Promoting Retention in Opioid Treatment among Women Experiencing Intimate Partner Violence: A Novel Stepped Care Model Targeting PTSD

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Abstract Women with opioid use disorder (OUD) are disproportionately impacted by intimate partner violence (IPV) and PTSD, with up to 78% of women receiving medication for opioid use disorder (MOUD) treatment experiencing IPV in the past 6 months. Regardless of PTSD diagnosis, 72%-78% of W-IPV experience clinically significant PTSD-related impairment in functioning. PTSD reduces treatment retention. Interventions effectively target PTSD to reduce substance, but many are not advised for IPV because they are exposure-based therapies for trauma that occurred in the past – not for trauma that is ongoing, as with IPV. Integrated interventions for other health conditions improve outcomes for MOUD treatment, yet no evidence-based treatments exist that integrate a much-needed focus on IPV and PTSD into MOUD treatment. Present-Centered Therapy+ (PCT+) and Helping to Overcome PTSD through Empowerment (HOPE) are two evidence-based, manualized behavioral interventions designed for women experiencing IPV (W-IPV) to reduce PTSD symptoms and other trauma-related outcomes. PCT+ focuses on helping W-IPV cope with current stressors that arise from their traumatic experiences; it can be delivered in 8 sessions by nonclinical, professional staff who may be more available and affordable in MOUD treatment settings. Some women may not respond to PCT+ alone and need additional treatment. HOPE is an IPV-specific cognitive behavioral therapy delivered in 16 sessions by Master’s level therapists and incorporates empowerment and stabilization treatment models. Our innovative approach packages these two interventions in a stepped care model to create PCT+2HOPE. This phased study conducted in three MOUD treatment settings in the United States northeast will be guided by the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. We will explore, prepare for, and then implement a randomized controlled trial to evaluate PCT+2HOPE versus treatment as usual while collecting data relevant for informing future sustainment. We will elicit input from W-IPV as well as direct service and supervisory staff to inform: protocols for systematically identifying IPV in OUD treatment settings, processes for referral to domestic violence service providers, and adaptation of the PCT+ and HOPE interventions (R33 phase). Then, we will evaluate the impact of PCT+2HOPE on promoting retention in MOUD treatment while improving secondary outcomes (e.g, PTSD, IPV, client-defined recovery) (R61 phase). We will explore whether the effectiveness of the interventions differ across and within racial and ethnic groups and based on SDOH. Building on established partnerships, our interdisciplinary study team includes community- based OUD and domestic violence service providers, and academic partners with expertise in IPV, PTSD and OUD-related care; addiction medicine; clinical trials with adaptive designs; community-partnered research; health disparities; and implementation science. Our study has potential for high impact by generating data on a reproducible and scalable approach that may transform treatment for the unique needs of W-IPV with OUD.