Posted 10.28.2020 | by AMRA

The over-prescription of opioids for chronic pain is a significant risk factor for drug abuse and addiction. About one-fifth of chronic pain patients double their opioid dosage over the course of two years, and so primary care psychological interventions are needed to reduce the risk of eventual misuse and dependence.

In a previous clinical trial, a mindfulness training program for opioid users reduced pain and opioid dosage in chronic pain patients. Garland et al. [American Psychologist] conducted a secondary analysis of that clinical trial, now examining whether physiological changes in heart rate variability (HRV) predict opioid dose reduction. HRV is the variation of time between each heartbeat and serves as a biomarker for increased autonomic nervous system self-regulation. Greater HRV is associated with relaxation and greater emotional and behavioral self-control.

The researchers randomly assigned 95 primary care patients who were prescribed opioids for the management of chronic musculoskeletal pain (66% female; 90% Caucasian; average age = 57 years) to Mindfulness-Oriented Recovery Enhancement (MORE) or a support group. Both MORE and support groups were delivered once weekly for 2 hours across 8 weeks.

MORE included didactics and practice in mindfulness, cognitive reappraisal, and savoring naturally occurring rewards that included 15 minutes a day of home practice in these skills. Emphasis was placed on making the skills relevant to substance abuse, pain, stress reduction and self-regulation. The support group included nondirective counseling, social support, home journaling, and discussions of chronic pain, stigma, and stress.

Daily opioid dosage before and after intervention was assessed using retrospective self-report and prescription data from the medical record. After intervention, HRV was measured via electrocardiogram during a 5-minute baseline recording and a 10-minute mindfulness meditation. The meditation instruction was a simple verbal prompt to attend to thoughts, feelings and sensations in the present without judgment and reactivity, and was the same for MORE participants and controls.

The results showed the MORE group reduced daily opioid dosage significantly more than the support group (Cohen’s d = 1.07). The MORE group decreased their average daily opioid dosage from 66 mgms to 45 mgms, while the support group increased their daily average dosage from 69 mgms to 156 mgms.

The MORE group showed a significantly greater increase in HRV during meditation relative to the rest period (d = .42) than controls. Decreased opioid dosage was partially meditated by the increase in HRV during meditation, suggesting that participants with the largest increases in HRV while meditating showed the largest decreases in opioid daily dose. Daily home practice in the MORE group correlated with reduced opioid dose (r = -.40) and increased HRV (r = .42).

The study shows that a training that includes a significant mindfulness component adapted to reduce the risk of opioid misuse can reduce daily opioid dosage in chronic pain patients. HRV findings suggest that autonomic nervous system activity occurring while meditating might confer greater self-regulation over pain and opioid use.

Interpretation of study findings are limited by primary reliance on retrospective self-reports of daily opioid dose. It is also unclear whether increased HRV while meditating is indicative of more state-like autonomic changes that endure over time, or simply reflects that people with prior meditative practice relax more during meditation than people without prior practice.


Garland, E. L., Hudak, J., Hanley, A. W., & Nakamura, Y. (2020). Mindfulness-oriented recovery enhancement reduces opioid dose in primary care by strengthening autonomic regulation during meditation. American Psychologist, 75(6), 840–852.

[Link to study]