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opioid misuse as defined by a validated cutoff point on the Current Opioid Misuse Measure (COMM >12) [7] . We used heart rate (HR) to measure cue responsiveness and high-frequency heart rate variability (HRV) to index parasympathetic regulation of hedonic responses, including attention to emotional information [8] . Participants were paid USD 200 for completing the IRB-approved study; all procedures complied with the Helsinki Declaration. The manualized 8-session MORE treatment involved group training in mindfulness to disengage attention from drug cues and intentionally reorient attention to visual, auditory, olfactory, gustatory, or tactile features of a pleasant experience (e.g., the warmth of the sun on one’s skin) while cultivating metacognitive awareness of positive emotions and cognitions arising in response to the pleasant event [9] . The 2-h sessions were led by a social worker and supervised weekly by the developer of MORE. Participants engaged in daily 15-min mindfulness sessions at home guided by a CD. The manualized SG control condition consisted of 8 weekly, 2-h sessions, in which a social worker facilitated emotional expression and discussion of chronic pain-related topics. MORE and SG session recordings were reviewed to maintain treatment fidelity. Participants performed a randomized, event-related affective picture-viewing task [10] in which they passively viewed neutral (furniture, neutral faces), pain-related (injuries, medical proceThe allostatic model posits that chronic drug use induces hedonic homeostatic dysregulation, in which motivation to obtain natural rewards (e.g., eating, copulation, affiliation) is reorganized around seeking drug-induced reward to alleviate dysphoria [1] . The downward shift in salience of natural reward relative to drug reward may represent a crucial tipping point leading to the loss of control over drug use that is characteristic of addiction. Heightened responsiveness to drug reward coupled with decreased responsiveness to natural reward has been observed in opioid-dependent individuals [2, 3] , predicts opioid consumption [4] , and may drive prescription opioid misuse and addiction [5] . Therapies that restructure reward responsiveness from valuation of drug reward to valuation of natural reward may be effective means of treating opioid misuse. We conducted an RCT of a Mindfulness-Oriented Recovery Enhancement (MORE) intervention for opioid misuse among chronic pain patients. MORE integrates skills to amplify natural reward processing with mindfulness and reappraisal techniques. In this RCT, relative to a support group (SG) control, MORE reduced opioid misuse and craving while decreasing pain symptoms [6] . Given its focus on orienting attention away from drug-related cues and towards healthful and socially affiliative objects and events, it is possible that MORE may regulate attention to hedonically relevant stimuli to shift the relative salience of drug and natural rewards, and thereby ameliorate opioid misuse. To test this exploratory hypothesis, we examined unpublished psychophysiological data from this trial (ClinicalTrials.gov identifier NCT01505101) [6] . Individuals with complete data (17 men and 34 women, mean age = 45.7 years, SD = 13.7, MORE n = 20; SG n = 31) from an affective picture-viewing paradigm conducted 1 week before and after the study treatments were selected for the present analysis. Chronic pain patients were recruited from primary and specialty care clinics and met the inclusion criteria if they took opioids nearly every day for >90 days. Most (84.3%) reported Received: June 9, 2016 Accepted after revision: November 9, 2016 Published online: February 10, 2017

psychotherapy and psychosomatics

Restructuring Hedonic Dysregulation in Chronic Pain and Prescription Opioid Misuse: Effects of Mindfulness-Oriented Recovery Enhancement on Responsiveness to Drug Cues and Natural Rewards