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Background: Interventions that promote healthy lifestyles are critical for the prevention of Alzheimer's disease and Alzheimer's disease related dementias (AD/ADRD). However, knowledge of the best practices for implementing AD/ADRD prevention in healthcare settings remains limited. Objective: We aimed to qualitatively identify barriers and facilitators to implementing a clinical trial of a novel lifestyle intervention (My Healthy Brain) in our medical center for older patients with subjective cognitive decline who are at-risk for AD/ADRD. Methods: We conducted focus groups with 26 healthcare professionals (e.g., physicians, psychology, nursing) from 5 clinics that treat older patients (e.g., memory care, psychiatry). Our qualitative analysis integrated two implementation frameworks to systematically capture barriers and facilitators to AD/ADRD prevention (Consolidated Framework for Implementation Science Research) that impact implementation outcomes of acceptability, appropriateness, and feasibility (Proctor's framework). Results: We found widespread support for an RCT of My Healthy Brain and AD/ADRD prevention. Participants identified barriers related to patients (stigma, technological skills), providers (dismissiveness of "worried well," doubting capacity for behavior change), clinics (limited time and resources), and the larger healthcare system (underemphasis on prevention). Implementation strategies guided by Expert Recommendations for Implementing Change (ERIC) included: developing tailored materials, training staff, obtaining buy-in from leadership, addressing stigmatized language and practices, identifying "champions," and integrating with workflows and resources. Conclusions: The results will inform our recruitment, enrollment, and retention procedures to implement the first randomized clinical trial of My Healthy Brain. Our study provides a blueprint for addressing multi-level barriers to the implementation of AD/ADRD prevention for older patients in medical settings.
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Demencia , Grupos Focales , Humanos , Demencia/prevención & control , Masculino , Femenino , Anciano , Personal de Salud/educación , Enfermedad de Alzheimer/prevención & control , Estilo de Vida , Disfunción Cognitiva/prevención & control , Centros Médicos AcadémicosRESUMEN
BACKGROUND: Individuals in early recovery face significant biopsychosocial stressors causing a preponderance of negative affect. Novel interventions are needed to improve mood and well-being to support recovery. Positive Recovery Journaling (PRJ) combines elements of positive psychology, behavioral activation, and journaling to emphasize what is going right and to encourage small, positive steps that align with an individual's values to make life in recovery more rewarding and therefore more reinforcing. Our objective was to determine PRJ's feasibility, acceptability, and impact on a set of strengths-based, multidimensional aspects of recovery, including satisfaction with life, happiness with recovery, and commitment to sobriety. METHODS: The study randomized adults in substance-use disorder treatment (N = 81) to PRJ or control. Those in PRJ were asked to practice PRJ daily and complete online surveys for four weeks; those in the control group completed online surveys for four weeks. We used multi-level modelling to determine intercept and slope for feasibility and acceptability outcomes as well as to compare differences in recovery indicators between treatment and control at baseline and Weeks 2, 4, and 8. We conducted intention-to-treat and per-protocol analyses for each recovery indicator. RESULTS: Participants were 53 % female, and 26 % Black, Indigenous, People of Color (BIPOC) and mean age of 39 years. PRJ participants attended 71 % of groups and completed 56 % of the daily PRJ entries. Treatment and control groups rated their study tasks (PRJ for the treatment group, surveys for the control group) as equally easy; however, the PRJ group rated PRJ as significantly more satisfying, helpful, and pleasant. Treatment and control were not significantly different on any recovery indicator. In post hoc analyses, we found that for those with <90 days sobriety at baseline (51 %), PRJ had a statistically significant beneficial effect for satisfaction with life, happiness with recovery, and numerous secondary recovery indicators. DISCUSSION: Results suggest a positive impact of PRJ on numerous recovery indices for those in earliest recovery. Integrating PRJ into support services among those with <90 days sobriety could reinforce what is going well in recovery to encourage its continued maintenance and thereby improve treatment outcomes.
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Estudios de Factibilidad , Psicología Positiva , Trastornos Relacionados con Sustancias , Humanos , Femenino , Adulto , Masculino , Trastornos Relacionados con Sustancias/psicología , Trastornos Relacionados con Sustancias/rehabilitación , Trastornos Relacionados con Sustancias/terapia , Psicología Positiva/métodos , Persona de Mediana Edad , Satisfacción PersonalRESUMEN
INTRODUCTION: Racial and ethnic inequities persist in receipt of prenatal care, mental health services, and addiction treatment for pregnant and postpartum individuals with substance use disorder (SUD). Further qualitative work is needed to understand the intersectionality of racial and ethnic discrimination, stigma related to substance use, and gender bias on perinatal SUD care from the perspectives of affected individuals. METHODS: Peer interviewers conducted semi-structured qualitative interviews with recently pregnant people of color with SUD in Massachusetts to explore the impact of internalized, interpersonal, and structural racism on prenatal, birthing, and postpartum experiences. The study used a thematic analysis to generate the codebook and double coded transcripts, with an overall kappa coefficient of 0.89. Preliminary themes were triangulated with five participants to inform final theme development. RESULTS: The study includes 23 participants of diverse racial/ethnic backgrounds: 39% mixed race/ethnicity (including 9% with Native American ancestry), 30% Hispanic or Latinx, 26% Black/African American, 4% Asian. While participants frequently names racial and ethnic discrimination, both interpersonal and structural, as barriers to care, some participants attributed poor experiences to other marginalized identities and experiences, such as having a SUD. Three unique themes emerged from the participants' experiences: 1) Participants of color faced increased scrutiny and mistrust from clinicians and treatment programs; 2) Greater self-advocacy was required from individuals of color to counteract stereotypes and stigma; 3) Experiences related to SUD history and pregnancy status intersected with racism and gender bias to create distinct forms of discrimination. CONCLUSION: Pregnant and postpartum people of color affected by perinatal SUD faced pervasive mistrust and unequal standards of care from mostly white healthcare staff and treatment spaces, which negatively impacted their treatment access, addiction medication receipt, postpartum pain management, and ability to retain custody of their children. Key clinical interventions and policy changes identified by participants for antiracist action include personalizing anesthetic plans for adequate peripartum pain control, minimizing reproductive injustices in contraceptive counseling, and addressing misuse of toxicology testing to mitigate inequitable Child Protective Services (CPS) involvement and custody loss.
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Investigación Cualitativa , Racismo , Trastornos Relacionados con Sustancias , Humanos , Femenino , Embarazo , Massachusetts/epidemiología , Trastornos Relacionados con Sustancias/psicología , Trastornos Relacionados con Sustancias/etnología , Trastornos Relacionados con Sustancias/epidemiología , Adulto , Racismo/psicología , Estigma Social , Adulto Joven , Etnicidad/psicología , Complicaciones del Embarazo/etnología , Complicaciones del Embarazo/psicología , Complicaciones del Embarazo/epidemiología , Disparidades en Atención de Salud/etnologíaRESUMEN
BACKGROUND: Black adults who smoke and have HIV experience immense stressors (eg, racial discrimination and HIV stigma) that impede smoking cessation success and perpetuate smoking-related health disparities. These stressors also place Black adults who smoke and have HIV at an increased risk of elevated interoceptive stress (eg, anxiety and uncomfortable bodily sensations) and smoking to manage symptoms. In turn, this population is more likely to smoke to manage interoceptive stress, which contributes to worse HIV-related outcomes in this group. However, no specialized treatment exists to address smoking cessation, interoceptive stress, and HIV management for Black smokers with HIV. OBJECTIVE: This study aims to test a culturally adapted and novel mobile intervention that targets combustible cigarette smoking, HIV treatment engagement and adherence, and anxiety sensitivity (a proxy for difficulty and responsivity to interoceptive stress) among Black smokers with HIV (ie, Mobile Anxiety Sensitivity Program for Smoking and HIV [MASP+]). Various culturally tailored components of the app are being evaluated for their ability to help users quit smoking, manage physiological stress, and improve health care management. METHODS: This study is a pilot randomized controlled trial in which Black combustible cigarette smokers with HIV (N=72) are being recruited and randomly assigned to use either (1) the National Cancer Institute's QuitGuide app or (2) MASP+. Study procedures include a web-based prescreener; active intervention period for 6 weeks; smartphone-based assessments, including daily app-based ecological momentary assessments for 6 weeks (4 ecological momentary assessments each day); a video-based qualitative interview using Zoom Video Communications software at week 6 for participants in all study conditions; and smartphone-based follow-up assessments at 0, 1, 2 (quit date), 3, 4, 5, 6, and 28 weeks postbaseline (26 weeks postquitting date). RESULTS: Primary outcomes include biochemically verified 7-day point prevalence of abstinence, HIV-related quality of life, use of antiretroviral therapy, and HIV care appointment adherence at 26 weeks postquitting date. Qualitative data are also being collected and assessed to obtain feedback that will guide further tailoring of app content and evaluation of efficacy. CONCLUSIONS: The results of this study will determine whether the MASP+ app serves as a successful aid for combustible cigarette smoking cessation, HIV treatment engagement, and physiological stress outcomes among Black people with HIV infection. If successful, this study will provide evidence for the efficacy of a new means of addressing major mental and physical health difficulties for this high-risk population. If the results are promising, the data from this study will be used to update and tailor the MASP+ app for testing in a fully powered randomized controlled trial that will evaluate its efficacy in real-world behavioral health and social service settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT05709002; https://clinicaltrials.gov/study/NCT05709002. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/52090.
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Negro o Afroamericano , Infecciones por VIH , Aplicaciones Móviles , Cese del Hábito de Fumar , Telemedicina , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Negro o Afroamericano/psicología , Infecciones por VIH/psicología , Proyectos Piloto , Fumadores/psicología , Cese del Hábito de Fumar/psicología , Cese del Hábito de Fumar/métodos , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
OBJECTIVE: The medical community has become aware of its role in contributing to the opioid epidemic and must be part of its resolution. Recovery community centers (RCCs) represent a new underused component of recovery support. METHODS: This study performed an online national survey of all RCCs identified in the United States, and used US Census ZIP code tabulation area data to describe the communities they serve. RESULTS: Residents of areas with RCCs were more likely to be Black (16.5% vs 12.6% nationally, P = 0.005) and less likely to be Asian (4.7% vs 5.7%, P = 0.005), American Indian, or Alaskan Native (0.6% vs 0.8%, P = 0.03), or live rurally (8.5% vs 14.0%, P < 0.0001). More than half of RCCs began operations within the past 5 years. Recovery community centers were operated, on average, by 8.8 paid and 10.2 volunteer staff; each RCC served a median of 125 individuals per month (4-1,500). Recovery community centers successfully engaged racial/ethnic minority groups (20.8% Hispanic, 22.5% Black) and young adults (23.5% younger than 25 years). Recovery community centers provide addiction-specific support (eg, mutual help, recovery coaching) and assistance with basic needs, social services, technology access, and health behaviors. Regarding medications for opioid use disorder (MOUDs), RCC staff engaged members in conversations about MOUDs (85.2%) and provided direct support for taking MOUD (77.0%). One third (36.1%) of RCCs reported seeking closer collaboration with prescribers. CONCLUSIONS: Recovery community centers are welcoming environments for people who take MOUDs. Closer collaboration between the medical community and community-based peer-led RCCs may lead to significantly improved reach of efforts to end the opioid epidemic.
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Trastornos Relacionados con Opioides , Humanos , Estados Unidos , Adulto , Masculino , Trastornos Relacionados con Opioides/rehabilitación , Trastornos Relacionados con Opioides/epidemiología , Femenino , Trastornos Relacionados con Sustancias/rehabilitación , Trastornos Relacionados con Sustancias/epidemiología , Encuestas y Cuestionarios , Persona de Mediana EdadRESUMEN
OBJECTIVE: The aim of the study is to explore the early parenting experiences among a cohort of postpartum individuals with opioid use disorder (OUD) both during and after the delivery hospitalization to identify areas of intervention to strengthen bonding and attachment. METHODS: Semistructured qualitative interviews with recently pregnant people with OUD assessed parenting needs, supports, and goals in the context of the demands of addiction treatment and early motherhood. Probes explored the relationship between early parenting experiences, addiction, and recovery, as well as enabling factors and barriers to mother-infant bonding. Interviews were completed between 2019 to 2020. A constant comparative methods approach was used for codebook development and analysis. RESULTS: Twenty-six women completed interviews a mean of 10.1 months postpartum. Twenty-four women were receiving methadone or buprenorphine treatment at delivery for OUD. Four interrelated themes emerged. Women experienced the following: (1) increased surveillance from healthcare workers who doubted their parenting ability; (2) a desire for a "normal" early parenting experience that was not disrupted by increased medical monitoring and surveillance; (3) complex and intersecting identities of being both a mother and a person in recovery; and (4) the importance of support from and advocacy by clinicians and peers to developing maternal confidence and connection. CONCLUSIONS: Interventions are needed to improve the early parenting experiences of opioid-exposed mother-infant dyads, to address the mutual mistrust between health care providers and parents, and to provide additional supports to families. Promotion of positive attachment and parental self-efficacy should be prioritized over increased surveillance and scrutiny to sustain maternal recovery trajectories into early childhood and foster family well-being.
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Madres , Trastornos Relacionados con Opioides , Lactante , Embarazo , Femenino , Humanos , Preescolar , Responsabilidad Parental , Trastornos Relacionados con Opioides/tratamiento farmacológico , Metadona/uso terapéutico , Atención a la SaludRESUMEN
Objective/Background: Sleep disturbance is a common and underappreciated feature of diabetes and sleep may contribute to glycemic control in people with type 2 diabetes (T2D). We conducted a 3-month trial to examine the efficacy of suvorexant in improving sleep and health outcomes in people with suboptimally controlled T2D and insomnia. Participants/Methods: This parallel, double-blind, randomized placebo-controlled trial was conducted using the sequential parallel comparison design (SPCD). Sixty-nine people with poorly controlled T2D (HbA1c ≥ 6.5) were randomized to placebo and/or suvorexant (10-20 mg). The primary outcome was subjective total sleep time (sTST), and secondary outcomes were Insomnia Severity Index (ISI) score and wake time after sleep onset (WASO). Exploratory outcomes included sleep efficiency, hemoglobin A1c (HbA1c), and C-reactive protein (CRP). Exploratory analyses were conducted on relationships between sleep and diabetes outcomes. Results: There were no significant improvements in sTST (p = 0.27), ISI (p = 0.86), or WASO (p = 0.94) among participants taking suvorexant compared to placebo. There were also no significant changes in any of the exploratory endpoints. Improvements in sleep were associated with improvements in both objective (ie, HbA1c) and subjective (ie, Diabetes Distress Scale) measures of diabetes, as well as reductions in depressive symptoms, independent of treatment assignment. Conclusion: The study did not find evidence that suvorexant is efficacious for insomnia in people with poorly controlled T2D. The associations of improved sleep with improvements in both diabetes-related metrics and depressive symptoms across groups highlight the importance of identifying and treating sleeping difficulties in this population. CT Registration #: Nct03818581.
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Objective: To evaluate feasibility, acceptability, and preliminary efficacy of heated yoga to treat moderate-to-severe depression.Design: An 8-week randomized controlled trial (RCT) of heated yoga versus waitlist control was conducted from March 2017 to August 2019.Methods: Participants in the yoga condition were asked to attend heated yoga classes at 2 community heated yoga studios at least twice weekly. We assessed acceptability and feasibility using exit interview and attendance data, respectively. The primary intervention efficacy outcome variable was change in the Inventory of Depressive Symptomatology-Clinician Rated (IDS-CR) score from baseline to post-intervention (week 8).Results: We randomized 80 participants and included 65 (mean [± SD] age 32.7 [± 11.7] years; 81.5% female) in the analyses (yoga n = 33, waitlist n = 32). The mean IDS-CR score at baseline was 35.6 (± 7.9) for the full sample, 36.9 (± 8.8) for yoga participants, and 34.4 (± 6.7) for waitlist participants. Participants attended an average of 10.3 (± 7.1) total classes over the 8-week intervention period. Yoga participants had a significantly greater pre- to post-intervention reduction in IDS-CR scores than waitlist participants (Cohen d = 1.04, P < .001). More yoga participants (59.3%; n = 16) than waitlist participants (6.3%; n = 2) evidenced larger treatment responses (IDS-CR ≥ 50% decrease in symptoms). Participants rated the heated yoga and its aftereffects positively in exit interviews.Conclusions: Approximately 1 heated yoga session per week (mean of 10.3 classes over 8 weeks) was associated with significantly greater reduction in depression symptoms than a waitlist control. Participants rated heated yoga positively. Taken together, results suggest feasibility, acceptability, and preliminary efficacy for patients with depression and warrant further research using active control conditions.Trial Registration: ClinicalTrials.gov identifier: NCT02607514.
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Depresión , Yoga , Adulto , Femenino , Humanos , Masculino , Depresión/terapiaRESUMEN
BACKGROUND: Mutual-help organizations (MHOs) play a crucial role for many individuals with alcohol use disorder (AUD) or other substance use disorders in achieving stable remission. While there is now substantial research characterizing who uses 12-step MHOs, very little is known about who becomes affiliated with newer and rapidly growing MHOs, such as Self-Management and Recovery Training ("SMART" Recovery). More research could inform knowledge regarding who may be best engaged by these differing pathways. METHODS: We conducted a cross-sectional analysis of participants (N = 361) with AUD recruited mostly from the community who were starting a new recovery attempt and self-selected into one of four different recovery paths: (1) SMART Recovery ("SMART-only"; n = 75); (2) Alcoholics Anonymous ("AA-only"; n = 73); (3) Both SMART and AA ("Both"; n = 53); and (4) Neither SMART nor AA ("Neither"; n = 160). We compared the groups on demographics, clinical history, treatment and recovery support service use, and indices of functioning and well-being. We computed descriptives and conducted inferential analyses according to the data structure. RESULTS: Compared to study participants choosing AA-only or Both, SMART-only participants were more likely to be White, married, have higher income and more education, be full-time employed, and evince a pattern of lower clinical severity characterized by less lifetime and recent treatment and recovery support services usage, lower alcohol use intensity and fewer consequences, and less legal involvement. AUD symptom levels, lifetime psychiatric diagnoses, psychiatric distress, and functioning were similar across MHO-engaged groups. CONCLUSION: SMART Recovery appears to attract individuals with greater psychosocial stability and economic advantage and less severe histories of alcohol-related impairment and legal involvement. Findings suggest that certain aspects specific to the SMART Recovery group approach, format, and/or contents may appeal to individuals exhibiting this type of profile. As such, SMART appears to provide an additional resource that expands the repertoire of options for individuals with AUD who seek recovery.
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BACKGROUND: As greater numbers of states in the United States and countries in the world continue to legalize cannabis for medical use, it has become increasingly important to assess patterns of cannabis use in individuals using cannabis for medical symptoms over time. A public health concern is that, like recreational cannabis, some individuals using cannabis for medical reasons may develop detrimental patterns of use, leading to the development of a cannabis use disorder (CUD). METHODS: In a 9-month longitudinal cohort study following a 12-week randomized, waitlist-controlled trial in 149 adults who used cannabis to alleviate insomnia, pain, depressed mood, or anxiety (RCT: NCT03224468), we assessed whether patterns of cannabis use for the 9 months following the RCT were associated with the development of CUD. RESULTS: We identified five unique trajectories of use; 31 participants (21%) had low stable or no use, 50 (34%) had medium stable use, 19 (13%) had high stable use, 26 (17%) showed de-escalating and 23 (15%) showed escalating use over 9 months following the RCT. Of 149 participants enrolled, 19 (13%) met diagnostic criteria for CUD at 12 months. Only the escalating cannabis use pattern predicted significantly higher rates of CUD compared to the low or no use category (OR = 4.29, 95% CI = 1.21 to 10.87, p = 0.02). CONCLUSIONS: These data indicate that most individuals using cannabis for medical symptoms have a stable pattern of use over the first year. Escalation of use may be a detrimental pattern that warrants further concern.
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Cannabis , Abuso de Marihuana , Trastornos Relacionados con Sustancias , Adulto , Humanos , Estados Unidos/epidemiología , Abuso de Marihuana/epidemiología , Abuso de Marihuana/diagnóstico , Estudios Longitudinales , Trastornos de AnsiedadRESUMEN
Background: Evidence for long-term effectiveness of commercial cannabis products used to treat medical symptoms is inconsistent, despite increasingly widespread use. Objective: To prospectively evaluate the effects of using cannabis on self-reported symptoms of pain, insomnia, anxiety, depression, and cannabis use disorder (CUD) after 12 months of use. Methods: This observational cohort study describes outcomes over 9 months following a 12-week randomized, waitlist-controlled trial (RCT: NCT03224468) in which adults (N = 163) who wished to use cannabis to alleviate insomnia, pain, depression, or anxiety symptoms were randomly assigned to obtain a medical marijuana card immediately (immediate card acquisition group) or to delay obtaining a card for 12 weeks delay (delayed card acquisition group). During the 9-month post-randomization period, all participants could use cannabis as they wished and choose their cannabis products, doses, and frequency of use. Insomnia, pain, depression, anxiety, and CUD symptoms were assessed over the 9-month post-randomization period. Results: After 12 months of using cannabis for medical symptoms, 11.7% of all participants (n = 19), and 17.1% of those using cannabis daily or near-daily (n = 6) developed CUD. Frequency of cannabis use was positively correlated with pain severity and number of CUD symptoms, but not significantly associated with severity of self-reported insomnia, depression, or anxiety symptoms. Depression scores improved throughout the 9 months in all participants, regardless of cannabis use frequency. Conclusions: Frequency of cannabis use was not associated with improved pain, anxiety, or depression symptoms but was associated with new-onset cannabis use disorder in a significant minority of participants. Daily or near-daily cannabis use appears to have little benefit for these symptoms after 12 months of use.
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BACKGROUND: Nondaily smoking is a widespread, increasingly prevalent pattern of smoking, particularly in ethnic minority and vulnerable populations. To date, no effective treatment approach for this type of smokers has been identified. OBJECTIVE: This study aims to use a randomized controlled trial to evaluate proof-of-concept markers of the Smiling instead of Smoking (SiS) app, a smoking cessation smartphone app designed specifically for nondaily smokers. This app was developed iteratively and is now in its third version. Previous studies have demonstrated acceptability and feasibility when participants were onboarded in person (study 1) and remotely (study 2) and showed within-person changes in line with hypothesized mechanisms of change. This is the first randomized test of this app. METHODS: In total, 225 adult nondaily smokers will be asked to undertake a quit attempt while using smoking cessation support materials for a period of 7 weeks. Participants will be randomized to use the SiS smartphone app, the National Cancer Institute smartphone app QuitGuide, or the National Cancer Institute smoking cessation brochure "Clearing the Air." Participants will take part in a 15-minute scripted onboarding phone call during which study staff will introduce participants to their support materials. Survey links will be sent 2, 6, 12, and 24 weeks after the participants' initially chosen quit date. The primary outcome is self-efficacy to remain abstinent from smoking at treatment end, measured using the Smoking Self-Efficacy Questionnaire. Secondary outcomes cover several domains relevant to treatment development and implementation: treatment acceptability (eg, satisfaction with smoking cessation support, measured using the Client Satisfaction Questionnaire, and app usability, measured using the System Usability Scale); treatment feasibility (eg, measured using the number of days participants used the SiS or QuitGuide app during the prescribed treatment period); and, in an exploratory way, treatment efficacy assessed using self-reported 30-day point prevalence abstinence. RESULTS: Recruitment began in January 2021 and ended June 2022. The final 24-week follow-up was completed in January 2023. This trial is funded by the American Cancer Society. CONCLUSIONS: This study is designed to test whether the prescribed use of the SiS app results in greater self-efficacy to abstain from smoking in nondaily smokers than commonly recommended alternative treatments and whether the SiS app treatment is acceptable and feasible. Positive results will mean that the SiS app warrants testing in a large-scale randomized controlled trial to test its effectiveness in supporting smoking cessation in nondaily smokers. The design of this study also provides insights into issues pertinent to smoking cessation smartphone app treatment development and implementation by measuring, in a randomized design, markers of treatment satisfaction, engagement with the technology and content of the treatment, and adherence to the treatment plan. TRIAL REGISTRATION: ClinicalTrials.gov NCT04672239; https://clinicaltrials.gov/ct2/show/NCT04672239. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/40867.
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INTRODUCTION: Alcohol use disorder (AUD) remains one of the most pervasive of all psychiatric illnesses conferring a massive health and economic burden. In addition to professional treatments to address AUD, mutual-help organisations such as Alcoholics Anonymous (AA) and newer entities like Self-Management and Recovery Training (SMART Recovery) play increasingly important roles in many societies. While much is known about the positive effects of AA, very little is known about SMART. Hence, this study seeks to estimate real-world patterns of utilisation and benefit from SMART Recovery as well as explore for whom (moderators) and how (mechanisms) SMART confers recovery benefits. METHODS AND ANALYSIS: Naturalistic, longitudinal, cohort study (n=368) of individuals with AUD recruited between February 2019 and February 2022, initiating a new recovery attempt who self-select into one of four groups at study entry: (1) SMART Recovery; (2) AA; (3) SMART+AA; (4) Neither SMART nor AA; (stratified by Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5) severity markers), with assessments conducted at intake, and 3 months, 6 months, 9 months, 12 months, 18 months and 24 months. Primary outcomes are: frequency of SMART and AA meetings attendance; per cent days abstinent and per cent days heavy drinking. Secondary outcomes include psychiatric distress; quality of life and functioning. Moderator variables include sex/gender; race/ethnicity; spirituality. Mediational variables include social networks; coping skills; self-efficacy; impulsivity. Multivariable regression with propensity score matching will test for patterns of attendance and effects of participation over time on outcomes and test for mechanisms and moderators. ETHICS AND DISSEMINATION: This study involves human participants and was approved by the Massachusetts General Hospital Institutional Review Board (Protocol #: 2017P002029/PHS). Results will be published in peer-reviewed journals and presented at conferences. REGISTRATION: This is a non-randomised, naturalistic, longitudinal, cohort study, and thus was not registered in advance. Results, therefore, should be considered exploratory.
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Alcoholismo , Automanejo , Humanos , Alcoholismo/terapia , Alcoholismo/psicología , Estudios Longitudinales , Estudios de Cohortes , Calidad de VidaRESUMEN
People with HIV (PWH) smoke at higher rates compared with the general population and have lower cessation rates. The primary aim of this study was to examine the impact of the COVID-19 pandemic on smoking in PWH. A survey was administered to participants in two smoking cessation trials in the United States. Mean cigarettes per day was 13.9 (SD 8.6), and participants reported they had smoked on average for 30.93 years (SD 10.4). More than half (55.7%) of participants (N = 140) reported not changing their smoking during the pandemic, while 15% reported decreasing, and 25% reported increasing their smoking. In bivariate analyses, worrying about food due to lack of money (χ2 = 9.13, df 2, p = 0.01) and greater Covid-related worry (rs = 0.19, p = 0.02) were significantly associated with increased smoking. Qualitative research may be needed to more clearly elucidate factors related to smoking behaviors among PWH.
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COVID-19 , Infecciones por VIH , Humanos , Estados Unidos , Motivación , Pandemias , COVID-19/epidemiología , Infecciones por VIH/epidemiología , Fumar/epidemiologíaRESUMEN
Objective: Ketamine is a novel and rapidly acting treatment for major depressive disorder (MDD). Benzodiazepines are commonly coprescribed with antidepressants in MDD. This study sought to examine data from a randomized clinical trial that compared a single infusion of intravenous (IV) ketamine to midazolam placebo in treatment-resistant depression (DSM-IV-TR MDD) and to assess whether the use of concomitant oral benzodiazepines differentially affected treatment response to ketamine versus midazolam.Methods: This trial ran from December 2015 to December 2016. Subjects who were taking oral benzodiazepines (n = 44) were compared to those who were not (n = 55). A significant treatment-by-benzodiazepine effect could be interpreted as a possible moderator of differential treatment response to ketamine versus midazolam. Benzodiazepine use was examined as both a binary and a continuous predictor, to assess the impact of dosage.Results: Benzodiazepine users did not differ from non-users on the original study's primary outcome measure, score on the 6-item Hamilton Depression Rating Scale (HDRS-6), at baseline, but the former had more severe anxiety. When oral benzodiazepine use was modeled as a binary predictor, benzodiazepine use did not impact differential treatment response. However, when benzodiazepine dosage was considered, there was a significant impact of benzodiazepine use on differential treatment response. Oral benzodiazepines significantly impacted HDRS-6 (P = .018) and Clinical Global Impressions-Severity of Illness scale (CGI-S; P = .008) scores at day 1 (24 hours post treatment); effects were nonsignificant for all day 3 outcomes. Among ketamine subjects, higher doses of benzodiazepines were associated with less improvement in depression scores at day 1.Conclusions: Concomitant oral benzodiazepines at higher doses may attenuate the antidepressant effects of IV ketamine at day 1 but not day 3 post-infusion.Trial Registration: ClinicalTrials.gov identifier: NCT01920555.
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Trastorno Depresivo Mayor , Ketamina , Humanos , Ketamina/efectos adversos , Trastorno Depresivo Mayor/tratamiento farmacológico , Trastorno Depresivo Mayor/complicaciones , Benzodiazepinas/uso terapéutico , Midazolam/uso terapéutico , Antidepresivos/uso terapéutico , Método Doble Ciego , Resultado del Tratamiento , Infusiones IntravenosasRESUMEN
Objective: Optimism is an important factor impacting health and human functioning. Originally conceptualized as a trait, increasing evidence indicates that optimism can change over time and could be an intervention target. Measures are needed that can capture changes in optimism.Design: In this secondary analysis, we compared the performance of a newly developed state measure, the State Optimism Measure (SOM), to the widely used trait measure, the Life Orientation Test-Revised (LOT-R), in detecting changes over time during a disruptive life event: the onset of the COVID-19 pandemic in the United States.Main Outcome Measures: Participants (n = 81) were nondaily smokers participating in a smoking cessation intervention, who completed the SOM and LOT-R before and after the initial COVID-19 outbreak.Results: Optimism declined from pre- to post-COVID-19 outbreak, as assessed by both scales (LOT-R: p=.0147,gav=0.23; SOM: p<.0001,gav=0.56). The change detected was greater when measured by the SOM (p<.0001). Changes in optimism were correlated with concurrent changes in perceived stress, positive affect, and negative affect.Conclusion: Our results suggest that the SOM has a greater sensitivity to detect within-person changes in optimism than the LOT-R and highlight the SOM's utility for longitudinal studies assessing changes in optimism.
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INTRODUCTION: Medications to treat opioid use disorder (MOUD) during pregnancy and in the postpartum period remain underutilized. A need exists to enhance our understanding of modifiable factors, facilitators, and barriers to MOUD utilization and adherence in the perinatal period to improve maternal and child outcomes. METHODS: The study conducted semi-structured qualitative interviews with recently pregnant people with opioid use disorder (OUD) to explore experiences as a pregnant and/or parenting person with OUD, perceptions of enabling factors and barriers to treatment utilization, incentivizing factors for maintaining adherence, and acceptability of ongoing supports to sustain treatment adherence. The study team used constant comparative methods to analyze transcripts and develop the codebook. The team double coded the transcripts, with an overall kappa coefficient of 0.88. RESULTS: The study team interviewed twenty-six women on average 10.1 months after delivery. All women had some prior experience using MOUD. Four unique themes emerged as barriers to medication utilization and adherence in the perinatal period: 1) Lack of agency and autonomy surrounding medication decisions because pregnancy or parenting status affected treatment adherence; 2) Hesitancy to use MOUD to minimize risk of newborn withdrawal; 3) Concern about increased scrutiny and potential loss of custody due to mandated child protective services reporting for opioid-exposure at delivery in Massachusetts; and 4) Perception that treatment environments, particularly methadone clinics, did not provide gender-responsive or equitable care, and standardized, inflexible visit regulations were particularly difficult to comply with in the early postpartum period. CONCLUSIONS: Women with OUD experienced a double bind when making perinatal treatment decisions, describing pressure to use MOUD with negative consequences after delivery. Key areas for possible intervention emerged from interviews. These areas include improving uptake of shared decision-making to increase patient autonomy and agency, particularly among those in the earliest stages of recovery during pregnancy; ongoing education around perinatal MOUD safety and efficacy; detangling MOUD and neonatal withdrawal signs from mandated child protective services reporting; and improving gender-responsive and equitable care in substance use disorder treatment programs, including incorporating the utilization of home visiting services for dosing assessments and administration in the early postpartum period.
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Buprenorfina , Trastornos Relacionados con Opioides , Analgésicos Opioides/uso terapéutico , Buprenorfina/uso terapéutico , Niño , Miedo , Femenino , Humanos , Recién Nacido , Metadona/uso terapéutico , Tratamiento de Sustitución de Opiáceos/métodos , Trastornos Relacionados con Opioides/terapia , EmbarazoRESUMEN
CONTEXT: Racial/ethnic inequities are well documented in both maternal-infant health and substance use disorder treatment outcomes. OBJECTIVE: To systematically review research on maternal-infant dyads affected by opioid use disorder (OUD) to evaluate for racial/ethnic disparities in health utilization or outcomes and critically assess the reporting and inclusion of race/ethnicity data. DATA SOURCES: Peer-reviewed literature in MEDLINE, Embase, and Web of Science from 2000 to 2020. STUDY SELECTION: Research reporting health utilization and outcomes data on dyads affected by OUD during pregnancy through the infant's first birthday. DATA EXTRACTION: We extracted data on race/ethnicity, study exposures/outcomes, how race/ethnicity data were analyzed, how authors discussed findings associated with race/ethnicity, and whether racism was mentioned as an explanation for findings. RESULTS: Of 2023 articles reviewed, 152 quantitative and 17 qualitative studies were included. Among quantitative studies, 66% examined infant outcomes (n = 101). Three articles explicitly focused on evaluating racial/ethnic differences among dyads. Among quantitative studies, 112 mentioned race/ethnicity, 63 performed analyses assessing for differences between exposure groups, 27 identified racial/ethnic differences, 22 adjusted outcomes for race/ethnicity in multivariable analyses, and 11 presented adjusted models stratified by race/ethnicity. None of the qualitative studies addressed the role that race, ethnicity, or racism may have had on the presented themes. CONCLUSIONS: Few studies were designed to evaluate racial/ethnic inequities among maternal-infant dyads affected by OUD. Data on race/ethnicity have been poorly reported in this literature. To achieve health equity across perinatal OUD, researchers should prioritize the inclusion of marginalized groups to better address the role that structural racism plays.
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Equidad en Salud , Trastornos Relacionados con Opioides , Racismo , Etnicidad , Femenino , Humanos , Lactante , Embarazo , Estados UnidosRESUMEN
BACKGROUND: Recent evidence highlights the significant detrimental impact of nondaily smoking on health and its disproportionate prevalence in underserved populations; however, little work has been done to develop treatments specifically geared toward quitting nondaily smoking. OBJECTIVE: This study aims to test the feasibility, acceptability, and conceptual underpinnings of version 2 of the Smiling Instead of Smoking (SiS2) smartphone app, which was developed specifically for nondaily smokers and uses a positive psychology approach. METHODS: In a prospective, single-group study, nondaily smokers (N=100) were prescribed use of the SiS2 app for 7 weeks while undergoing a quit attempt. The app assigned daily positive psychology exercises and behavioral tasks every 2 to 3 days, which guided smokers through using the smoking cessation tools offered in the app. Participants answered surveys at baseline and at 2, 6, 12, and 24 weeks postquit. Feasibility was evaluated based on app use and acceptability based on survey responses. The underlying conceptual framework was tested by examining whether theorized within-person changes occurred from baseline to end of treatment on scales measuring self-efficacy, desire to smoke, and processing of self-relevant health information (ie, pros and cons of smoking, importance of the pros and cons of quitting, and motivation). RESULTS: Participants used the SiS2 app on an average of 24.7 (SD 13.8) days out of the 49 prescribed days. At the end of treatment, most participants rated the functions of the app as very easy to use (eg, 70/95, 74% regarding cigarette log and 59/95, 62% regarding happiness exercises). The average score on the System Usability Scale was 79.8 (SD 17.3; A grade; A+ ≥84.1, B+ <78.8). Most participants reported that the app helped them in their quit attempt (83/95, 87%), and helped them stay positive while quitting (78/95, 82%). Large effects were found for within-person decreases in the desire to smoke (b=-1.5, 95% CI -1.9 to -1.1; P<.001; gav=1.01), the importance of the pros of smoking (b=-20.7, 95% CI -27.2 to -14.3; P<.001; gav=0.83), and perceived psychoactive benefits of smoking (b=-0.8, 95% CI -1.0 to -0.5; P<.001; gav=0.80). Medium effects were found for increases in self-efficacy for remaining abstinent when encountering internal (b=13.1, 95% CI 7.6 to 18.7; P<.001; gav=0.53) and external (b=11.2, 95% CI 6.1 to 16.1; P<.001; gav=0.49) smoking cues. Smaller effects, contrary to expectations, were found for decreases in motivation to quit smoking (P=.005) and the perceived importance of the pros of quitting (P=.009). Self-reported 30-day point prevalence abstinence rates were 40%, 56%, and 56% at 6, 12, and 24 weeks after the quit day, respectively. CONCLUSIONS: The SiS2 app was feasible and acceptable, showed promising changes in constructs relevant to smoking cessation, and had high self-reported quit rates by nondaily smokers. The SiS2 app warrants testing in a randomized controlled trial.
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BACKGROUND: The postpartum year is a vulnerable period for women with opioid use disorder, with increased rates of fatal and nonfatal overdose; however, data on the continuation of medications for opioid use disorder on a population level are limited. OBJECTIVE: This study aimed to examine the effect of discontinuing methadone and buprenorphine in women with opioid use disorder in the year following delivery and determine the extent to which maternal and infant characteristics are associated with time to discontinuation of medications for opioid use disorder. STUDY DESIGN: This population-based retrospective cohort study used linked administrative data of 211,096 deliveries in Massachusetts between 2011 and 2014 to examine the adherence to medications for opioid use disorder. Individuals receiving medications for opioid use disorder after delivery were included in the study. Here, demographic, psychosocial, prenatal, and delivery characteristics are described. Kaplan-Meier survival analysis and Cox regression modeling were used to examine factors associated with medication discontinuation. RESULTS: A total of 2314 women who received medications for opioid use disorder at delivery were included in our study. Overall, 1484 women (64.1%) continued receiving medications for opioid use disorder for a full 12 months following delivery. The rate of continued medication use varied from 34% if women started on medications for opioid use disorder the month before delivery to 80% if the medications were used throughout pregnancy. Kaplan-Meier survival curves differed by maternal race and ethnicity (the 12-month continuation probability was .65 for White non-Hispanic women and .51 for non-White women; P<.001) and duration of use of prenatal medications for opioid use disorder (12-month continuation probability was .78 for women with full prenatal engagement and .60 and .44 for those receiving medications for opioid use disorder ≥5 months [but not throughout pregnancy] and ≤4 months prenatally, respectively; P<.001). In all multivariable models, duration of receipt of prenatal medications for opioid use disorder (≤4 months vs throughout pregnancy: adjusted hazard ratio, 3.26; 95% confidence interval, 2.72-3.91) and incarceration (incarceration during pregnancy or after delivery vs none: adjusted hazard ratio, 1.79; 95% confidence interval, 1.52-2.12) were most strongly associated with the discontinuation of medications for opioid use disorder. CONCLUSION: Almost two-thirds of women with opioid use disorder continued using medications for opioid use disorder for a full year after delivery; however, the rates of medication continuation varied significantly by race and ethnicity, degree of use of prenatal medications for opioid use disorder, and incarceration status. Prioritizing medication continuation across the perinatal continuum, enhancing sex-specific and family-friendly recovery supports, and expanding access to medications for opioid use disorder despite being incarcerated can help improve postpartum medication adherence.