Targeting Military Opioid Misuse with Mindfulness-Oriented Recovery Enhancement

描述（由申请人提供）：慢性疼痛的现役军人（ADSM）处方阿片类药物滥用和成瘾对美国军方构成重大的公共卫生威胁。许多ADSM患有服务过程中产生的持续性疼痛，需要用阿片类药物进行适当的治疗。然而，慢性疼痛的ADSM患者中有很大一部分存在阿片类药物成瘾的风险。慢性疼痛患者的阿片类药物成瘾涉及认知、情感和行为放松管制，往往导致严重的功能损害和健康风险。处方阿片类药物成瘾可能源于长期从事阿片类药物滥用行为，如剂量增加、使用非法阿片类药物或使用阿片类药物自我治疗负面情绪。虽然已经开发出具有较低成瘾倾向的阿片类药物输送系统，但在缺乏维持性药物治疗的情况下，现有的治疗成功率很低。此外，寻求慢性疼痛治疗的人对现有的成瘾治疗反应特别差。传统的药物治疗在没有长期维持的情况下可能疗效有限，因为它们不能靶向并持久地改变不受控制的认知-情感习惯回路，这种习惯回路控制着由疼痛、压力和药物提示引起的食欲反应。因此，迫切需要预防干预措施，以有效解决ADSM中从慢性疼痛到阿片类药物滥用和成瘾风险链的关键认知情感介质。我们建议测试一种新的选择性预防干预，正念导向的恢复增强（MORE），它将正念训练、认知重新评估和自然奖励处理的增强结合起来，以增强心理健康，打破导致阿片类药物成瘾的疼痛、渴望和负面影响的循环。本提案的总体目标是确定MORE是否减少阿片类药物滥用，并防止慢性疼痛的ADSM中阿片类药物成瘾的发展，这些ADSM处于军事生命周期的重返社会阶段，并表现出阿片类药物滥用行为。将从科罗拉多州Fort Carson招募120名阿片类药物滥用ADSM并伴有慢性疼痛的患者，并随机分配到8个MORE小组或一个传统支持小组（SG）。评估将在治疗前后进行，并进行6个月的随访。我们假设，与SG相比，更多会显著减少阿片类药物滥用（主要结局），以及显著减少阿片类药物渴望和疼痛（次要结局）。我们假设临床结果将被注意偏倚（AB）、情绪调节、自主线索反应和积极心理过程的变化所介导。此外，我们假设治疗后AB和提示引起的心率变异性将预测阿片类药物滥用复发的发生和时间。R34资助的这一早期随机对照试验将允许对基于认知、情感和神经生物学模型的创新性ADSM预防干预进行严格测试。该R34提案建立在PI在该领域长达十年的临床和研究工作的基础上，包括他之前nida资助的R03。

DESCRIPTION (provided by applicant): Prescription opioid misuse and addiction among active duty service members (ADSM) with chronic pain present significant public health threats to the U.S. Military. Many ADSM suffer from persistent pain conditions incurred in the line of service that require appropriate medical treatment with opioids. Yet, a substantial subset of ADSM with chronic pain is at risk for developing opioid addiction. Opioid addiction among persons with chronic pain involves cognitive, affective, and behavioral deregulation that often results in serious functional impairment and health risks. Addiction to prescription opioids may emerge from prolonged engagement in opioid misusing behaviors, such as dose escalation, use of illicit opioids, or use of opioids to self-medicate negative emotions. Although opioid delivery systems with lower addiction liability have been developed, extant treatments have low rates of successful outcomes in the absence of maintenance pharmacotherapy. Moreover, persons seeking treatment for chronic pain respond especially poorly to existing addictions treatments. Conventional pharmacotherapies may have limited efficacy without long-term maintenance because they fail to target and durably alter deregulated cognitive-affective habit circuits which govern appetitive responses elicited by pain, stress, and drug cues. As such, prevention interventions are urgently needed to effectively address key cognitive-affective mediators of the risk chain from chronic pain to opioid misuse and addiction among ADSM. We propose to test a novel selective prevention intervention, Mindfulness-Oriented Recovery Enhancement (MORE), which integrates mindfulness training, cognitive reappraisal, and enhancement of natural reward processing to augment psychological health and break the cycle of pain, craving, and negative affect leading to the development of opioid addiction. The overarching aim of this proposal is to determine whether MORE reduces opioid misuse and prevents the development of opioid addiction among ADSM with chronic pain that are in the reintegration stage of the Military Lifecycle and exhibiting opioid misuse behaviors. A sample of 120 opioid misusing ADSM with chronic pain will be recruited from Fort Carson, CO, and randomly assigned to 8 group sessions of MORE or a conventional support group (SG). Assessments will be conducted at pre- and post-treatment, as well for 6 monthly follow-ups. We hypothesize that MORE will result in significantly greater reductions in opioid misuse (primary outcome) than the SG, as well as significantly greater decreases in opioid craving and pain (secondary outcomes). We hypothesize that clinical outcomes will be mediated by changes in attention bias (AB), emotion regulation, autonomic cue-reactivity, and positive psychological processes. Furthermore, we hypothesize that AB and cue- elicited heart rate variability following treatment will predict the occurrence and timing of relapse to opioid misuse. R34 funding for this early stage randomized controlled trial will allow for a rigorous test of an innovative prevention intervention for ADSM grounded in models from cognitive, affective, and neurobiological science. This R34 proposal builds on the PI's decade-long clinical and research work in this area, including his prior NIDA-funded R03.