The co-occurrence of chronic pain, psychological distress, and misuse of prescription opioids undermines the mission of the U.S. Military and inflicts suffering upon Veterans and their families. Approximately one-half of Service members have chronic pain following deployment, and nearly one-fifth engage in opioid misusing behaviors like unauthorized dose escalation and use of opioids to self-medicate stress and anxiety. The state of Utah (where the proposed study will be conducted) has one of the highest incidences of nonmedical use of opioids in the United States and a rapidly increasing rate of prescription opioid-related deaths. Indeed, an estimated 21% of Utah adults were prescribed opioids during the past year, of which approximately one in five report taking more than prescribed. Given that military personnel and Veterans have higher rates of pain-related conditions than the general population, their risk for opioid-related problems is significantly enhanced.

New scientific findings indicate that because stress worsens pain and increases habit responses in the brain, individuals who cope with stress and pain through opioids are likely to have the most serious and difficult-to-treat opioid-related problems. The recent wars in Iraq and Afghanistan have been marked by repeated deployments involving serious combat-related and occupational stress. Unfortunately, there are no evidence-based treatments that simultaneously address pain, opioid misuse, and psychological distress. To fill this gap, this research proposal aims to conduct a pragmatic trial of a novel integrative medicine approach combining Mindfulness-Oriented Recovery Enhancement (MORE) with conventional opioid pain management for Service members and Veterans. MORE aims to strengthen self-control over habit behaviors, increase flexible thinking under conditions of stress, and promote the sense of reward and meaning in the face of adversity.

This research project will help active duty Service members and Veterans with chronic pain and stress who are at risk for opioid misuse, and will also inform the treatment of civilians with similar issues. Should MORE prove to be effective in a community-based context, within 2 years following completion of the proposed project, it could be easily transported into military installations and Veterans Affairs Medical Centers in the United States and around the world, as well as in communities where no major military medical center is present. In these settings, MORE could be offered as a form of standard integrative health care provided to Service members and Veterans.

A secondary objective of the proposed project is to utilize lab-based assessments and mobile technology to understand how MORE works to create therapeutic change, and to predict whether and when Service members and Veterans are at risk for relapsing back to opioid misuse. To accomplish this objective, lab-based assessments will evaluate physiological reactivity to cues associated with past episodes of pain and opioid use, and a smartphone-based assessment will be used to evaluate opioid craving, pain, and negative mood in "the real world." Because changes in heart rate and other physiological factors may indicate the extent to which a person's brain has been triggered by opioid craving, this application of mind-body assessments to predict opioid misuse risk and treatment outcomes could facilitate early risk detection and penetrate denial.

The final objective of the project is to understand for whom MORE works best, to help ensure more efficient healthcare resource allocation to the Service members and Veterans who need it most. The proposed project will enable healthcare providers to more effectively deliver low-cost treatment to prevent progression toward opioid addiction, thereby averting costly inpatient stays, discharge from active duty military service, and social, legal, and occupational problems among Veterans. Ultimately, the proposed research could significantly enhance the psychological and physical health of military personnel and Veterans by addressing the need for new integrative medicine treatment options with findings from the leading edge of science.