Biopsychosocial contexts of timely and adequate prenatal care utilization among women with criminal legal involvement and opioid use disorder.

OBJECTIVE: Pregnant women with criminal legal involvement and opioid use disorder (CL-OUD) living in non-urban regions may be at risk for complex biomedical, psychological, and social barriers to prenatal care and healthy pregnancy. Yet, limited research has explored prenatal care utilization patterns among this subpopulation. This study describes the biopsychosocial factors of pregnant women with a history of criminal legal involvement and opioid use disorder (CL-OUD) associated with timely prenatal care initiation and adequate prenatal care utilization (APNCU). METHODS: Analyses were conducted on a subsample of medical record data from an observational comparative effectiveness study of medication treatment models for pregnant women with diagnosed opioid use disorder (OUD) who received prenatal care in Northern New England between 2015 and 2022. The subsample included women aged ≥ 16 years with documented criminal legal involvement. Analyses included χ2, Fisher exact tests, and multiple logistic regression to assess differences in timely prenatal care and APNCU associated with biopsychosocial factors selected by backwards stepwise regression. RESULTS: Among 317 women with CL-OUD, 203 (64.0%) received timely prenatal care and 174 (54.9%) received adequate care. Timely prenatal care was associated with having two or three prior pregnancies (aOR 2.37, 95% CI 1.07-5.20), receiving buprenorphine at care initiation (aOR 1.85, 95% CI 1.01-3.41), having stable housing (aOR 2.49, 95% CI 1.41-4.41), and being mandated to court diversion (aOR 4.06, 95% CI 1.54-10.7) or community supervision (aOR 2.05, 95% CI 1.16-3.63). APNCU was associated with having a pregnancy-related medical condition (aOR 2.17, 95% CI 1.27-3.71), receiving MOUD throughout the entire prenatal care period (aOR 3.40, 95% CI 1.45-7.94), having a higher number of psychiatric diagnoses (aOR 1.35, 95% CI 1.07-1.70), attending a rurally-located prenatal care practice (aOR 2.14, 95% CI 1.22-3.76), having stable housing (aOR 1.94, 95% CI 1.06-3.54), and being mandated to court diversion (aOR 3.11, 95% CI 1.19-8.15). CONCLUSION: While not causal, results suggest that timely and adequate prenatal care among women with CL-OUD may be supported by OUD treatment, comorbid indications for care, stable access to social resources, and maintained residence in the community (i.e., community-based alternatives to incarceration).

Integrated vs nonintegrated treatment for perinatal opioid use disorder: retrospective cohort study.

BACKGROUND: Pregnant women with opioid use disorder and their infants often experience worse perinatal outcomes than women without opioid use disorder, including longer hospitalizations after delivery and a higher risk for preterm delivery. Integrated treatment models, which combine addiction treatment and maternity care, represent an innovative approach that is widely endorsed, however, limited studies have compared the outcomes between integrated and standard, nonintegrated programs from real-world programs. OBJECTIVE: This study aimed to evaluate the perinatal and substance use outcomes for pregnant women with opioid use disorder receiving coordinated, colocated obstetrical care and opioid use disorder treatment (integrated treatment) and to compare it with those of women receiving obstetrical care and opioid use disorder treatment in distinct programs of care (nonintegrated treatment). STUDY DESIGN: In this observational, retrospective cohort study, we abstracted the perinatal and opioid use disorder treatment data from the records of pregnant women with opioid use disorder (n=225) who delivered at a rural, academic medical center from 2015 to 2017. The women either received integrated (n=92) or nonintegrated (n=133) opioid use disorder treatment and obstetrical care. Using inverse probability weighted regression models to adjust for a potential covariate imbalance, we evaluated the impact of the treatment model on the risk for preterm delivery and positive meconium or umbilical cord toxicology screens. We explored whether the number of obstetrical visits mediated this relationship by using a quasi-Bayesian Monte Carlo algorithm. RESULTS: Women receiving integrated treatment were less likely to deliver prematurely (11.8% vs 26.6%; P<.001) and their infants had shorter hospitalizations (6.5±4.8 vs 10.7±16.2 days). Using a robust inverse probability weighted model showed that receiving integrated treatment was associated with a 74.7% decrease in the predicted probability of preterm delivery (average treatment effect, -0.19; standard error, 0.14; P<.001). There were no differences in the risk for a positive meconium or umbilical cord toxicology screen, a marker for second and third trimester substance use, between women receiving integrated treatment and those receiving coordinated treatment (29.4% vs 34.6%; P=.41), however, integrated treatment was associated with significantly lower rates of positive maternal urine toxicology screens at the time of delivery (35.9% vs 74.4%; P<.001). CONCLUSION: Among a cohort of rural pregnant women with opioid use disorder, receiving integrated obstetrical care and opioid use disorder treatment was associated with a reduced risk for preterm birth, a lower risk for positive maternal urine toxicology screen at the time of delivery, and shorter infant hospitalization. This relationship was mediated by the number of obstetrical visits attended during pregnancy, suggesting that increased engagement with obstetrical care through integration of services may contribute to improved perinatal outcomes.

Workshop on Implementation Science and Digital Therapeutics for Behavioral Health.

Digital therapeutics can overcome many of the barriers to translation of evidence-based treatment for substance use, mental health, and other behavioral health conditions. Delivered via nearly ubiquitous platforms such as the web, smartphone applications, text messaging, and videoconferencing, digital therapeutics can transcend the time and geographic boundaries of traditional clinical settings so that individuals can access care when and where they need it. There is strong empirical support for digital therapeutic approaches for behavioral health, yet implementation science with regard to scaling use of digital therapeutics for behavioral health is still in its early stages. In this paper, we summarize the proceedings of a day-long workshop, "Implementation Science and Digital Therapeutics," sponsored and hosted by the Center for Technology and Behavioral Health at Dartmouth College. The Center for Technology and Behavioral Health is an interdisciplinary P30 Center of Excellence funded by the National Institute on Drug Abuse, with the mission of promoting state-of-the-technology and state-of-the-science for the development, evaluation, and sustainable implementation of digital therapeutic approaches for substance use and related conditions. Workshop presentations were grounded in current models of implementation science. Directions and opportunities for collaborative implementation science research to promote broad adoption of digital therapeutics for behavioral health are offered.

Effects of anxiety sensitivity on cannabis, alcohol, and nicotine use among adolescents: evaluating pathways through anxiety, withdrawal symptoms, and coping motives.

Anxiety sensitivity (AS) is a promising intervention target due to its relevance to negative health behaviors broadly, and substance use specifically. The aim of the current study was to evaluate the direct and indirect pathways through which elevated AS could relate to recent substance use among a national adolescent sample recruited via social-media. As predicted, AS was indirectly associated with greater likelihood of using alcohol, cigarettes, and electronic nicotine delivery systems in the past-month through anxiety symptoms. Regarding cannabis, AS was directly related to increased likelihood of past-month cannabis use; however, the indirect relation between AS and likelihood of past-month use via anxiety symptoms was not significant. Through chained indirect effects, AS was related positively to past-month alcohol and cannabis use via anxiety symptoms and coping-related motives, and through withdrawal symptoms and coping-related motives. Study findings can be used to generate hypotheses on potential pathways through which AS could prospectively relate to substance use among youth.

Workshop on the Development and Evaluation of Digital Therapeutics for Health Behavior Change: Science, Methods, and Projects.

The health care field has integrated advances into digital technology at an accelerating pace to improve health behavior, health care delivery, and cost-effectiveness of care. The realm of behavioral science has embraced this evolution of digital health, allowing for an exciting roadmap for advancing care by addressing the many challenges to the field via technological innovations. Digital therapeutics offer the potential to extend the reach of effective interventions at reduced cost and patient burden and to increase the potency of existing interventions. Intervention models have included the use of digital tools as supplements to standard care models, as tools that can replace a portion of treatment as usual, or as stand-alone tools accessed outside of care settings or direct to the consumer. To advance the potential public health impact of this promising line of research, multiple areas warrant further development and investigation. The Center for Technology and Behavioral Health (CTBH), a P30 Center of Excellence supported by the National Institute on Drug Abuse at the National Institutes of Health, is an interdisciplinary research center at Dartmouth College focused on the goal of harnessing existing and emerging technologies to effectively develop and deliver evidence-based interventions for substance use and co-occurring disorders. The CTBH launched a series of workshops to encourage and expand multidisciplinary collaborations among Dartmouth scientists and international CTBH affiliates engaged in research related to digital technology and behavioral health (eg, addiction science, behavioral health intervention, technology development, computer science and engineering, digital security, health economics, and implementation science). This paper summarizes a workshop conducted on the Development and Evaluation of Digital Therapeutics for Behavior Change, which addressed (1) principles of behavior change, (2) methods of identifying and testing the underlying mechanisms of behavior change, (3) conceptual frameworks for optimizing applications for mental health and addictive behavior, and (4) the diversity of experimental methods and designs that are essential to the successful development and testing of digital therapeutics. Examples were presented of ongoing CTBH projects focused on identifying and improving the measurement of health behavior change mechanisms and the development and evaluation of digital therapeutics. In summary, the workshop showcased the myriad research targets that will be instrumental in promoting and accelerating progress in the field of digital health and health behavior change and illustrated how the CTBH provides a model of multidisciplinary leadership and collaboration that can facilitate innovative, science-based efforts to address the health behavior challenges afflicting our communities.

Digital Presence of a Research Center as a Research Dissemination Platform: Reach and Resources.

BACKGROUND: Web-based platforms can be powerful tools for research dissemination. By leveraging the advantages of mass media and interpersonal channels of communication, Web-based dissemination platforms may improve awareness about, and subsequent adoption of, evidence-based practices (EBPs). Digital dissemination strategies can augment traditional dissemination models, improving stakeholder access to digestible and actionable information and promoting translation of EBPs. OBJECTIVE: This study aimed to describe the reach and content of the Web presence of a National Institute on Drug Abuse Center of Excellence and how it is used to disseminate research related to digital behavioral health approaches. METHODS: The Center for Technology and Behavioral Health (CTBH) has a website and regularly updated Facebook and Twitter accounts. The website features include summaries of digital behavioral health approaches and related empirical literature, a blog feed focused on the state of the science and technology concerning digital health care approaches, and a newsletter about Center activities. We extracted website usage metrics from Google Analytics and follower counts from social media accounts for the period from March 1, 2013, to July 17, 2018. RESULTS: Since the implementation of analytic tracking, 70,331 users have initiated 96,995 sessions on the CTBH website. The website includes summaries of 86 digital therapeutic programs, encompassing 447 empirical articles. There are 1160 posts in the CTBH blog feed, including 180 summaries of scholarly articles. The Twitter and Facebook accounts have 577 and 1500 followers, respectively. The newsletter has reached a growing subscriber network and has a high open rate relative to industry standards. CONCLUSIONS: The CTBH Web presence serves as a model for how to leverage accessible and easily updatable digital platforms as research dissemination channels. Digital dissemination tools can augment traditional dissemination strategies to promote awareness about evidence-based digital therapeutic approaches for behavioral health and health care more broadly.

Workshop on Emerging Technology and Data Analytics for Behavioral Health.

Wearable and portable digital devices can support self-monitoring for patients with chronic medical conditions, individuals seeking to reduce stress, and people seeking to modify health-related behaviors such as substance use or overeating. The resulting data may be used directly by a consumer, or shared with a clinician for treatment, a caregiver for assistance, or a health coach for support. The data can also be used by researchers to develop and evaluate just-in-time interventions that leverage mobile technology to help individuals manage their symptoms and behavior in real time and as needed. Such wearable systems have huge potential for promoting delivery of anywhere-anytime health care, improving public health, and enhancing the quality of life for many people. The Center for Technology and Behavioral Health at Dartmouth College, a P30 "Center of Excellence" supported by the National Institute on Drug Abuse at the National Institutes of Health, conducted a workshop in February 2017 on innovations in emerging technology, user-centered design, and data analytics for behavioral health, with presentations by a diverse range of experts in the field. The workshop focused on wearable and mobile technologies being used in clinical and research contexts, with an emphasis on applications in mental health, addiction, and health behavior change. In this paper, we summarize the workshop panels on mobile sensing, user experience design, statistics and machine learning, and privacy and security, and conclude with suggested research directions for this important and emerging field of applying digital approaches to behavioral health. Workshop insights yielded four key directions for future research: (1) a need for behavioral health researchers to work iteratively with experts in emerging technology and data analytics, (2) a need for research into optimal user-interface design for behavioral health technologies, (3) a need for privacy-oriented design from the beginning of a novel technology, and (4) the need to develop new analytical methods that can scale to thousands of individuals and billions of data points.

Developing the WorkingWell mobile app to promote job tenure for individuals with serious mental illnesses.

OBJECTIVE: Individuals living with serious mental illnesses are key stakeholders in user experience design and the development of the WorkingWell mobile app to enhance on-the-job follow-along support. In this study, Individual Placement and Support (IPS) consumers identify challenges in sustaining employment, provide data regarding their use of technology, and suggest technology-based solutions for coping on the job to inform app development. METHOD: Focus groups were conducted in 3 agencies providing IPS services to examine consumers' perspectives on supported employment, work, and their preferences for technology-based supports. Qualitative data were coded thematically in a multistep, collaborate approach to ensure trustworthiness. Survey data were collected to describe participants and their current technology use; these data were analyzed descriptively. RESULTS: A total of 25 IPS consumers reported work challenges related to interpersonal relationships and social situations; job characteristics, tasks, and expectations; illness- and treatment-related issues; lifestyle/wellness and conditions apart from work; and motivation. The majority owned mobile phones, felt comfortable using technology, and could see how technology-based tools could help sustain employment. Participants highlighted the potential benefits of technology-based supports for work challenges, and underscored the potential for independence and empowerment as a consequence. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Study findings suggest the value of a WorkingWell mobile app that is innovative, easy to access, self-directed, and individually tailored to enhance IPS follow-along support. The WorkingWell app, if proven effective, will provide an empowering set of tools designed with input from individuals with serious mental illnesses, and integrated into a single, accessible interface. (PsycINFO Database Record

The potential of technology for enhancing individual placement and support supported employment.

TOPIC: The potential of technology to enhance delivery and outcomes of Individual Placement and Support (IPS) supported employment. PURPOSE: IPS supported employment has demonstrated robust success for improving rates of competitive employment among individuals with psychiatric disabilities. Still, a majority of those with serious mental illnesses are not employed (Bond, Drake, & Becker, 2012). The need to promote awareness of IPS and expand services is urgent. In this study, we describe ways that technologies may enhance delivery of IPS supported employment across the care continuum and stakeholder groups. Directions for research are highlighted. SOURCES USED: published literature, clinical observations, IPS learning collaborative. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Technology has the potential to enhance direct service as well as workflow in the IPS supported employment process, which may lead to improved fidelity and client outcomes. Mobile and cloud technologies open opportunities for collaboration, self-directed care, and ongoing support to help clients obtain and maintain meaningful employment. Research is needed to evaluate efficacy of technology-based approaches for promoting client employment outcomes, to identify provider and organization barriers to using technology for IPS delivery, and to determine effective strategies for implementing technology with IPS in different settings and with diverse client audiences.

CHAT: development and validation of a computer-delivered, self-report, substance use assessment for adolescents.

The current study was conducted to construct and validate a computer-delivered, multimedia, substance use self-assessment for adolescents. Reliability and validity of six problem dimensions were evaluated in two studies, conducted from 2003 to 2008. Study 1 included 192 adolescents from five treatment settings throughout the United States (N = 142) and two high schools from Greater Boston, Massachusetts (N = 50). Study 2 included 356 adolescents (treatment: N = 260; school: N = 94). The final version of Comprehensive Health Assessment for Teens (CHAT) demonstrated relatively strong psychometric properties. The limitations and implications of this study are noted. This study was supported by an SBIR grant.

A multimedia psychosocial support program for couples receiving infertility treatment: a feasibility study.

OBJECTIVE: To develop and test the feasibility of a theory-driven, psychosocial support CD-ROM prototype for couples in infertility treatment. DESIGN: Focus group meetings with reproductive health experts, semistructured interviews with infertility patients, and content analysis of an infertility message board to determine content domains of the CD-ROM. Usability and acceptance testing of prototype CD-ROM based on predetermined feasibility criteria. SETTING: Private offices and fertility centers. PATIENT(S): Expert panel of 5 reproductive health specialists; interviews with 62 individuals with infertility (35 women, 27 men); feasibility study with 12 patients and 12 experts in reproductive medicine and infertility support. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Product usability/acceptance test. RESULT(S): Participant feedback and content analysis informed the development of a prototype patient education CD-ROM that uses audio, video, interactive tasks, and personalized feedback. Over 80% of participants successfully completed usability tasks, and over 90% rated prototype satisfaction as "good" to "excellent." Some areas were noted for improvement in navigation and refinement in delivery of instructions. Results strongly indicate an interest in an infertility multimedia support tool. CONCLUSION(S): Multimedia methods may serve as an effective, innovative psychosocial intervention for infertility patients and overcome barriers of limited local access to educational and support services.

Human fractalkine mediates leukocyte adhesion but not capture under physiological shear conditions; a mechanism for selective monocyte recruitment.

Fractalkine is a unique chemokine possessing a long mucin-like stalk and a transmembrane region that has been proposed to act as an adhesion molecule. We investigated the ability of fractalkine to recruit leukocytes from whole blood, using an immobilized fractalkine fusion protein in the parallel-plate flow-chamber assay. Significant adhesion of leukocytes to fractalkine peaked at 2 dynes/cm(2) but was minimal at 10 dynes/cm(2). In contrast, VCAM-1 could recruit cells from whole blood at 10 dynes/cm(2). Co-immobilization of fractalkine and VCAM-1 at 10 dynes/cm(2) resulted in a twofold increase in adherent cells compared with VCAM-1 alone, suggesting that fractalkine can mediate adhesion at high shear if combined with a molecule that can mediate leukocyte tethering. Pretreatment of blood with pertussis toxin eliminated this increase in adhesion, implicating intracellular signaling in fractalkine-mediated mechanisms of adhesion to co-immobilized fractalkine/VCAM-1. Analysis of the cell types recruited to fractalkine alone at low shear, or to fractalkine and VCAM-1 at 10 dynes/cm(2), revealed that monocytes were recruited to fractalkine with the highest specificity. In conclusion, fractalkine is unlikely to act alone at shear forces found in most vascular beds where it most likely co-operates with tethering molecules, e.g. VCAM-1, in the recruitment of monocytes.