Breaking the Cycle of Addiction How mindfulness-based approaches are supporting people to better cope with stress and 'be' with cravings. By Jud Brewer

It was spring 2005. I was sitting in a large audience at the XIII Mind and Life Dialogue in Washington, D.C., listening to different scientists converse with His Holiness the Dalai Lama, and wondering what to do.

I was in the second year of my residency training in psychiatry and had recently declared to a fellow trainee—both of us were in a small training cohort of residents at Yale who were planning to be physician researchers—that I wanted to study mindfulness for the treatment of addiction. He promptly replied: “You are going to kill your career.”

At the time, his career-killer comment was totally rational: a review of the scientific literature would have found a book chapter1 on Vipassana Meditation from 2004, a paper2 entitled “Spirituality, mindfulness and substance abuse” from 2005, and not much else. My colleague, along with much of the world, was skeptical that mindfulness could help people with serious addictions. Spirituality and mindfulness were pretty squishy subjects for scientists, who read from the Gospel of Data.

After the event session concluded, I meekly approached John Teasdale, a prominent psychologist who had recently helped integrate mindfulness into psychotherapy, as he left the stage. I asked him if researching mindfulness and addictions was worth exploring. His encouragement moved me from aspiration into action. I felt less alone.

In residency, whenever I interviewed a patient who was struggling with addiction, I could not shake the seeming coincidence that they were speaking the same language that I had been learning in my own meditation practice (I had started meditating at the beginning of medical school). They spoke of unpleasant thoughts, emotions, and body sensations that triggered significant cravings (that were also unpleasant). They would escape into drinking and various drugs, only to find themselves cycling between use, detox, rehab, and then back to use again. At the same time, I had been learning about the Buddhist concept of dependent origination: a cyclical existence driven by cravings, fueled by behaviors that scratched the itch of craving, only to make it itch more and more.

Thought and willpower-based cognitive approaches hadn’t been as successful as hoped, so in the mid-2000s, Alan Marlatt’s laboratory at the University of Washington began testing whether Vipassana meditation in incarcerated populations could help reduce relapse once people were released from prison. (It did.) Over the next several years, Sarah Bowen and Neha Chawla went on to formalize and test what is now known as Mindfulness-Based Relapse Prevention (MBRP).3

MBRP ushered in a new (based on a very old) way of approaching addiction. Instead of trying to teach people to force themselves to avoid “people, places, and things” that triggered substance use, or stop their “stinkin’ thinkin’” through cognitive behavioral approaches such as cognitive restructuring (e.g., changing negative thought patterns), it helped people turn toward their thoughts, emotions, and even cravings to change their relationship with them.4

After attending Mind & Life’s 2006 Summer Research Institute and receiving some pilot funding from its Varela Research Grant program, I tested an adaptation of MBRP in my outpatient substance use clinic. Bowen and colleagues had been busy testing MBRP in individuals who had recently completed intensive inpatient or outpatient treatment; I wanted to see if it could serve as a first line outpatient treatment for people who struggled with alcohol and cocaine addiction.

I was in the middle of residency at the time, and was still cutting my teeth on how to do clinical trials, so our team asked some simple research questions: 1) Could mindfulness training work as well as Cognitive Behavioral Training (CBT) in helping prevent relapse into substance use? 2) Might mindfulness be better than CBT for helping people cope with stress?

Stress is a common—if not the most common—trigger for relapse.5 I see this all of the time in my clinic, whether it is cigarettes, heroin, or even junk food: people learn to escape from anxiety and stress by intoxicating, numbing, or otherwise distracting themselves with substances. And stress can interfere with the prefrontal cortex6—an area of the brain thought to be critical for willpower and cognitive control. So it is no wonder that stress would be a big reason that someone relapses, which was precisely why we wanted to see if mindfulness training could help.

It is no wonder that stress would be a big reason that someone relapses, which was precisely why we wanted to see if mindfulness training could help.

In short, with all of the caveats that this was a small pilot study7 aimed at determining if it was worth doing full-scale research in this field, the answer to both of our questions was yes. Yes, both CBT and mindfulness training worked to help prevent relapse and yes, mindfulness training did a better job at helping people be less reactive—both psychologically and physiologically—in the face of personalized stressors.

Bowen, Marlatt, and colleagues extended their work to explore the role of mindfulness in smoking, where they found that brief mindfulness-based interventions could change college student smoking habits.8 At the University of Wisconsin, James Davis and colleagues had been testing a modification9 of Mindfulness-Based Stress Reduction (MBSR, on which MBRP is based) for smoking as well.

After finishing residency and establishing my own lab at Yale, I was struggling to help my patients quit smoking, so I joined in the fray. Thinking about the Buddhist concept of dependent origination, I saw real similarities between it and the core “habit loop”10 by which all addictions develop via reinforcement learning. This habit loop consists of three parts: a trigger, a behavior, and a reward. For example, stress (trigger) might make someone smoke (behavior), which in turn distracts them from their stressful situation (reward). I was curious, what if we developed a program that targeted this habit loop? Could it help people quit smoking—often the hardest addiction for someone to give up?

In our first randomized controlled trial of smoking cessation, we found that mindfulness training was five times better11 than cognitive-based approaches (the American Lung Association’s Freedom From Smoking program, a ‘gold-standard’ treatment) at helping people quit and stay quit. While this study was relatively small and aimed more at feasibility, our results were robust enough to examine not only whether it could help people quit, but how?

Here, we went back to the most basic of Buddhist concepts: craving. Working with Jake Davis, a scholar of early Buddhism, we explored the similarities12 between the ancient concept of dependent origination and modern-day reinforcement learning. We found that while the language was different, the concepts were in lock step with each other. In the Pali Canon, the analogy of craving as a fire is often used as a way to line up the cause-and-effect links in the endless cycles of rebirth; fires need fuel. My patients fuel their cravings every time they smoke a cigarette, setting up an endless cycle of smoking. Triggered by stress, nicotine withdrawal, environmental cues, or even boredom, they get a craving, and often mindlessly smoke a cigarette.

My patients fuel their cravings every time they smoke a cigarette, setting up an endless cycle of smoking.

I calculated the number of times one of my patients, who had been smoking for 40 years, had repeated this cycle, and the figure blew me away: about 293,000 times! When I showed my patient the math, he was equally stunned. The approach laid out in the canonical teachings of the Buddha to end these cycles of rebirth is basically to pay attention and “explore gratification to its end.”13 So that’s what I had my patient do: pay attention as he smoked, to see how rewarding it actually was. He, like many others, couldn’t believe that he’d never noticed that cigarettes taste and smell really bad.

Our lab followed this up with a research study. We found that one of the main mechanisms by which mindfulness training helped people quit smoking was by learning to not only become disenchanted with the behavior itself (exploring gratification to its end), but also by learning to be with cravings14 without reacting to them. Later studies15 led by Margarita Sala with app-based mindfulness training using experience sampling—capturing in-the-moment ratings of mood and cravings—found that higher awareness was associated with lower craving and lower negative affect. This makes sense as negative affect often drives craving, and craving itself is unpleasant, whereas mindfulness training may help individuals be more aware of these, and not get caught up in them.16 Katie Witkiewitz17 and others have further explored18 the relationship between craving and relapse prevention.19

Building on a serendipitous discovery20 from over a decade ago in which we found that expert meditators showed decreased brain activity in brain regions associated with craving and substance use (the posterior cingulate cortex), in collaboration with Amy Janes at Harvard, we found that app-based mindfulness training for smoking could target these brain mechanisms.21 Specifically, when shown images of people smoking, individuals who received app-based mindfulness training showed a strong correlation between deactivation of the posterior cingulate cortex and a reduction in cigarette use, whereas no effects were found with the National Cancer Institute’s QuitGuide app as an active comparison.

Alexsandra Zgierska, at University of Wisconsin, focused in on developing and testing treatments for alcohol addiction,22 while Eric Garland, at the University of Utah, developed a program called Mindfulness Oriented Recovery Enhancement (MORE),23 to help people suffering from chronic pain and opioid misuse.24 Given the opioid epidemic that began blossoming in the early to mid 2000’s, mechanistic treatments that show good efficacy, such as MORE, are increasingly needed.25

^{Jud shares his own use of meditation to relieve stress, the key role of awareness in changing habits, and more.}

So what are the key takeaways from applying mindfulness to the treatment of addictions? First, the field is very young: there is now enough research such that review articles and meta-analyses—signs that there are sufficient studies to summarize and compare—are now being written.26 Second, whether viewed from a Buddhist psychology or modern-day neuroscience standpoint, it seems that there is enough consistency in the current research to suggest that approaching craving from a reinforcement learning perspective27 may be more fruitful than continuing the current emphasis on willpower-based approaches.

Whether someone struggles with overeating or even anxiety, awareness may help individuals become disenchanted with unhealthy/unskillful behaviors, creating a freedom that allows for more (at least perceived) choice than the feeling of force that comes with self-control-based approaches.28 Third, while nuances exist in supporting specific substance use treatment, the process of addiction itself may be much broader than observable behavior, extending to self-related processes such as identification with mental states29 (e.g., “I am an anxious person”), and the core construct of the self.30

Caution is certainly needed as we move forward in our exploration of applying mindfulness to addiction treatment. Many individuals develop addictions because of trauma, so specific care is needed in applying and adapting current approaches to be trauma sensitive. Adverse effects31 of mindfulness approaches need better characterization, and the development of supports for individuals who experience such negative outcomes.32 Careful evaluation of treatments with attention to bias and comparison to active treatment conditions (as compared to no treatment or waitlist controls) is needed to determine which treatments are truly efficacious. And importantly, effectiveness and implementation studies are needed to examine how well a treatment works (and can be scaled up) in real world settings—few studies move beyond proof-of-concept or testing how well a treatment works in a research setting, which is very different than in clinics.33

With all of these caveats in mind, there is no greater need at this time for bringing forward addiction treatments that triangulate theory, mechanism, and clinical outcomes. Mindfulness may be the approach that brings all of these together. Our modern-day reliance on the individual—the self—may finally be showing cracks in its foundation, leading us back to ancient concepts that may help us transcend addiction, and ourselves in the process.

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Notes

1. 1.

   Marlatt, G. A., Witkiewitz, K., Dillworth, T. M., Bowen, S. W., Parks, G. A., Macpherson, L. M., … & Crutcher, R. (2004). Vipassana meditation as a treatment for alcohol and drug use disorders. Mindfulness and Acceptance: Expanding the Cognitive-Behavioral Tradition, 261-287.

2. 2.

   Leigh, J., Bowen, S., & Marlatt, G. A. (2005). Spirituality, mindfulness and substance abuse. Addictive Behaviors, 30(7), 1335-1341. https://doi.org/10.1016/j.addbeh.2005.01.010

3. 3.

   Bowen, S., Chawla, N., Collins, S. E., Witkiewitz, K., Hsu, S., Grow, J., … & Marlatt, A. (2009). Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial. Substance Abuse, 30(4), 295-305. https://doi.org/10.1080/08897070903250084 [Full article]

4. 4.

   Bowen, S., Witkiewitz, K., Clifasefi, S. L., Grow, J., Chawla, N., Hsu, S. H., … & Larimer, M. E. (2014). Relative efficacy of mindfulness-based relapse prevention, standard relapse prevention, and treatment as usual for substance use disorders: A randomized clinical trial. JAMA Psychiatry, 71(5), 547-556. https://doi.org/10.1001/jamapsychiatry.2013.4546

5. 5.

   Sinha, R. (2001). How does stress increase risk of drug abuse and relapse?. Psychopharmacology, 158(4), 343-359. https://doi.org/10.1007/s002130100917

6. 6.

   Arnsten, A. F. (2015). Stress weakens prefrontal networks: Molecular insults to higher cognition. Nature Neuroscience, 18(10), 1376-1385. https://doi.org/10.1038/nn.4087 [Full article]

7. 7.

   Brewer, J.A., et al. (2009). Mindfulness training and stress reactivity in substance abuse: Results from a randomized, controlled stage I pilot study. Substance Abuse, 30(4):306-17. https://doi.org/10.1080%2F08897070903250241 [Free full article]

8. 8.

   Bowen, S., & Marlatt, A. (2009). Surfing the urge: Brief mindfulness-based intervention for college student smokers. Psychology of Addictive Behaviors, 23(4), 666. https://doi.org/10.1037/a0017127

9. 9.

   Davis, J. M., Fleming, M. F., Bonus, K. A., & Baker, T. B. (2007). A pilot study on mindfulness based stress reduction for smokers. BMC Complementary and Alternative Medicine, 7(1), 1-7. https://doi.org/10.1186/1472-6882-7-2

10. 10.

    Brewer, J.A. (2017). The Craving Mind: From Cigarettes to Smartphones to Love -Why We Get Hooked and How We Can Break Bad Habits. Yale University Press.

11. 11.

    Brewer, J. A., Mallik, S., Babuscio, T. A., Nich, C., Johnson, H. E., Deleone, C. M., … & Rounsaville, B. J. (2011). Mindfulness training for smoking cessation: Results from a randomized controlled trial. Drug and Alcohol Dependence, 119(1-2), 72-80. https://doi.org/10.1016/j.drugalcdep.2011.05.027 [Full article]

12. 12.

    Brewer, J. A., Elwafi, H. M., & Davis, J. H. (2013). Craving to quit: Psychological models and neurobiological mechanisms of mindfulness training as treatment for addictions. Psychology of Addictive Behaviors, 27(2), 366. https://doi.org/10.1037/a0028490 [Full article]

13. 13.

    Brewer, J. A., Davis, J. H., & Goldstein, J. (2013). Why is it so hard to pay attention, or is it? Mindfulness, the factors of awakening and reward-based learning. Mindfulness, 4(1), 75-80. https://doi.org/10.1007/s12671-012-0164-8 [Full article]

14. 14.

    Elwafi, H. M., Witkiewitz, K., Mallik, S., Thornhill IV, T. A., & Brewer, J. A. (2013). Mindfulness training for smoking cessation: Moderation of the relationship between craving and cigarette use. Drug and Alcohol Dependence, 130(1-3), 222-229. https://doi.org/10.1016/j.drugalcdep.2012.11.015 [Full article]

15. 15.

    Sala, M., Roos, C. R., Brewer, J. A., & Garrison, K. A. (2021). Awareness, affect, and craving during smoking cessation: An experience sampling study. Health Psychology. https://doi.org/10.1037/hea0001105

16. 16.

    Brewer, J. (2019). Mindfulness training for addictions: Has neuroscience revealed a brain hack by which awareness subverts the addictive process?. Current Opinion in Psychology, 28, 198-203. https://doi.org/10.1016/j.copsyc.2019.01.014 [Free preprint]

17. 17.

    Witkiewitz, K., & Bowen, S. (2010). Depression, craving, and substance use following a randomized trial of mindfulness-based relapse prevention. Journal of Consulting and Clinical Psychology, 78(3), 362. https://doi.org/10.1037/a0019172 [Full article]

18. 18.

    Garland, E. L., Roberts-Lewis, A., Kelley, K., Tronnier, C., & Hanley, A. (2014). Cognitive and affective mechanisms linking trait mindfulness to craving among individuals in addiction recovery. Substance Use & Misuse, 49(5), 525-535. https://doi.org/10.3109/10826084.2014.850309

19. 19.

    Witkiewitz, K., Bowen, S., Douglas, H., & Hsu, S. H. (2013). Mindfulness-based relapse prevention for substance craving. Addictive Behaviors, 38(2), 1563-1571. https://doi.org/10.1016/j.addbeh.2012.04.001 [Full article]

20. 20.

    Brewer, J. A., Worhunsky, P. D., Gray, J. R., Tang, Y. Y., Weber, J., & Kober, H. (2011). Meditation experience is associated with differences in default mode network activity and connectivity. Proceedings of the National Academy of Sciences, 108(50), 20254-20259. https://doi.org/10.1073/pnas.1112029108

21. 21.

    Janes, A. C., Datko, M., Roy, A., Barton, B., Druker, S., Neal, C., … & Brewer, J. A. (2019). Quitting starts in the brain: A randomized controlled trial of app-based mindfulness shows decreases in neural responses to smoking cues that predict reductions in smoking. Neuropsychopharmacology, 44(9), 1631-1638. https://doi.org/10.1038/s41386-019-0403-y

22. 22.

    Zgierska, A., Rabago, D., Zuelsdorff, M., Coe, C., Miller, M., & Fleming, M. (2008). Mindfulness meditation for alcohol relapse prevention: A feasibility pilot study. Journal of Addiction Medicine, 2(3), 165. https://doi.org/10.1097/ADM.0b013e31816f8546

23. 23.

    Garland, E. L., Baker, A. K., Riquino, M. R., & Priddy, S. E. (2019). Mindfulness-oriented recovery enhancement. Handbook of Mindfulness-Based Programmes: Mindfulness Interventions from Education to Health and Therapy. Abingdon: Routledge.

24. 24.

    Garland, E. L., Manusov, E. G., Froeliger, B., Kelly, A., Williams, J. M., & Howard, M. O. (2014). Mindfulness-oriented recovery enhancement for chronic pain and prescription opioid misuse: Results from an early-stage randomized controlled trial. Journal of Consulting and Clinical Psychology, 82(3), 448. https://doi.org/10.1037/a0035798 [Full article]

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