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.

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.

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.

An Adaptation of Motivational Interviewing Increases Quit Attempts in Smokers With Serious Mental Illness.

INTRODUCTION: Smokers with serious mental illness (SMI) have a high smoking prevalence and a low quit rate. Motivational interviewing (MI) is an empirically supported approach for addressing substance use disorders and may motivate smokers with SMI to quit. METHODS: We randomized smokers (N = 98) with SMI to receive a single 45-minute session of (1) MI with personalized feedback or (2) interactive education. We hypothesized that participants receiving the MI intervention would be more likely to follow-up on a referral for tobacco dependence treatment, to make a quit attempt, and to quit smoking than those receiving the interactive educational intervention. RESULTS: Smokers receiving an MI intervention were significantly more likely to make a quit attempt by the 1-month follow-up (34.7% vs. 14.3%; OR = 4.39 [95% CI = 1.44 to 13.34], P = .009); however, these quit attempts did not translate into abstinence. In addition, 32.7% of those receiving MI followed-up on a referral for tobacco dependence treatment (vs. 20.4% receiving interactive education; OR = 2.02 [95% CI = 0.76 to 3.55], P = .157). MI Treatment Integrity Code ratings indicated that the interventions were easily distinguishable from each other and that MI was delivered with proficiency. Despite the intervention's brevity, participants reported high levels of therapeutic alliance with their therapist. CONCLUSIONS: A brief adaptation of MI with personalized feedback appears to be a promising approach for increasing quit attempts in smokers with SMI, but future research is required to determine how to best help smokers with SMI to attain sustained abstinence.

Exploring Issues of Comorbid Conditions in People Who Smoke.

UNLABELLED: Smoking affects comorbid disease outcomes, and patients with comorbid conditions may have unique characteristics that are important to consider when treating tobacco use. However, addressing tobacco in patients being treated for comorbid conditions is not a consistent practice. Recognizing the need for a "call-to-action" to address tobacco use in people with comorbid conditions, the Tobacco Treatment Network within the Society for Research on Nicotine and Tobacco (SRNT) convened a Comorbidities Workgroup to explore the relationship between smoking and comorbid disease to identify common themes including: the harms associated with continued tobacco use, the frequency of comorbid disease and tobacco use, the potential effect of comorbid disease on the ability to quit tobacco use, the association between tobacco use and suboptimal disease-specific treatment response, and evidence regarding potential approaches to improve addressing tobacco use in patients with comorbid disease. Five candidate conditions (psychiatric, cancer, cardiovascular, pulmonary, and human immunodeficiency virus infected patients) were explored. Across comorbid conditions, smoking adversely affects treatment efficacy and promotes other adverse health conditions. People with comorbid conditions who smoke are motivated to quit and respond to evidence-based smoking cessation treatments. However, tobacco cessation is not regularly incorporated into the clinical care of many individuals with comorbidities. Optimal strategies for addressing tobacco use within each comorbid disease are also not well defined. Further work is needed to disseminate evidence-based care into clinical practice for smokers with comorbid disease and addiction research should consider comorbid conditions as an important construct to explore. IMPLICATIONS: This article explores how physical and psychiatric conditions may interact in the treatment of tobacco dependence, and discusses the need for smoking cessation as a critical component of comorbid condition management. Five common comorbid domains-psychiatric, cancer, pulmonary, cardiovascular, and human immunodeficiency virus (HIV)-are highlighted to illustrate how these different conditions might interact with smoking with respect to prevalence and harm, motivation to quit, and cessation treatment utilization and success.

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.

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.

Determining Smoking Cessation Related Information, Motivation, and Behavioral Skills among Opiate Dependent Smokers in Methadone Treatment.

BACKGROUND: Over 80% of people in methadone treatment smoke cigarettes, and existing smoking cessation interventions have been minimally effective. OBJECTIVE: To develop an Information-Motivation-Behavioral Skills (IMB) Model of behavior change based smoking cessation intervention for methadone maintained smokers, we examined smoking cessation related IMB factors in this population. METHODS: Current or former smokers in methadone treatment (n = 35) participated in focus groups. Ten methadone clinic counselors participated in an individual interview. A content analysis was conducted using deductive and inductive approaches. RESULTS: Commonly known IMB factors related to smoking cessation were described. These factors included: the health effects of smoking and treatment options for quitting (information); pregnancy and cost of cigarettes (motivators); and coping with emotions, finding social support, and pharmacotherapy adherence (behavioral skills). IMB factors specific to methadone maintained smokers were also described. These factors included: the relationship between quitting smoking and drug relapse (information), the belief that smoking is the same as using drugs (motivator); and coping with methadone clinic culture and applying skills used to quit drugs to quitting smoking (behavioral skills). IMB strengths and deficits varied by individual. CONCLUSIONS: Methadone maintained smokers could benefit from research on an IMB Model based smoking cessation intervention that is individualized, addresses IMB factors common among all smokers, and also addresses IMB factors unique to this population.

HIV prevalence, risk behavior, knowledge, and beliefs among women seeking care at a sexually transmitted infection clinic in Mumbai, India.

Three hundred women presenting to a sexually transmitted infection (STI) clinic in Mumbai, India were surveyed and HIV tested. Thirty-nine percent were HIV infected; 80% were current sex workers, and HIV infection was not significantly associated with past-year sex work. Only 44% always used condoms with their noncommercial sex partners. Most believed that condom preparation is a male responsibility (58%); that condom use is a sign that partner trust is lacking (84%); and that if a woman asks her partner to use a condom, he will lose respect for her (65%). All women at STI clinics in India need HIV testing and culturally sensitive risk interventions.

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).

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.

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.

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.

Impact of adherence counseling dose on antiretroviral adherence and HIV viral load among HIV-infected methadone maintained drug users.

Adherence counseling can improve antiretroviral adherence and related health outcomes in HIV-infected individuals. However, little is known about how much counseling is necessary to achieve clinically significant effects. We investigated antiretroviral adherence and HIV viral load relative to the number of hours of adherence counseling received by 60 HIV-infected drug users participating in a trial of directly observed antiretroviral therapy delivered in methadone clinics. Our adherence counseling intervention combined motivational interviewing and cognitive-behavioral counseling, was designed to include six 30 minute individual counseling sessions with unlimited "booster" sessions, and was offered to all participants in the parent trial. We found that, among those who participated in adherence counseling, dose of counseling had a significant positive relationship with antiretroviral adherence measured after the conclusion of counseling. Specifically, a liner mixed-effects model revealed that each additional hour of counseling was significantly associated with a 20% increase in post-counseling adherence. However, the number of cumulative adherence counseling hours was not significantly associated with HIV viral load, also measured after the conclusion of counseling. Our findings suggest that more intensive adherence counseling interventions may have a greater impact on antiretroviral adherence than less intensive interventions; however, it remains unknown how much counseling is required to impact HIV viral load.

Strategies to improve access to and utilization of health care services and adherence to antiretroviral therapy among HIV-infected drug users.

We review five innovative strategies to improve access, utilization, and adherence for HIV-infected drug users and suggest areas that need further attention. In addition, we highlight two innovative programs. The first increases access and utilization through integrated HIV and opioid addiction treatment with buprenorphine in a community health center, and the second incorporates adherence counseling for antiretroviral therapy in methadone programs. Preliminary evaluations demonstrated that these strategies may improve both HIV and opioid addiction outcomes and may be appropriate for wider dissemination. Further refinement and expansion of strategies to improve outcomes of HIV-infected drug users is 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.

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.

Self-efficacy and depression as mediators of the relationship between pain and antiretroviral adherence.

The goals of this study were to examine the association between pain and antiretroviral adherence and to estimate the mediating effect of adherence self-efficacy and depression symptom severity. Surveys using audio computer-assisted self-interview were conducted among 70 HIV-infected current and former drug users enrolled in a methadone program. We assessed antiretroviral adherence and adherence self-efficacy using questions from the Adult Clinical Trials Group survey. We considered participants adherent if they reported taking at least 95% of prescribed antiretrovirals over the past seven days. We assessed depression symptom severity using the depression subscale of the Brief Symptom Inventory. Participants reported pain of any duration in response to a question from the Brief Pain Inventory. Participants reporting pain were 87% less likely to be classified as adherent compared to those without pain (Unadjusted OR = 0.13, 95%CI: 0.03-0.52). When we examined adherence self-efficacy as a mediator of the relationship between pain and adherence, criteria for partial mediation were met. Adjusting for self-efficacy, the beta coefficient for pain decreased by 23% but the independent relationship between pain and antiretroviral adherence was maintained. Mediation criteria were not met when we examined the mediating effect of depression symptom severity on the relationship between pain and adherence. Adjusting for depression symptom severity, the beta coefficient for pain decreased by 9% and the relationship between pain and antiretroviral adherence remained significant. Our results indicate that neither adherence self-efficacy nor depression symptom severity fully mediated the relationship between pain and adherence. HIV providers should recognize the potential impact of pain on antiretroviral adherence among current and former drug users.