Garland and Howard Addict Sci Clin Pract (2018) 13:14

https://doi.org/10.1186/s13722-018-0115-3 Addiction Science &

Clinical Practice

REVIEW Open Access

Mindfulness‑based treatment
of addiction: current state of the field
and envisioning the next wave of research
Eric L. Garland1* and Matthew O. Howard2

Abstract 
Contemporary advances in addiction neuroscience have paralleled increasing interest in the ancient mental training
practice of mindfulness meditation as a potential therapy for addiction. In the past decade, mindfulness-based inter-
ventions (MBIs) have been studied as a treatment for an array addictive behaviors, including drinking, smoking, opioid
misuse, and use of illicit substances like cocaine and heroin. This article reviews current research evaluating MBIs as
a treatment for addiction, with a focus on findings pertaining to clinical outcomes and biobehavioral mechanisms.
Studies indicate that MBIs reduce substance misuse and craving by modulating cognitive, affective, and psychophysi-
ological processes integral to self-regulation and reward processing. This integrative review provides the basis for
manifold recommendations regarding the next wave of research needed to firmly establish the efficacy of MBIs and
elucidate the mechanistic pathways by which these therapies ameliorate addiction. Issues pertaining to MBI treat-
ment optimization and sequencing, dissemination and implementation, dose–response relationships, and research
rigor and reproducibility are discussed.
Keywords:  Automaticity, Addiction, Dissemination, Dose–response, Mindfulness, Review, Reward, SMART

Background decades ago and prior to the current understanding of

Advances in biobehavioral science occurring over the addiction as informed by neuroscience. Yet, to the extent
past several decades have made significant headway in that behavioral therapies target dysregulated neurocogni-
elucidating mechanisms that undergird addictive behav- tive processes underlying addiction, they may hold prom-
ior. This large body of research suggests that addiction ise as effective treatments for persons suffering from
is best regarded as a cycle of compulsive substance use addictive disorders.
subserved by dysregulation in neural circuitry govern- Contemporary developments in addiction neurosci-
ing motivation and hedonic experience, habit behavior, ence have been paralleled by increasing interest in the
and executive function [1]. Though findings from the age-old mental training practice of mindfulness medi-
basic science of addiction have yielded novel treatment tation as a potential treatment for addictive behavior.
targets that may inform the development of promising This interest was sparked by the successful integration
pharmacotherapies, the behavioral treatment develop- of mindfulness techniques into secularlized behavioral
ment process often lags behind the ever-accelerating pace intervention programs, including Mindfulness-Based
of mechanistic discovery. In that regard, the mainstays Stress Reduction (MBSR) [2] and Mindfulness-Based
of behavioral addictions treatment, cognitive-behavioral Cognitive Therapy (MBCT) [3]. Standardized mind-
therapy and motivational interviewing, were developed fulness training programs were originally focused on
reducing emotional distress, and indeed, for psychiatric
*Correspondence: [email protected]
disorders and symptoms mindfulness-based interven-
1
Center on Mindfulness and Integrative Health Intervention tions (MBIs) have been shown through meta-analysis
Development, University of Utah, 395 South, 1500 East, Salt Lake City, UT to be efficacious and comparable to other active, head-
84112, USA
Full list of author information is available at the end of the article
to-head treatments [4]. More recently, MBIs like

© The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license,
and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/
publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Garland and Howard Addict Sci Clin Pract (2018) 13:14 Page 2 of 14

Mindfulness-Based Relapse Prevention (MBRP) [5] and reactivity by revealing the insubstantiality and ephem-
Mindfulness-Oriented Recovery Enhancement (MORE) erality of any particular content of consciousness. Neu-
[6] have been tailored to directly to address the mecha- ropsychological models of focused attention and open
nisms that undergird addiction. A growing body of con- monitoring have mapped these practices onto systems
trolled research studies demonstrates that MBIs may of interacting cognitive processes, including sustained
produce significant clinical benefits for users of a panoply attention, attentional re-orienting, conflict monitor-
of addictive substances, including alcohol, cocaine, nico- ing, retaining information online in working memory,
tine, and opioids. The aims of this report were to opera- inhibitory control, and emotion regulation [8]. Although
tionalize the construct of mindfulness with respect to focused attention and open monitoring have been dis-
therapeutic processes that mediate its potential efficacy; tinguished in the scientific literature, in practice they are
review the current state of research on mindfulness as a often combined, such that mindfulness practices typically
treatment for addiction; and to envision the next wave begin with focused attention and then develop into open
of research in this emerging and important field. With monitoring as the meditation session unfolds over time.
regard to setting a future research agenda here we high- Frequent and regular practice (e.g., daily) of mindful-
light issues related to: research rigor and reproducibility; ness techniques is thought to cultivate durable changes
treatment optimization based on mechanistic discover- in the trait-like propensity to be mindful in everyday life
ies; the sequencing of MBIs in multimodal treatment (i.e., dispositional or trait mindfulness) even when one is
packages; the need to consider dose–response relation- not engaged in meditation practice [9]. This increase in
ships; the translation and dissemination of MBIs into trait mindfulness is theorized to occur through neuro-
standard, community-based addiction treatment set- cognitive plasticity kindled by repeated activation of the
tings; and the possibility of construing mindfulness as an state of mindfulness during recurrent mindfulness prac-
integral component of a recovery-oriented lifestyle rather tice sessions [10]. In partial support of this hypothesis,
than a time-limited treatment. increases in the trajectory of state mindfulness produced
over time through meditation predicts increases in trait
Mindfulness as a means of targeting mechanisms mindfulness [11], and meta-analysis demonstrates that
of addiction the effects of MBIs on clinical outcomes are mediated by
Mindfulness operationalized increases in trait mindfulness [12]. Further, meta-analysis
Derived from ancient Indo-Sino-Tibetan contemplative of morphometric neuroimaging suggests that increased
practices and philosophies concerning the cultivation of practice of mindfulness meditation is associated with
awareness, the construct of mindfulness has been alter- neuroplastic changes in brain structure [13]. According
nately operationalized as a state, trait, and practice in the to operationalizations of the construct derived from fac-
modern scientific literature. MBIs provide training in tor analytic research, dispositional or trait mindfulness
practices designed to evoke the state of mindfulness—i.e., is characterized by the capacity to remain nonreactive
a state of metacognitive awareness characterized by an to and accepting of distressing thoughts and emotions;
attentive and nonjudgmental monitoring of moment-by- observe interoceptive and exteroceptive experience; dis-
moment cognition, emotion, sensation, and perception criminate emotional states; and be aware of automaticity
without perseveration on thoughts of past and future. [14]. These mindful qualities may serve as antidotes to
The practice of mindfulness has been proposed to involve addictive behavior; indeed, trait mindfulness, which has
two primary elements: focused attention and open moni- been correlated with enhanced cognitive control capaci-
toring [7, 8]. During the practice of focused attention, ties [15], is significantly inversely associated with sub-
attention is concentrated on a sensory object (often the stance use [16] and craving [17], and positively associated
sensation of breathing, but interoceptive and proprio- with the ability to disengage attention and recover auto-
ceptive body sensations or external visual foci can also nomic function following exposure to addiction-related
be used) while one acknowledges and then disengages cues [18, 19]. In contrast to trait mindfulness, which
from distracting thoughts and emotions. Focused atten- is associated with cognitive and behavioral flexibility,
tion practices often precede the practice of open moni- addiction may be characterized by mindlessness [20], i.e.,
toring, in which one observes both the arising of mental habitual or stereotyped responses that may be executed
contents as well as the field of awareness in which those automatically without conscious volition or strategic
contents arise [7]. Open monitoring is a metacognitive regard for distal consequences. In light of Tiffany’s clas-
state of awareness in the sense that it involves monitor- sic description of addiction as the product of automatic-
ing the content of consciousness while reflecting back on ity [21], mindfulness of one’s automatized behavioral and
the process or quality of consciousness itself. This form emotional reactions may allow for greater self-regulation
of mindfulness practice is thought to reduce emotional of habitual addictive behavior. Thus, mindfulness practice
Garland and Howard Addict Sci Clin Pract (2018) 13:14 Page 3 of 14

may evoke the state of mindfulness that accrues with maladaptive ways. Such tailoring is presumed necessary
each meditation practice session into a durable propen- for maximizing clinical effects of MBIs as treatments for
sity to exhibit the trait of mindfulness in everyday life, addiction, though no quantitative comparisons of tai-
thereby suffering as a buffer against addictive behavior. lored (e.g., MBRP) versus general (e.g., MBSR) MBIs have
been conducted for individuals with substance use disor-
Mindfulness‑based interventions for addiction ders. Comparative effectiveness research or dismantling
The most prominent MBIs (i.e., MBRP, MORE, mindful- trials are needed to determine whether such addiction-
ness training for smokers) for addiction were modeled specific tailoring increases effect sizes.
after the first generation of mindfulness-based thera-
pies like MBSR and MBCT in terms of their structure Therapeutic mechanisms of mindfulness as a treatment
and format. MBIs for addiction tend to be multi-week for addiction
interventions (approximately 8  weeks in duration) usu- In a mechanistic theoretical account of mindfulness as
ally delivered in a group therapy format. Each week, a treatment for addiction, Garland, Froeliger, & How-
participants are guided by a trained clinician in vari- ard conceptualized MBIs as means of mental training
ous mindfulness practices, including mindful breathing designed to exercise a number of neurocognitive pro-
and body scan meditations. These in-session mindful- cesses that become dysregulated during the process
ness practices are debriefed during a subsequent group of addiction [22]. Such mental training is provided by
process, after which new psychoeducational material is focused attention and open monitoring mindfulness
typically presented. Sessions often involve experiential practices, which in isolation and in tandem are thought
exercises to reinforce the mindfulness principles that to exercise processes crucial to the self-regulation of
had been introduced didactically. Participants are given addictive behavior such as attentional re-orienting, meta-
therapeutic homework, consisting of formal and informal cognition, reappraisal, and inhibitory control [8].
mindfulness practices as well as assignments to self-mon- From this perspective, MBIs can been seen as behav-
itor symptoms like craving and negative affect. Extant ioral strategies for strengthening the integrity of pre-
MBIs for addiction differ from one another in terms of frontally-mediated cognitive control networks that have
the types of mindfulness practices taught, the style in become atrophied by chronic drug use and hijacked
which these practices are delivered and debriefed (e.g., by drug-related cues and cravings during the process
MBRP uses open, non-directive inquiry whereas MORE of addiction. As adaptive cognitive control is restored
employs a directive approach with a high degree of posi- through mindfulness exercises, MBIs may increase func-
tive reinforcement), the length of at home mindfulness tional connectivity between these top-down prefrontal
practice sessions, and the specific psychoeducational networks and bottom-up limbic-striatal brain circuitry
content delivered. involved in reward processing and motivated behav-
MBIs for addiction are usually tailored to address path- ior [22]. Increased connectivity between top-down and
ogenic mechanisms implicated in addiction by target- bottom-up brain networks implicated in addiction (e.g.,
ing mindfulness techniques to addictive behaviors (e.g., frontostriatal circuitry) may provide the physiological
mindfulness of craving) and by discussing the applica- substrate through which mindfulness de-automatizes
tion of mindfulness skills to cope with addiction in eve- addictive behavior. Figure 1 depicts hypothesized neural
ryday life. For instance, MORE participants are guided functional mechanisms of MBIs for addiction. By aug-
to engage in the “chocolate exercise”— an experiential menting the capacity of the PFC to regulate subcortical
mindfulness practice designed to increase awareness of brain networks in a goal-directed manner, MBIs may
automaticity and craving [6]. During this exercise, par- strengthen a domain general neurocognitive resource
ticipants are instructed to hold a piece of chocolate close that can be used to modulate a variety of mechanisms
to their nose and lips and become mindful of the arising implicated in addiction, including reward processing,
of craving as they refrain from eating the chocolate. Dur- cue-reactivity, stress reactivity, etc. These hypothetical
ing this exercise, a comparison is made between the urge behavioral mechanisms are depicted in Fig.  2, and evi-
to swallow the chocolate and craving for addictive sub- dence for these mechanisms is reviewed below.
stances. Participants are then guided to adopt a metacog-
nitive stance toward their experience and deconstruct the Restructuring reward
craving into its constituent sensory, affective, and cogni- Through mechanistic effects of mindfulness-induced
tive components, noticing how the craving subsides over enhancements in functional connectivity between top-
time. Through this technique, clients learn to consciously down and bottom-up brain circuitry, MBIs may reverse
and adaptively respond to the urge to use substances the allostatic process by which normal reward learning is
rather than automatically reacting to appetitive cues in usurped by addictive substances. In that regard, Garland
Garland and Howard Addict Sci Clin Pract (2018) 13:14 Page 4 of 14

Fig. 1  Hypothesized neural mechanisms by which mindfulness-based interventions ameliorate addictive behavior. Garland et al. [20] model of
mindfulness-centered regulation posits that mindfulness-based interventions ameliorate the craving, negative affective states, and automatic habit
behaviors underpinning addiction by enhancing functional connectivity (1) within a “top-down” brain network subserving metacognitive atten-
tional (dlPFC, dACC, parietal cortex) and (2) between this metacognitive attentional control network and “bottom-up” brain structures implicated
in automaticity, memory consolidation, interoception, and hedonic regulation. Enhanced functional connectivity within and between these neural
circuits may allow individuals to self-regulate addictive impulses and restructure reward processes to support healthy, goal-oriented behavior. dlPFC
dorsolateral prefrontal cortex, dACC dorsal anterior cingulate cortex, PCC posterior cingulate cortex, DS dorsal striatum, VS ventral striatum, Thal
thalamus, HIPP hippocampus, Amy amygdala, OFC orbitofrontal cortex, MFC medial prefrontal cortex

recently advanced a novel hypothesis concerning the of subsequent food liking and enjoyment [26, 27], and
therapeutic mechanisms of mindfulness for treatment 8-weeks of mindfulness training increased the experience
of addiction: the restructuring reward hypothesis [23]. of reward derived from pleasant daily life activities [28].
The restructuring reward hypothesis states that mind- This application of mindfulness as a means of appreciat-
fulness may reduce addictive behavior by shifting the ing and focusing on natural rewards is termed savoring
relative salience of drug and natural rewards from valu- [29].
ation of drug-related reward back to valuation of natu- Though the aforementioned studies were not directly
ral rewards that were salient before the development of concerned with substance use disorder treatment, a
addiction. Though not the explicit aim of most MBIs, by mounting body of evidence supports the restructuring
virtue of their effects on enhancing attention regulation reward hypothesis and suggests that increasing natural
and positive affect, mindfulness training might nonethe- reward processing through MBIs might reduce craving
less increase pleasure from perceptual and sensorimotor and addictive behavior. In mechanistic analyses from
experiences in a fashion similar to sensate-focus tech- a RCT of MORE as a treatment for prescription opioid
niques [24] and promote positive emotion regulation by misuse among chronic pain patients, MORE produced
amplifying selective attentional processes [25]. Indeed, significant increases in cardiac-autonomic and electro-
brief mindfulness practice while eating increased ratings cortical responses to natural reward stimuli that were, in
Garland and Howard Addict Sci Clin Pract (2018) 13:14 Page 5 of 14

Fig. 2  Schema detailing the effects of mindfulness-based intervention components on mechanisms and outcomes implicated in the treatment of
addictive behavior

turn, associated with decreases in opioid craving [30, 31], orbitofrontal cortex (OFC) significantly increased in the
suggesting that MBI may restructure reward processing. MORE group relative to the comparison group. These
Further, recent analyses indicate that MORE enhances increases in functional connectivity, striatal, and rACC
autonomic responses to natural reward cues relative to savoring responses significantly predicted increases in
opioid cues, and increases in relative physiologic respon- positive affect and reductions in the quantity of cigarettes
siveness to natural versus opioid-related reward signifi- smoked over the course of treatment with MORE, sug-
cantly predicted reduced opioid misuse 3  months later gesting that mindfulness training may treat addiction by
[32]. These psychophysiological findings converged with restructuring function of brain reward circuitry. To be
ecological momentary assessment data collected dur- clear, MORE provides integrated training in mindfulness,
ing this trial, which indicated that MORE significantly reappraisal, and savoring skills, and therefore other MBIs
increased the trajectory of positive affect from moment- may or may not exert similar effects on restructuring
to-moment which in turn predicted decreased opioid the relative salience of natural and drug-related reward.
misuse following treatment [33]. However, other potential mechanisms of mindfulness as
These findings supporting of the restructuring reward a treatment for addiction have been identified in the lit-
hypothesis were paralleled by preliminary functional erature and are discussed below.
magnetic resonance imaging (fMRI) evidence of the
effects of MORE on nicotine dependent smokers. In a Executive functioning
pilot study of MORE as a smoking cessation intervention By strengthening top-down cognitive control, MBIs may
[34], smokers viewed cigarette images during a cue-reac- improve executive functions like self-control over auto-
tivity task, and then in a separate positive emotion regu- matic habits, decision-making, and response inhibition
lation task, either viewed or savored images representing that are crucial to reducing drug use and maintaining
natural rewards. Relative to a time matched comparison abstinence. In that regard, a small quasi-experimental
group, participants in MORE exhibited significant pre- study of a mindfulness and goal management training
post treatment reductions in ventral striatal responses to intervention for polysubstance use demonstrated signifi-
cigarette cues over time, and significant increases in ven- cant improvements in executive functioning, including
tral striatum and rostral anterior cingulate cortex (rACC) working memory, selective attention/response inhibition
during savoring of natural reward stimuli. Furthermore, and decision-making skills following mindfulness train-
resting state functional connectivity between rACC and ing relative to treatment as usual [35]. A subsequent pilot
Garland and Howard Addict Sci Clin Pract (2018) 13:14 Page 6 of 14

RCT with a sample of polysubstance users replicated significantly greater HRV recovery from stress-primed
these effects of combined goal management and mind- alcohol cues that were coupled with significantly greater
fulness training in laboratory-based tasks and ecologi- reductions in cue-induced distress over the recovery
cally valid measures of decision-making [36]. Similarly, period [48]. With regard to stress biomarker measures,
in a full-scale clinical trial, mindfulness-based addiction one study found that mindfulness training for smokers
treatment significantly improved smoking abstinence by was associated with significant within-group decreases
decreasing concentration difficulties [37]. In addition, in hair cortisol measures [49], and an nonexperimental
there is some evidence that MBIs for addiction increase study of MBSR found significant within-group decreases
activation in brain regions implicated in self-regulatory in awakening salivary cortisol levels among participants
executive functions: a small RCT showed that 2  weeks receiving inpatient treatment for substance use disor-
of mindfulness training was associated with significant ders [50]. To date, only one study has examined brain
reductions in smoking coupled with increased resting mechanisms of the stress regulatory effects of MBIs: in
state activity in the ACC and mPFC [38]. Such increased a RCT, an 8-week MBI for smoking cessation was asso-
prefrontal activation might facilitate mindfulness- ciated with significantly less amygdala and insula activa-
induced deautomatization of addictive responses. tion during stress exposure relative to an active control
condition, and reduced activity in these brain regions was
Dispositional mindfulness associated with decreased smoking by follow-up [51].
MBIs might also reduce addictive behavior by strength-
ening facets of dispositional/trait mindfulness. In a RCT Craving and cue‑reactivity
of MBRP among a heterogenous sample of individuals MBIs may reduce addictive behavior by decreasing sub-
with various substance use disorders, increases in dispo- jective craving and attentional and physiological indices
sitional mindfulness facets like acceptance, awareness, of drug cue-reactivity. In addition to the aforementioned
and nonjudgment significantly mediated the effect of smoking cessation study in which MORE reduced striatal
MBRP on decreasing craving following treatment [39]. responses to cigarette cues [34], decreased cue-reactivity
Similarly, in a large cluster RCT of MORE versus CBT or was observed in an RCT in which MORE was shown to
TAU, increases in dispositional mindfulness significantly significantly reduce attentional bias toward opioid cues
mediated the effect of MORE on reducing craving follow- [52] and decrease subjective craving responses during
ing treatment [40]. Finally, MORE significantly increased an opioid cue-reactivity protocol [30]. Similarly, in a lab-
the mindfulness facet of nonreactivity which, in turn, based brief mindfulness induction, mindful attention
predicted decreases in prescription opioid misuse [41]. to smoking cues significantly reduced craving coupled
with decreased activation in a craving-related region of
Stress reactivity and stress recovery the subgenual ACC [53]. These lab-based assessments
Given known linkages between stress and addiction [42, of craving as a mediator of MBI effects have been cor-
43], MBIs might ameliorate addictive behavior by atten- roborated by clinical research: in a large clinical trial,
uating stress reactivity and augmenting stress recov- the effects of mindfulness-based addiction treatment on
ery. Several studies of MBIs as treatments for addiction smoking abstinence were mediated by decreased crav-
have employed measures of heart rate variability (HRV), ing [37]. Similarly, a study of mindfulness training for
the beat-to-beat variation in heart rate driven by the smokers found that mindfulness significantly reduced
parasympathetic nervous system [44], as an index of the post-quit smoking urge ratings that were significantly
capacity to regulate physiological reactivity and recovery associated with smoking abstinence [54]. In addition to
from stress. In a sample of individuals receiving treatment targeting craving, mindfulness training aims to reduce
for substance use disorders, relative to a control group cognitive, affective, and behavioral reactivity. In the con-
and treatment-as-usual, MBRP was associated with sig- text of addiction, substance use is often a reaction to
nificantly greater increases in tonic HRV and phasic HRV increases in negative affect and craving. Thus, MBIs may
responses to stress [45]. Similarly, a mindfulness training undo this reaction by decoupling affective response and
intervention based on MBRP for individuals with alcohol craving from substance use. For example, brief instruc-
and/or cocaine use disorders was associated with signifi- tion in mindfulness as a means of coping with urges to
cantly attenuated sympathovagal HRV ratio during stress smoke attenuated the association between negative affect
exposure [46]. Among nicotine-deprived smokers, brief and smoking urges [55]. With regard to longer MBI pro-
mindfulness training was associated with significantly grams, MBRP has been shown to decouple associations
greater HRV during stress exposure than a control con- between depressed mood, craving, and substance use;
dition [47]. In a pilot RCT, compared to an active con- MBRP significantly reduced the association between
trol group, participation in MORE was associated with postintervention depressive symptoms and craving
Garland and Howard Addict Sci Clin Pract (2018) 13:14 Page 7 of 14

2  months following treatment, which in turn predicted treatments were associated with superior treatment out-
reduced substance use at 4-months follow-up [41, 56]. comes at posttreatment and follow-up assessments com-
A mindfulness-based smoking cessation intervention pared to comparison conditions” (p. 69). Effects (Cohen’s
derived from MBRP significantly reduced the associa- d/odds ratios) ranged from moderate-to-large across the
tion between craving and cigarette smoking [57]. In the synthesized effect sizes computed for studies within the
same vein, MORE significantly attenuated the association substance use (d = 0.33, − 0.49 to 0.17, p < 0.05), ciga-
between prescription opioid craving and opioid misuse. rette smoking (OR = 1.76, 0.99–3.15, p = 0.056), craving
(d = 0.68, − 1.11 to − 0.025, p < 0.01), and stress (d = 1.12,
Thought suppression − 2.24 to –0.01, p < 0.05) domains.
Finally, given that suppression of addictive urges exhausts With regard to secondary or mechanistic outcomes,
autonomic resources for self-control [58] and paradoxi- as expected, MBIs produced significant increases on
cally amplifies craving [59], MBIs may reduce addictive the Five Factor Mindfulness Questionnaires in all eight
behavior by providing an effective alternative to thought studies that used this measure (d = 0.62, − 0.02 to 1.26,
suppression. In support of this notion, a quasi-experi- p = 0.057). In individual studies, MBIs produced a host
mental study of incarcerated substance users found that of other significant salutary effects including increases
decreases in thought suppression mediated the effect in emotion regulation [41, 54], substance-related self-
of mindfulness training (i.e., Vipassana meditation) on efficacy [65, 66], and positive emotions [33], as well as
reducing alcohol use [60]. Similarly, in a pilot RCT of decreases in attentional bias [52, 66, 67], addictive auto-
alcohol dependent inpatients, MORE was shown to sig- maticity [66], dysphoric affect [40, 66], and pain sever-
nificantly reduce thought suppression which was in turn ity and related functional interference in patients with
associated with reductions in alcohol attentional bias chronic pain [41]. Several studies reported positive
[48]. associations between the degree to which participants
Though mechanistic research on MBIs has begun to engaged in mindfulness homework exercises and changes
amass, there are few psychophysiological and neuroim- in cigarette, marijuana, and alcohol use posttreatment
aging studies of MBIs as a treatment for addiction. Thus (e.g., [68–70]).
little data exists to either support or refute the neural Of the 34 RCTs reviewed in this meta-analysis, ten used
mechanistic models proposed in this section. Clearly, treatment-as-usual comparison groups, whereas two
more research is needed in this area. used inert comparison groups, sixteen employed an alter-
native psychotherapeutic treatment (typically matched to
Current state of the field: a review of clinical the MBI group vis-à-vis intensity, duration, and format),
outcomes of mindfulness‑based treatments and six examined brief mindfulness treatments compared
for addiction to alternative therapies in laboratory settings. Twenty-
A considerable body of findings has amassed supporting eight of the reports presented the first published findings
the capacity of MBIs to reduce substance use and attenu- from the related study and six reports presented results
ate factors promoting substance use, such as craving and of secondary analyses. Any given study could contribute
stress. Over the past decade, multiple systematic reviews findings only once to meta-analyses conducted within
have been conducted to identify the effects of MBIs on outcome domains. The adequacy of randomization was
addictive behaviors, and have found accumulated evi- examined in all studies and analysis of covariance and
dence for the positive effects of MBIs [61–63]. More linear mixed modeling were often used to control for
recently, a meta-analysis focused on the broad clinical any remaining pretreatment differences. Nearly half of
efficacy of MBIs for a range pf psychiatric disorders con- the studies had samples sizes less than fifty. Many studies
ducted subgroup analyses to examine the effects of MBIs had high attrition rates at posttreatment and subsequent
on addiction/smoking and found MBIs to be superior to follow-ups. Most of the 34 studies reviewed relied exten-
active control conditions and comparable to other evi- sively on self-report measures of substance use and other
dence-based treatments [4]. In the only published meta- constructs. All RCTs examined were single-site stud-
analysis solely focused on MBIs for substance misuse, ies. The most common methodological limitations were
Li, Howard, Garland, McGovern, and Lazar [64] identi- failure to interview collateral informants regarding study
fied 34 randomized controlled trials differing in terms participants’ substance use behaviors at posttreatment
of the types of MBI and comparison groups contrasted, and follow-up and to employ posttreatment and follow-
sample demographics, and measures of outcomes and up interviewers who were blind to participants’ treat-
other constructs. Despite the notable methodological ment assignments. Fewer than half of the RCTs employed
heterogeneity of these investigations, the authors con- objective verification of participants’ self-reported sub-
cluded that “virtually all studies found that mindfulness stance use, such as urinanalysis.
Garland and Howard Addict Sci Clin Pract (2018) 13:14 Page 8 of 14

Subgroup analyses within outcome domains indicated development research to optimize the next generation of
that MORE treatment was associated with larger effects MBIs as interventions for addiction. Thus, in the lifespan
than other MBIs for substance use, craving, stress, and of this nascent field, it is now an opportune moment to
mindfulness measures [64]. Studies comprised entirely answer definitively the question “Are MBIs efficacious
of men also reported larger effects for MBIs compared to and comparatively effective treatments for addiction?”
studies with samples comprised only of women or those Assuming an affirmative answer to the aforementioned
with mixed gender samples across measures of craving, question, studies should then aim to address research
stress, and mindfulness. questions pertaining to mediation (“How do MBIs
Li et  al. [64] also reported findings from a random improve addiction-related outcomes?”) and moderation
effects meta-regression analysis examining effects of MBI (“For whom do MBIs work most optimally to improve
type, primary type of substance misused, study sample addiction-related outcomes?”). As discussed in “Mind-
size, sample age and gender distributions, type of com- fulness as a means of targeting mechanisms of addiction”
parison group, treatment dosage in hours, and study section, a corpus of research has begun to amass on the
methodological rigor on effect sizes by domain. Results mediators of MBI effects on addiction. In contrast, there
indicated that studies with samples of only men experi- is very little research on moderators of MBIs. The only
enced larger reductions in levels of craving and stress, study of MBI moderators for addiction outcomes is a sec-
and significantly larger increases in levels of mindful- ondary analysis of data from two RCTs of MBRP, which
ness, compared to studies with samples comprised only found that patients with greater substance use disorder
of women or studies with samples comprised of women severity and more affective symptoms received signifi-
and men. Although the authors did not include a formal cantly greater benefit from mindfulness training than
search for “gray literature” related to MBI treatment of patients with low levels of substance use and affective
substance misuse, they noted that funnel plots and Egg- symptoms [72].
er’s test analyses suggested that their findings were not A number of additional research questions remain
likely due to publication bias. unanswered. Here we lay out an agenda for the next wave
Randomized controlled trials suggest that MBIs are a of research in the field.
promising treatment for substance misuse and exert their
effects via increases in levels of mindfulness across a wide Elucidating the neurobiological mechanisms
array of substance-misusing behaviors and clinical popu- of mindfulness as a treatment for addiction
lations. Future research should employ larger samples, Little is known about the neurobiological mechanisms of
longitudinal designs with follow-up periods of at least mindfulness as a treatment for addiction. Though various
1-year, manualized interventions with treatment fidelity conceptual models have been advanced [22, 23, 73], few
assessment, intent-to-treat analyses, and probability sam- tests of these specific neural hypotheses have been con-
pling designs allowing generalizability to specific clinical ducted. Adequately powered, randomized fMRI studies
and general populations. are needed to test basic mechanistic assumptions long
held in the field. For instance, do MBIs decrease addic-
Laying out a research agenda tive behavior by strengthening inhibitory control via acti-
Research rigor and reproducibility vation of top-down neural circuitry? Do MBIs decrease
MBIs are promising treatments for addiction. Results addictive behavior by reducing activation of bottom-up
from rigorous, full-scale RCTs indicate that MBIs can neural circuitry to drug cues? Similarly, functional neu-
produce short and long-term reductions in craving and roimaging methods are needed to test novel hypoth-
addictive behavior. At this juncture in the development eses, such as the restructuring reward hypothesis (“Do
of the field, additional Stage III and IV clinical trials (for MBIs restructure the relative responsiveness to drug and
a review of the NIH Stage Model, see [71]) are needed natural rewards by increasing functional connectivity
to replicate these promising findings via gold-standard between top-down and bottom-up neural circuits?”). Fur-
research design features including the use of active con- thermore, molecular neuroimaging (e.g., positron emis-
trol conditions, detailed fidelity monitoring procedures, sion tomography; PET) is needed to understand effects
and triangulation of self-reported outcomes with bio- of MBIs on neurotransmitters and neuropeptides impli-
chemical verification of drug use and blinded clinical cated in addictive behavior like dopamine, endogenous
evaluations. With additional replications of positive opioids, γ-aminobutyric acid (GABA), and endocannabi-
clinical outcomes, MBIs could rightfully be considered noids. Finally, dynamic effects of mindfulness practice
empirically-supported therapies for addictive behaviors. on addictive responses are unknown, and could be eluci-
Conversely, replication failures could indicate the need dated through functional neuroimaging techniques with
to “return to the drawing board” and engage in treatment high temporal resolution like electroencephalography
Garland and Howard Addict Sci Clin Pract (2018) 13:14 Page 9 of 14

(EEG) or magnetoencephalography (MEG). Such meth- sessions of motivational interviewing before initiating a
ods could answer other pertinent questions. For instance, course of mindfulness training might increase practice
does the acute state of mindfulness attenuate initial engagement and thereby boost clinical outcomes. Con-
attentional orienting to drug cues? Or, does mindfulness versely, mindfulness training might potentiate motiva-
facilitate attentional disengagement and recovery from tional enhancement therapy by increasing interoceptive
drug cue-exposure? These questions can be answered awareness of adverse consequences of addictive behavior
by investigating how mindfulness training influences the on bodily health. In a similar vein, mindfulness training
time course of neural responses to drug cues. might increase adherence to medication-assisted ther-
Although understanding treatment mechanism is not apy (MAT) by increasing awareness of how medication
necessary to establish a given treatment modality as an adherence allays the dysphoria associated with craving
empirically supported intervention, understanding the and thereby potentially improves quality of life. In turn,
mechanisms of mindfulness can inform the refinement of MAT might improve adherence to MBIs by attenuat-
MBIs to yield larger effect sizes and produce additional ing distracting withdrawal symptoms and decreasing
therapeutic benefits. A case in point is MORE, which obsessive thinking about obtaining the next drug dose,
was refined based on mechanistic discoveries. Follow- thereby freeing cognitive and motivational resources to
ing the first trial of MORE, it was found that mindfulness devote to learning mindfulness skills. Psychopharmaco-
reduces pain severity by fostering a shift from affective to logical interventions, cognitive training via computer- or
sensory processing of pain as innocuous sensory infor- smartphone-deployed technology, neurofeedback, and
mation [74]. As a result of this discovery, when MORE neurostimulation (via transcranial magnetic stimulation
was optimized as a treatment for prescription opioid or transcranial direct current stimulation) administered
misuse among chronic pain patients, the intervention prior to initiating a course of MBI might also improve
was modified to include a “mindfulness of pain” tech- cognitive function to facilitate learning of mindfulness
nique that involved using mindfulness to deconstruct techniques, and thereby improve MBI outcomes.
pain into its sensorial subcomponents and disentangle Sequential, multiple assignment, randomized trials
sensation from its affective overlay. Similarly, evidence (SMART) could be used to assess the efficacy of dynamic
that increasing physiological responsiveness to natural treatment regimens, including those that are individually
rewards via mindful savoring predicts decreased pre- tailored based on decision rules that dictate how the type
scription opioid misuse [75] and craving [30] has led to or dosing of treatment should change based on the spe-
an enriched emphasis on mindful savoring practice in the cific clinical needs of the patient [77]. For instance, MBI
MORE intervention. It is possible that these intervention non-responders might need a supplementary course of
refinements may account for the changes in brain reward motivational enhancement therapy, computerized cogni-
circuitry function observed among smokers treated with tive remediation, or booster sessions (see “The Need for
MORE [34]. As another example, recent investigation of Dose/Response Research” below) to enhance outcomes.
the role of the posterior cingulate cortex in meditation Finally, given that many MBIs are multimodal in nature
experience has implicated this brain region as a target for and combine various mindfulness meditation practices
neurofeedback interventions to potentiate the efficacy and psychoeducational modules, studies that employ the
of MBIs [76], and indeed, trials of such neurofeedback- multiphase optimization strategy (MOST) could also be
enhanced MBIs are underway (e.g., NCT02413177). used to examine the independent and additive effects of
various MBI treatment components on addictive behav-
Sequencing of mindfulness as a part of multimodal iors [78]. The MOST research process could allow for
treatment packages resource-intensive and complex MBIs to be pared down
It is not known whether MBIs are most efficacious as to their most efficacious elements to maximize efficacy
standalone treatments or as a part of a more compre- and efficiency by eliminating techniques that do not con-
hensive treatment package. In many inpatient addic- fer therapeutic benefits and augmenting those that do.
tions treatment programs, clients receive multiple
behavioral interventions (e.g., motivational enhance- The need for dose–response research
ment therapy, cognitive-behavioral therapy, dialectical In pharmacological research, it is imperative to examine
behavior therapy) during the same 30-day time frame. dose–response relationships to identify the optimal ther-
Further, optimal treatment sequencing has not been apeutic dose. Dose–response curves can help to identify
studied. For instance, would MBIs be more efficacious the dose needed to achieve a satisfactory clinical out-
following several sessions of motivational interview- come while minimizing the side-effect profile of the drug.
ing? Given that MBIs involve mindfulness practice, and Although MBIs delivered in clinical settings appear to
regular practice requires motivation, introducing several have few adverse effects [79], the costs and time required
Garland and Howard Addict Sci Clin Pract (2018) 13:14 Page 10 of 14

to deliver complex behavioral treatments like MBIs 3  years to complete depending on how long it takes a
necessitate dose–response considerations to identify the prospective instructor to meet the requirements, which
minimal therapeutic dose. Null effects of MBIs observed include personal practice and participation in multi-day
in Stage II or III clinical trials might very well be qualified meditation retreats, didactic and experiential workshop
by extent of mindfulness practice, and thus mindfulness training, experience leading multiple MBSR groups, and
practice engagement should be tested as a treatment out- clinical supervision [84]. Further complicating this issue,
come moderator. Furthermore, responder analyses might individuals without clinical licensure can be certified in
reveal that individuals classified as non-responders are MBSR, yet most addictions treatment settings require
those who do not meet the minimal therapeutic dose of staff to be licensed healthcare professionals. In contrast,
mindfulness skill practice whereas individuals classified other MBIs like MORE require clinical licensure but
as responders are those who surpass this minimal thera- entail a much briefer and less costly training process. It
peutic dose of practice. remains an open question for future research as to how
Given meta-analytic findings that extent of mindful- much clinical training, supervision, and personal prac-
ness practice is significantly associated with treatment tice experience is required for effective implementation
outcomes [80], different doses of mindfulness practice of MBIs in clinical settings. Moreover, it is not known
might produce different therapeutic effect sizes or differ- which training formats are most effective (in person,
ent durations of therapeutic effects for addicted popula- online, role play, virtual reality, etc.) in disseminating
tions. Most MBIs for addictive disorders (e.g., MBRP and MBIs. Issues around treatment fidelity are also crucial
MORE) are approximately 2 months in length given that to successful implementation of MBIs in clinical prac-
they were modeled on the canonical 8-week structure tice. However, few fidelity measures have been validated
of MBSR [81]. However, due to their clinical complex- for MBIs for addiction (for a notable exception, see 85),
ity, individuals with substance use disorders are typically treatment fidelity research is time intensive, and little is
excluded from participating in MBSR. Although MBIs known about empirical relations between clinician train-
like MORE and MBRP have produced significant reduc- ing format, therapist adherence/competence, and MBI
tions in addictive behaviors [64], it is plausible that to treatment outcomes. Similarly, the acceptability of MBIs
achieve full remission from moderate-to-severe sub- may influence their implementation in clinical practice
stance use disorder, patients might require additional settings. Factors influencing the acceptability of MBIs
weekly treatment sessions beyond the standard 8-weeks for the treatment of addiction are poorly understood.
of treatment. Moreover, following a full course of a multi- For instance, it is plausible that patients who initially
week MBI, periodic booster sessions might be needed experience mindfulness meditation as rewarding (i.e.,
to extend treatment benefits for the long-term. Such alleviating psychological distress and generating positive
booster sessions could come in the form of mindfulness sensations and emotions) or who are positively reinforced
practice sessions (with or without group process and psy- by the therapist for engaging in meditation practice may
choeducational content) conducted via in-person or tel- be most likely to continue to practice mindfulness skills.
emedicine formats, and their additive efficacy could be In contrast, patients who experience an exacerbation
tested with SMART research designs. of aversive thoughts and feelings during meditation or
who receive neutral responses from the therapist might
The challenge of dissemination/implementation be most likely to drop out from an MBI. Moreover, non-
One of the greatest challenges confronting the movement specific factors like therapeutic alliance, and allegiance
towards evidence-based practice in addictions treat- might drive MBI acceptability, adherence, and outcome
ment is the research-to-practice gap: that is, empirically- in a similar fashion to other behavioral therapies. Stra-
supported therapies with proven efficacy as revealed tegic attention to such factors might in fact boost the
by Stage II randomized clinical trials are often not suc- uptake and clinical efficacy of MBIs.
cessfully translated into effective clinical interventions In outlining issues pertaining to advancing the clinical
in standard addiction practice settings [82]. Successful science of MBIs, Dimidjian and Segal highlight the ten-
transfer of research to practice involves programmatic sion between the need to make MBIs disseminable in the
change in the form of activities including exposure, adop- context of real-world resource constraints and complex
tion, implementation, and practice of new empirically- client populations while not allowing outcomes to suf-
supported approaches [83]. These activities are especially fer as MBIs are scaled up in the translation to commu-
complicated in the context of MBI implementation, inso- nity treatment settings [86]. This is indeed a challenge,
far as many common MBIs require intensive instructor as MBIs with demonstrated efficacy in Stage II trials may
training. For example, the MBSR certification process fail to show effectiveness in Stage III and IV trials when
costs more than $10,000 and requires approximately delivered by community clinicians. Yet, work now needs
Garland and Howard Addict Sci Clin Pract (2018) 13:14 Page 11 of 14

to be done to understand the feasibility, acceptability, depression for more than two decades, yet it is only in
and impact of delivering MBIs in addiction treatment the past 10  years that research on MBIs for addiction
settings. has proliferated. This is a young scientific field, and more
research is needed to elucidate the clinical outcomes and
Mindfulness as a relapse prevention strategy mechanisms of this promising new treatment approach
versus mindfulness as a vehicle for recovery for addictive disorders. One recent meta-analysis [64]
Finally, it is unknown whether mindfulness might best indicates that MBIs produce statistically significant
ameliorate addiction through participation in time-lim- effects on craving (pooled Cohen’s d = 0.68) and sub-
ited interventions or if mindfulness should be used daily stance misuse (pooled Cohen’s d = 0.33), suggesting that
as part of a wellness lifestyle. With regard to the latter, MBIs may be efficacious treatments for addiction. Over-
shifting from an addiction-oriented lifestyle to adoption all, a number of RCTs with active control conditions
of a wellness lifestyle is conceptualized as integral to the have been conducted in the past decade—a sign that the
recovery model [87]. In this vein, studies should examine methodological rigor of this field is increasing. However,
mindfulness not only as a technique in circumscribed with several notable exceptions (e.g., [40, 91, 92]), few
interventions to prevent addiction relapse but also studies of MBIs for addiction have had large enough sam-
examine mindfulness as a long-term, sustainable health ple sizes to ensure the robustness and reproducibility of
behavior that promotes addiction recovery. Pursuit of a clinical outcomes. Moreover, few long-term follow-ups
healthy lifestyle is not something that is finalized over the have been conducted to assess the durability of observed
course of an 8-week intervention; to the contrary, main- treatment effects. In addition, as indicated earlier, little
tenance of physical health requires ongoing, regular exer- is known about mediators and moderators of MBIs for
cise and nutritious dietary choices on a daily basis that addiction, although understanding how and for whom
do not exceed the caloric needs of the individual. Why MBIs work is crucial to the overall evolution of this ther-
then should mindfulness practice be any different? As a apeutic approach. Lastly, research is needed to situate
point of consideration, 12-Step programs encourage par- MBIs into treatment sequences with high external valid-
ticipation in regular meetings for the entirety of one’s life. ity that adaptively address the needs of responders and
Similarly, mindfulness might need to be practiced daily non-responders in a way that can be realistically imple-
or nearly every day on an ongoing basis to achieve dura- mented in community-based treatment settings. Thus,
ble therapeutic effects and maintain addiction recovery, the nascent field of mindfulness treatment for addictive
especially in view of the chronicity of addictive disorders. behaviors remains open to rigorous, scientific explora-
From a neurobiological perspective, increasing grey tion and in need of innovative research questions and
matter density, strengthening of white matter tracts, methodologies.
synaptic remodeling, and other neuroplastic modifica- Coming full circle, MBIs are some of the newest addi-
tions to brain structure and function needed to undo the tions to the armamentarium of addictions treatment. It
pathophysiology of addiction might require recurrent is perhaps no coincidence that the rise of MBIs has been
mindfulness practice for the long-term. From a psycho- co-incident with advances in the neuroscience of sub-
logical perspective, long-term mindfulness practice may stance use disorders. In recognizing that addiction is, in
be needed to induce self-referential plasticity and facili- large part, mediated by cognitive and behavioral auto-
tate flexible reconfiguration of the self-schema in relation maticity propelled by alterations to hedonic regulatory
to the world [88] so as to restructure reward processes systems in the brain, this perennial form of human suffer-
away from valuation of drug reward and towards valua- ing may be especially tractable to treatment approaches
tion of personally meaningful pursuits and relationships like mindfulness that enhance top-down conscious con-
[23, 29]. This latter process is consistent with the ancient trol over bottom-up automatic habits and motivational
soteriological intention of mindfulness as a means of drives. Insofar as the original purpose of many mindful-
reducing craving by gaining insight into the true nature ness meditation practices was to extinguish craving by
of the self as impermanent and interdependent [89]— revealing the “middle way” between attachment to pleas-
paralleling Bateson’s classical cybernetic model of addic- ure and aversion to pain, MBIs may ultimately provide a
tion recovery [90]. skillful means of liberating the individual from the push
and pull of hedonic dysregulation underlying addiction.
Conclusion
The study of mindfulness as a treatment for stress and
Authors’ contributions
chronic pain is more than 30  years old, and research- ELG and MOH conceived the manuscript and wrote the final draft. Both
ers have investigated mindfulness as a treatment for authors read and approved the final manuscript.
Garland and Howard Addict Sci Clin Pract (2018) 13:14 Page 12 of 14

Author details and meta-analysis of morphometric neuroimaging in meditation practi-

1
 Center on Mindfulness and Integrative Health Intervention Development, tioners. Neurosci Biobehav Rev. 2014;43:48–73.
University of Utah, 395 South, 1500 East, Salt Lake City, UT 84112, USA. 2 Uni- 14. Baer RA, Smith GT, Hopkins J, Krietemeyer J, Toney L. Using self-report
versity of North Carolina at Chapel Hill, Chapel Hill, USA. assessment methods to explore facets of mindfulness. Assessment.
2006;13(1):27–45.
Acknowledgements 15. Anicha CL, Ode S, Moeller SK, Robinson MD. Toward a cognitive view
Not applicable. of trait mindfulness: distinct cognitive skills predict Its observing and
nonreactivity Facets. J Pers. 2012;80(2):255–85.
Competing interests 16. Karyadi KA, VanderVeen JD, Cyders MA. A meta-analysis of the relation-
The first author (ELG) developed the Mindfulness-Oriented Recovery Enhance- ship between trait mindfulness and substance use behaviors. Drug
ment (MORE) intervention, and has received income from the MORE treat- Alcohol Depend. 2014;143(Supplement C):1–10.
ment manual (Garland, 2013) and therapist trainings. 17. Garland EL, Roberts-Lewis A, Kelley K, Tronnier C, Hanley A. Cognitive
and affective mechanisms linking trait mindfulness to craving among
Availability of data and materials individuals in addiction recovery. Subst Use Misuse. 2014;49(5):525–35.
Not applicable. 18. Garland EL. Trait mindfulness predicts attentional and autonomic regula-
tion of alcohol cue-reactivity. J Psychophysiol. 2011;25(4):180–9.
Consent for publication 19. Garland EL, Boettiger CA, Gaylord S, Chanon VW, Howard MO. Mindful-
Not applicable. ness is inversely associated with alcohol attentional bias among recover-
ing alcohol-dependent adults. Cognit Ther Res. 2012;36(5):441–50.
Ethics approval and consent to participate 20. Langer EJ. Matters of mind: mindfulness/mindlessness in perspective.
Not applicable. Conscious Cogn. 1992;1(3):289–305.
21. Tiffany ST. A cognitive model of drug urges and drug-use behavior: role
Funding of automatic and nonautomatic processes. Psychol Rev. 1990;97:147–68.
ELG was supported by NIDA Grant R01DA042033 (PI: Garland) and NCCIH 22. Garland EL, Froeliger B, Howard MO. Mindfulness training targets neuro-
Grant R61AT009296 (PI: Garland) during the preparation of this manuscript. cognitive mechanisms of addiction at the attention-appraisal-emotion
interface. Front Psychiatry [Internet]. 2013 [cited 2017 Sep 27];4. https://
www.ncbi.nlm.nih.gov/pmc/articles/PMC3887509/.
Publisher’s Note 23. Garland EL. Restructuring reward processing with mindfulness-oriented
Springer Nature remains neutral with regard to jurisdictional claims in pub- recovery enhancement: novel therapeutic mechanisms to remediate
lished maps and institutional affiliations. hedonic dysregulation in addiction, stress, and pain. Ann N Y Acad Sci.
2016;1373(1):25–37.
Received: 16 December 2017 Accepted: 7 April 2018 24. Masters WH, Masters VJ. Human sexual response [Internet]. Bantam
Books; 1986 [cited 2017 Oct 8]. http://agris.fao.org/agris-search/search.
do?recordID=US201300428002.
25. Wadlinger HA, Isaacowitz DM. Fixing our focus: training attention to
regulate emotion. Soc Psychol Rev. 2010;15:75–102.
26. Hong PY, Lishner DA, Han KH, Huss EA. The positive impact of mindful
References
eating on expectations of food liking. Mindfulness. 2011;2(2):103–13.
1. Koob GF, Volkow ND. Neurobiology of addiction: a neurocircuitry analysis.
27. Hong PY, Lishner DA, Han KH. Mindfulness and eating: an experiment
Lancet Psychiatry. 2016;3(8):760–73.
examining the effect of mindful raisin eating on the enjoyment of sam-
2. Kabat-Zinn J. Full catastrophe living. NY: Delacorte Press; 1990 453 pp.
pled food. Mindfulness. 2014;5(1):80–7.
3. Segal Z, Williams JM, Teasdale JD. Mindfulness-based cognitive therapy
28. Geschwind N, Peeters F, Drukker M, van Os J, Wichers M. Mindfulness
for depression. New York: The Guilford Press; 2002.
training increases momentary positive emotions and reward experi-
4. Goldberg SB, Tucker RP, Greene PA, Davidson RJ, Wampold BE, Kearney
ence in adults vulnerable to depression: a randomized controlled trial. J
DJ, et al. Mindfulness-based interventions for psychiatric disorders: a
Consult Clin Psychol. 2011;79(5):618.
systematic review and meta-analysis. Clin Psychol Rev. 2018;59:52–60.
29. Garland EL, Farb NA, Goldin PR, Fredrickson BL. Mindfulness broadens
5. Bowen S, Chawla N, Marlatt GA. Mindfulness-based relapse prevention
awareness and builds eudaimonic meaning: a process model of mindful
for addictive behaviors. New York: Guilford Press; 2010.
positive emotion regulation. Psychol Inq. 2015;26(4):293–314.
6. Garland EL. Mindfulness-oriented recovery enhancement for addiction,
30. Garland EL, Froeliger B, Howard MO. Effects of mindfulness-oriented
stress, and pain. Washington, DC: NASW Press; 2013.
recovery enhancement on reward responsiveness and opioid cue-reac-
7. Lutz A, Slagter HA, Dunne JD, Davidson RJ. Attention regulation and
tivity. Psychopharmacology. 2014;231(16):3229–38.
monitoring in meditation. Trends Cogn Sci. 2008;12:163–9.
31. Garland EL, Froeliger B, Howard MO. Neurophysiological evidence for
8. Vago DR, Silbersweig DA. Self-awareness, self-regulation, and self-tran-
remediation of reward processing deficits in chronic pain and opioid
scendence (S-ART): a framework for understanding the neurobiological
misuse following treatment with mindfulness-oriented recovery
mechanisms of mindfulness. Front Hum Neurosci [Internet]. 2012 [cited
enhancement: exploratory ERP findings from a pilot RCT. J Behav Med.
2017 Oct 8];6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3480633/.
2015;38(2):327–36.
9. Tang Y-Y. Traits and states in mindfulness meditation. In: The neurosci-
32. Garland EL. Mindfulness-oriented recovery enhancement modulates
ence of mindfulness meditation [Internet]. Cham: Palgrave Macmil-
neurocognitive mechanisms and reward system function in addiction,
lan; 2017 [cited 2017 Sep 27]. p. 29–34. https://link.springer.com/
stress, and pain. New York, NY: In Sloan Kettering Memorial Hospital;
chapter/10.1007/978-3-319-46322-3_4.
2015.
10. Tang Y-Y, Hölzel BK, Posner MI. The neuroscience of mindfulness medita-
33. Garland EL, Bryan CJ, Finan PH, Thomas EA, Priddy SE, Riquino MR, et al.
tion. Nat Rev Neurosci. 2015;16(4):213–25.
Pain, hedonic regulation, and opioid misuse: modulation of momentary
11. Kiken LG, Garland EL, Bluth K, Palsson OS, Gaylord SA. From a state to a
experience by mindfulness-oriented recovery enhancement in opioid-
trait: trajectories of state mindfulness in meditation during intervention
treated chronic pain patients. Drug Alcohol Depend. 2017;173:S65–72.
predict changes in trait mindfulness. Pers Individ Dif. 2015;81:41–6.
34. Froeliger B, Mathew AR, McConnell PA, Eichberg C, Saladin ME, Carpenter
12. Gu J, Strauss C, Bond R, Cavanagh K. How do mindfulness-based cogni-
MJ, et al. Restructuring reward mechanisms in nicotine addiction: a pilot
tive therapy and mindfulness-based stress reduction improve mental
fMRI study of mindfulness-oriented recovery enhancement for cigarette
health and wellbeing? A systematic review and meta-analysis of media-
smokers. Evid Based Complement Alternat Med. 2017;8(2017):e7018014.
tion studies. Clin Psychol Rev. 2015;37:1–12.
35. Alfonso JP, Caracuel A, Delgado-Pastor LC, Verdejo-García A. Combined
13. Fox KC, Nijeboer S, Dixon ML, Floman JL, Ellamil M, Rumak SP, et al. Is
goal management training and mindfulness meditation improve
meditation associated with altered brain structure? A systematic review
Garland and Howard Addict Sci Clin Pract (2018) 13:14 Page 13 of 14

executive functions and decision-making performance in abstinent 58. Garland EL, Carter K, Ropes K, Howard MO. Thought suppression,
polysubstance abusers. Drug Alcohol Depend. 2011;117(1):78–81. impaired regulation of urges, and addiction-Stroop predict affect-
36. Valls-Serrano C, Caracuel A, Verdejo-Garcia A. Goal management training modulated cue-reactivity among alcohol dependent adults. Biol Psychol.
and mindfulness meditation improve executive functions and transfer to 2012;89(1):87–93.
ecological tasks of daily life in polysubstance users enrolled in therapeu- 59. Moss AC, Erskine JA, Albery IP, Allen JR, Georgiou GJ. To suppress, or not
tic community treatment. Drug Alcohol Depend. 2016;1(165):9–14. to suppress? That is repression: controlling intrusive thoughts in addictive
37. Spears CA, Hedeker D, Li L, Wu C, Anderson NK, Houchins SC, et al. behaviour. Addict Behav. 2015;44:65–70.
Mechanisms underlying mindfulness-based addiction treatment versus 60. Bowen S, Witkiewitz K, Dillworth TM, Marlatt GA. The role of thought sup-
cognitive behavioral therapy and usual care for smoking cessation. J pression in the relationship between mindfulness meditation and alcohol
Consult Clin Psychol. 2017;85(11):1029. use. Addict Behav. 2007;32(10):2324–8.
38. Tang Y-Y, Tang R, Posner MI. Brief meditation training induces smoking 61. Zgierska A, Rabago D, Chawla N, Kushner K, Koehler R, Marlatt A. Mindful-
reduction. Proc Natl Acad Sci USA. 2013;110(34):13971–5. ness meditation for substance use disorders: a systematic review. Subst
39. Witkiewitz K, Bowen S, Douglas H, Hsu SH. Mindfulness-based relapse Abuse. 2009;30(4):266–94.
prevention for substance craving. Addict Behav. 2013;38(2):1563–71. 62. Katz D, Toner B. A systematic review of gender differences in the effec-
40. Garland EL, Roberts-Lewis A, Tronnier CD, Graves R, Kelley K. Mindfulness- tiveness of mindfulness-based treatments for substance use disorders.
oriented recovery enhancement versus CBT for co-occurring substance Mindfulness. 2013;4(4):318–31.
dependence, traumatic stress, and psychiatric disorders: proximal out- 63. Chiesa A, Serretti A. Are mindfulness-based interventions effective for
comes from a pragmatic randomized trial. Behav Res Ther. 2016;77:7–16. substance use disorders? A systematic review of the evidence. Subst Use
41. Garland EL, Manusov EG, Froeliger B, Kelly A, Williams JM, Howard MO. Misuse. 2014;49(5):492–512.
Mindfulness-oriented recovery enhancement for chronic pain and 64. Li W, Howard MO, Garland EL, McGovern P, Lazar M. Mindfulness treat-
prescription opioid misuse: results from an early-stage randomized ment for substance misuse: a systematic review and meta-analysis. J
controlled trial. J Consult Clin Psychol. 2014;82(3):448. Subst Abuse Treat. 2017;75:62–96.
42. Sinha R. Chronic stress, drug use, and vulnerability to addiction. Ann N Y 65. Mermelstein LC, Garske JP. A brief mindfulness intervention for col-
Acad Sci. 2008;1141(1):105–30. lege student binge drinkers: a pilot study. Psychol Addict Behav.
43. Koob GF. A role for brain stress systems in addiction. Neuron. 2015;29(2):259.
2008;59(1):11–34. 66. Spears CA, Hedeker D, Li L, Wu C, Anderson NK, Houchins SC, et al.
44. Thayer JF, Lane RD. A model of neurovisceral integration in emotion Mechanisms underlying mindfulness-based addiction treatment versus
regulation and dysregulation. J Affect Disord. 2000;61(3):201–16. cognitive behavioral therapy and usual care for smoking cessation. J
45. Carroll H, Lustyk MKB. Mindfulness-based relapse prevention for sub- Consult Clin Psychol. 2017;85(11):1029.
stance use disorders: effects on cardiac vagal control and craving under 67. Garland EL, Howard MO. Mindfulness-oriented recovery enhancement
stress. Mindfulness. 2017;30:1–12. reduces pain attentional bias in chronic pain patients. Psychother Psycho-
46. Brewer JA, Sinha R, Chen JA, Michalsen RN, Babuscio TA, Nich C, et al. som. 2013;82(5):311–8.
Mindfulness training and stress reactivity in substance abuse: results from 68. Brewer JA, Mallik S, Babuscio TA, Nich C, Johnson HE, Deleone CM, et al.
a randomized, controlled stage I pilot study. Subst Abus. 2009;30:306–17. Mindfulness training for smoking cessation: results from a randomized
47. Paz R, Zvielli A, Goldstein P, Bernstein A. Brief mindfulness training controlled trial. Drug Alcohol Depend. 2011;119(1):72–80.
de-couples the anxiogenic effects of distress intolerance on reactivity 69. de Dios MA, Herman DS, Britton WB, Hagerty CE, Anderson BJ, Stein
to and recovery from stress among deprived smokers. Behav Res Ther. MD. Motivational and mindfulness intervention for young adult female
2017;95(Supplement C):117–27. marijuana users. J Subst Abuse Treat. 2012;42(1):56–64.
48. Garland EL, Gaylord SA, Boettiger CA, Howard MO. Mindfulness training 70. Murphy TJ, Pagano RR, Marlatt GA. Lifestyle modification with heavy
modifies cognitive, affective, and physiological mechanisms implicated alcohol drinkers: effects of aerobic exercise and meditation. Addict Behav.
in alcohol dependence: results of a randomized controlled pilot trial. J 1986;11:175–86.
Psychoactive Drugs. 2010;42(2):177–92. 71. Onken LS, Carroll KM, Shoham V, Cuthbert BN, Riddle M. Reenvisioning
49. Goldberg SB, Manley AR, Smith SS, Greeson JM, Russell E, Van Uum S, clinical science unifying the discipline to improve the public health. Clin
et al. Hair cortisol as a biomarker of stress in mindfulness training for Psychol Sci. 2014;2(1):22–34.
smokers. J Altern Complement Med. 2014;20(8):630–4. 72. Roos CR, Bowen S, Witkiewitz K. Baseline patterns of substance use
50. Marcus MT, Fine PM, Moeller FG, Khan MM, Pitts K, Swank PR, et al. disorder severity and depression and anxiety symptoms moderate the
Change in stress levels following mindfulness-based stress reduction in a efficacy of mindfulness-based relapse prevention. J Consult Clin Psychol.
therapeutic community. Addict Disord Their Treat. 2003;2(3):63. 2017;85(11):1041.
51. Kober H, Brewer JA, Height KL, Sinha R. Neural stress reactivity relates 73. Witkiewitz K, Lustyk MKB, Bowen S. Retraining the addicted brain: a
to smoking outcomes and differentiates between mindfulness and review of hypothesized neurobiological mechanisms of mindfulness-
cognitive-behavioral treatments. Neuroimage. 2017;151(Supplement based relapse prevention. Psychol Addict Behav. 2013;27(2):351.
C):4–13. 74. Garland EL, Gaylord SA, Palsson O, Faurot K, Mann JD, Whitehead WE.
52. Garland EL, Baker AK, Howard MO. Mindfulness-oriented recovery Therapeutic mechanisms of a mindfulness-based treatment for IBS:
enhancement reduces opioid attentional bias among prescription opi- effects on visceral sensitivity, catastrophizing, and affective processing of
oid-treated chronic pain patients. J Soc Soc Work Res. 2017;28:493–509. pain sensations. J Behav Med. 2012;35(6):591–602.
53. Westbrook C, Creswell JD, Tabibnia G, Julson E, Kober H, Tindle HA. Mind- 75. Garland EL, Howard MO, Zubieta J-K, Froeliger B. Restructuring hedonic
ful attention reduces neural and self-reported cue-induced craving in dysregulation in chronic pain and prescription opioid misuse: effects of
smokers. Soc Cogn Affect Neurosci. 2011;8(1):73–84. mindfulness-oriented recovery enhancement on responsiveness to drug
54. Davis JM, Manley AR, Goldberg SB, Smith SS, Jorenby DE. Randomized cues and natural rewards. Psychother Psychosom. 2017;86(2):111–2.
trial comparing mindfulness training for smokers to a matched control. J 76. Van Lutterveld R, Houlihan SD, Pal P, Sacchet MD, McFarlane-Blake C, Patel
Subst Abuse Treat. 2014;47(3):213–21. PR, et al. Source-space EEG neurofeedback links subjective experience
55. Bowen S, Marlatt A. Surfing the urge: brief mindfulness-based interven- with brain activity during effortless awareness meditation. Neuroimage.
tion for college student smokers. Psychol Addict Behav J Soc Psychol 2017;151:117–27.
Addict Behav. 2009;23(4):666–71. 77. Collins LM, Nahum-Shani I, Almirall D. Optimization of behavioral
56. Witkiewitz K, Bowen S. Depression, craving, and substance use following dynamic treatment regimens based on the sequential, multiple assign-
a randomized trial of mindfulness-based relapse prevention. J Consult ment, randomized trial (SMART). Clin Trials. 2014;11(4):426–34.
Clin Psychol. 2010;78(3):362. 78. Collins LM, Baker TB, Mermelstein RJ, Piper ME, Jorenby DE, Smith SS, et al.
57. Elwafi HM, Witkiewitz K, Mallik S, Thornhill TA IV, Brewer JA. Mindfulness The multiphase optimization strategy for engineering effective tobacco
training for smoking cessation: moderation of the relationship between use interventions. Ann Behav Med. 2011;41(2):208–26.
craving and cigarette use. Drug Alcohol Depend. 2013;130(1):222–9.
Garland and Howard Addict Sci Clin Pract (2018) 13:14 Page 14 of 14

79. Shonin E, Van Gordon W, Griffiths MD. Are there risks associated with 86. Dimidjian S, Segal ZV. Prospects for a clinical science of mindfulness-
using mindfulness for the treatment of psychopathology? Clin Pract. based intervention. Am Psychol. 2015;70(7):593–620.
2014;11(4):389–92. 87. Jacobson N, Greenley D. What is recovery? A conceptual model and
80. Parsons CE, Crane C, Parsons LJ, Fjorback LO, Kuyken W. Home practice explication. Psychiatr Serv. 2001;52(4):482–5.
in mindfulness-based cognitive therapy and mindfulness-based stress 88. Garland EL, Hanley AW, Baker AK, Howard MO. Biobehavioral mechanisms
reduction: a systematic review and meta-analysis of participants’ of mindfulness as a treatment for chronic stress: an RDoC perspective.
mindfulness practice and its association with outcomes. Behav Res Ther. Chronic Stress. 2017;1(1):2470547017711912.
2017;1(95):29–41. 89. Garland EL, Black DS. Mindfulness for chronic pain and prescription opi-
81. Kabat-Zinn J. An outpatient program in behavioral medicine for oid misuse: novel mechanisms and unresolved issues. Subst Use Misuse.
chronic pain patients based on the practice of mindfulness meditation: 2014;49(5):608–11.
theoretical considerations and preliminary results. Gen Hosp Psychiatry. 90. Bateson G. The cybernetics of “self”: a theory of alcoholism. Psychiatry.
1982;4(1):33–47. 1971;34(1):1–18.
82. Carroll KM. Dissemination of evidence-based practices: how far 91. Bowen S, Witkiewitz K, Clifasefi SL, Grow J, Chawla N, Hsu SH, et al.
we’ve come, and how much further we’ve got to go. Addiction. Relative efficacy of mindfulness-based relapse prevention, standard
2012;107(6):1031–3. relapse prevention, and treatment as usual for substance use disorders: a
83. Simpson DD. A conceptual framework for transferring research to prac- randomized clinical trial. JAMA Psychiatry. 2014;71(5):547–56.
tice. J Subst Abuse Treat. 2002;22(4):171–82. 92. Spears CA, Hedeker D, Li L, Wu C, Anderson NK, Houchins SC, et al.
84. Woods S. MBSR teacher qualification and certification [Internet]. UCSD Mechanisms underlying mindfulness-based addiction treatment versus
Center for Mindfulness. 2018 [cited 2018 Mar 1]. http://mbpti.org/ cognitive behavioral therapy and usual care for smoking cessation. J
programs/mbsr/mbsr-teacher-certification/. Consult Clin Psychol [Internet]. 2017 [cited 2017 Aug 7]. https://www.
85. Chawla N, Collins S, Bowen S, Hsu S, Grow J, Douglass A, et al. The ncbi.nlm.nih.gov/pubmed/28650195.
mindfulness-based relapse prevention adherence and competence
scale: development, interrater reliability, and validity. Psychother Res.
2010;20(4):388–97.

Ready to submit your research ? Choose BMC and benefit from:

• fast, convenient online submission

• thorough peer review by experienced researchers in your field
• rapid publication on acceptance
• support for research data, including large and complex data types
• gold Open Access which fosters wider collaboration and increased citations
• maximum visibility for your research: over 100M website views per year

At BMC, research is always in progress.

Learn more biomedcentral.com/submissions