Mindfulness‐based cognitive therapy for chronic noncancer pain and prescription opioid use disorder: A qualitative pilot study of its feasibility and the perceived process of change

Abstract Background Mindfulness‐based interventions have a positive impact on pain, craving, and well‐being in both patients with chronic pain and those with opioid use disorder (OUD). Although data are limited, mindfulness‐based cognitive therapy (MBCT) might be a promising treatment for patients with chronic noncancer pain combined with OUD. The aim of this qualitative study was to explore the feasibility and process of change during MBCT in this particular population. Methods In this qualitative pilot study, 21 patients who were hospitalized for rotation to buprenorphine/naloxone as agonist treatment for chronic pain and OUD were offered MBCT. Semistructured interviews were conducted to explore experienced barriers and facilitators to MBCT. Patients who participated in MBCT were also interviewed on their perceived process of change. Results Of 21 patients invited to participate in MBCT, 12 initially expressed interest but only four eventually participated in MBCT. The timing of the intervention, group format, somatic complaints, and practical difficulties were identified as the main barriers to participation. Facilitating factors included having a positive attribution toward MBCT, an intrinsic motivation to change, and practical support. The four MBCT participants mentioned several important mechanisms of change, including reduction of opioid craving and improved coping with pain. Conclusions MBCT offered in the current study was not feasible for the majority of patients with pain and OUD. Changing the timing of MBCT by providing it at an earlier stage of the treatment and offering MBCT in an online format may facilitate participation.


INTRODUCTION
Although opioids are potent analgesics, there is no evidence supporting long-term use in chronic noncancer pain (Nury et al., 2022). Yet, a substantial proportion of patients with chronic pain are treated with opioids-in the United States, around 15% (Groenewald et al., 2022). It has been estimated that around 10% of patients who use prescription opioids for chronic pain develop an opioid use disorder (OUD) (Vowles et al., 2015), characterized by an urge to use opioids (craving), failure to cut down on opioid use, and impairment in daily activities (Els et al., 2017). Next to their analgesic effects, some patients also report the use of opioids to cope with negative emotions (Wasan et al., 2007). Indeed, anxiety and depression frequently co-occur in patients with chronic pain (van Rijswijk et al., 2019), and opioid use itself also increases the risk for developing mood symptoms (Leung et al., 2022). Together, this may accumulate into a downward spiral of pain, negative emotions, craving, and increasing prescription opioid use (Garland, 2014).
In order to break this downward spiral, psychological treatment aimed at coping with pain, craving, and negative emotions might be helpful to improve quality of life and reduce opioid use. Mindfulnessbased interventions (MBIs) may be specifically suitable for this population by helping patients to allow negative emotions, including pain and mood symptoms, and replace automatic reactions, including opioid use, by more conscious and helpful responses. MBIs can cultivate specific mindfulness skills, such as self-awareness, acceptance, and self-compassion (Garland, 2014;Garland et al., 2012;Kim et al., 2018).
During MBIs, patients practice to be aware in the present moment and to have a nonjudgmental attitude to their current experience (Kabat-Zinn & Hanh, 2009).
MBIs have repeatedly been shown effective in improving coping with negative emotions, both in patients with mood and anxiety disorders (Goldberg et al., 2018) and in patients with chronic pain (Chiesa & Serretti, 2011;Esmer et al., 2010;Garland et al., 2012Garland et al., , 2014. Studies specifically focusing on patients who use prescription opioids for pain are promising; a small study reports pain reduction with an effect size of 0.86 . Other studies find moderate effect sizes on reducing craving and opioid use (Cooperman et al., 2021;Garland et al., 2014Garland et al., , 2016.
However, some patients experience barriers toward participation in an MBI, including barriers related to pain and organizing transportation . Furthermore, most studies focus primarily on patients with chronic pain but without OUD. It is currently unknown whether these MBIs are equally appropriate for the treatment of patients with both chronic pain and OUD.
Given the limited data on MBIs for patients with chronic pain combined with prescription OUD and its potential effectiveness, the aim of this pilot study was to assess the feasibility of mindfulness-based cognitive therapy (MBCT) in this population. It is essential to assess the ability and willingness of patients to participate in this treatment and identify any adaptations that need to be made before conducting larger studies. Our secondary aim was to assess the process of change for patients who participated in the MBI to get an initial indication of its effectiveness. Our study was conducted in a patient group that was offered agonist treatment with buprenorphine/naloxone (BuNa) prior to the MBI.

Study design
A qualitative pilot study was conducted to assess feasibility and process of change for MBCT in patients with chronic pain and OUD.  protocol (protocol no. 2015-1551) and concluded that it met these criteria for exemption.
All patients scheduled for BuNa rotation were informed on the possibility to participate in the study during hospitalization (see flowchart Appendix S1), either face-to-face or over phone. Patients who agreed to participate in the study gave written informed consent prior to data collection and were explained that MBCT would be scheduled 3 months after the rotation. Patients did not receive financial compensation for their participation.

Participants
Participants were recruited among patients referred for opioid agonist treatment with BuNa. Participants were adults, met ICD-11 criteria for chronic pain (persistent or recurring noncancer pain lasting ≥3 months) (Treede et al., 2019), and met the Diagnostic and Statistical

Intervention
MBCT was based on the original MBCT protocol for recurrent depression of Segal et al. (2018).

Qualitative interviews
Patients were interviewed in a semistructured manner. In the first interview, prior to start of MBCT, patients were asked (1)

Data analysis
Data analysis was done using a thematic analysis approach (Braun & Clarke, 2006). Two researchers joined the study for data analysis:

Study flow
We screened 39 patients from clinical admission for BuNa rotation between April 2020 and July 2021, of which 24 patients successfully participated in BuNa rotation and 21 patients agreed to be included in data collection for this study. Nine (43%) out of the 21 patients did not want to participate in MBCT. The primary reasons for this were having already participated in an MBI before, having too much pain, too much travel distance and time, and not being interested in psychosocial interventions. Three patients out of this group were interviewed to further explore their barriers to participation. The study flow is also described in Appendix S1.
Twelve patients initially expressed interest in MBCT, but eight of these patients refrained from participating in the 3 months before the start of MBCT. From these eight patients, two patients were only interviewed during their first moment of choice (when being positive about participation), two were interviewed only during their second moment of choice (when refraining from participation), and four were interviewed at both these timepoints. In Appendix S2, it is described which patients participated in how many interviews. The primary reasons for choosing not to participate later in the process were MBCT being too late within the treatment process and practical difficulties.
Four patients (19%) participated in MBCT. Three out of these patients were interviewed prior to MBCT about barriers and facilitators. One patient participated in all eight sessions, two patients participated in seven sessions, and one patient participated in six sessions. All four patients attended the silent day. All four patients were interviewed to explore their perceived process of change.

Baseline characteristics of interviewed population
Fifteen of 21 patients participated in at least one qualitative interview.
The baseline demographic and clinical characteristics of the interviewed population (n = 15) can be seen below in Table 1 (see Appendix   S3 for a description of the entire population).
Prior to BuNa rotation, patients used oxycodone (nine patients) or fentanyl (six patients), with an average oral morphine equivalent dose of 169 mg.

Barriers and facilitators of MBCT participation
From analysis of the interviews, three categories of barriers and facilitators emerged: (1) personal characteristics, (2) psychosocial factors, and (3) MBCT training factors (see Table 2). See Appendix S4 for illustrative quotes.

Personal characteristics
Mindset. Barriers to MBCT participation were a negative view and low expectations of MBCT, an avoiding coping style regarding difficult feelings, and a somatic attribution of pain.
Pain. Some patients expected that pain or fatigue itself would hinder participation. They worried that somatic complaints would get worse during MBCT sessions, for example, by sitting in uncomfortable poses for longer periods. A long travel distance also served as a barrier, as sitting in a car worsened pain. One of the MBCT participants mentioned that some days he had too much pain to meditate.  Being solution driven, goal oriented, and flexible and getting easily along with other people also facilitated participation.

Facilitators
Pain. Patients hoped that MBCT would reduce their pain, teach them to accept and cope with pain better, and provide distraction from the pain.

Mood symptoms.
Almost all patients talked about learning how to cope with anxiety and worries, and to accept themselves more. Two patients expressed the wish to be more present and enjoy the current moment. Most patients wanted to learn how to protect their boundaries. They hoped that MBCT would reduce overreacting to emotions and make them less chaotic and irritable. Wishing to reduce stress was mentioned as well.
Addiction. Patients hoped MBCT would reduce or distract from craving for and dependency to their medication. They also wanted to learn how to deal with withdrawal symptoms. One patient wanted to communicate more openly about opioid use and OUD. One patient participated in MBCT to prevent relapse into opioid use.  Table 3). See Appendix S4 for illustrative quotes. For this patient group, data saturation could not be reached due to the small number of participants in MBCT.

General changes
Emotion regulation. Patients expressed that they were more in touch with and observant of their emotions after MBCT. One patient's anxious emotions had diminished. Another patient who struggled with anger mentioned that this had reduced as well. Patients reported enjoying more moments of calmness and happiness.
Thoughts. Patients expressed that they became better in accepting the current situation as it is. All patients felt calmer than before MBCT, and one patient slept better. Furthermore, patients were more compassionate toward themselves, such as putting less blame on themselves than before. All patients reported that they could distance themselves from their thoughts. Two patients mentioned that they felt less "mental chaos." One patient experienced an improved ability to focus attention.
Behavior. Patients expressed they learned to set boundaries, plan better, and take rest when needed. Another patient became better in dealing with feelings of restlessness. Patients also reported participating more in activities that they enjoyed.
Interpersonal. Patients described that after MBCT, it was easier to talk with others about their problems, to be more honest and open about how they were feeling. One patient experienced more empathy toward others and one participant expressed feeling like "herself" again after MBCT (happier and calmer), which was confirmed by her partner.

Specific to population
Pain. Two patients mentioned that participation in MBCT had no direct effect on their pain. One patient, however, said that MBCT helped in creating a feeling of calmness, and that this feeling reduced pain levels.
He had realized that having stress also led to headaches. All patients expressed that they became better in dealing with pain, either by letting it go, by looking for distractions, or by accepting it. Patients also became aware of the influence of stress on pain. One patient expressed that the body scan meditation was helpful in focusing on where in the body she felt pain and accepting it. Another patient experienced his daily life was less affected by pain than prior to MBCT, and that he was part of society again.

Addiction.
A patient expressed that when being stressed, he normally would crave for opioids. MBCT helped to reduce stress and in this way reduced craving. This patient also expressed an increased ability to cope with craving by reflecting on the craving, realizing why he was craving for opioids, and being aware of the negative consequences of giving in to the craving. Patients also said MBCT helped to focus on something else when experiencing craving or opioid withdrawal symptoms, such as a body scan meditation.

Barriers, facilitators, and implications
We offered MBCT 3 months after initiating BuNa treatment. A frequently mentioned barrier to participation was that MBCT was offered late within the treatment process. Offering MBCT earlier might mean that patients could use mindfulness skills to deal with difficult moments of increased pain or craving during pharmacotherapy. Indeed, in a recent pilot study, 15 patients participated in Mindfulness-Oriented Recovery Enhancement (MORE) during methadone substitution therapy. Unlike our population, these patients were primarily using illicit opioids at baseline, but they also all had chronic pain. The MORE group was compared with a group being offered counseling. In both treatment arms, there was little dropout during this period (Cooperman et al., 2021), indicating that this timing is feasible for an MBI. Furthermore, patients participating in MORE, as addition to rotation to methadone, had more reductions in craving, illicit opioid use, and pain compared to patients rotating to methadone with counseling (Cooperman et al., 2021). In future research on MBCT in patients with chronic pain and OUD, MBCT could be offered in adjunct to rotation to opioid agonist therapy or any other intervention, such as tapering. As patients in our study mentioned, they may use coping skills that they learn during the MBI to cope with pain or craving during the change in medication.
Other barriers included mental complaints and the fear that pain and mental complaints would get worse with MBCT, and not wanting to participate in a group. Regarding these fears, giving patients the opportunity to try out a single MBCT session may be a solution to take some worries away.
There were also practical barriers to participation: having other responsibilities, limited social support, too much pain, and too many mental complaints. Having limited time and practical/social support have also been identified as barriers in other studies on feasibility of MBIs in patients using opioids for chronic pain  as well as in different populations with somatic or psychiatric complaints (Brintz et al., 2020;Ewais et al., 2020;Hanssen et al., 2020;Janssen et al., 2020;Schoultz et al., 2016

Perceived process of change
While our study gives insight in the barriers and facilitators to participation, we are limited in drawing conclusions about the effectiveness of the intervention. The four MBCT participants indicated that changes in their pain coping, opioid craving, and an increased sense of functioning contributed to their recovery process. They all perceived MBCT as useful. Improved pain coping has also been reported in another qualitative study in 21 patients with chronic low back pain and long-term opioid use participating in an MBI . Yet, quantitative studies with more patients are necessary to draw conclusions about the effectiveness of MBCT in this patient population.

Strengths and limitations
A strength of our study is the representative sample of patients from clinical practice that we asked to participate in our study, allowing us to investigate the barriers to participation in depth. A limitation, however, is that due to the limited number of MBCT participants, data saturation was not achieved regarding our questions on the process of change during MBCT.

CONCLUSION
Although the participants who completed the MBCT were generally positive, MBCT in the current form is not feasible for the majority of the patient population. We identified multiple barriers to MBCT participation, including timing of the intervention and practical difficulties.
Changing the timing of the MBCT by providing it at an earlier stage of the treatment and offering MBCT in an online format may facilitate participation. Furthermore, psychoeducation and giving patients the opportunity to try out a single MBCT session might support them to make a decision toward participation too.

ACKNOWLEDGMENTS
The authors would like to thank all patients who participated in this study.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.