An Ultra-Brief Mindfulness-Based Intervention for Patients in Treatment for Opioid Addiction with Buprenorphine: A Primary Care Feasibility Pilot Study

Commentary With Study Protocol: Implementation and Effectiveness of Mindfulness-Oriented Recovery Enhancement (MORE) as an Adjunct to Methadone Treatment for Opioid Use Disorder (IMPOWR-MORE)

Traditional methadone treatment (MT) for opioid use disorder (OUD) fails to systematically address the physical pain, emotion dysregulation, and reward processing deficits that co-occur with OUD, and novel interventions that address these issues are needed to improve MT outcomes. Mindfulness-Oriented Recovery Enhancement (MORE) remediates the hedonic dysregulation in brain reward systems that is associated with OUD. Our pilot and phase 2 randomized controlled trials of MORE were the first to demonstrate MORE's feasibility, acceptability, and efficacy as delivered in MT clinics; MORE significantly reduced drug use (eg, benzodiazepines, barbiturates, cocaine, marijuana, opioids, and other drugs), craving, depression, anxiety, and pain among people with OUD. However, uptake of novel, efficacious interventions like MORE may be slow in MT because time and resources are often limited. Therefore, to best address potential implementation issues and to optimize future MORE implementation and dissemination, in this study, we will utilize a Type 2, Hybrid Implementation-Effectiveness study design. We will not only evaluate MORE's effectiveness but also assess barriers and facilitators to integrating MORE into MT. MT clinicians will receive training in (1) a higher intensity MORE implementation strategy consisting of training in the full MORE treatment manual or (2) a minimal intensity implementation strategy consisting of a simple, scripted mindfulness practice (SMP) extracted from the MORE treatment manual with minimal training. We aim to: (1) using a Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, examine barriers and facilitators to implementation of MORE and SMP in MT, and evaluate strategies for optimizing training, fidelity, and engagement, (2) optimize existing MORE and SMP training and implementation toolkits, including adaptable resources that can accelerate the translation of evidence into practice, and (3) compared to usual MT, evaluate the relative effectiveness of MORE plus MT or SMP plus MT (N = 450).

Effects of live-online, group mindfulness training on opioid use and anxiety during buprenorphine treatment: A comparative effectiveness RCT

BACKGROUND

Office-based opioid treatment with buprenorphine has emerged as a popular evidence-based treatment for opioid use disorder. Unfortunately, psychosocial stress, anxiety, pain, and co-morbid substance use increase patients' risk for relapse. We designed this study to compare the effects of complementing buprenorphine treatment with 24 weeks of a live-online Mindful Recovery Opioid Care Continuum (M-ROCC) group to a time and attention-matched, live-online Recovery Support Group (RSG) active control condition.

METHODS

We plan to enroll a maximum of N = 280 and randomize at least N = 192 patients prescribed buprenorphine through referrals from office-based and telemedicine buprenorphine treatment providers and social media advertisements. Participants will be randomly assigned to M-ROCC or RSG and will be blinded to their treatment condition. The primary outcome for this study will be biochemically confirmed periods of abstinence from illicit opioids, as measured by self-reported use and randomly collected, video-observed oral fluid toxicology testing during the final 12 weeks of study participation. Secondary outcomes include changes in Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and pain interference scores between baseline and week 24.

RESULTS

The trial was funded by the National Institutes of Health, HEAL Initiative through NCCIH (R33AT010125). Data collection is projected to end by September 2023, and we expect publication of results in 2024.

CONCLUSION

If the M-ROCC intervention is found to be effective in this format, it will demonstrate that live-online mindfulness groups can improve outcomes and address common co-morbidities like anxiety and pain during buprenorphine treatment.

Psychological distance intervention reminders reduce alcohol consumption frequency in daily life

Modifying behaviors, such as alcohol consumption, is difficult. Creating psychological distance between unhealthy triggers and one's present experience can encourage change. Using two multisite, randomized experiments, we examine whether theory-driven strategies to create psychological distance-mindfulness and perspective-taking-can change drinking behaviors among young adults without alcohol dependence via a 28-day smartphone intervention (Study 1, N = 108 participants, 5492 observations; Study 2, N = 218 participants, 9994 observations). Study 2 presents a close replication with a fully remote delivery during the COVID-19 pandemic. During weeks when they received twice-a-day intervention reminders, individuals in the distancing interventions reported drinking less frequently than on control weeks-directionally in Study 1, and significantly in Study 2. Intervention reminders reduced drinking frequency but did not impact amount. We find that smartphone-based mindfulness and perspective-taking interventions, aimed to create psychological distance, can change behavior. This approach requires repeated reminders, which can be delivered via smartphones.

Efficacy of a Brief Mindfulness Intervention in Underserved Individuals Receiving Inpatient Treatment for Opioid Use Disorder: A Pilot Study

Introduction A mindfulness intervention is a mind-body complementary health approach that focuses on the relationships between mind, body, brain, and behavior. Mindfulness-Based Stress Reduction (MBSR) and similar mindfulness programs have been shown to decrease drug craving and relapse and improve emotional regulation, stress, pain, and anxiety. To our knowledge, a very limited number of studies have examined its efficacy in individuals from underserved populations. Underserved populations experience disparities in healthcare access, and as a result, see poorer addiction-related outcomes. The goal of this pilot study was to utilize an evidence-based, neuroscience-informed brief mindfulness intervention to improve mental health and decrease substance use behavior in a vulnerable, underserved population in New Jersey suffering from opioid use disorder (OUD). Methods We implemented a brief MBSR intervention in 15 underserved individuals undergoing inpatient medication-assisted treatment (MAT) for OUD. Individuals received weekly intervention sessions lasting one hour over six weeks. Furthermore, they practiced mindfulness for 10 minutes daily. Participants completed pre-and post-mindfulness intervention surveys to examine their mental well-being, drug craving, perceived stress, and emotional regulation. Results Within-subjects t-test results showed that compared to pre-intervention, participants showed significantly decreased perceived stress (t(14) =2.401, p=.015) and significantly decreased difficulty in emotional regulation (t(13) =3.426, p=.002 ) at post-intervention. They also showed significantly decreased drug craving post-intervention (t(14) =5.501, p=.<001). Anxiety decreased post-intervention but was not statistically significant (t(14) =1.582, p=.068). Conclusion This pilot study demonstrates that a brief mindfulness intervention can be effective for underserved individuals with OUD. Consistent with our hypothesis, results showed that a six-week mindfulness intervention could reduce everyday stress, drug craving, and difficulties in emotional regulation. In the future, a large-scale randomized control trial should be conducted with a control group to demonstrate the efficacy of this useful intervention.

Differences in buprenorphine treatment quality across physician provider specialties

BACKGROUND

The number and types of clinicians prescribing buprenorphine treatment for opioid use disorder (OUD) have increased over the past two decades, but there is little information on how potential indicators of quality of care to patients receiving buprenorphine vary by provider specialty.

METHODS

We used the Medicaid Analytic eXtract from 2009 to 2014 to identify buprenorphine treatment episodes. We assigned physician specialties to episodes based on whether an episode had at least one outpatient claim linked to specialists in addiction, behavioral health, opioid treatment program (OTP), pain, or primary care provider (PCP). We then used logistic regressions to estimate the association of linked physician specialty and achievement of the following process of care measures: at least 180-day duration, no co-occurring opioid analgesics, no co-occurring benzodiazepines, infectious disease screening, liver function test, drug and toxicology screenings, evaluation and management visits, and counseling.

RESULTS

Episodes linked to PCPs had significantly lower odds of achieving 180-day duration, an absence of opioid analgesics, an absence of benzodiazepines, drug and toxicology screenings, and counseling compared to addiction, behavioral health, and/or OTPs. Episodes linked to PCPs had significantly higher odds of undergoing infectious disease screenings, liver function tests, and evaluation and management visits compared to all specialty categories.

CONCLUSIONS

Episodes were more likely to achieve process of care measures related to the specialties of their physicians, but no specialty consistently demonstrated better performance compared to PCPs. Our findings highlight the need for models that can better integrate physical and behavioral health services for OUD treatment.

Virtual Peer Support in Women's Health for Pregnant People and Mothers With Substance Use Disorder

OBJECTIVE

To evaluate the effectiveness of a virtual peer support group associated with a women's health unit for mothers and pregnant people with substance use disorder.

DESIGN

The project was guided by the Centers for Disease Control and Prevention's Framework for Program Evaluation in Public Health. Pre-/postintervention surveys were used to evaluate outcomes.

SETTING

Women's health unit in a 325-bed hospital with 900 births a year in the U.S. Midwest and a virtual online meeting format.

PARTICIPANTS

Thirteen people with substance use disorder.

INTERVENTION/MEASUREMENTS

Participants were recruited by nurses on the women's health unit and in existing online meetings. Participants attended a 12-week session of facilitated substance use disorder peer support meetings through an online virtual format. Surveys included the Depression, Anxiety, and Stress Scale; the Alcoholics Anonymous Intention Scale; and pre-/postintervention surveys developed by the authors. Descriptive statistics and narrative description of qualitative data were used.

RESULTS

The Depression, Anxiety, and Stress Scale scores were reduced, on average, by 25%, indicating that participants showed improvement in these conditions. Responses to open-ended questions showed that participants found the meetings helpful for developing coping mechanisms. The virtual space was seen as a comfortable, safe space where participants were able to develop community.

CONCLUSION

Substance use disorder treatment continues to challenge health care providers across the United States. Peer support meetings have been effective in the treatment of people with substance use disorder. Nursing has the holistic historical precedence of creating effectual education and support programs. This program evaluation exemplifies that women's health units are an appropriate location where nurses can integrate this established evidence-based treatment modality.

A Conceptual Model of the Influence of Mindfulness-Based Interventions on Stress and Quality of Life in Patients With Chronic Conditions

Individuals with chronic conditions are susceptible to stress-related health complications. Left unattended, chronic stress exacerbates inflammation, diminishes quality of life (QOL), and increases all-cause mortality. Here, we suggest a theoretical framework promoting the use of mindfulness-based interventions (MBIs) in patients with chronic conditions and a conceptual model of how MBIs may influence stress and QOL.

Adjunct interventions to standard medical management of buprenorphine in outpatient settings: A systematic review of the evidence

BACKGROUND

A growing body of research has examined adjunctive interventions supportive of engagement and retention in treatment among patients receiving buprenorphine for opioid use disorder (OUD). We conducted a systematic review of the literature addressing the effect on key outcomes of adjunctive interventions provided alongside standard medical management of buprenorphine in outpatient settings.

METHODS

We included prospective studies examining adults receiving buprenorphine paired with an adjunctive intervention for the treatment of OUD in an outpatient setting. Data sources included Medline, Cochrane Central Register of Controlled Trials, CINAHL and PsycINFO from inception through January 2020. Two raters independently reviewed full-text articles, abstracted data and appraised risk of bias. Outcomes examined included abstinence, retention in treatment and non-addiction-related health outcomes.

RESULTS

The final review includes 20 manuscripts, 11 randomized control trials (RCTs), three secondary analyses of RCTs and six observational studies. Most studies examined psychosocial interventions (n = 14). Few examined complementary therapies (e.g., yoga; n = 2) or technological interventions (e.g., electronic pill dispensation; n = 3); one study examined an intervention addressing structural barriers to care (patient navigators; n = 1). Low risk of bias RCTs found no evidence that adding psychosocial interventions to buprenorphine treatment improves substance use outcomes.

CONCLUSIONS

Research is needed to identify adjunctive interventions with potential to support medication adherence and addiction-related outcomes for patients engaged in buprenorphine treatment. Data from clinical trials suggest that lack of ready access to psychosocial treatments should not discourage clinicians from prescribing buprenorphine.

Feasibility and acceptability of mindful recovery opioid use care continuum (M-ROCC): A concurrent mixed methods study

As opioid overdose deaths increase, buprenorphine/naloxone (B/N) treatment is expanding, yet almost half of patients are not retained in B/N treatment. Mindfulness-based interventions (MBIs) designed to promote non-judgmental awareness of present moment experience may be complementary to B/N treatment and offer the potential to enhance retention by reducing substance use and addressing comorbid symptoms. In this pilot study, we examined the feasibility and acceptability of the Mindful Recovery OUD Care Continuum (M-ROCC), a trauma-informed, motivationally sensitive, 24-week MBI. Participants (N = 18) were adults with Opioid Use Disorder prescribed B/N. The study team conducted assessments of satisfaction, mindfulness levels, and home practice, as well as qualitative interviews at 4 and 24-weeks. M-ROCC was feasible in a sample with high rates of childhood trauma and comorbid psychiatric diagnoses with 89% of participants retained at 4-weeks and 72% at 24-weeks. Positive qualitative interview responses and a high rate of participants willing to refer a friend (100%) demonstrates program acceptability. Participant mindfulness increased from baseline to 24-weeks (β = 0.24, p = 0.001, d = 0.51), and increases were correlated with informal mindfulness practice frequency (r = 0.7, p < 0.01). Although limited by small sample size, this pilot study highlights the feasibility and acceptability of integrating MBIs into standard primary care Office-Based Opioid Treatment (OBOT) among a population with substantial trauma history.

Mindfulness and Behavior Change

Initiating and maintaining behavior change is key to the prevention and treatment of most preventable chronic medical and psychiatric illnesses. The cultivation of mindfulness, involving acceptance and nonjudgment of present-moment experience, often results in transformative health behavior change. Neural systems involved in motivation and learning have an important role to play. A theoretical model of mindfulness that integrates these mechanisms with the cognitive, emotional, and self-related processes commonly described, while applying an integrated model to health behavior change, is needed. This integrative review (1) defines mindfulness and describes the mindfulness-based intervention movement, (2) synthesizes the neuroscience of mindfulness and integrates motivation and learning mechanisms within a mindful self-regulation model for understanding the complex effects of mindfulness on behavior change, and (3) synthesizes current clinical research evaluating the effects of mindfulness-based interventions targeting health behaviors relevant to psychiatric care. The review provides insight into the limitations of current research and proposes potential mechanisms to be tested in future research and targeted in clinical practice to enhance the impact of mindfulness on behavior change.

Treatment of opioid use disorder in primary care

Opioid use disorder (OUD) is a common, treatable chronic disease that can be effectively managed in primary care settings. Untreated OUD is associated with considerable morbidity and mortality-notably, overdose, infectious complications of injecting drug use, and profoundly diminished quality of life. Withdrawal management and medication tapers are ineffective and are associated with increased rates of relapse and death. Pharmacotherapy is the evidence based mainstay of OUD treatment, and many studies support its integration into primary care settings. Evidence is strongest for the opioid agonists buprenorphine and methadone, which randomized controlled trials have shown to decrease illicit opioid use and mortality. Discontinuation of opioid agonist therapy is associated with increased rates of relapse and mortality. Less evidence is available for the opioid antagonist extended release naltrexone, with a meta-analysis of randomized controlled trials showing decreased illicit opioid use but no effect on mortality. Treating OUD in primary care settings is cost effective, improves outcomes for both OUD and other medical comorbidities, and is highly acceptable to patients. Evidence on whether behavioral interventions improve outcomes for patients receiving pharmacotherapy is mixed, with guidelines promoting voluntary engagement in psychosocial supports, including counseling. Further work is needed to promote the integration of OUD treatment into primary care and to overcome regulatory barriers to integrating methadone into primary care treatment in the US.