Mindfulness-based programs for substance use disorders: a systematic review of manualized treatments

MBRP is a manualized, structured protocol that integrates formal meditation practices with the cognitive behavioral approach of relapse prevention treatment. The core goals of MBRP are to: 1) cultivate awareness of internal (e.g., emotions, thoughts) and external (e.g., environmental) substance use cues to create opportunities to address triggers rather than instinctively using substances; and 2) practice (both via imagination and in vivo exposure) remaining with unpleasant affective, cognitive, or physical experiences without automatically seeking to escape or avoid the situation [13, 54]. MBRP courses are typically in a group format and consist of eight, 120-min sessions. Each session begins with a guided mindfulness practice and is followed by “inquiry,” a discussion (similar to Socratic questioning) about the client’s present moment experience of the practice. The first session uses experiential exercises focused on bodily sensations (e.g., taste and smell) designed to introduce the rationale for mindfulness by examining the role that “autopilot” plays in daily life and contrasting it with mindful awareness of experiences. The second and third sessions shift to other aspects of current experience such as sight and sound. Clients are encouraged to notice triggers and urges for substance use and to practice exercises throughout the day to encourage exiting autopilot and increasing mindfulness. Sessions four through six focus on mindfulness of thoughts and emotions. For example, clients begin to bring awareness to patterns of behavior and antecedents to relapse and are taught to notice thoughts, sensations, or emotions that might arise while remaining focused on the present moment experience. Clients are instructed to remain mindful of the present moment despite the unpleasant sensation as a method of allowing time and space to make a less impulsive, skillful decision. In sessions seven and eight, clients discuss generalizing learned practices and facilitating an environment that can support continued practice of mindfulness and changes made to substance use.

MBRP is one of, if not the most, researched MBI for SUD. Bowen and colleagues [55] conducted an initial pilot feasibility and efficacy trial of MBRP. They found MBRP to be feasible to implement and found initial support for efficacy as measured by significantly lower substance use rate, decreases in craving, and increases in acceptance and acting with awareness as compared to TAU. Other large scale RCTs and meta-analyses have shown the efficacy of MBRP with a range of samples (e.g., [56, 57]), treatment delivery modalities (e.g., [13, 56, 57]), and treatment targets [14, 56, 58]. Recent research includes RCTs designed to replicate or expand earlier findings (i.e., to new populations, examining adjunctive interventions) and secondary data analyses that seek to identify potential mechanisms of change and treatment moderators.

Mindfulness Oriented Recovery Enhancement (MORE) integrates elements of mindfulness training, cognitive restructuring, and positive psychology to address the factors theorized to maintain SUD [22]. More specifically, the three foundational elements of MORE are mindfulness, reappraisal, and savoring [22]. Mindfulness is described as a way to identify triggers and break the habit of automatic engagement in substance use in response to those triggers. Reappraisal is the process by which an individual reassesses a stressful event to be something more positive and constructive, as opposed to negative and destructive. Savoring is the act of focusing one’s attention on the positive, pleasing, and growth-inducing elements of an event. These foundational elements of MORE are the guiding principles that influence the ten-session protocol.

The standard protocol includes 10, 120-min group sessions that guide participants through the three foundational elements. The first three sessions of the MORE protocol are focused on laying the groundwork for the course by introducing the three foundational elements of MORE. In addition to introducing the practice of mindfulness, the first session presents the idea of automaticity, or “autopilot,” and the relationship between automaticity and engaging in substance use [22]. During sessions one through three, clients are asked to engage in a variety of experiential practices that range from focused attention of the breath, reframing an ordinary encounter on the street, to mindfully savoring an object in one’s immediate field of vision.

Sessions four through seven are centered around the Buddhist notion of impermanence, and the themes build upon the foundation of mindfulness. Session four and five are concentrated on the role that craving plays in substance use. Clients are asked to see the fleeting nature of any feeling, craving included, and to allow those temporary feelings to move through one’s body and mind without engaging with them or trying to change them. Clients experience the nature of craving when interacting with an object that is perceived as a treat (a piece of chocolate), then observe those same feelings of craving during a stressful situation [22]. Session six introduces the role that aversion plays in the recovery process, and how urges can be intensified when one tries to push away thoughts about drugs or alcohol. Session seven builds upon the nature of impermanence by highlighting the fleeting nature of our physical bodies and stresses the deleterious effects that toxic substances and health-risk behaviors have on our fragile existence. The primary exercise used during this session is the Impermanent Body Exercise. This practice asks the participants to bring an awareness to the facts that we will all get sick, we will all age, and we will all eventually die.

MORE was originally developed and tested during an NIH-funded Stage 1 RCT for alcohol dependence. That study demonstrated that MORE could significantly improve physiological recovery from stress and drinking-related triggers [22]. Since that initial pilot trial of the MORE protocol, the program has been adapted and modified to fit the needs of various addictive behaviors such as opioid use disorder (OUD), internet gaming disorder, and chronic pain with prescription misuse.

One of the primary processes that MORE targets is the urge to engage in substance use (i.e., craving). A large-scale RCT compared MORE to Cognitive Behavioral Therapy (CBT) and TAU in 180 male patients with co-occurring psychiatric and substance use disorders [15, 46]. Garland and colleagues found reductions in craving in all three conditions, with greater reductions in MORE than CBT, but not TAU. In addition to a reduction in craving, MORE was associated with greater decreases in post-traumatic stress symptoms versus both CBT and TAU.

Several recent trials have leveraged ecological momentary assessment (EMA) to explore the impact of MORE on craving, pain, and affective states. In one stage 1 RCT, EMA was utilized to examine the effects of MORE versus TAU on opioid craving, pain, and positive affect on individuals enrolled in methadone maintenance therapy (MMT) [51]. Compared to TAU, participants in MORE reported significantly greater decreases in opioid wanting (44% decrease) and opioid urge (50% decrease). EMA data also showed that participants in MORE reported a greater number of cravings (n = 303) than participants in TAU (n = 87), but MORE participants reported those cravings as being significantly less intense than those experienced by individuals in TAU. Participants in MORE also reported having 129% greater self-control over cravings than participants in TAU. Garland and colleagues also collected EMA data from a subset of individuals (n = 55) from a larger RCT to test the efficacy of MORE versus a support group (SG) at reducing perceived pain and improving affective state [48]. Participants were chronic pain patients with daily, to near daily, use of prescription opioids. Through the 8-weeks of the intervention, participants in the MORE group showed a 7% reduction in pain, compared to a 3% increase among the SG; thus pain intensity improved over the 8 weeks of MORE relative to the SG. Over the same duration, participants in MORE were 2.75 times more likely to be emotionally regulated than participants in the SG. Mean opioid misuse scores decreased during treatment by 7.06 in the MORE group and by 3.25 in SG.

Another mechanism that the MORE program may affect is cue reactivity. One study evaluated the impact of MORE versus a SG on the late positive potential (LPP) index of opioid cue-reactivity relative to reactivity to neutral cues in 135 individuals with chronic opioid use [52]. The LPP was used to measure prolonged attention to the opioid cues. Garland and colleagues found that for individuals in the SG, post-treatment LPP remained significantly higher in response to opioid cues compared to the neutral cues. Participants in MORE exhibited significantly greater decreases in the LPP response to opioid cues and also exhibited greater increases in the LPP response to natural reward cues from pre- to post-treatment. In another study, Garland and colleagues tested the relative responsiveness to natural reward and opioid cues in 51 individuals who used prescription opioids [49]. There was a significant group × time effect on heart rate variability (HRV) responsivity, indicating that compared to the SG, the MORE group experienced significantly greater increases in HRV responsivity in response to drug elicited cues.

Garland and colleagues also conducted a secondary data analysis to compare the effects of MORE on opioid attentional bias (AB) compared with a SG in 115 individuals who used prescription opioids [47]. The pre-treatment opioid AB significantly moderated the effect of the treatment condition on post-treatment opioid AB, indicating that the effects of treatment significantly differed by pre-treatment opioid AB. The post-treatment opioid AB score for MORE and SG participants (with pre-treatment opioid AB as a covariate) revealed a statistically significant effect of the treatment condition, with MORE participants showing significantly lower levels of opioid AB at post-treatment than SG participants. The reductions in opioid AB over the course of treatment predicted lower levels of opioid misuse at 3-month follow-up. All of these findings suggest that MORE may sever associations between conditioned drug cues and their reward value via bottom-up mechanisms and that decreasing attentional fixation on opioid cues may reduce the risk of future opioid misuse.

In an analysis of proximal outcome data collected from a larger RCT, Garland and colleagues looked at the effectiveness of MORE versus a SG on pain severity, opioid misuse, positive affect, meaning in life, and self-transcendence in 95 opioid treated chronic pain patients [50]. They found that there was a significant effect of intervention group on change in positive affect, meaning in life, savoring, and self-transcendence, indicating that MORE increased these attributes more so than the SG. For the clinical variables, there was a significant effect of intervention group on change in pain at post-treatment and change in opioid misuse risk by 3-month follow-up, such that MORE resulted in greater improvements in these variables than did the SG.

Mindful Awareness in Body-Oriented Therapy (MABT) is a manualized, mindfulness-based approach that is designed to teach interoceptive skills for self-care [23]. Interoception is the ability to process signals that originate in the body and is broadly described as the overall sensations, or state, of the body [60]. MABT is different from most mindfulness-based practices in that it specifically focuses on teaching the client mind-body skills that are designed to help with a dysregulated awareness of sensory information. There appears to be a link between a deficient interpretation of sensory information and poor emotion regulation [24]. The intervention involves eight, 90-min group sessions over eight consecutive weeks. To meet the primary aim of MABT, the course is broken down into three specific stages. Stage 1 (sessions 1 and 2) is geared toward identifying bodily sensations (identification). Often clients are unaware that physical sensations can be identified, and so, the first two sessions are aimed at teaching body literacy through a response to expected sensations (i.e. the client grasping her arm and feeling the pressure created) [24].

Stage 2 of the MABT program (sessions 3 and 4) is directed at learning and developing strategies for interoceptive awareness (access), which is a more advanced aspect of body literacy that adds upon the skills learned in the first stage [23]. This stage focuses on sensations that are still quite overt and apparent, such as the sensation of breathing in and out, but clients are beginning to refine their bodily awareness. Clients progress from sensing continuous movements in the body to perceiving specific areas of the body (chest, foot, etc.) to develop the skills of interoception.

The final stage of MABT (sessions 5 through 8) is aimed at developing the ability to maintain/sustain interoceptive awareness throughout one’s daily life (appraisal) [23]. The ability to sustain this awareness of bodily sensations allows the client to detach oneself from the uncomfortable physical sensations that may be occurring in a situation, and allow themselves to reframe the experience more positively. The ability to investigate and determine the origin of the physical sensations that are occurring during a particular event, or emotional state of being, allow the client to take charge of their experience and perform the necessary actions for self-care that are more productive than engaging in substance use.

In a large-scale RCT of 217 women enrolled in three separate outpatient treatment facilities, researchers determined if MABT resulted in improved interoceptive awareness and mindfulness skills (primary outcomes), emotion regulation (self-report and psychophysiology), symptomatic distress (e.g., depression and trauma-related symptoms), and substance use and craving compared with women’s health education (WHE), and TAU alone [23]. Price and colleagues found that MABT produced significantly greater improvements in mindfulness from pre- to post-intervention among participants who completed six or more sessions, as compared to the other groups. However, this effect was not significant in ITT analyses, including all participants with any available data. MABT also produced greater improvements in most factors of interoceptive awareness, including noticing, attention regulation, emotional awareness, self-regulation, body listening, and trust, as compared to the other two groups. However, MABT did not result in greater improvements in depression or trauma symptoms, both secondary outcomes, compared to the other two treatment groups (symptoms improved in all groups). Participants in both MABT and WHE conditions, compared with TAU, showed significantly greater improvement in the proportion of days abstinent; however, there were no significant differences across groups in relapse or craving.

A longitudinal follow-up of the previously mentioned RCT examined the number of days abstinent, overall psychological well-being, interoceptive awareness, and mindfulness skills across the three conditions through 12-month follow-up assessments among 187 of the original 217 participants [53]. Looking at the primary outcome of days abstinent from substance use among those who completed at least six sessions of treatment, the MABT and WHE groups showed a greater number of days abstinent compared to the TAU group at the 6-month and 12-month follow-up. The improvements in the number of days abstinent among MABT participants were maintained from 3 to 12 months, whereas TAU and WHE showed continuous declines in abstinent days, particularly at 12 months. There were no group differences observed for MABT vs. WHE in the percent of days abstinent or relapse at any assessment time-point.

Mindfulness-Based Addiction Treatment (MBAT) is a protocol that closely follows the procedures and rationale of Mindfulness-Based Cognitive Therapy (MBCT). Wetter and colleagues took most of the material from the MBCT handbook, but they removed the depression focused content and replaced it with information regarding substance use (e.g. smoking cessation material, alcohol abstinence, etc.) [25]. Three primary aims lead the eight, 120-min group sessions, including: (1) becoming aware of thoughts, emotions, and physical sensations from moment to moment, (2) creating a different way of relating to those thoughts, emotions, and physical sensations, and (3) using ones new-found awareness to separate oneself from those various occurrences that are arising [25]. Like the other mindfulness-based protocols reviewed, the primary aim of MBAT is to awaken clients to the automatic nature of substance use by teaching them the skills of noticing present moment feelings and sensations and detaching themselves from urges to engage in substance use.

The MBAT course is broken down into two primary sections. Sessions 1–4 are geared toward teaching clients how to direct and focus their attention [26]. This is done using a crawl-walk-run framework that has participants learn to focus their attention on something that is constantly occurring regardless of whether attention is paid to it or not, such as the sensation of breathing. Sessions 5–8 are aimed at using the skills of focused attention to help navigate through difficult situations that are related to substance use. Clients are taught specific techniques, primarily one titled “breathing space,” to find some room between stimulus and response [25]. For example, the group may be lead through a visualization exercise in which clients picture a situation where engaging in substance use would have been automatic. Clients are asked to pause the scenario just before visualizing engagement in substance use and are directed to instead observe the breath. This pause allows clients to detach from their feelings of craving and gives them the necessary space to investigate what is arising in them physically and emotionally.

In a large-scale RCT, Vidrine and her research team wanted to test the effects of the MBAT protocol on smoking cessation compared with CBT and a usual care (UC) condition comprised of brief individual counseling sessions based on the Treating Tobacco Use and Dependence Clinical Practice Guideline [25] among 412 adult smokers. Results from the study found that participants in the MBAT condition had a higher percentage of 7-day point percentage abstinence compared with the other two groups, but the difference was not statistically significant (32.5% in UC, 39.1% in CBT, and 42.1% in MBAT at 4 weeks post quit day). Among participants classified as still smoking at final treatment sessions, recovery of abstinence was examined. The MBAT condition had significantly higher recovery rates after relapse than both the CBT and UC groups 1 week following the end of treatment (13.2% in UC, 7.0% in CBT, and 26.8% in MBAT) and 26 weeks post-quit day (0% in UC, 3.5% in CBT, and 7.1% in MBAT).

Additional data collected during the parent study described above examined the cognitive and affective mechanisms underlying MBAT versus CBT and UC for smoking cessation, including: positive and negative affect, dependence, withdrawal, craving, agency, and subjective bias towards cigarettes [26]. Spears and colleagues found that members in the MBAT group perceived greater volitional control over smoking and lower volatility of anger than CBT and UC. Although the mediators of the effect of MBAT versus CBT on lapse recovery were not observable because of small subsamples, greater perceived volitional control over smoking and lower affective volatility could be mechanisms explaining why MBAT may be a better option than both CBT and UC for promoting lapse recovery in smokers. There were no other significant differences between MBAT and CBT, nor were there significant indirect effects of MBAT versus CBT, suggesting that mindfulness and cognitive-behavioral approaches may similarly influence several of the psychosocial mechanisms implicated in tobacco dependence.

Mindfulness Training for Smoking Cessation (MTS) is built upon the foundational ideas outlined in both MBSR and MBRP, but was tailored specifically for individuals who are trying to stop smoking [27]. The eight-week protocol is broken down into eight, 90-min group sessions. The primary aims of the MTS course are to (1) teach participants the skills of observing thoughts, feelings, and sensations as they are occurring in the present moment, and (2) hone the ability to accept and allow the current situation to be just as it is [16].

Sessions one and two introduce participants to how smoking has become a learned behavior through habituation and associative learning [27]. The first session introduces clients to the visceral feelings of craving, and how the urge to smoke manifests itself in the body. Session two presents the primary tool that participants can use during times of craving. The acronym RAIN (Recognize, Accept, Investigate, and Note) is used as an easy-to-remember mnemonic that clients can use when feelings of craving arise [27]. Session three introduces a traditional meditation practice, loving-kindness (metta meditation), where clients direct well wishes towards oneself and others. This practice is introduced to help clients engage with stress and negative feelings with an empathetic mind, and a kind acceptance of those feelings. Session four is the most unique aspect of the MTS course, and this is the session that sets it apart from many other MBIs, in that it encourages a formal declaration of abstinence. This session is aptly named “quit day,” and clients are asked to commit to not smoking, and are given techniques to build upon the skills of noticing the sensations that are arising in the body, primarily craving, during initial abstinence from smoking [16]. Sessions 5–7 introduce participants to how specific triggers can hinder long-term abstinence and how mindfulness practices (mindfulness of breath, RAIN, and mindful walking) can be integrated into one’s daily life to help them identify triggers and avoid smoking. Session eight summarizes all of the tools and techniques learned throughout the program and explores ways of maintaining mindful awareness in the future.

The feasibility and effectiveness of MTS was initially tested in 2013 with 55 young adult smokers [16]. This small scale pilot study found that point prevalent smoking abstinence was higher in MTS than controls, though the difference was not significant. The promising, yet underpowered results of this study have encouraged larger-scale research on the effects of the MTS protocol.

An RCT conducted by Kober and colleagues compared the effects of MTS on smoking cessation with the American Lung Association’s Freedom from Smoking (FFS) program [16]. More specifically, they looked at whether stress reactivity, including neural activity during stressful scripts, related to smoking cessation directly after treatment as well as at the 3-month post-treatment follow-up. The sample included 23 smokers between the ages of 18–60 who smoked more than 10 cigarettes per day. Both treatments reduced smoking, but the MTS group demonstrated a greater rate of reduction in cigarette use during treatment, which was maintained during the 3-month post-treatment follow-up. The MTS group showed a trend toward greater 1-week point prevalence abstinence at the end of treatment (55% vs. 23%), and this difference became statistically significant at the 17-week follow-up (44% vs. 7%). Across all participants, neural activity during the stressful scenarios in the bilateral amygdala, anterior insula, mid insula, hippocampus, parahippocampal gyrus, thalamus, middle occipital gyrus, midbrain, cerebellum, and right posterior insula, as well as a second region spanning the midline across cuneus/precuneus and posterior cingulate cortex, were correlated with less reduction in cigarettes smoked per day at post-treatment [16]. During stressful scenarios, participants in the FFS group (vs. the MTS group) exhibited increased neural reactivity in several brain regions including the left amygdala, anterior, middle, and posterior insula, and bilateral portions of parahippocampal gyrus and hippocampus, putamen, thalamus, midbrain and cerebellum [16]. The MTS group did not show greater neural reactivity in any region during the stressful scenarios.

Moment-by-Moment in Women’s Recovery (MMWR) was developed as an adaptation of MBSR, specifically designed for low income, racially, and ethnically diverse women currently enrolled in residential SUD treatment [28]. MMWR is intended to be administered in a residential setting, a feature that distinguishes it from other MBIs [28].

MMWR is comprised of eight, 90-min group sessions, and one four-hour intensive retreat day. The first session is an introduction to mindfulness, including the definition of mindfulness and how mindfulness can play an integral role in the recovery process [29]. Sessions two and three are focused on demonstrating the automatic and constant nature of thoughts, feelings, and emotions that arise throughout the day. The theme for session three is geared at empowering clients, and showing them that the perception of their environment can dictate how a situation appears (i.e. positive or negative).

Sessions 4–6 are the core lessons dedicated to learning and practicing mindfulness skills. Session four is devoted to understanding the role that negative emotions can play in relapse [29]. The emotions of anxiety, fear, and panic are the focus of this session, and clients are asked to engage in experiential exercises to practice the skill of mindfulness during these uncomfortable situations. Session five is focused on the emotions of guilt and shame [29], which often play a role in relapse. Clients are guided through a visualization exercise to practice using mindfulness while experiencing these emotions. Practicing these skills while in a safe environment helps to give clients confidence in their new skills, and helps to bolster their confidence in their ability to prevent relapse. Session six is dedicated to using mindfulness while interacting with others, including mindful communication and the importance of positive self-talk [29].

Session seven is a four-hour “retreat” day that allows clients to immerse themselves in silent meditation to practice the skills they have been learning throughout the course. Session eight is aimed at teaching participants how to engage mindfully with anger and violence. The emotion of anger is the focus of this session, and participants are asked to identify and observe their own triggers for anger. In the final session, all of the activities and skills that were presented during the course are reviewed to solidify and sustain the concepts learned.

The MMWR intervention has a very specific and niche target population that lends itself well to researching the effects of the intervention without many confounding variables. In a large-scale RCT, Black and colleagues tested the efficacy of MMWR on improving SUD treatment retention when applied as an adjunctive intervention to residential treatment compared with a neurobiology of addiction psychoeducation course (control condition) [17]. The sample was comprised of 200 adult women diagnosed with SUD and admitted to the residential SUD treatment program study site. The primary outcomes of the study were discharge status (if a client developed the necessary skills to complete residential treatment), days until discharge (the number of days a client remains in residential treatment beginning with the first day of the intervention and ending at day 150), and self-report measures of mindfulness disposition, perceived stress, distress tolerance, emotion regulation, psychological distress, affect, and drug and alcohol craving [17]. The count of women defined as treatment completers (client completed SUD treatment) was 43/100 in the MMWR group versus 31/100 in the control group. The count of women in-residence (client still at the residential treatment site at day 150) was 15/100 in the MMWR group and 27/100 in the control group. Among the 84 treatment non-completers (client left the facility before the end of treatment), satisfactory progress was made by 16/42 women in the MMWR group and 10/42 women in the control group. However, there were no differences between conditions for any of the self-report measures, including craving.