Zullig KJ, Lander LR, Tuscano M, Hobbs GR, Faulkenberry L (2018) Incorporating Mindfulness-Based Relapse Prevention into Outpatient Therapy for Treatment of Opioid Use Disorder with Medication-Assisted Treatment. Ann Community Med Pract 4(1): 1032.

West Virginia leads the United States (US) in drug overdose deaths with overdoses occurring at a rate of 52 per 100,000 people [1]. The greatest number of overdoses is due to opioid misuse [2]. Being diagnosed with a substance use disorder still carries a high burden of stigma. That, combined with the rural nature of West Virginia, results in inadequate treatment resources. It is estimated that over 152,000 West Virginians have a substance abuse problem [3], but only a small portion of those individuals receive treatment. Currently medication-assisted treatment (MAT) with buprenorphine is the treatment of choice endorsed by the US Substance Abuse and Mental Health Services Administration (SAMHSA) for opioid use disorders.

In August of 2016, the US Department of Health and Human Services (HHS) increased access to MAT with buprenorphine by allowing eligible practitioners to request approval to treat up to 275 patients. This has major implications for the expansion of MAT at both the national and state level. While SAMHSA endorses that MAT be a combination of medication, counseling, and behavioral therapy, there are no specific recommendations as to what form of counseling or behavioral therapy is most effective for individuals with opioid use disorders. One of the confounding factors in identifying effective interventions with individuals with substance use disorders is that approximately 40% of individuals presenting with substance use disorders also have a co-occurring mental health diagnosis according to the 2014 National Survey on Drug Use and Health [4]. Therefore, integrating and adapting effective evidenced-based treatments into MAT has the potential to improve outcomes and decrease rates of relapse and overdose.

Systematic reviews of the efficacy of mindfulness as an adjunct treatment for substance use disorders suggest two primary models for preventing relapse among those with substance abuse: Mindfulness-Based Relapse Prevention [5,6], and Mindfulness Oriented Recovery Enhancement [7- 9]. Conceptually, mindfulness addresses the relapse cycle by cultivating the awareness of triggers, attending mindfully to the discomforts the triggers elicit, and teaching targeted skills in dealing with craving. By shifting the non-judging attention to the direct experience of sensations, thoughts, and emotions and away from the reactions, stories and judgments of what are often painful experiences, the automatic and habitual reactions are broken, enabling recovery.

Despite evidence of the efficacy of mindfulness as an evidence-based adjunctive treatment for substance use disorders[6,10,11], little research has been conducted to test the effectiveness of Mindfulness-Based Relapse Prevention (MBRP) in a naturalistic outpatient setting for those in recovery from opioid use disorder receiving medication-assisted treatment. MBRP is designed to be most effective after initial stabilization in treatment has been established, integrating mindfulness practices with cognitive-behavioral relapse prevention to maintain treatment gains and develop a lifestyle further supporting well-being and recovery.

With this goal in mind,in a project funded by the US Centers for Disease Control and Prevention,this research team is testing the effectiveness of MBRP in a naturalistic outpatient setting for those in recovery from opioid use disorder receiving medication-assisted treatment (IRB Protocol # 1708720058R001). Using a quasi-experimental design, participants self-select into the treatment (MBRP) or comparison groups (treatment as usual). The outcomes tracked include 1) participants’ retention in substance abuse treatment, 2) participants’ relapse on any prohibited substance, 3) participant’s time to relapse, 4) participants’ self-reported craving, anxiety, and depression levels; and 5) participants’ self-reported mindfulness.In the MBRP group, participants attend a biweekly 60-minute session for 24 weeks led by a licensed therapist who is part of our research team.Measures are administered at baseline, 12 weeks, 24 weeks, and 36 weekspost-intervention. Participants receive a $10 gift card each time they complete the measures for a total of $40 if they complete the study.

Preliminary evidence suggests that MBRP can be successfully incorporated as a potential outpatient therapy for treatment of opioid use disorder with MAT, which has not been previously explored.Our first group of participants completed the 24-week MBRP Intervention recently providing us with our first study measures estimates.The preliminary retention rate for MBRP participants is 77% (10 of 13 participants retained) and 89% (17 of 19 participants retained) for comparison participants.The rate of relapse for MBRP participants is 23% (3 relapses) and 63% (12 relapses) for comparison participants. One person in the comparison group relapsed five times, which impacted this calculation.All relapses were on non-opioids.For the self-report measures, only limited data is available at this time from baseline to 12-weeks (mid-intervention) and thus inferential statistics have not yet been calculated owing to the limited sample size. However, in examining frequencies for the self-report measures from baseline to 12-weeks, Drug Craving, Anxiety, and Depression are decreasing in both groups, but decreasing more rapidly in the MBRP group.This is paired against increasing Mindfulness in the MBRP group and no change in the comparison group, as expected.

Although it is still early in the project, preliminary findings are encouraging for MBRP as an effective outpatient therapy with MAT for those suffering from opioid use disorder.Integrating and adapting effective evidenced-based treatments into MAT has the potential to improve outcomes and decrease rates of relapse and overdose. This project aims to further explore the effectiveness of MBRP with individuals in MAT. If found to be effective, our intention is to work with theWest Virignia Bureau for Behavioral Health and Health Facilities to integrate MBRP into MAT programs around the state. Currently both state and federal resources are available to expand MAT, yet no standard of counseling or behavioral therapy has been established as most complimentary to MAT. Thus, the results of this study are likely to contribute critical new knowledge and to improve the practice of psychosocial treatment delivery for individuals in MAT, especially for those with co-occurring disorders.

This editorial was supported by Grant Number, 6R49CE002109-05-06, funded by the US Centers for Disease Control and Prevention.Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.

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