A research team at the Icahn School of Medicine at Mount Sinai in the US has reported results from a randomised clinical trial in which adding an eight-week Mindfulness-Oriented Recovery Enhancement (MORE) programme for patients with opioid use disorder receiving medication treatment changed prefrontal activity in response to drug cues and reduced craving. The study was published on 28 October in the journal JAMA Psychiatry.
Opioids are narcotic substances that include heroin, fentanyl and some painkillers. Medication treatments such as methadone and buprenorphine have been used in the US for decades, but the research team noted in the paper that overdose deaths remain high and that more approaches targeting the brain mechanisms underlying addiction are needed. The study tested mindfulness as one such approach: adding it to medication treatment rather than asking patients to stop taking their medication.
Scenes from Trainspotting included: first randomised trial to confirm findings using brain imaging
The study took place at Samaritan Daytop Village, a long-term inpatient treatment facility in New York. According to a Mount Sinai press release, 86 adults with opioid use disorder took part, all of whom were taking methadone or buprenorphine. Participants were randomly assigned to receive either MORE or the comparison treatment, psychoeducational supportive therapy, for eight weeks. The comparison treatment was also delivered over the same period in the same group format, to assess the difference made by mindfulness itself. The trial ran from November 2020 to September 2024.
The research team used functional magnetic resonance imaging (fMRI) before and after treatment. Participants completed a task involving regulating their responses while viewing images related to drugs and images of natural rewards in everyday life, such as food. They were also shown drug-related scenes from Trainspotting, a film about drug addiction. This was intended to show how the brain responds to stimuli closer to real life than laboratory images. The researchers described it as the first randomised clinical trial to use fMRI to examine how mindfulness-based treatment changes brain function in addiction.
Two hours once a week for eight weeks: mindfulness, reappraisal and savoring combined
MORE is a group programme developed by Professor Eric Garland of the University of California San Diego (UCSD), who also co-authored this study. According to the paper, participants met once a week for two hours, for eight sessions.
The programme comprises three practices. The first is mindfulness training: noticing the body and mind in the present moment. The second is cognitive reappraisal: looking at situations that trigger thoughts of drugs from a different perspective. The third is savoring: deliberately lingering on positive moments in everyday life, such as sunshine or a warm cup of tea. As addiction deepens, people can find it difficult to feel pleasure in anything other than drugs; savoring is intended to help them reconnect with the everyday pleasures that have become dulled.
The more the brain shifted towards everyday pleasures, the more craving fell
The results fell into three areas. First, in a task requiring participants to try to regulate their responses to drug-related images, the MORE group showed a greater reduction than the comparison group in lateral prefrontal activity biased towards drugs. The prefrontal cortex is involved in controlling impulses and assessing what is valuable.
Within the MORE group, craving fell more among those whose prefrontal response to drug cues changed more substantially, and among those who showed greater ventromedial prefrontal activity while savoring images of food. In other words, the extent to which the brain’s focus shifted from drugs towards natural rewards in everyday life was associated with reduced craving. The paper said this association was seen only in the MORE group.
There was also a difference when participants watched the film scenes. In the MORE group, medial prefrontal activity was less synchronised with the drug scenes than in the comparison group, and participants whose synchronisation fell more substantially also experienced a greater reduction in craving triggered by the scenes. At follow-up about four months after treatment ended, the MORE group had longer periods of abstinence than the comparison group.
Senior author Professor Rita Goldstein said in a press release: “Prefrontal function in addiction is not fixed, and recovery of brain function is possible.” First author Dr Yuefeng Huang said that while opioid treatment medications save lives, they are not designed to retrain the way the brain responds to cues that trigger craving. The changes observed in this study, he explained, may be part of what recovery in the brain looks like.
It does not replace medication; only dozens of participants were included in the final analyses
The first point to make about this study is that MORE does not replace medication treatment. All participants were receiving methadone or buprenorphine, with mindfulness added to their treatment. The research team also positioned MORE as an adjunct to medication treatment. The findings should not be read as meaning that mindfulness alone can overcome opioid addiction.
The numbers also need to be viewed with care. The press release said 86 people took part, but according to the paper’s abstract, 59 participants were included in the drug-cue response analysis (24 in the MORE group and 35 in the comparison group), 37 in the film-viewing analysis, and 38 in the four-month follow-up analysis (13 in the MORE group and 25 in the comparison group). The difference in abstinence duration was statistically significant, but the reported effect size was small. Of those included in the drug-cue analysis, 13 were women, around 22%. The researchers said that the findings need to be confirmed in larger and more diverse groups of participants and in other treatment settings, and that they will increase the number of women taking part to examine how sex and hormones affect treatment response.
This is not the first time MORE has been tested in opioid recovery settings. In another clinical trial published online in the same journal in December 2023, 154 patients with chronic pain at five methadone treatment centres in New Jersey, US, received MORE by video over eight weeks. They had lower risks of drug reuse and dropping out of treatment than the group receiving usual treatment alone. The Mount Sinai study sought to investigate what changes in the brain might accompany such effects.
Not meditation spent sitting in silence, but practice in reappraisal and savoring
When people think of meditation, they may first picture sitting cross-legged for a long time and emptying the mind. MORE, the programme used in this study, is somewhat different. Participants met in groups to notice their present-moment sensations, see situations that trigger craving from a different perspective, and practise savoring small everyday pleasures, alongside medical treatment. In an age of information overload and constant stimulation, the ability to notice what is capturing our attention and what we are missing is not a challenge exclusive to people with addiction. For people who give their days over to smartphones and short-form videos, savoring can also be a way in to something they can start practising straight away.
In addiction recovery, meditation’s role is less about taking the place of medication and healthcare professionals than about helping people build the skills to manage their minds alongside that care. This study offers one glimpse of that possibility. This reporting did not establish how widely mindfulness programmes are used in addiction treatment settings in South Korea. We hope that evidence emerging overseas will also be discussed among recovery services and mindfulness instructors there. If you are receiving treatment for addiction, it is best to consult your healthcare professional before starting meditation.
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