Sustaining recovery for people on opioid agonist treatment with conversational agents

PROJECT SUMMARY/ABSTRACT Almost half of all people receiving buprenorphine for opioid use disorder discontinue treatment within the first year, due to substance use and medication stigma and other recovery challenges such as stress, emotional dysregulation, and social isolation. We aim to improve retention in buprenorphine treatment through a smartphone-delivered, stigma-informed recovery support intervention. We propose to develop embodied conversational agents (ECA), i.e., animated computer agents that simulate natural and intuitive face-to-face conversations, proven successful in several clinical trials in assisting people with health-related challenges. Intervention participants will be engaged to interact with the ECA and maximize its uptake so that they can better cope with stigma, stay connected with recovery services and continue to receive buprenorphine. The ECA will deliver an acceptance-based intervention originating in cognitive-behavioral therapy, delivering a combination of didactic components, educational stories, experiential activities, motivational interviewing and mindfulness exercises to help participants overcome negative thoughts and emotions related to internalized substance use and intervention stigma. ECA activities will be based on our recently completed acceptance- based stigma intervention, shown to increase care engagement of people with opioid use disorder. In instances where participants experience a crisis with increased relapse risks, a clinic dashboard will generate staff alerts prompting clinician outreach. In year one, we will co-design and pilot-test the ECA system involving 10 OBAT patients. Guided by usability engineering and health stigma frameworks, we will design ECA activities and the clinic dashboard to help people on MOUD respond more effectively to manifestations of stigma and build recovery capital. In years 2 and 3, we will conduct a multi-arm 3:1 randomized, controlled pilot study, enrolling 100 people initiating buprenorphine treatment in three intervention subgroups of 25 participants each. Intervention group participants will be engaged in ECA use with different strategies to maximize uptake and compared to 25 control participants receiving usual care at the BMC office–based addiction treatment clinic. We will estimate the ECA’s effects for the primary outcome of retention in buprenorphine treatment 12 months post randomization, assessed for all intervention participants vs. control participants and pairwise for each of the three subgroups vs the control group separately. Similarly, we will assess the intervention’s effects on adherence to buprenorphine and opioid use at 6 and 12 months; and on changes in stigma and recovery capital scores (exploratory outcomes). This project will also test processes, instruments, and interactions between users, the system and the OBAT clinic, informing a subsequently planned R01 hybrid type implementation and effectiveness RCT. By addressing stigma and recovery challenges, this intervention can help improve buprenorphine treatment retention and support long-term recovery from opioid-use disorder.