Reducing Tobacco Smoke Exposure in High-Risk Infants: A Randomized, Controlled Trial.

OBJECTIVE: To evaluate a hospital-initiated intervention to reduce tobacco smoke exposure in infants in the neonatal intensive care unit. STUDY DESIGN: A randomized, controlled trial compared motivational interviewing plus financial incentives with conventional care on infant urine cotinine at 1 and 4 months' follow-up. Mothers of infants in the neonatal intensive care unit (N = 360) who reported a smoker living in the home were enrolled. Motivational interviewing sessions were delivered in both the hospital and the home. Financial incentives followed session attendance and negative infant cotinine tests postdischarge. RESULTS: The intervention effect on infant cotinine was not significant, except among mothers who reported high baseline readiness/ability to protect their infant (P ≤ .01) and mothers who completed the study within 6 months postdischarge (per protocol; P ≤ .05). Fewer mothers in the motivational interviewing plus financial incentives condition were smoking postdischarge (P ≤ .01). More mothers in the motivational interviewing plus financial incentives group reported a total home and car smoking ban at follow-up (P ≤ .05). CONCLUSIONS: Motivational interviewing combined with financial incentives reduced infant tobacco smoke exposure in a subset of women who were ready/able to protect their infant. The intervention also resulted in less maternal smoking postpartum. More robust interventions that include maternal and partner/household smoking cessation are likely needed to reduce the costly effects of tobacco smoke exposure on children and their families. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01726062.

Proactive delivery of nicotine replacement therapy to families of hospitalized infants in a NICU: A randomized controlled pilot trial.

Neonatal ICU (NICU) hospitalizations provide opportunities to engage individuals/families who smoke with evidence-based cessation treatments to protect infants from tobacco smoke exposure. The aim of this pilot study was to establish the feasibility and potential efficacy of providing motivational advice and NRT (MA+NRT) to families of NICU infants. RCT methodology equally allocated participants who reported ≥1 household smoker (N=32) from a large NICU to MA+NRT or referral to a Quitline. The primary outcome was accepting NRT patches (MA+NRT) and use of NRT. Bayesian analyses modeled NRT use as a function of treatment group. Most MA+NRT participants (81.3%; n=13) accepted the patches. No Quitline participants called the Quitline. NRT use differed across groups, indicating a 0.907 posterior probability that a positive effect for MA+NRT exists (RR=2.32, 95% CI=[0.68-11.34]). This study demonstrated feasibility and acceptability for offering NRT and motivational advice to NICU parents and supports further intervention refinement with NICU families.

A comparison of common practices for identifying substance use during pregnancy in obstetric clinics.

BACKGROUND: Substance use during pregnancy has been linked to adverse birth and other outcomes. Screening and intervention in the prenatal clinic are recommended, and reliance on patient reports or selective urine drug screening is inadequate. The aim of this prospective project was to determine substance use identification rates associated with common screening practices, compared to universal screening, among pregnant women seeking care at an urban, academic obstetric clinic. METHODS: Women attending their first prenatal visit (N = 275) completed a self-report questionnaire on lifetime and current substance use. A urine drug screening was also conducted, the results of which were not reported to providers. Participants' charts were reviewed to obtain the results of provider-ordered screens. RESULTS: The sample was primarily African-American and Latino, with Medicaid insurance. Ten women (4.6%) reported current marijuana use, while more than double that number (n = 27; 11.6%) screened positive for marijuana via universal screening. The majority of women who screened positive via universal screening did not have a provider-ordered urine drug screening, and less than one-third (29.3%) of clinician-ordered screens were positive for at least one substance. Finally, 90% of women who reported they were using marijuana were not selected by providers for a screen. DISCUSSION: Data demonstrate the high proportion of women using marijuana and the limitations of patient self-report and selective, nonroutine screening to identify substance use during pregnancy. Effective, standardized, clinic-wide strategies are needed to support providers in identifying pregnant women who use substances in order to increase the frequency of education and intervention.

Psychological Flexibility and Depression in New Mothers of Medically Vulnerable Infants: A Mediational Analysis.

Objectives Maternal depression in the postpartum period is prevalent and associated with negative child outcomes, including behavior problems and cognitive delays. Mothers of children admitted directly after birth to the neonatal intensive care unit (NICU) are at even higher risk for depressive symptoms and infants born premature and/or at low birth weight may be more vulnerable to the adverse effects of maternal depression. Understanding mechanisms, particularly modifiable mechanisms, involved in the development or persistence of depressive symptoms is critically important for developing effective treatments. Methods The longitudinal, secondary analysis investigated the role of psychological inflexibility (rigidly avoiding or attempting to control distressing internal experiences, precluding present moment awareness of contingencies and engagement with important values) as a mediator of the relationship between early (1-2 weeks postpartum) and later (3 and 6 months postpartum) depressive symptoms among mothers with an infant in the NICU. Results Psychological inflexibility measured 2 weeks after infant discharge from the hospital fully mediated the relationship between early and later depressive symptoms at 3 months postpartum, with partial mediation at 6 months, while controlling for factors previously found predictive of postpartum depression. Conclusions for Practice Psychological inflexibility may be a mechanism by which postpartum depressive symptoms persist after hospital discharge among new mothers with a NICU infant. Acceptance and Mindfulness therapies which specifically target psychological inflexibility may be promising interventions to reduce depressive symptoms postpartum.

Depression in the barrio: An analysis of the risk and protective nature of cultural values among Mexican American substance users.

Understanding the effect of cultural values on depression and how social networks influence these relationships may be important in the treatment of substance-using, Mexican American populations. Latino cultural values, familismo, personalismo, fatalismo, and machismo, may be associated with depression among Latinos. The current study identified the association of traditional Latino values on depressive symptomatology among a sample of Mexican American heroin injectors. A cross-sectional research design and field-intensive outreach methodology were utilized to recruit 227 Mexican American men. Participants were categorized into depressed and nondepressed groups. Relations among cultural values and depression were examined using logistic regression. Findings indicate that drug-using men with higher familismo and fatalismo scores are protected against depressive symptomatology. Relations between familismo and depression seem to be moderated by having a drug use network. In addition, findings reveal that age is inversely related to depressive symptomatology. Young Mexican American heroin users who do not ascribe to traditional Latino values may be highly associated with depression and therefore more vulnerable to riskier drug use behaviors. Moreover, drug-using social networks may affect the protective nature of certain cultural values. Further research is needed to identify whether culturally tailored treatments can cultivate these values while simultaneously undermining the effect of substance-using social networks in order to reduce depression symptoms among this group of high-risk substance users.

Cognitive-behavioral therapies for depression and substance use disorders: An overview of traditional, third-wave, and transdiagnostic approaches.

BACKGROUND: The co-occurrence of depression and substance use disorders (SUD) is highly prevalent and associated with poor treatment outcomes for both disorders. As compared to individuals suffering from either disorder alone, individuals with both conditions are likely to endure a more severe and chronic clinical course with worse treatment outcomes. Thus, current practice guidelines recommend treating these co-occurring disorders simultaneously. OBJECTIVES: The overarching aims of this narrative are two-fold: (1) to provide an updated review of the current empirical status of integrated psychotherapy approaches for SUD and depression comorbidity, based on models of traditional cognitive-behavioral therapy (CBT) and newer third-wave CBT approaches, including acceptance- and mindfulness-based interventions and behavioral activation (BA); and (2) to propose a novel theoretical framework for transdiagnostic CBT for SUD-depression, based upon empirically grounded psychological mechanisms underlying this highly prevalent comorbidity. RESULTS: Traditional CBT approaches for the treatment of SUD-depression are well-studied. Despite advances in the development and evaluation of various third-wave psychotherapies, more work needs to be done to evaluate the efficacy of such approaches for SUD-depression. CONCLUSION: Informed by this summary of the evidence, we propose a transdiagnostic therapy approach that aims to integrate treatment elements found in empirically supported CBT-based interventions for SUD and depression. By targeting shared cognitive-affective processes underlying SUD-depression, transdiagnostic treatment models have the potential to offer a novel clinical approach to treating this difficult-to-treat comorbidity and relevant, co-occurring psychiatric disturbances, such as posttraumatic stress.

Naltrexone plus bupropion reduces cigarette smoking in individuals with methamphetamine use disorder: A secondary analysis from the CTN ADAPT-2 trial.

INTRODUCTION: Methamphetamine (MA) use is marked by high rates of comorbid tobacco smoking, which is associated with more severe drug use and worse clinical outcomes compared to single use of either drug. Research has shown the combination of naltrexone plus oral bupropion (NTX-BUP) improves smoking cessation outcomes in non-MA-using populations. In the Accelerated Development of Additive Pharmacotherapy Treatment (ADAPT-2) study, NTX-BUP successfully reduced MA use. Our aim in this secondary data analysis was to examine changes in cigarette smoking among the subgroup of participants reporting comorbid tobacco use in the ADAPT-2 trial. METHODS: The multi-site ADAPT-2 study used a randomized, double blind, sequential parallel comparison design to evaluate treatment with extended-release injectable NTX (380 mg every 3 weeks) combined with once-daily oral extended-release BUP (450 mg/day) vs matching injectable and oral placebo in outpatients with moderate or severe MA use disorder. The study assessed smoking outcomes, based on self-reported timeline followback (TLFB) data, twice/week for 13 weeks. RESULTS: Of the 403 participants in the ADAPT-2 trial, 290 reported being current cigarette smokers (71.9 %). The study found significant differences (p's < 0.0001) for each smoking outcome indicating greater change in the proportion of nonsmoking days, number of cigarettes smoked per week, and consecutive nonsmoking days, all favoring the group receiving NTX-BUP versus placebo. CONCLUSIONS: NTX-BUP was associated with significant reductions in self-reported cigarette smoking in the context of concurrent treatment for MA use disorder. These off-target medication effects warrant prospective investigation using biochemically confirmed measures of smoking abstinence. The development of NTX-BUP as a co-addiction treatment strategy has a potential for high public health impact.

Facilitating treatment initiation and reproductive care postpartum to prevent substance-exposed pregnancies: A randomized bayesian pilot trial.

BACKGROUND: For non-treatment-seeking women who use substances during pregnancy, immediately postpartum may be an optimum time for intervention. Our study tested a novel, brief, hospital-initiated, adaptive motivational interviewing plus acceptance and commitment therapy (MIACT) intervention to facilitate treatment initiation and reproductive planning postpartum among mothers who used substances during pregnancy. METHODS: Mothers (N = 64) with an infant admitted to a neonatal intensive care unit were enrolled if they or their infant tested positive for an illicit substance at delivery or had a documented positive drug screen during pregnancy. A parallel group, randomized controlled design assigned participants to MIACT or conventional care (CC), with assessments at week 2 and 4 during treatment and follow-up at 2 and 6 months post treatment. Bayesian generalized linear modeling was used to evaluate outcomes as a function of treatment. RESULTS: Results indicated that during treatment the MIACT group demonstrated an 84% probability of benefit relative to CC with regard to initiating treatment (RR=1.5), however the effect was not seen at follow-up. MIACT was also associated with an increased probability of attending a postpartum obstetrics visit (RR=1.4), and receiving contraception during treatment and at both follow-ups, with posterior probabilities of 96% or higher and relative risks ranging from 1.5 to 5.1 at varying timepoints. Substance use rates for the MIACT versus CC were higher at follow-up. CONCLUSIONS: Brief, hospital-initiated interventions can assist postpartum mothers who use substances to enter treatment and obtain contraception in order to reduce future substance-exposed pregnancies.

Predicting HCV Incidence in Latinos with High-Risk Substance Use: A Data Science Approach.

Hepatitis C virus (HCV) in the U.S. has tripled in the prior five years, and injecting drug use is the primary risk for HCV, with up to 90% of older and former people who inject drugs (PWIDs) testing positive. Laboratory testing of HCV for any PWIDs is the gold standard, however many PWIDs lack access to health treatment or services. Identifying risks of HCV via a data science approach would aid community health workers (CHW) to rapidly link those most at risk of infection with treatment. This study employed a data-science approach to determine the strongest risk factors of HCV in a sample of Mexican-Americans WIDs n = 221 (96 negative/125 positive). Data included 238 demographic and psychosocial predictors. A Random Forest machine learning algorithm demonstrated significant prediction improvement over baseline no information rate comparison. Strongest risks for positive HCV included sharing drug-use equipment and younger age at first heroin use; receiving drug-education during incarceration was protective. A ROC curve fit to the prediction yielded an area under the curve of 0.77. Predictive variables of HCV in the present analysis can be obtained via screening by CHW. Identification of patients most at risk of HCV within community settings can maximize treatment utilization.

The Impact of Increased Hydrocodone Regulation on Opioid Prescribing in an Urban Safety-Net Health Care System.

BACKGROUND: Hydrocodone-combination analgesics were changed from Schedule III to Schedule II to discourage the prescribing of these analgesics. Our primary aim was to explore the effect of hydrocodone rescheduling on opioid prescribing within an urban safety-net health care system. METHODS AND DESIGN: Data were extracted from electronic records of ambulatory patients (N = 82,432 patients) prescribed hydrocodone-combination, codeine-combination, or tramadol opioid analgesics (N = 200,675 prescriptions) between October 6, 2013 and October 6, 2015. Data analyses modeled predicted probabilities of hydrocodone-combination prescriptions (HCPs). Chronic opioid therapy (COT) for chronic pain (ie, ≥3 opioid prescriptions/12 months) and morphine milligram equivalency (MME) levels were also examined. RESULTS: The probability of providers writing HCPs decreased significantly from pre- to postrescheduling (0.525 vs 0.158, respectively, P < .0001). However, this coincided with large probability increases in codeine-combination (0.064 vs 0.269) and tramadol prescriptions (0.412 vs 0.573). The probability of HCPs varied across physician specialty (P < .0001), patient diagnoses (P < .0001), COT versus non-COT patients (P < .0001), and patient characteristics (sex, race/ethnicity, and age; P < .05). COT patients received significantly more opioid prescriptions in the postrescheduling period (M = 4.81 vs M = 4.27; P < .0001). Patients on <20 MME/day increased slightly from pre- to postrescheduling (P < .0001). DISCUSSION: Significant declines in HCPs occurred after rescheduling; however, one third of patients prescribed opioids remained on doses ≥20 MME/day. Codeine- and tramadol-prescription probabilities increased significantly and providers may have an increased perception of safety about these medications. Physicians and health care systems must reduce their overreliance on opioids in treating pain, especially chronic pain, as all opioids incur some level of risk.

Family Physicians' Perceived Prevalence, Safety, and Screening for Cigarettes, Marijuana, and Electronic-Nicotine Delivery Systems (ENDS) Use during Pregnancy.

OBJECTIVE: Assess perceptions of prevalence, safety, and screening practices for cigarettes and secondhand smoke exposure (SHSe), marijuana (and synthetic marijuana), electronic nicotine delivery systems (ENDS; eg, e-cigarettes), nicotine-replacement therapy (NRT), and smoking-cessation medications during pregnancy, among primary care physicians (PCPs) providing obstetric care. METHODS: A web-based, cross-sectional survey was e-mailed to 3750 US physicians (belonging to organizations within the Council of Academic Family Medicine Educational Research Alliance). Several research groups' questions were included in the survey. Only physicians who reported providing "labor and delivery" obstetric care responded to questions related to the study objectives. RESULTS: A total of 1248 physicians (of 3750) responded (33.3%) and 417 reported providing labor and delivery obstetric care. Obstetric providers (N = 417) reported cigarette (54%), marijuana (49%), and ENDS use (24%) by "Some (6% to 25%)" pregnant women, with 37% endorsing that "Very Few (1% to 5%)" pregnant women used ENDS. Providers most often selected that very few pregnant women used NRT (45%), cessation medications (ie, bupropion or varenicline; 37%), and synthetic marijuana (23%). Significant proportions chose "Do not Know" for synthetic marijuana (58%) and ENDS (27%). Over 90% of the sample perceived that use of or exposure to cigarettes (99%), synthetic marijuana (99%), SHS (97%), marijuana (92%), or ENDS (91%) were unsafe during pregnancy, with the exception of NRT (44%). Providers most consistently screened for cigarette (85%) and marijuana use (63%), followed by SHSe in the home (48%), and ENDS (33%) and synthetic marijuana use (28%). Fewer than a quarter (18%) screened consistently for all substances and SHSe. One third (32%) reported laboratory testing for marijuana and 3% reported laboratory testing for smoking status. CONCLUSION: This sample of PCPs providing obstetric care within academic settings perceived cigarettes, marijuana, and ENDS use to be prevalent and unsafe during pregnancy. Opportunities for increased screening during pregnancy across these substances were apparent.

The Perceived Role of Family in Heroin Use Behaviors of Mexican-American Men.

The influence of the family is not well understood as it relates to drug use behaviors of Hispanic male adults. We examined the family's influence on drug use behavior, as perceived by Hispanic men who use heroin. One-time qualitative interviews were conducted with 21 current and former heroin users who participated in a larger study on long-term heroin use in Mexican-American men. Data were analyzed using a thematic analysis approach. Three main themes emerged: family as a supportive environment for heroin use; heroin as a family legacy; and, the family's strategies for helping to stop using heroin. A sub-theme emerged on the paradox of family involvement, which spanned the three main themes. This research lays a foundation for future work to disentangle the risks and benefits of family involvement to inform culturally-centered therapies and cultural adaptations to traditional therapeutic approaches with Mexican-American men who abuse drugs.