Telehealth Mindfulness-Oriented Recovery Enhancement As an Adjunct to Methadone Maintenance Treatment: Proximal Outcomes from a RCT

Introduction: People with an OUD need effective treatments. Methadone maintenance treatment (MMT) is the most commonly prescribed medication for OUD, and particularly for communities of color from low socioeconomic contexts. Yet, 50% who begin MMT discontinue within a year, and 50% retained in MMT relapse within 6 months. Chronic pain and negative affective states, affecting most people on MMT, could be contributing to relapse. Novel interventions that address chronic pain, emotional distress, and opioid relapse among people on MMT are needed. Mindfulness-Oriented Recovery Enhancement (MORE) combines training in mindfulness, reappraisal, and savoring skills to target cognitive, affective, and behavioral mechanisms that lead to opioid relapse. To provide access to this evidence-based intervention during the COVID-19 pandemic, MORE has begun to be delivered through telehealth. Here, we conducted a NIH-funded randomized clinical trial (RCT) to test the efficacy of telehealth MORE for people with OUD and pain receiving MMT. Our central hypothesis is that MMT effectiveness will be enhanced by MORE.

Methods: This RCT (N=154) was conducted in methadone clinics in New Brunswick and Newark New Jersey, in a highly diverse sample where 49% of participants were either Black, Latinx, or another non-white race/ethnicity. Participants were randomized to telehealth MORE delivered over Zoom via tablets plus MMT treatment as usual (TAU) or TAU only at each clinic. Proximal outcomes were measured with ecological momentary assessments (EMA) of pain, stress, positive affect, craving, and relapse collected twice a day throughout the 8 weeks of treatment. Long-term drug use outcomes are still being collected for this trial, which is nearing completion.

Results: Nearly three-quarters of participants randomized to MORE received the minimal intervention dose (³ 4 MORE sessions). Compared to TAU, MORE led to significantly greater reductions in pain (B =-.007, SE =.001, p<.001) and stress (B=-.003, SE=.001, p=.014) from moment to moment. MORE also led to significantly greater increases in positive affect from moment to moment (B=.004, SE=.001, p<.001), and higher levels of positive affect predicted lower levels of opioid craving (B= -.227, SE = .01, p<.001). Participants in MORE reported being more aware of the triggers for their cravings (B= -.22, SE = .09, p=.029) and reported trying harder to stop themselves from using opioids in the wake of a craving (B=2.95, SE=1.24, p=.026). In contrast, participants in usual methadone treatment reported feeling more positive in response to cravings (B=2.28, SE = .64, p<.001). When they relapsed, participants in MORE tended to report less severe opioid relapses (i.e., a single episode of use) than participants in usual methadone treatment, who tended to describe their relapses as opioid binges (i.e., repeated use of opioids) (B=.53, SE=.25, p=.04).

Conclusions and Implications: Telehealth MORE appears to be a viable means of increasing access to MORE among vulnerable communities where social workers with specific training in evidence-based interventions are scarce. In this trial, MORE was efficacious for improving momentary pain and affective states - proximal factors known to be linked with long-term clinical outcomes among people with OUD.