Implicit opioid associations in OUD treatment: prediction of treatment response and moderation by mindfulness-oriented recovery enhancement

Abstract Background Substance use is sustained partly through implicit associations toward drugs – i.e. automatic positive attitudes and motivational responses toward drug-related cues. Such implicit associations may be inferred by behavioral measures that capture the relative ease, speed, or priming of those associations. However, implicit opioid associations in patients with opioid use disorder (OUD) remain underexplored, and it is unknown whether mindfulness-based interventions such as Mindfulness-Oriented Recovery Enhancement (MORE) can modify implicit associations to support recovery. Methods We conducted secondary analyses of data from a clinical trial of adults with OUD (N = 154), randomized to either methadone treatment as usual (TAU) or TAU plus MORE. Participants completed an opioid implicit association test (IAT) at baseline. Days of opioid use were tracked over 16 weeks. Data were analyzed using logistic and zero-inflated negative binomial (ZINB) regressions to examine the impact of baseline IAT scores on future opioid use and MORE’s moderating effect. Results In the TAU group, each 1-unit increase in IAT D score was associated with a 216% increase in the odds of opioid use (OR = 3.16, p = 0.049). However, in the MORE group, IAT scores were not significantly associated with future opioid use (OR = 0.58, p = 0.57). ZINB analysis revealed that each 1-unit increase in IAT D score predicted 0.96 fewer days of use in MORE relative to TAU (B = –1.25; SE = 0.58; p = 0.030). Conclusions Implicit attitudes toward opioids predicted higher opioid use among individuals receiving methadone. However, MORE attenuated this relationship and may counteract automatic cognitive biases that sustain opioid use.