Mindful interoceptive mapping: Elucidating a novel mechanism for treating opioid misuse and chronic pain

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PROJECT ABSTRACT Mindfulness-based interventions (MBIs) are emerging as efficacious treatment options for the 11.5 million Americans with chronic pain on long-term opioid analgesic pharmacotherapy, but all mindfulness practice in- structions are not the same. Most MBIs use the breath as the focal point of mindfulness practice; Mindfulness Oriented Recovery Enhancement (MORE) uses pain. MORE teaches chronic pain patients to mindfully decon- struct a pain percept into its constituent affectively-valenced physical sensations and map each sensation’s pre- cise bodily location. This mindful interoceptive mapping (MIM) process typically reveals a combination of un- pleasant sensations (e.g., “stabbing”), spaces within the body that are entirely absent of sensation, and even pleasant sensations (e.g., “warmth”) co-existing at any given moment. In this way, MIM broadens the scope of pain management beyond a myopic focus on symptom reduction. Cultivating awareness of pleasant bodily sen- sations stands to be particularly therapeutic for opioid-treated chronic pain patients because (i) pleasant expe- riences are analgesic, (ii) both chronic pain and opioid exposure can lead to hedonic deficits, and (iii) the ina- bility to experience natural pleasure is a core mechanism of addictive behavior. There is an urgent and unmet need to identify non-pharmacological techniques that increase chronic pain patients’ embodied experience of pleasure in the service of decreasing their pain and opioid use. Without better pain management techniques, vulnerable opioid-treated chronic pain patients will continue to be at risk for transitioning from prescription opioid use for pain management to opioid misuse and addiction. Consistent with the HEAL (Helping to End Addiction Long-term) Initiative priorities, our long-term goal is to enhance pain management and prevent opi- oid misuse by optimizing MBIs for opioid-treated chronic pain patients. The proposed project’s central hypoth- esis is that MIM instruction will enable chronic pain patients to recontextualize unpleasant sensation as only one somatic aspect in a larger field of pleasant bodily sensation, and thereby alter their subjective experience of pain and their desire for pain medication. This project is the next logical step in a program of research in which we (i) created the only digital sensation manikin that simultaneously assesses both pleasant and unpleasant bodily sensations, (ii) developed a psychometrically sound and clinically useful pleasant sensation ratio (pleas- ant/unpleasant), and (iii) conducted two preliminary randomized clinical trials in which we found mindfulness training increased the pleasant sensation ratio (↑pleasant/unpleasant), which in turn decreased opioid desire and pain as well as aberrant medication-related behavior associated with opioid misuse (AMRB) and pain func- tional interference. Our preliminary data suggests both MIM and traditional mindful breathing increase pleas- ant sensation ratios. What we do not know is if MIM and mindful breathing differentially impact pleasant sen- sation ratios. Knowing which type of mindfulness instruction most effectively increases pleasant sensation ra- tios will allow us to better remediate hedonic deficits and, thereby, better treat opioid misuse and addiction.