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).

Emergency Department Peer Support Program and Patient Outcomes After Opioid Overdose.

Importance: Patients treated in emergency departments (EDs) for opioid overdose often need drug treatment yet are rarely linked to services after discharge. Emergency department-based peer support is a promising approach for promoting treatment linkage, but evidence of its effectiveness is lacking. Objective: To examine the association of the Opioid Overdose Recovery Program (OORP), an ED peer recovery support service, with postdischarge addiction treatment initiation, repeat overdose, and acute care utilization. Design, Setting, and Participants: This intention-to-treat retrospective cohort study used 2014 to 2020 New Jersey Medicaid data for Medicaid enrollees aged 18 to 64 years who were treated for nonfatal opioid overdose from January 2015 to June 2020 at 70 New Jersey acute care hospitals. Data were analyzed from August 2022 to November 2023. Exposure: Hospital OORP implementation. Main Outcomes and Measures: The primary outcome was medication for opioid use disorder (MOUD) initiation within 60 days of discharge. Secondary outcomes included psychosocial treatment initiation, medically treated drug overdoses, and all-cause acute care visits after discharge. An event study design was used to compare 180-day outcomes between patients treated in OORP hospitals and those treated in non-OORP hospitals. Analyses adjusted for patient demographics, comorbidities, and prior service use and for community-level sociodemographics and drug treatment access. Results: A total of 12 046 individuals were included in the study (62.0% male). Preimplementation outcome trends were similar for patients treated in OORP and non-OORP hospitals. Implementation of the OORP was associated with an increase of 0.034 (95% CI, 0.004-0.064) in the probability of 60-day MOUD initiation in the half-year after implementation, representing a 45% increase above the preimplementation mean probability of 0.075 (95% CI, 0.066-0.084). Program implementation was associated with fewer repeat medically treated overdoses 4 half-years (-0.086; 95% CI, -0.154 to -0.018) and 5 half-years (-0.106; 95% CI, -0.184 to -0.028) after implementation. Results differed slightly depending on the reference period used, and hospital-specific models showed substantial heterogeneity in program outcomes across facilities. Conclusions and Relevance: In this cohort study of patients treated for opioid overdose, OORP implementation was associated with an increase in MOUD initiation and a decrease in repeat medically treated overdoses. The large variation in outcomes across hospitals suggests that treatment effects were heterogeneous and may depend on factors such as implementation success, program embeddedness, and availability of other hospital- and community-based OUD services.

The role of social connection in opioid use disorder treatment engagement.

OBJECTIVE: Medications for opioid use disorder (OUD or MOUD) treatment combining pharmacotherapy with psychosocial support are effective for managing OUD. However, treatment engagement remains a challenge, with retention rates ∼30%-50%. Although social connection has been identified as important to recovery, it remains unclear whether and how social factors can bolster participation in treatment. METHOD: Individuals receiving MOUD at three outpatient treatment programs (N = 82) and healthy community controls (N = 62) completed validated measures assessing social connection including (a) size, diversity, and embeddedness of social networks; (b) perceived social support and criticism within familial relationships; and (c) subjective social status. For those receiving MOUD, we also examined how aspects of social connection related to opioid (re)use and treatment engagement (medication adherence, group, and individual meeting attendance) assessed over ∼8 weeks/person. RESULTS: Compared to controls, individuals receiving MOUD had smaller and less diverse and embedded social networks (Cohen's d > 0.4), and despite similar levels of perceived social support (d = 0.02), reported higher levels of social criticism (d = 0.6) and lower subjective social status (d = 0.5). Within the MOUD group, higher social network indices correlated specifically with higher therapeutic group attendance (Rs > 0.30), but not medication adherence, while higher levels of perceived criticism correlated with more frequent opioid use (R = 0.23). Results were mostly robust to control for sociodemographic variables, psychological distress/COVID-19, and treatment duration, but differed by MOUD type/program. CONCLUSIONS: These findings highlight the potential importance of assessing an individual's social capital, promoting positive social connection, and continuing to assess the implementation and value of psychosocial support in MOUD treatment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Telehealth Mindfulness-Oriented Recovery Enhancement vs Usual Care in Individuals With Opioid Use Disorder and Pain: A Randomized Clinical Trial.

Importance: Methadone treatment (MT) fails to address the emotion dysregulation, pain, and reward processing deficits that often drive opioid use disorder (OUD). New interventions are needed to address these factors. Objective: To evaluate the efficacy of MT as usual (usual care) vs telehealth Mindfulness-Oriented Recovery Enhancement (MORE) plus usual care among people with an OUD and pain. Design, Setting, and Participants: This study was a randomized clinical trial conducted from August 2020 to June 2022. Participants receiving MT for OUD and experiencing chronic pain were recruited at 5 clinics in New Jersey. Interventions: In usual care, participants received MT, including medication and counseling. Participants receiving MORE plus usual care attended 8 weekly, 2-hour telehealth groups that provided training in mindfulness, reappraisal, and savoring in addition to usual care. Main Outcomes and Measure: Primary outcomes were return to drug use and MT dropout over 16 weeks. Secondary outcomes were days of drug use, methadone adherence, pain, depression, and anxiety. Analyses were based on an intention-to-treat approach. Results: A total of 154 participants (mean [SD] age, 48.5 [11.8] years; 88 female [57%]) were included in the study. Participants receiving MORE plus usual care had significantly less return to drug use (hazard ratio [HR], 0.58; 95% CI, 0.37-0.90; P = .02) and MT dropout (HR, 0.41; 95% CI, 0.18-0.96; P = .04) than those receiving usual care only after adjusting for a priori-specified covariates (eg, methadone dose and recent drug use, at baseline). A total of 44 participants (57.1%) in usual care and 39 participants (50.6%) in MORE plus usual care returned to drug use. A total of 17 participants (22.1%) in usual care and 10 participants (13.0%) in MORE plus usual care dropped out of MT. In zero-inflated models, participants receiving MORE plus usual care had significantly fewer days of any drug use (ratio of means = 0.58; 95% CI, 0.53-0.63; P < .001) than those receiving usual care only through 16 weeks. A significantly greater percentage of participants receiving MORE plus usual care maintained methadone adherence (64 of 67 [95.5%]) at the 16-week follow-up than those receiving usual care only (56 of 67 [83.6%]; χ2 = 4.49; P = .04). MORE reduced depression scores and ecological momentary assessments of pain through the 16-week follow-up to a significantly greater extent than usual care (group × time F2,272 = 3.13; P = .05 and group × time F16,13000 = 6.44; P < .001, respectively). Within the MORE plus usual care group, EMA pain ratings decreased from a mean (SD) of 5.79 (0.29) at baseline to 5.17 (0.30) at week 16; for usual care only, pain decreased from 5.19 (0.28) at baseline to 4.96 (0.29) at week 16. Within the MORE plus usual care group, mean (SD) depression scores were 22.52 (1.32) at baseline and 18.98 (1.38) at 16 weeks. In the usual care-only group, mean (SD) depression scores were 22.65 (1.25) at baseline and 20.03 (1.27) at 16 weeks. Although anxiety scores increased in the usual care-only group and decreased in the MORE group, this difference between groups did not reach significance (group × time unadjusted F2,272 = 2.10; P= .12; Cohen d = .44; adjusted F2,268 = 2.33; P = .09). Within the MORE plus usual care group, mean (SD) anxiety scores were 25.5 (1.60) at baseline and 23.45 (1.73) at 16 weeks. In the usual care-only group, mean (SD) anxiety scores were 23.27 (1.75) at baseline and 24.07 (1.73) at 16 weeks. Conclusions and Relevance: This randomized clinical trial demonstrated that telehealth MORE was a feasible adjunct to MT with significant effects on drug use, pain, depression, treatment retention, and adherence. Trial Registration: ClinicalTrials.gov Identifier: NCT04491968.

Mindfulness-oriented recovery enhancement in opioid use disorder: Extended emotional regulation and neural effects and immediate effects of guided meditation in a pilot sample.

OBJECTIVE: Mindfulness-Oriented Recovery Enhancement (MORE) is an efficacious intervention to aid recovery from substance use disorder. This study in a pilot sample of individuals in treatment for opioid use disorder (OUD) characterizes longer-term changes after the MORE intervention and immediate effects of a brief MORE guided meditation session. DESIGN: Twelve female participants in residential treatment for OUD completed an 8-week MORE intervention. Participants completed two sessions: one before and one after the 8-week MORE intervention. Each session included an emotional regulation questionnaire outside an MRI scanner first and then a 10-minute guided MORE meditation inside the scanner during which functional magnetic resonance imaging (fMRI) data were collected. Emotional regulation was measured after 8-weeks of MORE intervention. In addition, functional connectivity (i.e. correlated fMRI signal) between regions in a hypothesized affect regulation network was measured during the meditation state to assess change in brain network function due to 8-weeks of MORE. For each 10-min guided meditation, we also assessed their mood and opioid craving. RESULTS: Nine participants completed all measurements. Participants' emotional regulation difficulty significantly decreased after 8-weeks of MORE intervention. Furthermore, after 8-weeks of MORE, there was significantly increased connectivity between left ventromedial prefrontal cortex and left amygdala and between left ventrolateral prefrontal cortex and left nucleus accumbens captured during a meditation state. In both sessions, positive mood significantly increased after 10-min of guided mediation, however opioid craving was not significantly influenced. CONCLUSIONS: This pilot study characterizes potential benefits of 8-week MORE intervention in improving emotional regulation difficulty and brain function. A 10-min guided MORE meditation may immediately improve mood, with potential to reduce acute stress- or cue-provoked craving. These results warrant future studies with larger sample size.

Predictors of intentional fentanyl use: Market availability vs consumer demand.

BACKGROUND: Attempts to reduce opioid overdoses have been complicated by the dramatic rise in fentanyl use. While market forces contributing to fentanyl proliferation in the illicit drug supply have increased inadvertent exposure to the drug, rising fentanyl use may also be driven by growing consumer demand. Interventions to reduce the spread of fentanyl must be based on an understanding of the motivations underlying its use. METHODS: Data for this cross-sectional study were derived from a computerized self-administered survey completed by a convenience sample of 432 people who use illicit opioids (PWUO) recruited from methadone and detoxification programs in NJ. The anonymous survey was based on a prior qualitative study of attitudes and behaviors surrounding opioid use. Multivariate analysis identified correlates of intentional fentanyl use in the full sample and among sub-populations of white and non-white PWUO. RESULTS: In the full sample, intentional fentanyl use was associated with white race/ethnicity, younger age, polydrug use, and a preference for the drug effects of fentanyl, which more than tripled the probability of intentional use (AOR=3.02; 95% CI=1.86-4.89; p=.000). Among whites, a preference for the fentanyl drug effects was also the strongest predictor of intentional use (AOR=5.34; 95% CI=2.78-10.28; p=.000). Among non-whites, however, exposure, not preference, was the primary driver of use, with intentional use more than doubling (AOR=2.48; 95% CI=1.04-5.91; p<.05) among those living in high fentanyl dispersion counties. CONCLUSION: The motivations underlying fentanyl use are multifactorial and vary across populations of PWUO, indicating a need for targeted interventions to counter the increasing spread and adverse consequences of fentanyl use. In order to counteract the increasing spread and adverse consequences of fentanyl use, these findings indicate a need for harm-reduction interventions, like drug testing or supervised injection sites, that address the differing motivations for fentanyl use among PWUO.

A pilot randomized clinical trial of mindfulness-oriented recovery enhancement as an adjunct to methadone treatment for people with opioid use disorder and chronic pain: Impact on illicit drug use, health, and well-being.

BACKGROUND: Chronic pain is highly prevalent among people in methadone maintenance treatment (MMT) for opioid use disorder and is known to be an important contributor to treatment discontinuation and opioid relapse. Mindfulness-Oriented Recovery Enhancement (MORE) is one of the few interventions developed and tested as an integrated treatment to simultaneously address both pain and illicit opioid use; however, this study is the first to evaluate MORE as an adjunct to MMT. METHODS: Randomized individuals in MMT (N = 30) received MORE plus methadone TAU (n = 15) or methadone TAU, only (n = 15). Participants in the MORE arm received their MMT, as usual, and attended eight, weekly, two-hour MORE groups at their MMT clinics. Participants in the TAU arm received their MMT, as usual, and group or individual counseling, as required by the clinic. TAU counseling consisted of relapse prevention, cognitive-behavioral therapy, and supportive treatment. TAU participants did not receive any mindfulness-based intervention. Participants completed assessments at baseline, post-treatment (i.e., 8-weeks post-baseline), and follow-up (i.e., 16-weeks post-baseline). RESULTS: Participants in MORE evidenced significantly fewer baseline adjusted days of illicit drug use and significantly lower levels of craving through 16-week follow-up compared to TAU. Also, Participants in MORE reported significantly lower levels of pain, physical and emotional limitations, depression, and anxiety through 16-week follow-up compared to TAU. Conversely, participants in MORE reported significantly higher levels of well-being, vitality, and social functioning through 16-week follow-up compared to TAU. CONCLUSION: MORE could be an effective adjunct to MMT, and larger trials are warranted.

New and Emerging Opioid Overdose Risk Factors.

PURPOSE OF REVIEW: The purpose of this review is to provide a review of the current literature surrounding opioid overdose risk factors, focusing on relatively new factors in the opioid crisis. RECENT FINDINGS: Both a market supply driving force and a subpopulation of people who use opioids actively seeking out fentanyl are contributing to its recent proliferation in the opioid market. Harm reduction techniques such as fentanyl testing strips, naloxone education and distribution, drug sampling behaviors, and supervised injection facilities are all seeing expanded use with increasing amounts of research being published regarding their effectiveness. Availability and use of interventions such as medication for opioid use disorder and peer recovery coaching programs are also on the rise to prevent opioid overdose. SUMMARY: The opioid epidemic is an evolving crisis, necessitating continuing research to identify novel overdose risk factors and the development of new interventions targeting at-risk populations.

Opioid overdose in the age of fentanyl: Risk factor differences among subpopulations of overdose survivors.

BACKGROUND: Although fentanyl is the drug most frequently implicated in overdose deaths, the association between overdose risk and attitudes and behaviors surrounding fentanyl in opioid-using communities has remained understudied. Possible subpopulation differences in fentanyl-related overdose risk remain equally unexamined. This paper addresses these gaps by exploring the association between overdose and fentanyl-related attitudes/behaviors in three subpopulations of overdose survivors. METHODS: In this cross-sectional study, we sampled 432 individuals who currently or recently used opioids from New Jersey methadone and acute residential detoxification programs. Using multinomial regression analysis, we compared overdose risk factors, including fentanyl-related attitudes/behaviors, of those who never overdosed with three subgroups of overdose survivors who experienced: 1. recent overdoses occurring after, but not before, fentanyl expansion; 2. past overdoses occurring before, but not after, fentanyl expansion; 3. persistent overdoses occurring before and after fentanyl expansion. RESULTS: Forty percent of respondents had knowingly used fentanyl and 38% deliberately sought overdose-implicated drugs. Respondents with persistent overdoses represented under 10% of the sample but accounted for 44% of all lifetime overdoses (x̅ =8.03 vs. 1.71 for the full sample). This was also the only subgroup for whom PTSD (AOR=3.84; 95%CI=1.45-10.16; p=.01) and fentanyl-seeking (AOR=1.50; 95% CI=1.16-1.94; p=.01) were significant overdose risk factors. Those with recent overdoses engaged in frequent drug combining (AOR=2.28; 95% CI=1.19-6.98; p=.05), which could have led to inadvertent fentanyl use. Those with past overdoses were not at overdose risk from fentanyl-seeking or drug combining and had rates of methadone treatment comparable to rates of those with no overdoses. CONCLUSION: Harm reduction strategies will need to address consumers' evolving drug preferences as fentanyl continues to saturate local drug markets. Targeting comprehensive interventions, including mental health treatment, to the small group of opioid users with longstanding overdose histories may reduce the burden of overdose in opioid-using communities.

"A Blessing and a Curse:" Opioid Users' Perspectives on Naloxone and the Epidemic of Opioid Overdose.

Background: To address the alarming rise in opioid overdose deaths, states have increased public access to the overdose reversal medication, naloxone. While some studies suggest that increased naloxone accessibility reduces opioid overdose deaths, others raise concerns about unintended consequences, such as increases in risky drug use and opioid re-use post-overdose to counter naloxone-induced withdrawal symptoms. Few studies have examined the impact of expanded naloxone access on the attitudes and behaviors of opioid users. Methods: In this qualitative study, we conducted in-depth, semi-structured interviews with 36 English-speaking opioid users 18+ years of age. Informants were recruited from an urban methadone clinic, a needle exchange program and a residential treatment program. The approximately hour-long interviews focused on users' attitudes and behaviors surrounding naloxone, opioid use and overdose. Transcribed audio-recordings of interviews were analyzed using NVivo. Results: Informants were ambivalent about naloxone, widely acknowledging its life-saving benefits while reporting such negative effects as severe withdrawal symptoms and the promotion of riskier drug use. Naloxone-induced withdrawal, coupled with misperceptions about naloxone's pharmacological effects, prompted overdose survivors to rapidly re-use opioids and refuse hospitalization following an overdose reversal. About half the sample believed naloxone led to greater risk-taking by others, such as fentanyl use or use in higher quantities, but did not endorse riskier drug use themselves. Conclusions: The results suggest the need for targeted education about the pharmacological effects of naloxone and better strategies for managing naloxone-induced withdrawal. Future research should focus on the extent to which naloxone is associated with greater opioid risk-taking.

Emergency department-based peer support for opioid use disorder: Emergent functions and forms.

Emergency department (ED)-based peer support programs aimed at linking persons with opioid use disorder (OUD) to medication for addiction treatment and other recovery services are a promising approach to addressing the opioid crisis. This brief report draws on experiences from three states' experience with such programs funded by the SAMHSA Opioid State Targeted Repose (STR) grants. Core functions of such programs include: Integration of peer supports in EDs; Alerting peers of eligible patients and making the patient aware of peer services; and connecting patients with recovery services. Qualitative data were analyzed using a general inductive approach conducted in 3 steps in order to identify forms utilized to fulfill these functions. Peer integration differed in terms of peer's physical location and who hired and supervised peers. Peers often depend on ED staff to alert them to potential patients while people other than the peers often first introduce potential patients to programming. Programs generally schedule initial appointments for recovery services for patients, but some programs provide a range of other services aimed at supporting participation in recovery services. Future effectiveness evaluations of ED-based peer support programs for OUD should consistently report on forms used to fulfill core functions.

Mindfulness-Oriented Recovery Enhancement reduces opioid craving among individuals with opioid use disorder and chronic pain in medication assisted treatment: Ecological momentary assessments from a stage 1 randomized controlled trial.

BACKGROUND: Methadone maintenance therapy (MMT) is an efficacious form of medication assisted treatment for opioid use disorder (OUD), yet many individuals on MMT relapse. Chronic pain and deficits in positive affective response to natural rewards may result in dysphoria that fuels opioid craving and promotes relapse. As such, behavioral therapies that ameliorate chronic pain and enhance positive affect may serve as useful adjuncts to MMT. This analysis of ecological momentary assessment (EMA) data from a Stage 1 randomized clinical trial examined effects of Mindfulness-Oriented Recovery Enhancement (MORE) on opioid craving, pain, and positive affective state. METHODS: Participants with OUD and chronic pain (N = 30) were randomized to 8 weeks of MORE or treatment as usual (TAU). Across 8 weeks of treatment, participants completed up to 112 random EMA measures of craving, pain, and affect, as well as event-contingent craving ratings. Multilevel models examined the effects of MORE on craving, pain, and affect, as well as the association between positive affect and craving. RESULTS: EMA showed significantly greater improvements in craving, pain unpleasantness, stress, and positive affect for participants in MORE than for participants in TAU. Participants in MORE reported having nearly 1.3 times greater self-control over craving than those in TAU. Further, positive affect was associated with reduced craving, an association that was significantly stronger among participants in MORE than TAU. CONCLUSION: MORE may be a useful non-pharmacological adjunct among individuals with OUD and chronic pain in MMT.

The Effects of Positive Affect and Episodic Future Thinking on Temporal Discounting and Healthy Food Demand and Choice Among Overweight and Obese Individuals: Protocol for a Pilot 2×2 Factorial Randomized Controlled Study.

BACKGROUND: Unhealthy behaviors (eg, poor food choices) contribute to obesity and numerous negative health outcomes, including multiple types of cancer and cardiovascular and metabolic diseases. To promote healthy food choice, diet interventions should build on the dual-system model to target the regulation and reward mechanisms that guide eating behavior. Episodic future thinking (EFT) has been shown to strengthen regulation mechanisms by reducing unhealthy food choice and temporal discounting (TD), a process of placing greater value on smaller immediate rewards over larger future rewards. However, these interventions do not target the reward mechanisms that could support healthy eating and strengthen the impact of EFT-anchored programs. Increasing positive affect (PosA) related to healthy food choices may target reward mechanisms by enhancing the rewarding effects of healthy eating. An intervention that increases self-regulation regarding unhealthy foods and the reward value of healthy foods will likely have a greater impact on eating behavior compared with interventions focused on either process alone. OBJECTIVE: This study aimed to introduce a protocol that tests the independent and interactive effects of EFT and PosA on TD, food choice, and food demand in overweight and obese adults. METHODS: This protocol describes a factorial, randomized, controlled pilot study that employs a 2 (affective imagery: positive, neutral) by 2 (EFT: yes, no) design in which participants are randomized to 1 of 4 guided imagery intervention arms. In total, 156 eligible participants will complete 2 lab visits separated by 5 days. At visit 1, participants complete surveys; listen to the audio guided imagery intervention; and complete TD, food demand, and food choice tasks. At visit 2, participants complete TD, food demand, and food choice tasks and surveys. Participants complete a daily food frequency questionnaire between visits 1 and 2. Analyses will compare primary outcome measures at baseline, postintervention, and at follow-up across treatment arms. RESULTS: Funding notification was received on April 27, 2017, and the protocol was approved by the institutional review board on October 6, 2017. Feasibility testing of the protocol was conducted from February 21, 2018, to April 18, 2018, among the first 32 participants. As no major protocol changes were required at the end of the feasibility phase, these 32 participants were included in the target sample of 156 participants. Recruitment, therefore, continued immediately after the feasibility phase. When this manuscript was submitted, 84 participants had completed the protocol. CONCLUSIONS: Our research goal is to develop novel, theory-based interventions to promote and improve healthy decision-making and behaviors. The findings will advance decision-making research and have the potential to generate new neuroscience and psychological research to further understand these mechanisms and their interactions. TRIAL REGISTRATION: ISRCTN Registry ISRCTN11704675; http://www.isrctn.com/ISRCTN11704675 (Archived by WebCite at http://www.webcitation.org/760ouOoKG). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/12265.

Field Test of a Dialectical Behavior Therapy Skills Training-Based Intervention for Smoking Cessation and Opioid Relapse Prevention in Methadone Treatment.

Objective: Almost all individuals in methadone treatment for opioid dependence smoke cigarettes, and half of people in methadone treatment have an opioid relapse within six months. Dialectical behavior therapy (DBT) skills training has shown promise for addressing substance use and a variety of health behaviors and conditions; however, it has never been evaluated for smoking cessation in any population. The objective of this study was to field test a DBT skills training-based intervention for tobacco dependence and opioid relapse prevention (DBT-Quit) among people in methadone treatment. Methods: We recruited seven individuals in methadone treatment to participate in a field test of DBT-Quit. Participants attended 12 weekly 90-minute DBT skills training groups, focusing on mindfulness, emotion regulation, and distress tolerance skills. Participants received nicotine patches for eight weeks and completed assessments at baseline, 6 weeks (mid-treatment), and 12 weeks (post-treatment). Results: All but one participant (86%, n = 6) attended at least 50% of intervention sessions. Participants were "very" or "mostly" satisfied with the intervention. At 12 weeks, all but one (86%, n = 6) had made a quit attempt, and one (14%) had seven-day point prevalence abstinence. Participants were smoke-free for 24 hours (14%, n = 1), 7 to 14 days (43%, n = 3), and 30 to 59 days (29%, n = 2). Participants smoked significantly fewer cigarettes per day at 6 weeks and 12 weeks as compared to baseline. No participants used illicit drugs. As compared to baseline, at follow-up there were no significant differences in difficulties with emotion regulation, distress tolerance, or mindfulness. Conclusions: A DBT skills training-based intervention for individuals who smoke and have an opioid use disorder is feasible and acceptable in methadone treatment and may help this population prevent drug relapse, attempt to quit smoking, experience smoke-free days, and cut down on their smoking. More research is needed to determine the optimal structure and components of a DBT skills-based intervention for drug relapse prevention and smoking cessation. Further, a randomized controlled trial of DBT-Quit is needed to determine the efficacy of DBT skills training for smoking cessation and drug relapse prevention in this population.

Considering Systemic Barriers to Treating Tobacco Use in Clinical Settings in the United States.

The Comorbidity Workgroup of the Tobacco Treatment Research Network, within the Society for Research on Nicotine and Tobacco, previously highlighted the need to provide tobacco treatment to patients diagnosed with comorbid physical and mental health conditions. Yet, systemic barriers in the United States health care system prevent many patients who present for medical treatment from getting the evidence-based tobacco treatment that they need. The identified barriers include insufficient training in the epidemiologic impact of tobacco use, related disorders, and pharmacological and behavioral treatment approaches; misunderstanding among clinicians about the effectiveness of tobacco treatment; lack of therapeutic support from clinical staff; insufficient use of health information technology to improve tobacco use identification and treatment; and limited time and reimbursement for clinicians to provide treatment. We highlight three vignettes demonstrating the complexities of practical barriers at the health care system level. We consider each of the barriers in turn and discuss evidence-based strategies that could be implemented in the clinical care of patients with comorbid conditions. In addition, in the absence of compelling data to guide implementation approaches, we offer suggestions for potential strategies and avenues for future research. Implications: Three vignettes highlighted in this article illustrate some systemic barriers to providing tobacco treatment for patients being treated for comorbid conditions. We explore the barriers to tobacco treatment and offer suggestions for changes in training, health care systems, clinical workflow, and payment systems that could enhance the reach and the quality of tobacco treatment within the US health care system.

Pilot Study of a Tailored Smoking Cessation Intervention for Individuals in Treatment for Opioid Dependence.

Introduction: Over 85% of opioid-dependent individuals in methadone treatment smoke cigarettes; however, smoking cessation interventions are minimally effective in this population. To better help opioid-dependent individuals quit smoking, we developed and pilot-tested an intervention, based in the Information-Motivation-Behavioral Skills (IMB) model of behavior change, which could be tailored to address individual barriers to smoking cessation in this population. Methods: We randomized participants (n = 83) in methadone treatment to the eight-session, IMB model-based, intervention plus nicotine replacement therapy (intervention, n = 41) or a facilitated referral to the state Quitline (control, n = 42). All participants completed assessments at baseline, 3 months, and 6 months. Results: Intervention participants completed a median of five sessions (interquartile range [IQR] 3-8) and had significantly higher intervention satisfaction than control participants. Intervention participants reported smoking significantly fewer cigarettes per day at 3 months (median [IQR] = 6 [4-15]) and 6 months (median [IQR] = 8 [4-14]) as compared control participants at 3 months (median [IQR] = 10 [5-20]) and 6 months (median [IQR] = 10 [6-20]). Fifty-six percent of the intervention group and 41% of the control group a made a quit attempt during the study (p = .16). At 3 months, 7% (n = 3) of intervention participants and none of the control participants were abstinent from smoking (p = .23). At 6 months, 2% of participants in both groups were abstinent. Twenty-four percent and 10% of the intervention and control group participants, respectively, reported 20 or more smoke-free days (p = .43). Conclusions: An IMB model-based smoking cessation intervention for opioid-dependent smokers is feasible and acceptable in methadone treatment and may help methadone maintained smokers cut down on their smoking. Implications: This is the first study of a tailored, IMB Model-based, smoking cessation intervention for opioid dependent smokers. Results showed that opioid dependent smokers are willing and able to participate in an IMB model-based smoking cessation intervention, and this intervention may help this population cut down on their smoking. Also, the Quitline seems less feasible and acceptable for this population than a face-to-face intervention. Further research is needed to determine how to integrate smoking cessation treatment into methadone programs and how to improve interventions so that treatment gains can lead to long-term abstinence in this population.

Influence of Psychiatric and Personality Disorders on Smoking Cessation Among Individuals in Opiate Dependence Treatment.

OBJECTIVE: We aimed to evaluate how psychiatric and personality disorders influence smoking cessation goals and attempts among people with opiate dependence who smoke. This information could aid the development of more effective cessation interventions for these individuals. METHODS: Participants (N = 116) were recruited from two methadone clinics, completed the Millon Clinical Multiaxial Inventory-III, and were asked about their smoking behavior and quitting goals. We used the Least Absolute Shrinkage and Selection Operator (LASSO) method, a technique commonly used for studies with small sample sizes and large number of predictors, to develop models predicting having a smoking cessation goal, among those currently smoking daily, and ever making a quit attempt, among those who ever smoked. RESULTS: Almost all participants reported ever smoking (n = 115, 99%); 70% (n = 80) had made a serious quit attempt in the past; 89% (n = 103) reported current daily smoking; and 59% (n = 61) had a goal of quitting smoking and staying off cigarettes. Almost all (n = 112, 97%) had clinically significant characteristics of a psychiatric or personality disorder. White race, anxiety, and a negativistic personality facet (expressively resentful) were negative predictors of having a cessation goal. Overall, narcissistic personality pattern and a dependent personality facet (interpersonally submissive) were positive predictors of having a cessation goal. Somatoform disorder, overall borderline personality pattern, and a depressive personality facet (cognitively fatalistic) were negative predictors of ever making a quit attempt. Individual histrionic (gregarious self-image), antisocial (acting out mechanism), paranoid (expressively defensive), and sadistic (pernicious representations) personality disorder facets were positive predictors of ever making a quit attempt. Each model provided good discrimination for having a smoking cessation goal or not (C-statistic of .76, 95% CI [0.66, 0.85]) and ever making a quit attempt or not (C-statistic of .79, 95% CI [0.70, 0.88]). CONCLUSIONS: Compared to existing treatments, smoking cessation treatments that can be tailored to address the individual needs of people with specific psychiatric disorders or personality disorder traits may better help those in opiate dependence treatment to set a cessation goal, attempt to quit, and eventually quit smoking.

Improving Quality of Care for Hospitalized Smokers with HIV: Tobacco Dependence Treatment Referral and Utilization.

BACKGROUND: Most persons living with HIV smoke cigarettes and tend to be highly dependent, heavy smokers. Few such persons receive tobacco treatment, and many die from tobacco-related illness. Although advancements in antiretroviral therapy (ART) have increased the quality and quantity of life, the health harms from tobacco use diminish these gains. Without cessation assistance, thousands will benefit from costly ART, only to suffer the consequences of tobacco-related disease and death. A study was conducted to examine in detail inpatient tobacco treatment for smokers with HIV. METHODS: Data collected at hospital admission and data collected by tobacco treatment specialists were examined retrospectively for all inpatients with HIV who were admitted to an academic medical center for a five-year period. Specifically, the prevalence of cigarette smoking, factors predictive of referral to tobacco treatment, referral for tobacco treatment, treatment participation, and abstinence at six months posttreatment were measured. Differences in referral and treatment participation between all smokers and smokers with HIV were also assessed. RESULTS: Among the 422 admitted persons with HIV, 54.5% smoked and 21.7% were referred to inpatient tobacco treatment services. Substance abuse and tobacco-related diagnoses were predictive of referral to inpatient tobacco treatment specialists. Among the 14 treatment participants reached for follow-up, 11 (78.6%) made quit attempts and 3 (21.4%) reported abstinence. Smokers with HIV were less likely to be referred to and treated by tobacco treatment services than all smokers admitted during the same time frame. CONCLUSIONS: Although tobacco is a major cause of mortality, few smokers with HIV are offered treatment during hospitalization. Those who are treated attempt to quit. Hospitalization offers a prime opportunity for initiating smoking cessation among those with HIV.