Okay, good afternoon or good evening, depending on where you are. To everyone, I'm Dr. David Stifler, and on behalf of the, my screen's mixed up here, on behalf of the American Academy of Addiction Psychiatry, I wanna welcome you to today's webinar in our series on Advanced Addiction Psychotherapy. This is a monthly series focused on evidence-based intensive psychotherapy training for addiction psychiatry fellows and faculty. It's hosted in partnership with the Oregon Health and Science University and New York University. We're excited you could join us today and offer you these live trainings that are always held on the second Wednesday of each month from 5.30 to 7 p.m. Eastern time. Today's presentation will focus on mindfulness-oriented recovery enhancement. Our next presentation will be in October with our very own Dr. Chris Blazes. We'll talk about practical neurobiology and using recovery capital. You can check the AAAP website for updates on other upcoming speakers. Turn it over to you, Chris. All right, great. Well, we're grateful to have Dr. Eric Garland with us today. He's a PhD LCSW. He's the endowed professor in health sciences at Sanford Institute for Empathy and Compassion and professor in the Department of Psychiatry at University of California, San Diego, having just recently moved there from the University of Utah. So Dr. Garland is a developer of the innovative mindfulness-based therapy focused on insights derived from affective neuroscience. Excuse me one second. And it's called MORE or Mindfulness-Oriented Recovery Enhancement. He's published more than 250 scientific manuscripts and received more than $80 million in research grants to conduct clinical trials of mindfulness and addiction for chronic pain and other disorders. In recognition of his expertise, Dr. Garland was appointed by the NIH director, Dr. Francis Collins, to the NIH HEAL multidisciplinary work group to help guide the $2 billion HEAL initiative and to use science to halt the opioid crisis. In a recent bibliometric analysis of mindfulness research published over the last 55 years, Dr. Garland was found to be the most prolific author on mindfulness research in the world. And mindfulness is something that I have been able to integrate into my practice in the care of our patients and it's been remarkably effective. And so we're very grateful to learn more about this innovative approach and welcome Dr. Garland and thank you. Thank you, Dr. Blazes, Dr. Stifler. It's an honor and a pleasure to be able to speak with you all today. I definitely believe in the AAAP and I think it's a great organization and I'm very pleased to see the organization really embrace psychotherapy and the role of psychotherapy in the treatment of addiction. So today I'm gonna be speaking with you about the psychotherapeutic approach that I developed called Mindfulness Oriented Recovery Enhancement or MORE. So what I hope to do today is to lay out a conceptual framework. So describe some of the pathogenic mechanisms that are underlying the comorbidity of addiction and emotional dysregulation and chronic pain to describe some of these mechanistic targets that we really need to address if we want to make traction and help people with this complex comorbidity. And then I'm gonna talk about the way that we address this through Mindfulness Oriented Recovery Enhancement. So I'll describe the therapy, some of the background theory behind it. I'll describe some of the techniques and demonstrate one of the techniques. And then I'll talk about research evidence on this model. So that's what I hope to accomplish today. So to begin, addiction, as we all know here, is a complex problem, and it's often driven by both physical and emotional pain. Just by way of an example, 50% of patients with an opioid use disorder have chronic pain, and a third of patients with OUD have a mental health diagnosis like depression or PTSD. And so because of these complex issues, there's a lot of pain that's caused by addiction. And because of these complex issues, even with gold standard treatments for opioid addiction, like buprenorphine or methadone, about one out of every two patients relapses within six months. So we need adjunctive approaches to improve addiction treatment outcomes. And I think that's really the potential role where psychotherapy can assist in this process. However, there are few psychological treatment approaches that have been shown to be efficacious for the comorbidity of addiction, emotional dysregulation, and chronic pain. And so to fill this gap, I've spent the last 15 years developing and testing one such psychotherapeutic approach called mindfulness-oriented recovery enhancement, which I think takes an innovative approach to dealing with these problems. So that's why I'm here to talk with you today. So just to lay out some context for this, for this focus really on the opioid crisis, in 2015, Nobel Prize winning economist, Case and Deaton found that for the first time in many decades, the US mortality rate was rising precipitously, to which they attributed in large part to the opioid crisis, a crisis that has been termed a disease of despair in the sociological literature. And the disease of despair has many sources, from the rising tide of income inequality to the lack of opportunity, to intergenerational violence and trauma, and the egocentric materialism and social isolation that's such a part of modern culture. And in the face of this vacuum of meaning, it was perhaps inevitable that life would become more painful, and indeed it did. Rates of chronic pain soared in the United States, where an estimated 50 million Americans experience pain each year. And so to address this epidemic of pain, opioid prescriptions climbed. In 2015, 38% of adults in the US had used an opioid that year. And so this dramatic increase in the incidence of opioid prescriptions was paralleled by increases in opioid misuse and opioid use disorder. And this is still a problem today, I'm sure you guys know all these statistics. So in 2022, 8.5 million Americans engaged in opioid misuse, and 6.5 million had an opioid use disorder. But focusing on this larger group of those who misuse opioids, 41% of people who misused opioids obtained the opioid from a prescription or from a healthcare provider. And so that tells me that chronic pain is continuing to fuel this crisis. You know, there's a lot of discussion about fentanyl and illicit synthetic opioids really flooding the market, causing a lot of mortality, which it certainly is. But I think we can't ignore the fact that chronic pain is a continued vector that is in part fueling this crisis. And so I wanna begin this talk with a clinical anecdote. A patient came to see me for help with chronic pain and opioid-related problems. He had received a series of five failed back surgeries. And after each one had been prescribed higher and higher doses of opioids, he knew he had a problem with opioids. He knew he was taking too high of a dose. But as he so poignantly stated to me, I just don't wanna be in pain. So I asked him a question that I ask many patients like this. I asked him to tell me about a time when he wasn't in so much pain, or maybe when his pain didn't bother him at all. And he told me that on the weekends when his grandkids came over and he watched them play in the backyard, he became so focused and so absorbed in watching them play that it brought joy to his heart. And in that moment, he didn't notice his pain. His pain was temporarily gone. And so was his desire for opioids in that moment. And this clinical anecdote's probably familiar to those of you who work with patients like this. But I think it hints at a potential therapeutic mechanism that could be leveraged to help address the opioid crisis. So to understand this claim, we need to understand the role that hedonic dysregulation plays in pain, pleasure, and addiction. So traditionally in Western philosophy, pleasure and pain are considered opposites on this hedonic balance, such that increasing experiences of pain are thought to outweigh the experience of pleasure in everyday life. But modern neurobiology suggests that pleasure and pain are not mere opposites. But they actually operate through a common emotional currency in the brain, mediated by the mesocortico-limbic dopamine circuit and the endogenous opioid system. And these same brain systems that mediate the experience of pleasure and pain can become hijacked by addictive drugs like opioids through an allostatic process in which chronic exposure to the drug, so in this case, chronic exposure to the opioid, causes neuroplastic changes in corticolimbic and corticostriatal brain circuitry that has a number of deleterious effects. It increases sensitivity to pain, stress, and drug-related cues, but at the same time, it decreases sensitivity to the pleasure and meaning derived from naturally rewarding objects and events in the social environment. So in other words, as the individual becomes more and more dependent on the drug just to feel okay, they become less able to experience a natural healthy sense of pleasure, joy, and meaning out of everyday life. And this drives them to take higher and higher doses of the drug to preserve a dwindling sense of wellbeing. And this then in turn becomes a downward spiral that ultimately leads to the loss of self-control over opioid use that's characteristic of opioid addiction. But it's kind of interesting if you think about it. You know, why can some patients take the opioid as prescribed by their physician, whereas others go on to misuse the opioid or develop an opioid addiction? And answering this question, this basic clinical science question, has motivated a great deal of my research over the past decade. So one of the ways that we answer this question is we use tasks from cognitive neuroscience. And I know that I'm supposed to be talking about psychotherapy today, and I certainly will, but I moonlight as a neuroscientist. I'm not a real neuroscientist, I just play one on TV. So we use this task called the dot probe task. In the dot probe task, there's a computer screen and it's split in two. On one side of the screen is a pain related image, on the other side of the screen is a neutral image, and these images are displayed for a very brief amount of time, about a fifth of a second. So it's just a flash, after which they disappear and a dot pops up. And the participant's task is to choose the side with the dot, and then the computer measures reaction times. And it turns out that people with chronic pain are faster to find the dot when it replaces a pain image than when it replaces a neutral image, indicating that they have an attentional bias or a hyper fixation of attention on pain related information. We also pair, let me see if I can get my pointer working here. We also pair neutral images and naturally rewarding positive images, and we pair drug images and neutral images. And a number of years ago, my colleagues and I were the first to find that people with chronic pain, with chronic pain who had an opioid use disorder were faster to find the dot when it replaced the opioid image than when it replaced the neutral image, indicating that they had an attentional bias or a hyper fixation of attention towards the opioid related cue. And this opioid attentional bias significantly predicted opioid misuse 20 weeks following the end of treatment, indicating as the downward spiral model would suggest that opioid misuse and addiction is actually linked with increased sensitization to opioid related cues. So essentially what we're doing here is we're measuring the extent to which a patient is being triggered by the drug cue. We have an objective laboratory based measure of how much somebody is being triggered. But in my lab, we also measure this process of hedonic dysregulation with a task called the emotion regulation task. So in the emotion regulation task, you show patients emotional images. In response to negative emotional images, patients are asked to either view the image or to reappraise the image by reframing the meaning of the content of the image in such a way as to reduce its negative emotional impact. So to reappraise this image of this mother and child screaming in fear, one might think the mother and child faced the tragedy, but in facing the tragedy, it brought them closer together as a family. And thinking about the image in this way might then make it less distressing. So in response to positive emotional images, like this image of this father and son enjoying a day at the beach, patients are asked to either view the image or to savor the image by focusing their attention on what's pleasant, beautiful, and good in the image and appreciating and amplifying any positive emotions or pleasant body sensations arising during the savoring practice. And during this task, we measure an array of psychophysiological variables, including heart rate variability, which is the beat-to-beat variation in heart rate that is driven by the parasympathetic nervous system and governed by a higher-order network of brain structures involved in regulating attention and emotion. So with this task, we found a number of years ago that relative to patients who take opioids as prescribed by their doctors, here shown in the blue bars, opioid misusing chronic pain patients, here depicted in the red bars, showed significant blunting of high-frequency heart rate variability during reappraisal, viewing positive images, and savoring positive images, indicating that they have a specific deficit in the ability to shift their emotions in a positive direction. They just struggle to make themselves feel better naturally. And we find converging evidence using EEG data during a similar task here. So here are brain waves in blue from patients who don't misuse opioids. These individuals are able to decrease their brain's reactivity from viewing negative images to reappraising negative images. So the reappraisal calms down the negative emotional brain reactivity. But look at the pattern we see in patients who misuse opioids. Not only can they not reappraise effectively, but actually when they engage in reappraisal, it backfires and it aggravates the negative emotional brain reactivity. And then all the way on the right, we can see brain waves during positive emotion regulation. So here in blue, these are brain waves from patients who don't misuse opioids. So these folks are able to increase their brain's reactivity from viewing positive images to savoring positive images. But in red, here you can see brain waves from patients with a full opioid use disorder. Here you see total blunting of brain response during positive emotion regulation. These folks just struggle to make themselves feel better naturally. And so if this is part of the problem that's driving opioid misuse and addiction, if opioid misuse and addiction are associated with this blunted capacity to experience and to increase healthy positive emotions and natural healthy pleasure, then we need interventions that can address this mechanism. And to that end, I developed Mindfulness Oriented Recovery Enhancement, or MORE, which is an integrative mind-body therapy that unites three great traditions within psychotherapy. Mindfulness training, cognitive behavioral therapy, and positive psychology. And MORE weaves these components together into a structured, manualized, systematic therapy approach that is designed to simultaneously address addictive behavior, emotional distress, and physical pain. So MORE is a sequence treatment. It begins at the foundation of mindfulness training, which by virtue of strengthening attentional control and meta-awareness, is used to synergize more elaborate therapeutic techniques like savoring and, excuse me, like reappraisal and savoring. And ultimately, these techniques in turn are intended to elicit experiences of self-transcendence, the sense of being connected to something greater than the self. And these treatment components are intended to activate a series of therapeutic mechanisms that are in turn intended to produce clinically significant change in a range of treatment targets that are relevant to chronic pain, psychiatric symptoms, and addictive behavior itself. I'm wondering if my little task bar here is in the way of your screen, so I'm going to try to move it out of the way here. So just to note here in this slide that MORE has been tested in an array of randomized controlled trials for a wide range of addictive behaviors, including addictive use of opioids, alcohol, illicit drugs, cigarette smoking. We studied MORE for obesity and even for behavioral addictions like internet addiction. But the bulk of the research on MORE has been focused on MORE as a treatment for opioid misuse and opioid use disorder. And so that's really going to be the main thrust of my presentation today. So MORE is a structured, manualized treatment. It's typically delivered over eight weekly group therapy sessions. Group sessions are about one and a half to two hours long. They begin with a formal mindfulness meditation practice, followed by a debrief and group process, which is just exquisitely important in helping patients to consolidate what they've learned from the mindfulness practice, and then to apply that learning to addressing their symptoms of addiction, emotional distress, and pain in everyday life. After the group process, new psychoeducational material is delivered, and here the session topics are listed on the left. Sessions end with some sort of experiential, excuse me, experiential exercise, some sort of mind-body practice designed to hammer home the concepts that you're trying to teach. And then participants are asked to practice homework consisting of 15 minutes of mindfulness reappraisal and or savoring practice a day. They're also asked to practice a very brief mindfulness technique called the stop practice right before taking illegal drugs or before taking medications like methadone or suboxone. And I'm going to talk more about that technique in a moment. But before we progress further, I think we should talk a little bit about the construct of mindfulness, what it is, what it does, and then I think we should practice some together. So what's mindfulness? You know, we hear that term everywhere. It's all over the place. Mindfulness is on magazine covers at the supermarket checkout stand, but I want to kind of demystify this concept and give you a scientific operationalization. So in my view, mindfulness is a form of mental training that involves cultivating awareness and acceptance of your thoughts, your emotions, and your sensations in the present moment, and observing these mental contents as if you were a witness. So this is this capacity for meta-awareness. Now mindfulness is actually a very simple process, and it begins by focusing your attention on an object. And that object could be any object, but we often begin with the most convenient object, which is the sensation of the breath. We're always breathing. We've always got the breath with us. So it's a convenient point of focus of mindfulness. So we start by focusing our attention on the breath, and then if you're anything like me or most people, after 10, 20 seconds, your mind starts to wander to other thoughts or emotions or sensations, and then you just notice where the mind has wandered off to. Then you acknowledge and accept that thought or feeling or distraction, and then you let it go and you return your attention back to the object of mindfulness, back to the breath. So now you've done one loop of mindfulness, but with each loop of mindfulness, you're actually strengthening the mind's capacity for meta-awareness, for the awareness of awareness, which in my view is really one of the key drivers of the therapeutic effects of mindfulness. One other point to notice here in this schematic is that many people think mindfulness, and I would add here, many patients have a misunderstanding about mindfulness. There are some myths around mindfulness, which I think become real clinical barriers to delivering this technique. One of those myths is that mindfulness means I'm going to have a totally focused and totally blank mind. I'm just going to close my eyes, my mind is going to go blank, and I'm going to be in this blissful nirvana, and if I'm not experiencing that, then I'm doing it wrong. But that's a misconception, actually, that I think really alienates patients in learning this technique, because in reality, the whole loop is the practice of mindfulness. Focusing, attentional focusing on the object is only the first step, but then the mind wanders, you notice the mind wandering, you acknowledge and accept the mind wandering, you bring your attention back to the breath. That whole loop is the practice of mindfulness. To some degree, all of these steps actually are valuable and important in developing the cognitive capacities of mindfulness. Some of the work that we do in MORE is really to reframe patients' expectations of what mindfulness is and what the patient should be experiencing, and that reframing helps to generate motivation and helps patients to stay engaged with the practice. Through this loop of mindfulness, we're strengthening the mind's capacity for meta-awareness. As I said, I think this is really a key driver of the therapeutic effects of mindfulness. A lot of people think of mindfulness as a relaxation technique, but it's really not a relaxation technique. Relaxation is more of a side effect of mindfulness practice rather than the practice itself. Instead, the therapeutic effects of mindfulness appear to be driven by strengthening attentional control, emotion regulation, and self-awareness. Together, these capacities strengthen the quality of self-regulation. I think that has clear and direct application to the treatment of addiction. Let's dive in a little bit more here into this concept of meta-awareness, because I think it's quite important in understanding how mindfulness works. At any one moment in life, there are two levels of awareness operating. There are two levels of consciousness operating, or at least two levels. One is the object level of awareness. The object level of awareness is constituted by our thoughts, our feelings, our sensations, our perceptions. These objects of awareness are actually arising or occurring within a larger field of awareness. There is this other level of awareness, the meta-level of awareness, which allows us to observe and monitor the objects of awareness. Mindfulness is really all about this process of monitoring and observing, this process of meta-awareness. I think this quote nicely captures this construct. If we are able to see it, then we are no longer merely it. We must be more than it. Whether the it is pain, depression, or fear, meta-awareness allows one to disidentify from thoughts, emotions, and body sensations as they arise, and simply be with them instead of being defined by them. Through meta-awareness, one realizes this pain is not me. This depression is not me. These thoughts are not me. If you still don't understand this concept from this quote, which is understandable because it's a pretty abstract thing, I think we can give a visual depiction of this process through this work of art by M.C. Escher. When you're staring at the crystal ball, it doesn't matter if the image in the crystal ball is smiling, or crying, or laughing, or raging. In the moment when you've stepped back from the crystal ball and are now observing that reflection in the crystal ball, you have now freed yourself from that suffering. This motion of stepping back and observing, the stepping back and witnessing your own experience as if you could witness your own experience as if your thoughts, and feelings, and sensations, and perceptions were an object like any other object. In that moment, you have freed yourself from that suffering. That is, I think, a depiction of one of the key ways in which mindfulness helps us to heal. I think rather than talk about this, because mindfulness is really more of an experiential thing than just an intellectual thing, maybe we can practice some mindfulness together. I hope you're interested in doing that because I think that's a good thing to do next. Let's do a little bit of mindfulness practice together. I'm going to lead you on the basic more mindful breathing practice now. What I'd like you to do is I'd like you to get yourself into a comfortable position. Most people find it more comfortable to allow their eyes to close, but you can keep your eyes open and relaxed on a spot in front of you, and turning your attention inward, noticing the sensation of the body, making contact with the chair. We have this word, contact. What is it really? Perhaps it's a sensation of warmth, or heaviness, or some other sensation. Just noticing those sensations now. And then when you're ready, shifting the focus of the attention to the sensation of the breath moving into the nostrils. noticing the temperature of that air it's warmth or coolness just noticing the natural sensation of the breath in this moment and soon you may begin to notice that the mind begins to wander it may have already wandered to sounds or thoughts feelings And if the mind wanders, that's okay. That's what minds do. you can just notice where the mind has wandered off to. Acknowledging and accepting that thought, or feeling, or distraction. You might even tell yourself in the space of your own mind, it's okay to have this thought, or feeling, right now. Whatever it is, it's okay. And then you can let it go. And gently, but firmly, return the focus of the attention. back to the sensation of the breath moving into the nostrils. noticing the warmth or the coolness of that air. And it really doesn't matter how many times the mind wanders, because each time that the mind wanders, you notice where it wanders off to, and acknowledge and accept that thought or feeling. and return the focus of the attention back to the breath. You are learning to step back, to step back, to step back from thoughts and feelings into the open space of mindfulness. You're strengthening mindfulness, and soon you can begin to notice that thoughts and feelings, distractions, come and go all on their own, like clouds passing in a clear and like clouds thoughts and feelings seem to come out of nowhere and change shape and fade into the distance all on their own There's no need to hold on to them, or to push them away. You can just let them go. And a part of the mind is like those thoughts, passing like clouds. But there is a deeper part of the mind. the space in which the clouds pass, the observing awareness. just watching, just observing, peacefully. And you can focus on that part of the mind now, or you can continue to focus on the breath. Now you can take one long moment to focus on whatever positive experiences have arisen during this practice. Appreciating and savoring those experiences now. Or you can continue to focus on the breath. And when a deeper part of your mind knows, how each time that you practice this, it will become easier and easier to go even more deeply to the state of mindfulness. You may feel a little more comfortable, a little more centered, and a little more encouraged when you complete this practice and bring your attention back. All right. Good work. And that, that's always the first, the first thing that we say to our patients when we complete mindfulness practice, we provide them positive reinforcement and tell them good work. And then the next processing question that we use, and recall that in Moore, the group process is just incredibly important for consolidating the learning from the mindfulness practice and generalizing that learning to addressing symptoms in everyday life. So the next processing question is to ask the patient, what did you like best about that experience? So rather than using some sort of open-ended form of inquiry, we use this directive form of inquiry, which actually has some embedded indirect suggestions. So there's an implication in the question, what did you like best? And of course the implication is that there was actually something that happened during mindfulness practice that the patient liked. So we're sort of forcing the patient's mind to search, to perform this trans derivational search, if you will, to, to, to access a positive or therapeutic moment during the mindfulness practice. And then we proceed through, we proceed through processing using an approach that, that we call PURR. And PURR is an acronym that I developed to help therapists remember how to process mind-body techniques effectively with their patients. So we want our therapists to process mindfulness in a PURR way. And PURR stands for phenomenology, utilization, reframing, education, and building positive expectancy and reinforcement. And these, these processing principles are really what I think is sort of the secret sauce to helping your patients to maximize the mindfulness experience. And when I, when I do trainings and more therapist trainings and more, which I have a therapist training and more coming up on November 8th and 9th, we spend about two full days learning this PURR approach to processing and, and practicing this approach in, in role plays, therapist, client role plays to really learn how to implement this processing approach, which I think is so critical to helping our patients to learn how to practice mindfulness effectively, to motivate them, to engage in the practice, to help them to build self-efficacy and, and to set the expectation that this practice will be therapeutic. So I can't get into all these processing principles now, but I'll just touch on them briefly. So we, we process in a phenomenological way. So we help patients to clearly articulate what happened to them during the mindfulness practice, to break down their conscious experience into sequences and steps. And we're basically got, we're helping the patient to articulate what happened to them during the mindfulness practice in order to help them to uncover these therapeutic moments or moments of positive experience, which, which really is, is sort of the reward, if you will, which is really key to helping people, I think, particularly with addiction who have a reward deficit to engage in this practice when they recognize that there's something positive or enjoyable or pleasurable from the practice, that's, what's going to help motivate them to stick with the practice. We also use utilization techniques. So we help the patient to draw a connection between their in-session mindfulness practice and what that means for addressing the problems that they're facing in their everyday life. We use reframing techniques to, in particular, to help patients to deal with challenges that arise during mindfulness practice. So our goal really is to always reframe whatever happens in the mindfulness practice session as the practice of mindfulness. So in other words, we just reframe challenges that arise during mindfulness practice as the practice of mindfulness, and that helps patients to feel more successful. We provide a lot of psychoeducation about the, the, the subtle shifts in the states of consciousness that occur during mindfulness practice. And we educate patients about what does it mean for them and their mental health and their addiction, that they're learning these skills, how can they be applied? We also do a lot of positive expectancy building. So we try to, we try to leverage the placebo effect and help patients to just begin to believe that this practice will help them. And then lastly, we use a heavy dose of positive reinforcement because we know from, you know, over a century of behavioral learning principles that, that reinforcement is a powerful way of, of facilitating learning. So in MORE, we're really leveraging all of these processing principles and I would have loved to demonstrate this with you today, but I think this, this presentation really isn't formatted to have me to have a dialogue, verbal dialogue with one of you. But if you're interested in seeing how this processing approach unfolds, I really encourage you to come take the full MORE training because we have many patients who come to us who have said stuff like, you know, mindfulness doesn't work for me. I hate mindfulness. I just can't do mindfulness. And we move them through this, this pure process and coming out the other side of it, they feel much more empowered and encouraged and, and, and begin to experience the benefits of mindfulness. So, so, so that's the basic cornerstone, the MORE approach that we're providing mindfulness training in every session. Patients are learning mindfulness meditation, but as they begin to learn the skill, then they learn how to apply the skill to addressing aversive symptoms like chronic pain or craving. So taking the example of chronic pain, people with chronic pain typically experience pain as this monolithic, solid and unremitting experience. It's this terrible, awful thing that always seems to be there. And on top of it, they overlay a layer of suffering. So they say, why me? This isn't fair. This pain is ruining my life. But in MORE, we teach patients mindfulness skills to remove this emotional overlay, to peel back the emotional overlay, and then to deconstruct the pain experience into its subcomponent sensations. So rather than focusing on some terrible, awful anguish in the body, we teach patients to use mindfulness to zoom in to the experience of pain and to break it down into sensations of heat or tightness or tingling, as well as to notice the spaces in between those sensations where there's either no sensation at all, or potentially pleasant sensations right next to the painful ones. So using mindfulness to cultivate interoceptive awareness in this way may actually decrease emotional bias during pain perception and thereby decrease the intensity of pain. But we use a very similar technique in MORE to help patients to cope with craving by breaking the craving down into its cognitive, emotional, and sensory components. So I want to share with you a clip here of a patient describing this process. Let's see if I can get this to work, and hopefully you can hear it. And hopefully I can work my zoom well enough to play it for you, which is looking iffy here. Iffy here. Let's see. Too many zoom screens, too many task bars. I don't think I can do it. Bummer. Hmm. Okay. Forget it. As we talked about that, my back does hurt a lot, a lot of the time. But I felt that same thing. I felt as I concentrated on it, I felt it ease and move, and move, and I felt the pain decrease. And like was said, I probably felt the pain go down as I let it, as I let it relax, and as I let it float, I let it, let the edges go away, and just let the whole thing be an experience and float there. The pain probably went down a good 40%. So, more is more than mindfulness, though. And one of the things, one of the therapeutic processes that really arises out of mindfulness is the practice of reappraisal, which is the cornerstone of cognitive behavioral therapy, this notion that if we can challenge and change the way we think about the events of our lives, it can actually improve our emotional response. And so, and more, we don't throw out this cognitive change strategy, we actually, we integrate it into the healing process. And this notion arises out of what I call my mindfulness to meaning theory, which essentially asserts that mindfulness facilitates perspective taking, increases cognitive flexibility, and enables an individual to take a broader perspective on their life situation. And out of that broader perspective, they can generate a reappraisal of the stressors and adversity that they're facing, which in turn can propel a cycle of meaning and well-being. So, essentially, what that looks like clinically is the standard sort of Albert Ellis ABCDE cognitive restructuring approach, but we just inject a little bit of mindfulness into the middle of the process between C and D. So, before the patient begins to use logical disputation of the negative thoughts about the stressful life event, we teach, we ask them to practice a minute or two of mindfulness as a way of increasing cognitive flexibility and opening the mind to new perspectives. But then the third component of more is the savoring component. And I think this is one of the most unique, unique parts of more because to my knowledge, there are very few psychotherapies that teach this approach. And in this approach, what we're doing is we're actually teaching patients to focus mindful awareness on a pleasant life event, a pleasant stimulus, something that they find beautiful or life affirming, and then to turn and tune the senses toward that experience. So, we teach this by, when we do in-person more groups, a great way to teach this is to bring in a bouquet of roses and to let each patient take a rose out of the bouquet. And then we guide the patient to focus mindful attention on the beautiful colors, textures, and scent of the flower, as well as the touch of the petals against the skin. And during this process, patients are guided to cultivate a metacognitive reflective attitude to become aware of the arising of positive emotions and pleasant body sensations, and then to turn their attention inward and savor the positive inner feeling. And the metaphor we give them is to savor that positive inner feeling almost as if you were taking water and allowing water to seep into the soil. So, allowing it to permeate and pervade their being. Then patients are asked to practice this technique with naturally occurring, pleasant everyday experiences in their life. And this technique is intended to amplify natural reward processing in the brain, boost positive emotions, elicit meaning in life, and cultivate self-transcendence, the sense of interconnectedness between the self and the world. So, by way of example, imagine that you were watching a beautiful sunset at the beach, or maybe you have done this recently, you have a memory of this, and you're standing at the seashore. And imagine savoring this moment, really appreciating the visual beauty, the colors of the sky, the sound of the waves, the temperature of the air, the wind through your hair. And imagine that sense of connectedness, connectedness that you feel to those that you're sharing this experience of beauty with. But perhaps that sense of connectedness extends beyond, and you feel this deep sense of connection or communion with the world around you. Potentially even the sense of connection or communion with all things. And a sense of expansiveness, as if your self could just expand to the horizon and beyond. And imagine how the body might feel in that moment. Profound sense of peace, comfort, warmth, maybe even a sensation of pleasure or even bliss. And if you were to tune your senses and turn them and if you were to tune your senses and turn them, turn your attention inward into that positive inner feeling, and then allow it to expand, to grow, to pervade your sense of being. That would be an example of this savoring practice. And so that is the therapeutic foundation of more mindfulness reappraisal and savoring. And then we turn these techniques to address addictive behavior. So one of the techniques we teach in MORE is the stop technique, which is a really brief mindfulness technique. We ask patients to stop before taking opioid medication, if these are patients who are misusing prescription opioids, or if they're about to take an illegal drug, and to stop and before taking the drug to practice a few minutes of mindful breathing as a way of calming down the mind, calming down the body. So imagine in your case, imagine that you're a patient taking oxycodone, for example, but you also misuse oxycontin and you're in between doses and it's been several hours since you've taken your last dose and you really want to take this dose. You open up the pill bottle, you take out your pill, you're bringing it right before your face, you're about to eat the pill, and then I tell you to stop and don't eat it. What do you think you would observe in that moment? Well, you probably observe craving. You probably observe how your attention keeps getting captured by the sight of the pill. But you could also observe in that moment that it's possible to have an urge to take the drug, but to not take the drug, that the urge and the action are separable. And then lastly, and if you get too overwhelmed by this process, you can always return the focus of your attention back to the breath as a way to calm down the mind, calm down the body. Then finally, you can proceed with intention. Of course, it's always the patient's chance to, excuse me, always the patient's choice to take the drug. But if they're going to take the drug, they should do it with full mindfulness. They should do it with full awareness of what they're doing. And this act deserves attention, respect, and awareness. But in the case, let's say we could also use this technique to help strengthen the commitment to recovery. So in the case of taking Suboxone or Methadone, for example, the patient could stop right before taking this life-saving medication and really use the time to contemplate the meaning of their recovery, to be very intentional about taking this medication, to remind themselves of how taking the medication is improving their life. And then we expand upon this technique with a full-blown mindfulness of craving technique, where we're guiding the patient. We bring in a piece of chocolate into the session. We ask the patient to bring it up to their nose and lips to smell the chocolate, to get a bunch of saliva going and really feel the urge to eat the chocolate. But then we tell them to not eat the chocolate. And then in that moment, to use mindfulness to actually zoom into and deconstruct the craving as a way to regulate craving. And this becomes really sort of like a stepping stool to then learning how to use this technique to overcome craving for addictive drugs. And so through this integration of mindfulness reappraisal and savoring techniques, Moore aims to modify associative learning mechanisms that have become hijacked during the allostatic process of addiction by strengthening top-down cognitive control functions to restructure bottom-up reward learning from valuing drugs back to valuing natural healthy rewards. And this therapeutic focus accords with what I call my restructuring reward hypothesis. This idea that if we can help the patient to shift from valuing the drug back to valuing natural healthy rewards, this will reduce craving and addictive behavior. And in my view, not only as an addiction scientist, but also as a psychotherapist working with patients with substance use disorders for about 20 years, I think this is the essential therapeutic process in addiction recovery. The person in recovery must relearn what is and what is not important in life, what is and what is not meaningful in life. They must reclaim that sense of meaning that had been stolen by the drug and reinvest it back into the people, the activities, and the values that they once cared about. Okay, so I've given you a lot of background and a lot of theory, and I've described them more in prevention, but what about the evidence for this treatment? So now I want to give you a whirlwind tour of the results from a large body of research. So MORE has been studied in actually 13 randomized controlled trials to date involving more than 1300 patients. There have been meta-analyses on MORE that show that MORE produces significantly greater reductions in addictive behaviors, psychiatric symptoms, and chronic pain relative to a wide range of active control treatments. So MORE is an evidence-based therapy. I just want to highlight some of these studies for you here today. So the first study I want to highlight is the first NIH-funded stage two randomized controlled trial of MORE. This was a study with 115 chronic pain patients who had been taking prescription opioids for about 10 years. Three-quarters of the sample reported misusing opioids at baseline, and there are high rates of comorbid psychopathology in this sample. And in this study, we compared MORE to a standard supportive psychotherapy control group. And in summary of the findings, we found that MORE led to significantly greater reductions in pain severity and pain-related functional interference than the supportive psychotherapy control condition. So pain interference measures how much pain interferes with a person's activity level, their mood, their walking, their work, their relationships, their sleep, and their enjoyment of life. We also found that MORE reduced symptoms of opioid misuse that were consistent with an opioid use disorder diagnosis. So there was a 63% reduction in opioid misuse in the MORE group compared to a 32% reduction in the support group. So these data show that MORE was about twice as efficacious as supportive psychotherapy. My body is, it has pain all the time with the metal and my, you know, my back and the rods and all the screws and everything in it, but I, it's okay. I mean, and that's where I get you. The point is when I do the breathing, these other things are okay, and I can, for several days, I didn't take any pain meds. So in this study, we also measured hedonic dysregulation with the dot probe task that we talked about earlier, and we found the first evidence in the scientific literature that a mindfulness-based intervention could reduce the pain attentional bias. So after eight weeks of treatment with MORE, patient's attention was less hyperfixated on, was less biased towards pain-related information. But we also found that MORE significantly decreased the opioid attentional bias, and we recently replicated these effects in a much larger randomized controlled trial. So after eight weeks of treatment with MORE, patient's attention was less triggered by, was less fixated on drug-related cues. And some of the most interesting data from the study came from heart rate collected during this dot probe task. We found that across the board, MORE led to significantly greater reductions in heart rate than the control condition. And not surprisingly, the more heart rate slowed during viewing the opioid and the pain photographs, the less aroused, the less triggered, the less stimulated patients felt by those images, and that made perfect sense. But we found the opposite pattern in response to the pleasurable photographs. The more patients' heart rate slowed as they viewed the pleasurable photographs, the more aroused, the more stimulated they felt by those images, and we took this to mean that perhaps MORE was increasing physiological sensitivity to natural healthy pleasure. So we wanted to understand the clinical implications of these findings, and we conducted a multivariate path analysis and found that the effect of MORE on reducing opioid craving was statistically mediated by changing the heart rate response to the pleasure cue condition. So in other words, MORE was reducing opioid craving by enhancing physiological responsiveness to natural healthy pleasure. And in this study, we also collected ecological momentary assessments, so we asked patients to rate their pain and their mood state up to four times a day, every day during the course of treatment. So this gives you a ton of data, 224 time points per individual, and we found that more was decreasing pain from moment to moment in everyday life. We also found that more was increasing positive emotions from moment to moment in everyday life. In fact, patients and more had 2.75 times the odds of patients in the control group to be positively emotionally regulated over the course of treatment. It wasn't actually the decreases in pain that predicted reduced opioid misuse, but rather patients who showed the largest increases in momentary positive emotions reported the greatest decreases in opioid misuse. And these findings, in conjunction with the heart rate findings, provided support for my restructuring reward hypothesis, this idea that helping people to develop a natural healthy sense of pleasure in everyday life will reduce addictive behavior. So then we replicated these results in another stage to randomize control trial and found once again that more reduced opioid misuse and chronic pain severity. But in this study, we also showed that more significantly increased an array of positive psychological functions like positive emotions, savoring, meaning in life, and self-transcendence, this sense of interconnectedness between the self and the world. And the effect of more on reducing pain and opioid misuse was linked with increases in these positive psychological functions, suggesting that one way to treat the disease of despair is to teach people how to savor natural healthy pleasure, joy, and self-transcendence. But at the same time, we wondered if we added more to standard medications for opioid use disorder, would more actually improve addiction treatment outcomes? So in conjunction with my colleague Nina Cooperman at Rutgers University, we conducted a pilot randomized control trial funded by the National Institutes of Health. We studied more combined with methadone treatment for patients in inner city New Brunswick, New Jersey. And this was a pilot study. We didn't expect to see a significant effect in the sample of 30 patients in inner city New Jersey, predominantly black and Latinx folks. But actually, we did see a significant effect of more. More led to significantly fewer days of drug use, less chronic pain, and less depression than standard addictions treatment. We also found that more cut the intensity of opioid cravings by 50%. So we were really encouraged by these pilot study results. So then we expanded on this trial and conducted a larger NIH-funded randomized control trial of more in methadone treatment. And this study was published earlier this year in JAMA Psychiatry. So in this study, we delivered more through telehealth, through a Zoom-like platform like we did here, like we're doing here. And we found that adding more standard addictions treatment for patients receiving methadone significantly improved addiction treatment outcomes. So patients in more had a 42% lower rate of relapse back to drug use than standard addictions treatment. Patients in more had a 59% lower rate of dropout from addictions treatment than treatment as usual. Patients in more also had significantly fewer days of opioid use and drug use. And more was associated with greater methadone adherence. So these data really show that I think that more is efficacious for this issue and that adding more standard addictions treatment significantly improves addiction treatment outcomes. But around this time, we were also starting to wonder about more's mechanism. So we wanted to get under the hood and start to understand how more was changing the brain. To do this, we brought patients into the lab and had them view opioid photographs while we measured their brain reactivity with EEG. And we found that more led to really massive decreases in brain drug Q reactivity compared to supportive psychotherapy. So after eight weeks of more, the brain was exhibiting less of a craving-related reactivity profile using EEG. And these are the first data from a randomized controlled trial showing that a mindfulness-based intervention can reduce drug Q reactivity in the brain. So given the novelty and the significance of these findings, they were published in the top journal Science Advances a couple of years ago. But in a separate randomized controlled trial, we showed that more actually increased neurophysiological responses to natural healthy rewards using EEG and skin conductance responses as the metric. In addition, more increased healthy positive emotions while patients were viewing naturally rewarding cues of smiling babies, lovers holding hands, beautiful sunsets. And the effect of more on reducing opioid misuse was statistically mediated by increases in this natural reward responsiveness. And these data provide really, I think, strong support for my restructuring reward hypothesis. This idea that if we can help patients to shift from valuing the drug back to valuing natural healthy rewards, this will reduce addictive behavior. And so these studies then led to the largest randomized controlled trial of more ever conducted. The study was funded by the National Institute on Drug Abuse. And the results of this trial were published in the top journal JAMA Internal Medicine a couple of years ago. So in this study, there were 250 chronic pain patients, all of whom were prescribed opioids and all of whom were misusing opioids at the beginning of the trial. Patients reported pain levels of 5.5 out of 10 on average. They had been in pain for about 15 years and they were taking high opioid doses at baseline, an average of about 100 morphine milligram equivalents a day. And in addition to an array of chronic pain conditions, patients also suffered from a range of psychiatric disorders, including major depression, full blown opioid use disorder, generalized anxiety and PTSD. And in summary of the findings from this trial, we found that more reduced opioid misuse by 45% at the nine month follow up point, nearly tripling the effect of standard supportive psychotherapy. Were also significantly reduced opioid dosing and significantly reduced opioid craving in everyday life. And so these data, I think, really demonstrate clearly the efficacy of MORE as a treatment for opioid misuse. But at the same time, MORE significantly reduced chronic pain symptoms and emotional distress. And the effect sizes that we observed for MORE in reducing chronic pain exceed those observed for the current gold standard psychological treatment for chronic pain, CBT. So about 50% of patients reported clinically significant reductions in chronic pain. I went into a meditative state relatively quickly, but I was noticing the sensations of my pain and the one that I'd once thought that I wanted to work on. And I kept, what I've done in the past is that one place hurts and I've moved it to another place that didn't hurt. And so I've tried to move this pain to the same place and I couldn't do it. It would not, nothing would happen. And then I focused on my breathing. And as I would breathe in, I breathed it into the spot and I breathed out and I could feel, which of course is just in my brain, but I can feel the pain leaving out my nose and I just breathe in and breathe out. And so when it, and it's pretty much gone. So we really observed profound effects, not only in reducing addictive behavior, but also in alleviating physical pain and in alleviating emotional pain. So we found that more had robust antidepressant effects or also significantly reduced PTSD symptoms. So 59% of patients who met criteria for PTSD reported clinically significant reductions in PTSD symptoms following treatment with MORE. And MORE improved an array of positive psychological factors, including increased positive emotions, enhancing meaning in life and boosting self-transcendence. So taken together, these data suggest that MORE is a broad spectrum treatment that can simultaneously address addiction, chronic pain, and the psychiatric conditions that often co-occur with these problems. And we recently replicated these results in a clinical trial funded by the Department of Defense. So in a sample of 230 veterans and active duty military personnel, we once again found through an eight month follow-up that MORE significantly outperformed supportive psychotherapy in reducing chronic pain symptoms, in reducing opioid use, in reducing positive urine screens for illicit drugs, and at the same time, MORE decreased craving, catastrophizing and anhedonia and boosted positive affect. So we're seeing really here that this is an efficacious treatment for the comorbidity of opioid use and chronic pain. But we've also shown that MORE increases natural healthy reward responses. And this is a computerized body map on which patients locate pleasant and unpleasant sensations. Pleasant sensations are represented in blue and unpleasant sensations are represented in red. And I don't think you need any statistics at all to see there's a massive effect of MORE here. MORE is just massively increasing pleasant sensations in the body and shifting the ratio of pleasant to unpleasant sensations. So helping patients to shift from experiencing the body as a place of anguish to becoming a place of refuge. And finally, and I want to save plenty of time for questions here. So I just want to finish on this set of findings here. We were interested in how self-transcendent experiences occurring during deep meditative states might have anti-addictive properties. So in the DoD study, we brought patients into the lab and had them practice mindfulness meditation while we recorded their brain activity with EEG. And we found that patients treated with MORE showed significant increases in frontal midline theta, EEG activity during mindfulness meditation. And the deeper the states of self-transcendence that the patient achieved during mindfulness meditation, the stronger the theta activity in the brain. And the effect of MORE on reducing opioid use was statistically mediated by increases in this frontal midline theta, EEG activity. Now this is interesting because frontal midline theta is a well-known biomarker of cognitive control, but it also increases during states of flow when the normal sense of self is temporarily suspended and transcended during deep cognitive absorption with ongoing activity. So these data suggest that mindfulness meditation may provide a means of endogenous theta stimulation or self-stimulation of theta oscillations in the prefrontal cortex, and this might increase self-control over addictive behavior. And we recently replicated these results in the largest neuroscientific study of mindfulness as a treatment for addiction ever conducted. This was published in Science Advances. In a sample of 165 chronic opioid users, we once again brought them into the lab and had them practice mindfulness meditation while we recorded their brain activity with EEG. And I love data like this, so here's the game. Which one of these four brain maps is not like the other? This is your brain on MORE. This is your brain after eight weeks of MORE. So it kind of reminds me of that old commercial, this is your brain on drugs, remember the egg frying in the pan? So this is your brain on MORE. And once again, the deeper the states of self-transcendence that patients achieve during mindfulness meditation, the stronger the frontal midline theta activity in the brain, and the effect of MORE on reducing opioid misuse through a nine-month follow-up was statistically mediated by this increase in frontal midline theta power. So we have two independent randomized controlled trials showing the same finding. So this really, I think, speaks to this potentially being an important therapeutic mechanism by which mindfulness alleviates addictive behavior. So taking stock of all these studies, what do we know? We know that MORE is efficacious for decreasing addictive behavior and craving, and at the same time, MORE significantly decreases physical and emotional pain, but MORE also enhances positive emotions, reward, and the sense of meaning in life. And these therapeutic effects are linked with increases in self-regulation and experiences of self-transcendence. So taken together, this body of work supports my restructuring reward hypothesis, this notion that if we can help patients to increase natural healthy pleasure, joy, meaning, and transcendence, this will come to outweigh the pull of drug-related reward and thereby reduce addictive behavior. So in conclusion, MORE is an efficacious treatment for addiction, stress, and chronic pain, as demonstrated by 13 randomized controlled trials. MORE's mechanisms of action include reducing drug Q reactivity, enhancing natural reward processing, strengthening self-regulation, and eliciting self-transcendence. And given MORE's clear clinical efficacy, I think it's now time to disseminate this therapy, which is why I'm speaking with you today. This is really becoming a major focus of my work. So I've been working hard to disseminate this therapy to clinicians across the US and internationally. So to date, I've trained more than 900 social workers, psychologists, nurses, and physicians, including psychiatrists, to deliver this therapy, who are now delivering MORE as part of their standard clinical practice. And I hope some of you will be interested in learning this technique and getting trained with me. I think it's also time to consider how we might optimize MORE by combining it with other neuroscience-informed therapeutics like neurofeedback, neurostimulation, and psychedelics. But ultimately, teaching people to take in the good and mindfully savor natural healthy pleasure may provide the learning signal needed to restore adaptive hedonic regulation and ultimately to reverse addiction. So I want to thank you for your attention. I want to thank the funders of this work. And I want to call your attention to the next MORE training, which is going to be held on November 8th and 9th by Zoom. So if you're interested in getting trained, just shoot me an email or go to my website. I also have a new book on MORE, which has been published by Guilford Press. So this is the treatment manual that outlines the whole MORE treatment approach. So you follow that manual to help deliver this therapy. And I now have time for some questions. So I'd love to take your questions. Thank you, Dr. Garland. And I just have to say, this is compelling and exciting data. I think sometimes we develop a sense of learned helplessness because the medications that we use are very important and critically important. But sometimes the outcomes aren't as great as we had hoped for. And now I think it's showing how a combination of medications plus psychotherapies can be really effective. So thank you for your work. My pleasure. Virginia, if you're still there, I'd be happy to unmute you. You can ask your question. I know you asked it earlier, but I'll unmute you. Yeah, thank you. Sorry, I think I posted it to the wrong panel. But Eric, you mentioned people with opioid use disorder not being able to reappraise in a so-called normal way. So I'm wondering folks with opioid use disorder who are taking medications for opioid use disorder, like buprenorphine or methadone. You're wondering about whether they have trouble reappraising as well? Exactly. So if they are on an opioid agonist or partial agonist, would you still see that difference in reappraisal? Yeah, that's interesting that you asked that question. We recently published a paper in American Journal of Psychiatry with Rita Goldstein's group that looked at reappraisal and savoring using fMRI with patients with opioid use disorder who were in treatment. And it did seem that the reappraisal brain function was fairly intact. But the interesting deficit was with regard to the relationship between savoring and reappraisal. So that there was hyperactivity in the brain's reward system in the corticosteretal circuit during reappraisal relative to when they were savoring. So they were basically putting more energy, if you will, into reappraising as a way of coping with drugs. And there were less brain resources, if you will, in this corticosteretal circuit to savor. So that's what we found in that study. But we weren't able to compare patients who were being treated with a medication, opioid use disorder, to untreated patients. That would be an important contrast, too. Yeah, yeah. So I guess that leads me to a second question that came up, because you're talking about more as treatment for opioid use disorder. But in all of these studies that you've shown, it's always in addition to medication for opioid use disorder? Or has it ever been tried as treatment alone? Good question. So in the JAMA Internal Medicine study of patients in primary care, in that sample, those patients were prescribed opioid analgesics. So they were taking hydrocodone, oxycodone, et cetera. And they were misusing the opioid. 62% of the sample met full OUD criteria. So they were not taking buprenorphine or methadone. And we found that more was helpful in that population. So in people with illicit OUD, we haven't done a head-to-head comparison of more versus medication for OUD. But like Dr. Blazes says, that's not really how I'm conceptualizing it. I really think more is more of an adjunct that could be integrated with medication treatment to improve outcomes. For sure. I don't think it's either-or. Great, great. Thank you. One of the things that I always like to do is to kind of think of bridging between two areas of psychology or medicine. And in kind of the psychoanalytic realm, people talked about the observing ego. And the observing ego seems to really be like what you're talking about with kind of meta awareness and finding the witness state. And it just seems like that in and of itself has significant therapeutic benefit and might be kind of the core of how this works. I think so. I think it's a key step along the pathway. I think that observing ego or that meta awareness, however you want to frame it, is one of the key ingredients. And then the other is this, as you and I were talking about before the session started, this purely affective piece, which is this bottom-up experience of natural, healthy reward, which in the ancient yogic tradition is characterized by bliss. Meditation is known to produce bliss in the classical Indian tradition. So I think those two pieces of the witness consciousness and the bliss are very powerful together. And one of the things that's interesting that this lecture came up right before the one I'm going to give next week is that I talk about how experiencing joy and recovery is part of the treatment plan and recovery capital and measuring recovery capital fits in beautifully with what you were describing today. Absolutely. Absolutely. And a lot of the work in that area, as I understand it, and particularly around behavioral activation as a therapy, getting our patients to do positive activities and rewarding meaningful activities, that's obviously really important. But the problem is when you have somebody with a really complex, difficult psychopathology, you could put them in a situation like bring them to a party with a bunch of nice people and delicious food and great music, and the person is still going to suffer because they're lost in their own mind, ruminating and focusing on the negative. So adding this technique, this cognitive technique of savoring to tune the mind towards the positive stimulus and to really extract all the goodness that they can get out of that experience. I think that's a key part to this recovery process. Well, once again, Dr. Garland, thank you so much for giving this talk. I feel smarter for having witnessed this talk. There was a question that, will the recording be available? And it absolutely will be. And we'll ask you if you can make the PDF available of your slides. And thank you again, and thank you, everybody, for your attention. And we look forward to seeing you next month, where next month's lecture will tie in very nicely with what we talked about today. So thanks, everybody. Thanks, Dr. Garland. Bye, everyone. My pleasure.

addiction psychotherapy

mindfulness-oriented recovery enhancement

MORE

Dr. Eric Garland

opioid misuse

chronic pain

emotional distress

cognitive behavioral therapy

positive psychology

neural pathways

clinical trials

natural rewards