Mindfulness group therapy cut opioid misuse in primary care

Clinical takeaway: For chronic pain patients on long-term opioids who are misusing them, a short group behavioral program is defensible on economics alone. Availability, not price, is the harder question.

Opioid misuse in a long-term pain patient is usually not a discrete event. It develops over months, in someone whose function depends on the medication, and it is often identified at a visit scheduled for something else. The clinical difficulty is that the finding rarely comes with an actionable next step. Tapering risks losing the patient; continuing unchanged accepts a rising risk of overdose.

About one in four patients on long-term opioid therapy misuse their medication, which raises the risk of overdose and of progression to opioid use disorder. Treatments designed to address the pain and the misuse together have cleared randomized trials, but they remain scarce in primary care and compete for funding against residential and intensive outpatient addiction services with longer economic track records.

The distinguishing feature of these programs is a defined skill sequence, mindfulness for pain and craving, cognitive reappraisal for the emotions that drive use, and savoring to rebuild responsiveness to ordinary rewards, rather than group support alone. A cost-effectiveness analysis of a randomized trial in 250 adults with chronic pain and ongoing opioid misuse, treated in primary care clinics and followed nine months, examined how that comparison holds.

Opioid misuse persisted in 54% of patients assigned to the intervention, an eight-session group program called Mindfulness-Oriented Recovery Enhancement (MORE), compared with 78% of those assigned to the control, eight sessions of supportive group psychotherapy. Both were measured at nine months by a composite of self-reporting, blinded clinician rating, and urine screen. Pain severity, depression and anxiety scores, and daily opioid dose were also lower in the intervention group in the parent trial.

The intervention cost $28 more per patient, or $116 per case of misuse averted. Both arms ran the same number of therapy hours, so nearly all of the cost difference was training the MORE therapists at $900 apiece.

The cost-effectiveness analysis drew on a randomized trial run in Utah primary care clinics from 2016 to 2020. Patients qualified if they had taken daily opioid analgesics for at least 90 days and scored 9 or higher on the Current Opioid Misuse Measure. Those receiving cancer treatment or with psychosis, suicidal behavior, or severe non-opioid substance use disorder were excluded. Participants averaged 51.8 years of age, 64% were women, and they had lived with pain for a mean of 14.7 years. Most were taking oxycodone or hydrocodone, at a mean morphine equivalent daily dose of 101 mg. Costs were reported in 2023 dollars.

The program has been tested in more than 16 randomized trials with over 2,500 participants and taught to more than 1,200 clinicians. Implementation studies extend to California, New Jersey, methadone programs, and orthopedic surgery. The authors argue that private and public plans should fund dissemination and point to opioid litigation settlements now reaching the states as a source.

"My hope is that MORE can become a central part of the standard of care, not only in addiction treatment settings, but also upstream in primary care, where we have a chance to intervene before opioid misuse progresses to more severe addiction," said Eric Garland, PhD, professor of psychiatry at UC San Diego School of Medicine, who developed MORE and founded the MORE Science Institute.

Source: Wilson, et al.(2026 Jun 26) Value Health. Economic Evaluation of Mindfulness-Oriented Recovery Enhancement for the Treatment of Opioid Misuse