Mindfulness-based therapy for substance use

Mindfulness-based approaches teach people to pay attention to the present moment, including cravings, emotions and body sensations, without judging them or acting on them automatically. In substance use treatment the best-known program is mindfulness-based relapse prevention (MBRP). Studies report some benefits, but systematic reviews describe the evidence as limited, so this page sets out both sides.

What mindfulness-based approaches are

A mindfulness-based intervention (MBI) is a structured program that trains attention and non-judging awareness, usually through meditation and short practices woven into daily life. In treatment for substance use, the aim is to change how a person responds to urges and to unpleasant feelings that can lead to use. Mindfulness skills also appear inside other therapies, such as dialectical behavior therapy and acceptance and commitment therapy.

MBRP is a group aftercare program that blends mindfulness practice with cognitive behavioral relapse prevention, as the National Center for Complementary and Integrative Health (NCCIH) describes it. It is designed for people who have already finished an initial course of treatment.

How it works in outline

The idea behind MBRP, as described in a 2014 JAMA Psychiatry trial, is that people often act on cravings or negative moods on "automatic pilot." Sessions cover the role of that automatic pilot in addiction, the use of mindfulness in high-risk situations, and the balance between acceptance and action.

NCCIH notes that researchers have suggested mindfulness may lower the risk of return to use by strengthening the ability to monitor and cope with discomfort from craving or negative mood. This is a proposed mechanism, not a settled one.

What sessions can look like

In the 2014 trial, MBRP was delivered as eight weekly two-hour group sessions with 6 to 10 participants. Each session combined 20 to 30 minute guided meditations, experiential exercises and discussion of how to apply the skills. Participants were taught formal practices, such as sitting meditation, and shorter informal practices to use in everyday life. Homework was assigned in the mindfulness and relapse prevention groups.

What the research says

The most cited trial, by Bowen and colleagues in JAMA Psychiatry (2014), assigned 286 adults who had completed initial treatment to MBRP, standard relapse prevention, or usual aftercare based on 12-step and education. At six months, both MBRP and relapse prevention groups reported lower risk of relapse than usual aftercare, and relapse prevention was better at delaying a first return to drug use. At twelve months, MBRP participants reported fewer days of substance use and less heavy drinking than either other group. The authors note limits, including differences in therapist training and homework between groups and reliance on self-report.

A broader picture comes from a 2017 systematic review and meta-analysis by RAND researchers in the Journal of Addiction Medicine, covering 9 randomized trials and 901 participants. It found no statistically significant difference between MBRP and comparison treatments for relapse or for how often people used substances. It found small differences favoring MBRP on withdrawal and craving symptoms. The reviewers rated the quality of evidence as low for most outcomes and very low for others, and said they had "limited confidence" in the estimates. They found negligible evidence of adverse events.

NCCIH's clinical digest on psychological and physical approaches agrees that many studies have small samples, methodological problems and findings that have not been consistently replicated. It does report some positive results. A 2023 trial of 378 veterans, testing behavioral treatments for chronic pain, found mindfulness meditation reduced the risk of daily cannabis use by 85 and 81 percent at 3 and 6 months compared with an education group, with no effect on tobacco or alcohol use. Adding a mindfulness program to methadone treatment was also linked to benefits in people with opioid use disorder and chronic pain.

Limits and cautions

• MBRP is a supplement to aftercare, not a replacement for other care. It was tested in people who had already completed treatment.
• Results differ by outcome and by study. Some benefits appeared late (twelve months) or only for craving, and others were not found at all.
• NCCIH states that meditation is considered safe for healthy people but that rare reports describe it causing or worsening symptoms in people with certain psychiatric problems, a question not yet fully researched. Anyone with a condition such as trauma-related symptoms may want to raise this first; see trauma-informed care and co-occurring mental health conditions.
• The programs studied include practice between sessions, which asks for time and effort.

Mindfulness also appears on the broader list of holistic and complementary approaches. A qualified clinician can say whether it suits a particular person.

Questions to ask a clinician

• Is this a structured program such as MBRP, or a general mindfulness class?
• Who leads it, and what training do they have in treating substance use?
• Would it replace or add to my current treatment and medication?
• Could mindfulness practice make any other symptoms I have, such as anxiety or trauma reactions, worse?
• What is expected between sessions, and what if I cannot keep up with the practice?