Patient navigation for pregnant individuals with opioid use disorder: Results of a randomized multi-site pilot trial.

BACKGROUND AND AIMS: Patient navigation (PN) may benefit pregnant individuals with opioid use disorder (OUD) by improving treatment adherence. We examined participant enrollment, session delivery and assessment feasibility for a PN intervention among pregnant participants and compared PN preliminary effectiveness for OUD treatment engagement with participants in usual care (UC). DESIGN: This study was a pilot single-blinded multi-site randomized trial. SETTING: Two academic medical centers in Pennsylvania (n = 57) and Utah (n = 45), United States participated. PARTICIPANTS: One hundred and two pregnant adult participants unestablished (fewer than 6 weeks) on medication for OUD (MOUD) were randomized to PN (n = 53) or UC (n = 49). INTERVENTION: PN was composed of 10 prenatal sessions (delivered after baseline but before the prenatal assessments) and four postnatal sessions (delivered before the 2- and 6-month postpartum assessments) focused upon OUD treatment and physical/mental health needs. UC involved brief case management. MEASUREMENTS: Feasibility assessments included consent, session delivery and assessment rates. Mixed-effect models for intent-to-treat (ITT) and per protocol (PP, received six or more sessions) populations were estimated to compare outcomes of MOUD use, secondary outcomes of substance use disorder (SUD) treatment attendance and non-prescribed opioid use, and exploratory outcome of overdose at baseline, predelivery and 2 and 6 months postpartum. FINDINGS: We consented 87% (106 of 122) of the proposed target, delivered ~60% of sessions delivered and completed ≥ 75% assessments. PN ITT and PP had better MOUD adherence, SUD treatment attendance, non-prescribed opioid use and overdose outcomes than UC. Notable changes included good evidence for greater percentage change in days for PN PP MOUD use from baseline to 2 months postpartum [PN = 28.0 versus UC = -10.9, 95% confidence interval (CI) = 9.7, 62.1] and some evidence for baseline to 6 months postpartum (PN = 45.4 versus UC = 23.4, 95% CI = -0.7, 48.2). PN PP percentage change in days for SUD treatment attendance also showed good evidence for improvements from baseline to prenatal assessment (PN = 7.4 versus UC = -21.3, 95% CI = 3.3, 53.5). PN compared to UC participants reported fewer overdoses at 2 months (PN = 11.9%/UC = 16.1%) and at 6 months postpartum (PN = 3.8%/UC = 6.2%). CONCLUSIONS: Patient navigation appears to be associated with improvements in opioid use disorder treatment engagement and overdoses during pregnancy. This pilot trial shows the feasibility of the intervention and a future large-scale trial.

Cluster analysis to identify patient profiles and substance use patterns among pregnant persons with opioid use disorder.

The study objective was to identify distinct profiles of pregnant persons with opioid use disorder (PP-OUD) using cluster analysis and examine difference in substance use patterns between profiles. We examined data from 104 PP-OUD ≤ 32 weeks of gestation who were recruited into a behavioral health clinical trial at two academic medical centers. We used Partitioning Around Medoids analysis to identify clusters and explored patterns of substance use and substance use treatment between clusters using bivariate statistical tests and regression methods. We identified two distinct clusters of participants, including 'Group A' (n = 68; 65.4 %) and 'Group B' (n = 36; 34.6 %). Group A had fewer members who were not employed (38 % vs 58 %) and incarcerated (3 % vs 8 %) compared to Group B. Group A compared with Group B included more members with: a history of overdose (72 % vs 50 %); anxiety (85 % vs 25 %); ≥moderate pain (76 % vs 22 %); ≥moderate depression (75 % vs 36 %); ≥moderate drug use severity (94 % vs 78 %); and, more days of cannabis (mean: 6.2 vs 2.3 days), stimulant (mean: 4.5 vs 1.3 days), and injection heroin (mean: 1.3 vs 0 days) use in the past 30 days (P < 0.05 for all comparisons). Clusters of PP-OUD differed with respect to sociodemographic characteristics, mental health conditions, and substance use patterns. More research is needed to confirm identified profiles and assess treatment outcomes associated with cluster membership.

Effectiveness of Residential Treatment for Juveniles with Problematic Sexual Behavior: A Systematic Review.

Juveniles with problematic sexual behaviors are often placed in residential treatment. However, little is known about the effectiveness of such treatments in terms of reducing recidivism or enhancing mental wellbeing. To better understand the impact of residential treatment for these juveniles we conducted a Systematic Review on studies that reported recidivism rates. PRISMA guidelines were followed. 1126 studies were initially identified, with only six meeting the final inclusion criteria. Sexual recidivism rates averaged 5.20% across the six studies, which is similar rates of non-residential treatments. The results suggest that certain client factors predict recidivism, for example youth labeled as obsessive offenders were more likely to recidivate compared to those labeled as opportunistic. Most studies also measured non-sexual crimes post treatment; recidivism rates for sexual misconduct tended to be lower than for other crimes. Despite the significant intrusion of residential treatment centers, remarkably few empirical studies exist to establish their effectiveness in reducing recidivism. The comparable recidivism rates to non-residential treatment programs begs the question of whether residential centers add value beyond outpatient care and suggest that less restrictive interventions may be sufficient. Helping youth evidencing problematic sexual behaviors involves complex dynamics, however caution is recommended on relying on residential treatment.

Group Homes and COVID-19: Perspectives of Youth Residents, Staff, and Caregivers.

OBJECTIVE: This study explored the perspectives of being in a youth group home during the COVID-19 pandemic from youth residents, staff, and caregivers. METHODS: We conducted semi-structured interviews with 9 youth residents, 8 group home staff members, and 13 caregivers of residents. All participants were connected to the group home before and during the COVID-19 pandemic. Thematic analysis was used to identify lived experience themes. RESULTS: Two overarching themes were identified among the youth residents-Safety response to COVID-19 and Socialization changes due to COVID-along with three subthemes: Structure leading to separation, Support and belonging amid a pandemic, and Competency. Three overarching themes were identified among the group home staff: Safety response to COVID-19, Increased responsibility, and Mental health changes because of a pandemic. Finally, three overarching themes were identified among the guardians of youth residents: Safety response to COVID-19, Belief in a mental health impact on the child, and Communication during a pandemic. Conclusions: The findings provide the experiences among three group home stakeholders. Overall, they demonstrated resilience in a setting and time when resilience was essential. Finally, the findings offer insight on the basis of which group homes/organizations can prepare for crises of a great magnitude, including vital communication elements.

Mindfulness and Savoring: A Commentary on Savoring Strategies and Their Implications for Addiction Treatment.

Background: A central facet of the popular understanding of mindfulness practice is the non-judgmental observation of all thoughts and feelings. Savoring is a cognitive practice developed out of economics and positive psychology, which involves the conscious mental engagement with positively-valenced interoceptive and exteroceptive stimuli, which in turn amplifies the derived pleasure experience. Results: When incorporated into mindfulness-based interventions (MBIs), savoring holds promise in improving outcomes related to reward processing, such as positive affect and well-being. The growing body of mindfulness literature also suggests that the inclusion of savoring in MBIs may be key in treating disorders of reward dysregulation, such as addiction. If savoring does indeed reduce craving, this phenomenon offers a point of union for divergent neurobiological theories of addiction. Conclusion: In this commentary, we explore the existing literature on savoring and mindfulness practices as it relates to addictive disorders, posit underlying neurocognitive mechanisms, and present future areas of research.

Pregnancy and the Opioid Crisis: Heightened Effects of COVID-19.

The opioid epidemic continues to affect pregnant women with opioid use disorder adversely in unique and enduring ways. The onset of the coronavirus disease 2019 (COVID-19) pandemic and the necessary public health measures implemented to slow the transmission have increased barriers to care for these same women. This commentary explores the implications of these measures and discusses strategies we have developed to manage these challenges based on our work in a clinical trial providing patient navigation to pregnant mothers with OUD. We believe these solutions can be applied in medical, behavioral health, and research settings through the pandemic and beyond to increase the quality of care and resources to this vulnerable population.

Sexual Assault Prevention: A Randomized Control Trial of a Standard Military Intervention and a Motivational Interview Enhancement.

Despite increased efforts to prevent sexual assault in military environments, the problem continues at an alarming rate. Sexual assault prevention programs (SAPP) attempt to respond to this issue, yet little is known about their effectiveness within a military environment. This randomized controlled trial examined the potential efficacy of the 2015 United States Air Force (USAF) SAPP compared to that same program with an additional motivational interviewing (MI) enhancement. The MI enhancement involved both self-guided and group discussions designed to elicit change talk toward preventing sexual assault through bystander interventions. Research questions included the general efficacy of the USAF's SAPP in shifting factors linked to sexual assault, specifically participants' endorsement of beliefs associated with sexual assault, beliefs eceived the pretest via e-mailabout intervening as a bystander when confronted with a hypothetical sexual assault situation, and participants' reported willingness to intervene to stop a sexual assault. Fifty-one college students participated, of whom 64% had a history of military involvement. Primary outcome measures included bystanders' willingness and confidence to intervene as well as indicators of rape myth acceptance. Participants in the standard USAF SAPP showed no significant change in willingness or confidence to intervene as bystanders from pretest to posttest. By contrast, those who received a relatively short MI enhancement showed statistically significant increases in their willingness to intervene as bystanders. Neither group showed changes in sexual assault myths. Enhancing SAPPs with a motivational enhancement effort seems justified, especially given the relative low resources involved in introducing such a program.

A pilot multisite study of patient navigation for pregnant women with opioid use disorder.

The opioid crisis continues to affect pregnant and postpartum women the United States, with the number of pregnant women diagnosed with opioid use disorder (OUD) quadrupling over the last decade. The associated increase in morbidity and mortality among mother and baby warrants prompt, targeted intervention efforts that improve engagement, linkage of care, and treatment retention. Patient navigation (PN) is a chronic care intervention that can directly address this need by helping women identify medical, behavioral, and psychosocial care goals. Moreover, PN can assist women in preparing for, engaging in, and maintaining patient participation in necessary services. Specifically, PN includes strengths-based case management, 1-1 clinical support, motivational interviewing, and addiction-relapse prevention programming. The objective of this article is to present the study protocol of a pilot multisite randomized clinical trial, entitled: Optimizing Pregnancy and Treatment Interventions for Moms 2.0 (OPTI-Mom 2.0; NCT03833245). In this study, we build upon a proof-of-concept study, employing evidence-informed frameworks for protocol and intervention expansion in order to construct a PN intervention tailored for pregnant women with OUD in central Utah and southwestern Pennsylvania. Our protocol provides an initial framework of a potentially impactful intervention and may guide development of future programs. Importantly, this study further establishes the evidence-base-with potential to ameliorate serious adverse opioid-related outcomes and improve health for women and their children.

Motivational interviewing adherence tools: A scoping review investigating content validity.

OBJECTIVE: We sought to understand the content validity of Motivational Interviewing (MI)as a concept and the relative emphasis of specific MI aspects by assessing MI adherence measures. METHOD: We followed PRISMA guidelines for scoping reviews. Twenty-eight adherence measures were identified. From these, 407 specific MI adherence codes were extracted and submitted to content analysis. RESULTS: Fifteen MI themes emerged, 13 focused on clinician behaviors and 2 on client responses. Four themes (OARS, MI Spirit, evoking motivation, and MI-inconsistent behaviors) accounted for 72% of all codes. No other theme (e.g., preventing/responding to resistance, engaging ambivalence) accounted for more than 6% of codes. One measure assessed 11 of 15 themes; on average, 5.68 themes were assessed with a mean of 14.54 questions per measure. Process and psychometric characteristics of the measures are described. CONCLUSIONS/PRACTICE IMPLICATIONS: MI adherence measures agree about the importance of certain aspects of MI but lag behind current research and best skill practice. Considerable variance exists in assessing MI nuances and specific behaviors, suggesting questions about what constitutes MI in practice settings and what should be taught. Importantly, most measures focused only on the counselor's behavior, missing the impact of MI on the client.

Sexual Assault Prevention Efforts in the U.S. Air Force: A Systematic Review and Content Analysis.

The issue of sexual assault in the U.S. military is problematic and prevalent. All military branches have undertaken an effort to develop and implement sexual assault prevention programs (SAPPs), yet these programs lack a rigorous and independent evaluation process, limiting an understanding of effectiveness. We examined the four official SAPPs that have been used within the U.S. Air Force (USAF) over the past decade by comparing their content and process with best practice suggestions for SAPPs. Content of the four USAF SAPPs was evaluated on 47 different criteria grouped into the following program elements: content, process, and outcome. Independent ratings of the criteria were reliable, and results indicated strengths and opportunities for improvement. Most notably, evidence of an objective program evaluation system is lacking. Recommendations for improving SAPPs are offered.

Short-Term Interventions for Survivors of Intimate Partner Violence: A Systematic Review and Meta-Analysis.

Intimate partner violence (IPV) impacts millions of adults and children every year and can result in homicide, legal proceedings, the involvement of child welfare, and the need for emergency shelter for survivors and their families. Survivors of IPV may develop psychological and somatic symptoms to the trauma, including anxiety, depression, and other mental health related disorders in addition to facing numerous safety, financial, and social challenges. To reestablish stability, effective short-term interventions are needed in order to address these issues survivors face. This systematic review and meta-analysis summarizes the extant literature on short-term interventions for survivors of IPV. Twenty-one studies are included in the analysis and overall effect sizes calculations and moderator analysis were conducted. On average, effects sizes were large (g = 1.02) suggesting that most sort-term interventions are effective, however CBT-based interventions that were tailored to IPV survivors achieved the largest effect sizes. Results of this study are presented in a question and answer format with the intent to guide practitioners, researchers and policy makers. IPV survivors access services in a variety of shelter and outpatient settings and present diverse needs. Although this study contributes a systematic review of the existing literature on IPV, there are relatively few rigorous outcome studies and even fewer that reflect the diversity in this population and the complexity of responding to IPV in real-world settings.

Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: Motivational Interviewing (MI) is a method for encouraging people to make behavioral changes to improve health outcomes. We used systematic review and meta-analysis to investigate MI's efficacy in medical care settings. METHODS: Database searches located randomized clinical trials that compared MI to comparison conditions and isolated the unique effect of MI within medical care settings. RESULTS: Forty-eight studies (9618 participants) were included. The overall effect showed a statistically significant, modest advantage for MI: Odd ratio=1.55 (CI: 1.40-1.71), z=8.67, p<.001. MI showed particular promise in areas such as HIV viral load, dental outcomes, death rate, body weight, alcohol and tobacco use, sedentary behavior, self-monitoring, confidence in change, and approach to treatment. MI was not particularly effective with eating disorder or self-care behaviors or some medical outcomes such as heart rate. CONCLUSION: MI was robust across moderators such as delivery location and patient characteristics, and appears efficacious when delivered in brief consultations. PRACTICE IMPLICATIONS: The emerging evidence for MI in medical care settings suggests it provides a moderate advantage over comparison interventions and could be used for a wide range of behavioral issues in health care.

The effectiveness and applicability of motivational interviewing: a practice-friendly review of four meta-analyses.

This article reviews the research support for Motivational interviewing (MI) so that practitioners can make informed decisions about the value and applicability of MI in their clinical work. We highlight the evidence from the three published meta-analyses of MI and a recent meta-analysis that we completed. MI is significantly (10%-20%) more effective than no treatment and generally equal to other viable treatments for a wide variety of problems ranging from substance use (alcohol, marijuana, tobacco, and other drugs) to reducing risky behaviors and increasing client engagement in treatment. Although most client-related variables are unrelated to outcomes (e.g., age, gender, severity), some decisions about treatment format (e.g., individual vs. group) are important. For example, relying solely on group-delivered MI appears to be less effective than one-on-one MI, whereas delivering MI with problem feedback is likely to generate better outcomes for some problems than MI alone.

A meta-analysis of parent training: moderators and follow-up effects.

A meta-analysis of 63 peer-reviewed studies evaluated the ability of parent training programs to modify disruptive child behaviors and parental behavior and perceptions. This analysis extends previous work by directly comparing behavioral and nonbehavioral programs, evaluating follow-up effects, isolating dependent variables expressly targeted by parent training, and examining moderators. Effects immediately following treatment for behavioral and nonbehavioral programs were small to moderate. For nonbehavioral programs, insufficient studies precluded examining follow-up effects. For behavioral programs, follow-up effects were small in magnitude. Parent training was least effective for economically disadvantaged families; importantly, such families benefited significantly more from individually delivered parent training compared to group delivery. Including children in their own therapy, separate from parent training, did not enhance outcomes.

Interpretations of child compliance in individuals at high- and low-risk for child physical abuse.

OBJECTIVE: Our studies compared individuals at high- and low-risk for child physical abuse on measures of social information processing. METHOD: Two studies were conducted using similar methods. Twenty-eight childless women in Study 1 and 36 mothers in Study 2 read vignettes of parent-child interactions in which the child's level of compliance was difficult to interpret. Participants were asked a series of questions about the child's behavior and their own reactions. RESULTS: Accuracy and bias in identifying compliant behavior were assessed using a signal detection paradigm. In both samples, high- and low-risk participants did not differ in their overall accuracy in identifying children's behaviors. However, they used different evaluation standards such that high-risk participants were biased toward seeing more noncompliance and low-risk participants were biased toward seeing more compliance. High- and low-risk participants also made different types of errors in interpreting children's behavior. Low-risk participants were more likely to misinterpret noncompliant behavior as compliant, and there was a trend for high-risk participants to not perceive compliant behavior when it occurred. There were no differences in reported disciplinary responses in either study and the results for affective reactions were mixed. CONCLUSIONS: Specific differences in social information processing between high- and low-risk individuals replicated across samples, suggesting a reliable association between evaluation standards and risk of child physical abuse. However, the absence of differences in reported discipline and inconsistent findings on affective reactions indicate the need to identify the mechanism through which cognition influences parenting behavior.