Shame among Sexual Violence Survivors in Opioid Use Disorder Treatment: Event-level and longitudinal effects on Cravings, Substance Use, and Treatment Engagement

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Project Summary Opioid use disorder (OUD) is a growing public health concern and has a high prevalence, morbidity, and mortality. Sexual violence (SV) and OUD co-occur at high rates. Among individuals with OUD, SV is associated with a severe clinical course (e.g., increased substance use) and poorer OUD treatment outcomes (e.g., premature discontinuation). Despite clear clinical relevance of the role of SV in OUD treatment, no studies have explicated mechanisms that contribute to the worsening of outcomes. One such mechanism is shame. Shame is pronounced among individuals in OUD treatment as well as those who have a history of SV. Operationalized as the emotional core of stigma, shame is cyclical in nature and fluctuates daily in response to internal and environmental cues. However, no study has evaluated the role of shame in relation to short-term (cravings, substance use, medication adherence, motivation for changing substance use, self-efficacy for changing substance use) and long-term clinical outcomes (number of appointments missed, treatment dropout) for individuals in OUD treatment, in the context of other factors that impact treatment (social support, psychological distress, prior treatment history, stressful events). The specific aims of the K99 phase of this K99/R00 are to 1) iteratively develop and refine an ecological momentary assessment (EMA) protocol among individuals with OUD treatment with a history of SV, which will facilitate formative work and training in EMA. To accomplish this aim, an initial EMA survey protocol will be developed based on prior literature, followed by a 30-day EMA pilot (n=20- 24, in two phases), which will be then followed by individual cognitive interviews to inform the final EMA measures and protocol in the R00 phase. The specific aim of the R00 phase is to identify the associations between momentary fluctuations in shame and short-term clinical outcomes as well as aggregate levels of shame and long-term clinical outcomes among a sample of 122 individuals engaged in OUD treatment with a lifetime history of SV, using EMA. Participants will complete baseline measures, 30 days of EMA, and follow-up assessments at 3- and 6 months. The PI, Dr. Bhuptani, will work with an experienced team of mentors with complementary areas of knowledge/expertise (Drs. Ana Abrantes, Jennifer Merrill, and Lindsay Orchowski) to develop expertise in three areas of training that are well-matched to the career goals of the PI, including (1) EMA methods and analysis, (2) measurement of OUD-specific outcomes, and (3) professional development skills. Successful completion of the research and training detailed in this proposal will prepare the PI to become an independent clinical scientist and develop a program of research focused on identifying mechanisms that impact clinical and treatment outcomes among individuals with comorbid substance use and trauma conditions. Identifying event- level associations between shame and clinical outcomes will be the first step in the development of just-in-time interventions to improve such outcomes.