As a scientist and clinician, I’ve long been struck by how trauma, chronic pain, and addiction often travel together. For many patients, these conditions form a tangled knot that is difficult to unravel with traditional therapies. Most psychotherapeutic approaches treat trauma, pain, and addiction in isolation, yet what patients truly need is an integrated approach that addresses them simultaneously. Post-traumatic stress disorder (PTSD) is highly prevalent among people with chronic pain and opioid use disorder (OUD), yet there are few evidence-based treatments designed to address this complex comorbidity.

That’s why I’m excited to share results from our NIH-funded study, published in Nature Mental Health, involving 241 patients with PTSD, chronic pain, and opioid misuse. We found that Mindfulness-Oriented Recovery Enhancement (MORE) led to clinically significant reductions in PTSD symptoms in 59 percent of participants. In addition, patients in MORE became better at regulating their autonomic nervous system responses through reappraisal, as shown by decreased skin conductance responses (a measure of physiological arousal). Importantly, when patients learned to regulate trauma symptoms through MORE, this led to decreases in opioid misuse. In other words, healing trauma was a key pathway through which patients reduced their reliance on opioids.

How MORE Works: Reappraisal as a Therapy Skill

At the heart of these findings is the skill of reappraisal—a cognitive strategy taught in MORE that helps patients regulate negative emotions and self-destructive behaviors. Reappraisal involves reframing the meaning of stressful or traumatic experiences to reduce their emotional impact. Reappraisal can also be used to counter the thoughts that drive craving and addiction relapse.

Reappraisal is the cornerstone of cognitive-behavioral therapy (CBT). However, in MORE, we inject an element of mindfulness practice into the reappraisal process to disrupt negative cognitive habits, induce positive emotions, increase psychological flexibility, and enhance perspective taking.

For therapists, this means helping clients learn the following sequence:

• Pause and observe the automatic cognitive-emotional reaction to a triggering and stressful life event.
• Identify the thought or interpretation fueling the distress (e.g., “I can’t handle this pain,” or “I’m broken because of what happened to me”).
• Integrate mindfulness to disrupt the negative thinking patterns, increase psychological flexibility, and regulate the autonomic nervous system, reducing rumination and emotional overwhelm.
• Reframe the meaning of the stressful event by considering alternative perspectives (e.g., “This pain is difficult, but I can meet it with compassion,” “Just because I’m craving doesn’t mean I need to use,” or “Surviving this trauma shows my strength”).
• **Take positive actions **to cope with the stressor.

By practicing reappraisal, patients increase their capacity to regulate negative emotions, which not only alleviates PTSD symptoms but also reduces the drive to self-medicate with substances (like opioids, alcohol, cannabis, or other drugs).

Healing Without Re-Exposure: Mindfulness, Reappraisal, and Savoring

One of the most distinctive aspects of MORE is that it helps patients reduce PTSD symptoms without requiring them to relive traumatic memories. Traditional trauma-focused therapies often rely on exposure or narrative processing, which can be overwhelming for some patients. In contrast, MORE integrates mindfulness, reappraisal, and savoring to build emotion regulation in a gentler, yet powerful way.

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• Mindfulness teaches patients to observe and titrate exposure to trauma-related thoughts and bodily sensations with nonjudgmental awareness, reducing rumination and autonomic arousal.

• Reappraisal allows patients to shift the meaning of distressing experiences, reframing trauma as evidence of resilience rather than permanent damage.

• Savoring introduces a counterbalance: patients actively cultivate positive emotions by focusing on moments of safety, beauty, or connection, which strengthens reward pathways and restores a sense of hope.

By combining these practices, MORE helps patients regulate trauma symptoms indirectly without forcing them to re-experience the traumatic event itself. This approach empowers patients to loosen trauma’s grip on their nervous system while simultaneously reducing the drive to self-medicate with substances.

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For therapists, this means MORE offers a non-exposure-based pathway to trauma healing that is especially valuable for clients who may be hesitant or unable to engage in traditional trauma processing. Instead of retraumatization, patients experience regulation, perspective, and renewed capacity for joy.

Why This Matters for Clinical Practice

For therapists working with clients who present with trauma, pain, and addiction, these findings offer practical guidance:

• Target trauma directly. PTSD symptoms are not just co-occurring; they actively fuel opioid misuse. Addressing trauma can reduce cravings and relapse risk.
• Teach mindfulness-based reappraisal. MORE provides structured practices that therapists can integrate into sessions, helping clients shift their relationship to pain, trauma memories, and cravings.
• Work across conditions simultaneously. Instead of treating PTSD, chronic pain, and addiction in silos, MORE equips therapists with skills that cut across these domains, offering a unified therapeutic approach.
• Focus on empowerment. Patients often feel trapped by trauma and pain. Teaching them to reappraise and savor positive experiences restores a sense of agency and hope.

A New Path Forward

This study demonstrates that MORE is not only effective for reducing opioid misuse, but it is also a powerful intervention for trauma. In fact, previous research has shown that MORE reduces PTSD symptoms among people with substance use disorder to a much greater extent than typical trauma-focused CBT. By teaching patients to regulate negative emotions through reappraisal, MORE helps untangle the knot of PTSD, chronic pain, and addiction.

For therapists, this means having a therapy that is:

• Evidence-based, tested in NIH-funded trials
• Practical, with skills that can be taught and reinforced in session
• Holistic, addressing trauma, pain, and addiction together rather than separately

My mission is to train clinicians in these skills so they can bring hope and healing to patients facing some of the most difficult challenges. If you’re a therapist or a client seeking tools to help with trauma, pain, and addiction, MORE offers a way to restore regulation, reduce cravings, and rebuild lives.

References

Parisi, A., Hudak, J., Froeliger, B., & Garland, E. L. (2023). Mindfulness-Oriented Recovery Enhancement reduces post-traumatic stress via reappraisal among patients with chronic pain and co-occurring opioid misuse. Nature Mental Health, 1(7), 489-500.

Garland, E. L., Hanley, A. W., Nakamura, Y., Barrett, J. W., Baker, A. K., Reese, S. E., ... & Donaldson, G. W. (2022). Mindfulness-oriented recovery enhancement vs supportive group therapy for co-occurring opioid misuse and chronic pain in primary care: a randomized clinical trial. JAMA internal medicine, 182(4), 407-417.

Garland, E. L., Roberts-Lewis, A., Tronnier, C. D., Graves, R., & Kelley, K. (2016). Mindfulness-Oriented Recovery Enhancement versus CBT for co-occurring substance dependence, traumatic stress, and psychiatric disorders: Proximal outcomes from a pragmatic randomized trial. Behaviour research and therapy, 77, 7-16.