.01), and they had less self-awareness of being happy, sad, and anxious compared to both the GP and AA groups. We caution definitive interpretation of these seemingly important results until we compare the emotional reactivity of an opioid abstinent control using automatic detection in speech. These findings encourage continued research strategies in SUBX patients to target the specific brain regions responsible for relapse prevention of opioid addiction.

I started out skeptical of the methods and researchers, but, from what I can tell, the methods don’t seem to be fringe pseudoscience.

I don’t know what to make of the associations of Blum, it looks like he was involved in very important research on the genetics of alcoholism in 1990. Since then, it looks like he’s been involved in a lot of entrepreneurial ventures. Bios say that he’s on faculty at Department of Psychiatry and McKnight Brain Institute, but I could find no reference to him on  their website.

Berman appears to have a robust academic career and is affiliated with NIAAA, VA, Boston University and ATTC.

The article was also peer reviewed.

What do you think?