Comparing CM and CBT
OUD, CM
DISORDER
Although both CM and CBT methods have the potential to improve medication adherence, CBT-based strategies have greater potential for dissemination than CM. Although CM is widely accepted as an efficacious treatment for substance use disorder and remains an accepted program for substance use cessation in the Veteran’s Administration system [In addition, it is possible that these complimentary strategies are differentially effective at different treatment stages. Evidence suggests that CM reward effects diminish, whereas CBT strategies gain momentum over time [While these long-term abstinence results are promising, the traditional CBT for substance use tested in these studies did not explicitly address mindfulness, delay discounting, or engagement with substance-free alternative activities and did not address medication adherence. Based on behavioral economic theory, brief motivational interviewing plus substance-free activities session plus mindfulness (BSM) could alter time orientation to value the future more and changing behavior to pursue drug-free rewards and manage cravings that are prevalent during treatment initiation. BSM is likely to be a critical mechanism to support medication adherence and promote recovery and can be delivered efficiently in a brief format.At this point, there is considerable evidence of the effectiveness of CM and the CBT strategies in BSM for substance use abstinence, but less compelling or complete evidence of how these methods address adherence to buprenorphine-naloxone, the current state of the science treatment for OUD [Our research team seeks to compare the effectiveness of these two different interventions for MOUD adherence by conducting a sequential multiple assignment randomized trial (SMART) to assess sequential, individual, and combined effects of these two forms of treatment across MOUD initiation and maintenance. We will randomize 280 buprenorphine-naloxone initiating patients to receive either CM or BSM for their first 4 physician visits for MOUD. Adherence will be established via attendance and toxicology screen. Participants who are adherent will enter maintenance intervention (remaining in their assigned intervention condition for up to 6 months). Those who are not adherent for the initial intervention period will be re-randomized to receive either the other intervention or a combined intervention and will then continue to receive this intervention for an additional 6 months.