Loneliness and Opioid Use Disorder: Can Mindfulness Help?

woman with eyes closed practicing mindfulness
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Can mindfulness help with loneliness and opioid use disorder? The short answer is yes – but not in the way you might guess.

We’ll elaborate on that answer below.

First, though, we’ll explain why this topic – the relationship between loneliness and substance use disorder (SUD) – interests us.

We operate a substance use disorder treatment center in Williamson, West Virginia. For those unfamiliar with the state, it’s important to understand that the entire state of West Virginia sits in the Appalachian Mountains. It has a population of around 1.8 million people, a majority of whom live in communities with less than 2,500 residents. Census data shows that 64 percent of West Virginians live in rural areas, placing it third, after New Hampshire – where we also operate a substance use disorder treatment center – and Vermont.

A quick note: substance use disorder (SUD) is the clinical phrase used by mental health and medical professionals describe the condition most people previously called addiction. We’ll use substance use disorder (SUD) and opioid use disorder (OUD) throughout this article, and occasionally use the word addiction.

Now let’s talk get to the matter at hand, and talk about loneliness, OUD, and mindfulness.

Rural Communities and Increased Risk of Opioid Use Disorder

As we mention above, two of the SUD treatment centers we operate are in states with a large percentage of rural residents: West Virginia and New Hampshire. Previous research shows the following factors increase risk of opioid misuse, disordered use, and overdose for people living in rural areas:

  • Poverty
  • Isolation
  • Limited access to:
    • General health care
    • Mental health care
    • Addiction treatment
    • Transportation
  • Limited social support
  • Homelessness
  • Unemployment
  • Hunger/food instability

While loneliness is not on that list it’s clear to us that factors like poverty, isolation, lack of social support, unemployment, and hunger may all contribute to a sense of loneliness. In addition, we know loneliness itself can contribute to emotional issues associated with substance use disorder, such as anxiety and depression. Studies show that mindfulness training, in combination with medication-assisted treatment for opioid use disorder (MOUD), can decrease risk of relapse, reduce drug-related cravings, and mitigate symptoms of anxiety and depression that often increase risk of relapse.

That’s why two studies published recently caught our attention:

First Study:

The publication “Testing Mindfulness-Based Relapse Prevention with Medications for Opioid Use Disorder Among Adults in Outpatient Therapy: A Quasi-experimental Study” offers valuable evidence on the positive impact of a specific approach to mindfulness training during medication-assisted treatment for opioid use disorder called mindfulness-based relapse prevention, or MBRP.

Second Study:

The publication “Assessing Loneliness among Adults Receiving Outpatient Treatment with Medication for Opioid Use Disorder (MOUD)” is a supplemental study to the initial study we describe above. Researchers simply added one more metric – loneliness – to the comprehensive metrics used to measure the impact of MBRP on individuals with OUD in MAT programs with MOUD.

We’ll start this discussion by focusing on the first study, the one on mindfulness: we’ll describe the participants, method, and results. Then we’ll shift focus the second study, the one on loneliness. Since the participants and method in that study are identical to the first study, we’ll limit our analysis to the results on that single additional metric, loneliness.

Before we discuss these studies, we’ll offer a brief update on the opioid crisis in West Virginia. This information will help clarify the importance of exploring every option available to support our rural patients in rural areas like Appalachia, where there are significant barriers to lifesaving treatment and support for people with OUD.

West Virginia and the Opioid Crisis: Facts and Figures

This is the most current data on drug overdose in West Virginia for 2019-2021:

  • 2019: 870 overdose deaths
  • 2020: 1330 overdose deaths
  • 2021: 1,553 overdose deaths

When we compare those numbers to the rest of the country, we uncover a disturbing fact: those rates are far above the national average. Rates for 2019 were 250 percent higher than the national average and rates for 2020 were 280 percent higher than the national average – we don’t have access to a confirmed national rate for 2021. However, we do know that overall, about 80 percent of all overdose deaths for 2019-2021 involved opioids.

That’s why we need to studies like the ones awe discuss in this article: the ongoing opioid epidemic threatens the health and safety of all our citizens, and individuals in rural areas like West Virginia are at increased risk of opioid use disorder (OUD) and opioid overdose.

With all that in mind, let’s take a look at that first study.

The Effect of Mindfulness-Based Relapse Prevention (MBRP) during MAT for OUD

Randomized controlled trials (RCTs) on the effectiveness of behavioral support – meaning counseling, therapy, and other complementary treatment modalities such as mindfulness – in combination with MOUD show mixed results.  A review of available studies conducted in 2017 showed roughly half yielded positive results, while the other half showed no measurable difference between patients on MOUD who engaged in behavioral therapy and those who didn’t. The patients for whom therapy helped reported that contingency management – i.e., strategies to avoid or rebound from relapse – had the most beneficial effect on their recovery journey.

However, the phenomenon of co-occurring disorders confound these results. The 2019 National Survey on Drug Use and Health (NSDUH) indicates that almost half of people diagnosed with SUD also meet clinical criteria for a mental health disorder, a.k.a. a co-occurring disorder. To address the dual challenge of treating individuals with SUD and a co-occurring mental health disorder, one approach researchers and clinicians explore is mindfulness. Since mindfulness-based therapeutic techniques are known to improve mental health outcomes, researchers theorize that supporting patients in SUD treatment with complementary mindfulness interventions will improve outcomes.

Two primary approaches to using mindfulness in SUD treatment show promise:

  • Mindfulness-oriented Recovery Enhancement (MORE)
  • Mindfulness-based Relapse Prevention (MBRP)

The latter approach – MBRP – has an extensive, robust evidence base. Therefore, a group of researchers based in West Virginia – a mountainous, rural state located entirely in Appalachia – conducted a study on the impact of MBRP on a group of individuals diagnosed with opioid use disorder (OUD) who engage in medication-assisted treatment (MAT) with safe, effective, Federal Drug Administration (FDA) medication for opioid use disorder, known as MOUD.

To learn more about mindfulness in SUD treatment, please visit the blog section of our website and read this article:

The Role of Mindfulness in Recovery

That article will give you general idea of how mindfulness can help people in treatment for any type of addiction. The studies we discuss in this article are focused specifically on people with OUD who participate in medication-assisted treatment (MAT) with medication for opioid use disorder (MOUD).

First Study: Outcomes and Metrics

In this study on the impact of mindfulness training on recovery, researchers collected data related to the following four outcomes:

1. Treatment Retention

  • Patients who missed two consecutive sessions, or missed two sessions within 24 weeks, were not included in the data set
  • Relapse to any substance use.
  • Any use of alcohol or non-prescribed medication met criteria for relapse, as identified by self-report and urine screens

2. Psychological Risk Factors for Relapse

Researchers measured mindfulness with the 5-Facet Mindfulness Questionnaire (FFMQ). This assesses five self-reported mindfulness skills:

  • Observing
  • Describing
  • Acting with awareness
  • Non-judgment of inner experience
  • Non-reactivity to inner experience

Those are the four outcomes they designed the study to measure. Now let’s look at their study design and participants.

First Study: Participants and Process

Researchers recruited 80 participants living in rural West Virginia. All study participants:

  • Had a clinical diagnosis for opioid use disorder (OUD)
  • Participated in medication-assisted treatment (MAT) with medication for opioid use disorder (MOUD)
  • Self-reported as substance free for at least 90 days before study initiation
  • Chose between two treatment options:
    • Standard MAT with MOUD with treatment as usual (TAU). TAU include cognitive behavioral therapy (CBT) and individual counseling.
    • MAT with MOUD plus mindfulness-based relapse prevention (MBRP). MBRP included bi-weekly, 60-minute mindfulness training sessions every week for 24 weeks.
  • Received assessments for all five outcomes – treatment retention, relapse, cravings, psychological risk factors for relapse, and mindfulness – at the following intervals:
    • Baseline, i.e., study initiation (except retention)
    • 12 weeks after study initiation
    • 24 weeks after study initiation
    • 36 weeks after study initiation

This study is designed to answer questions that are relevant to the next steps that we – as a society in general, and we – as treatment professionals – need to take in our efforts to mitigate the ongoing harm caused by the opioid epidemic and overdose crisis.

Behavioral intervention is an essential part of medication-assisted treatment (MAT). Federal regulations require individuals in MAT programs to participate in therapy and counseling. The more we know about which types of therapy and counseling help reduce relapse, prevent overdose, reduce co-occurring mental health symptoms, and improve overall quality of life for people in MAT for OUD with MOUD, the better we can tailor treatment plans to give each patient the best possible chance of achieving long-term, sustainable recovery.

With that in mind, let’s look at the results.

Mindfulness-Based Relapse Prevention (MBRP) or Treatment As Usual (TAU): Was There a Difference?

We’ll report these results one metric at a time, in the order we introduce them above, starting with treatment retention.

Here’s what the researchers found.

Retention: Did MBRP Affect Treatment Retention?

  • 12 weeks:
    • MBRP group: 91%
    • TAU group: 91%
  • 24 weeks:
    • MBRP group: 80%
    • TAU group: 76%
  • 36 weeks:
    • MBRP group: 74%
    • TAU group: 71%

There was no statistically significant difference in retention between the MBRP group and the TAU group.

Relapse: Did MBRP Affect Relapse Rates?

45% of participants relapsed at least once during the 36-week study. The MBRP group showed lower relapse rates than the TAU group.

Here’s the detailed breakdown by time point and experimental group.

  • 12 weeks:
    • MBRP group: n/a
    • TAU group: n/a
  • 24 weeks:
    • MBRP group: 31%
    • TAU group: 40%
  • 36 weeks:
    • MBRP group: 43%
    • TAU group: 47%

Of note from this data set is the fact that only 4% – a total of 4 participants – relapsed to opioid use. The majority of relapse events involved methamphetamine, alcohol, and benzodiazepines. Relapse rates were higher, overall, in the TAU group.

Cravings: Did MBRP Reduce Cravings?

Higher scores indicate higher frequency and intensity of drug cravings.

Here’s the data by assessment time point and experimental group.

  • Baseline:
    • MBRP group: 22.3
    • TAU group: 23.1
  • 12 weeks:
    • MBRP group: 20.9
    • TAU group: 22.3
  • 24 weeks:
    • MBRP group: 20.1
    • TAU group: 20.3
  • 36 weeks:
    • MBRP group: 19.5
    • TAU group: 19.3

It’s important to recognize that while there was no statistically significant difference in cravings between the MBRP group and TAU group, both groups reported significant reduction in cravings. This emphasizes the crucial role of behavioral therapy in reducing cravings for individuals with OUD on MAT with MOUD.

Depression: Did MBRP Reduce Depressive Symptoms?

Higher scores indicate higher frequency and intensity of depressive symptoms.

Here’s the data by assessment time point and experimental group.

  • Baseline:
    • MBRP group: 7.1
    • TAU group: 5.1
  • 12 weeks:
    • MBRP group: 4.3
    • TAU group: 5.2
  • 24 weeks:
    • MBRP group: 4.2
    • TAU group: 5
  • 36 weeks:
    • MBRP group: 3.6
    • TAU group: 3.9

This data set shows that the MBRP group experienced statistically greater reductions in depressive symptoms, compared to the TAU group.

Anxiety: Did MBRP Reduce Anxiety?

Higher scores indicate higher frequency and intensity of symptoms associated with anxiety.

Here’s the data by assessment time point and experimental group.

  • Baseline:
    • MBRP group: 9
    • TAU group: 6.5
  • 12 weeks:
    • MBRP group: 6.6
    • TAU group: 6.5
  • 24 weeks:
    • MBRP group: 6.1
    • TAU group: 6
  • 36 weeks:
    • MBRP group: 5.5
    • TAU group: 5.7

This data set is somewhat misleading. The leveling off – meaning almost identical scores – recorded at 12 and 24 weeks mask the statistically greater overall reduction reported by the MBRP group compared to the TAU group. Overall, the MBRP group showed a 40% decrease in symptoms related to anxiety, while the TAU group showed a 12% decrease in symptoms related to anxiety.

Mindfulness: Did MBRP Increase Mindfulness?

Higher scores indicate a higher level of self-reported mindfulness, as determined by the five components of mindfulness addressed in the mindfulness assessment.

Here’s the data breakdown by time point and experimental group.

  • Baseline:
    • MBRP group: 3
    • TAU group: 3.1
  • 12 weeks:
    • MBRP group: 3.4
    • TAU group: 3.3
  • 24 weeks:
    • MBRP group: 3.4
    • TAU group: 3.3
  • 36 weeks:
    • MBRP group: 3.5
    • TAU group: 3.3

Like the data on anxiety, this data set may also be a challenge to interpret. What this data shows is that participants in the MBRP group showed a 17% increase in mindfulness overall, compared to a 6% increase for the TAU group. In addition, the MBRP group showed statistically higher levels of self-reported mindfulness at 12, 24, and 36 weeks, despite showing lower levels of self-reported mindfulness at baseline.

When we consider this data set as a whole, we see robust evidence for the use of MBRP in treatment for people with OUD in MAT programs with MOUD. This data teaches us at least two things: both treatment-as-usual (TAU) with therapy/counseling and mindfulness (MBRP) effectively reduce rates of relapse and increase treatment retention. Treatment adherence and relapse rates – in the absence of any behavioral treatment at all – are far higher than those reported in this study. The second thing we learn from this data is that, compared to treatment as usual, MBRP:

  • Reduces cravings more effectively
  • Decreases anxiety more effectively
  • Reduces depressive symptoms more effectively

In addition – and this comes as no surprise – individuals who engaged in MBRP reported increased mindfulness, which experts recognize improves outcomes for people in recovery.

Now we have one more metric to discuss: loneliness.

Loneliness and Opioid Use Disorder: The Impact of Mindfulness

Remember: the study on loneliness is the same study as the one we describe in detail above. The only difference is that in the second study, researchers added one more metric: loneliness. They hypothesized that the mindfulness group would report less loneliness over time than the treatment-as-usual group.

Were they right?

Let’s take a look.

Loneliness: Compared to Treatment-as-Usual (TAU) Did MBRP Decrease Loneliness?

Researchers measured loneliness with the 20-item Revised-UCLA Loneliness Scale (R-UCLA). Higher scores indicate higher levels of loneliness.

Here are the results, offered by time point and experimental group.

  • Baseline:
    • MBRP group: 45.4
    • TAU group: 43.2
  • 12 weeks:
    • MBRP group: 41.2
    • TAU group: 6
  • 24 weeks:
    • MBRP group: 40.2
    • TAU group: 42.0
  • 36 weeks:
    • MBRP group: 40
    • TAU group: 41

There are two important takeaways from this set of data. First, we note that in both groups, rates of loneliness decreased over time: since loneliness is a risk factor for addiction and overdose, this confirms the validity of behavioral interventions alongside MAT for OUD with MOUD. Second, we note that although there was no significant difference in reported loneliness, on average, over the 36-week study, the MBRP group reported a 10 percent reduction in loneliness, compared to the 5 percent reduction reported by the TAU group.

How this Data Helps Us Help People With OUD

One way this research helps is by adding to the evidence base that supports the use of behavioral interventions – e.g. therapy, counseling, mindfulness techniques – in MAT programs for people diagnosed with opioid use disorder.

That tells us that in our treatment centers in New Hampshire and West Virginia, we’re on the right track: we include behavioral counseling in all our treatment programs.

Next, evidence from the first study shows that MBRP is more effective than standard counseling in reducing cravings, depression, and anxiety: that’s critical information for us, since many of our patients have co-occurring mental health disorders in addition to opioid use disorder. We can now use that evidence to support our efforts to create individualized treatment plans for people with anxiety and/or depressive disorders.

We know that when we treat the whole person – meaning treating any as well as any mental health disorder – outcomes improve, and individuals have a greater chance at achieving sustainable, lifelong recovery.

Finally, this data teaches us that behavioral interventions decrease loneliness in people with OUD in MAT programs. Although the data did not match the experimental hypothesis – researchers thought the MBRP group would experience greater reductions in loneliness – the results speak volumes. When individuals with OUD in MAT programs with MOUD participate in therapy, counseling, and/or mindfulness training, their levels of loneliness decrease. That decrease has a mirror: decreased loneliness means an increased sense of social connection. Combined, those two developments – a decrease in loneliness and an increase in social connection – can increase the likelihood of a full and successful recovery from opioid use disorder.