Substance use patterns, sociodemographics, and health profiles of harm reduction service recipients in Burlington, Vermont.

BACKGROUND: Understanding current substance use practices is critical to reduce and prevent overdose deaths among individuals at increased risk including persons who use and inject drugs. Because individuals participating in harm reduction and syringe service programs are actively using drugs and vary in treatment participation, information on their current drug use and preferred drugs provides a unique window into the drug use ecology of communities that can inform future intervention services and treatment provision. METHODS: Between March and June 2023, 150 participants in a harm reduction program in Burlington, Vermont completed a survey examining sociodemographics; treatment and medication for opioid use disorder (MOUD) status; substance use; injection information; overdose information; and mental health, medical, and health information. Descriptive analyses assessed overall findings. Comparisons between primary drug subgroups (stimulants, opioids, stimulants-opioids) of past-three-month drug use and treatment participation were analyzed using chi-square and Fisher's exact test. RESULTS: Most participants reported being unhoused or unstable housing (80.7%) and unemployed (64.0%) or on disability (21.3%). The drug with the greatest proportion of participants reporting past three-month use was crack cocaine (83.3%). Fentanyl use was reported by 69.3% of participants and xylazine by 38.0% of participants. High rates of stimulant use were reported across all participants independent of whether stimulants were a participant's primary drug. Fentanyl, heroin, and xylazine use was less common in the stimulants subgroup compared to opioid-containing subgroups (p < .001). Current- and past-year MOUD treatment was reported by 58.0% and 77.3% of participants. Emergency rooms were the most common past-year medical treatment location (48.7%; M = 2.72 visits). CONCLUSIONS: Findings indicate high rates of polysubstance use and the underrecognized effects of stimulant use among people who use drugs-including its notable and increasing role in drug-overdose deaths. Crack cocaine was the most used stimulant, a geographical difference from much of the US where methamphetamine is most common. With the increasing prevalence of fentanyl-adulterated stimulants and differences in opioid use observed between subgroups, these findings highlight the importance and necessity of harm reduction interventions (e.g., drug checking services, fentanyl test strips) and effective treatment for individuals using stimulants alongside MOUD treatment.

Examining the predictive utility of behavioral economic demand indices and subjective effects on the actualized reinforcing value of menthol cigarettes and potential alternatives.

INTRODUCTION: Considering recent and proposed bans on menthol cigarettes, methods are needed to understand the substitutability of potential menthol cigarette alternatives (MCAs) for menthol cigarettes. This study examined the prospective relationship between behavioral economic demand indices and subjective effects of usual brand menthol cigarettes (UBMC) and preferred MCAs with subsequent performance on a laboratory-based concurrent-choice task comparing UBMC and MCAs. METHODS: Eighty participants who typically smoked menthol cigarettes completed this clinical lab study. After sampling each product, participants completed the cigarette purchase task (CPT) and modified cigarette evaluation questionnaire (mCEQ). Following one-week of substituting their preferred MCA for their UBMC, participants completed a 90-min concurrent-choice self-administration task comparing their UBMC and preferred MCA. Linear regression models explored associations between CPT demand indices and mCEQ subjective effects in the lab with subsequent response effort for UBMCs on the concurrent-choice task. RESULTS: Three demand indices for UBMC were positively associated with UBMC response effort: Essential Value (EV; p=.02), Omax (p=.02), and breakpoint (p=.04). Four CPT demand indices for the preferred MCA significantly corresponded with UBMC response effort: EV (p=.03), Pmax (p=.04), Omax (p=.03), and breakpoint (p=.03). Subjective effects captured by the mCEQ were not associated with response effort. CONCLUSIONS: Demand indices reflecting Persistence (i.e., sensitivity to escalating price) predicted effort to obtain UBMC puffs on the concurrent-choice task. Among this sample, the CPT captured information on the relative reinforcing value (i.e., addiction potential) of combustible tobacco products similar to the longer self-administration task. IMPLICATIONS: In an ever-changing product market, assessing the reinforcing efficacy of menthol cigarettes and putative substitutes quickly and with validity is an important methodological tool for understanding abuse liability. Results suggest that behavioral economic demand indices of cigarette purchase task efficiently capture information on the relative reinforcing value of usual brand menthol cigarettes and plausible alternative tobacco products, similar to a 90-min in-laboratory self-administration task.

Smoking cessation interventions for U.S. adults with disabilities: A systematic review.

INTRODUCTION: People with disabilities disproportionately use tobacco products. However, little is known about cessation interventions tailored for people with disabilities. The objective of this study was to conduct a systematic review of smoking cessation interventions for adults with disabilities. METHODS: Six electronic databases (Cochrane, CINAHL Plus [EBSCOhost], Embase [Ovid], Medline [Ovid], PsycINFO [Ovid], and Web of Science) were searched to identify eligible interventions for people with disabilities (e.g., vision, hearing, mobility, communication, cognition, self-care) through July 2023. Two independent coders evaluated the records and extracted data from studies that met inclusion criteria. Qualitative synthesis was conducted on the included studies in 2023. RESULTS: One randomized controlled trial and one nonrandomized study met the inclusion criteria. Both studies used mindfulness-based procedures to reduce cigarette use in adults with mild intellectual disability. The outcome was defined as self-reported cigarette use at follow-up, which ranged from 1 year to 3 years. Limited information was provided on how the interventions were tailored to meet the unique needs of people with disabilities in either study. CONCLUSION: Two interventions conducted in adults with mild intellectual disability showed promising results using mindfulness-based procedures; however, the studies did not address barriers reported by people with disabilities, nor tailor the interventions to meet the needs of the target population. Research is needed to address tobacco use disparities among people with a range of disabilities. Current cessation interventions would be enhanced by integrating disability identifiers alongside other demographic information in future studies and reporting subgroup analyses in adults with disabilities.

Substitutability of menthol cigarette alternatives: a clinical trial.

INTRODUCTION: This study assessed the substitutability of plausible combustible menthol cigarette alternatives (MCAs) for usual brand menthol cigarettes (UBMCs) in adults who smoke menthol cigarettes. METHODS: Following three in-lab sampling sessions, 80 adults aged 21-50 who smoke menthol cigarettes chose their preferred MCA: (1) a menthol roll-your-own cigarette (mRYO), (2) a menthol filtered little cigar (mFLC) or (3) a non-menthol cigarette (NMC). Participants were instructed to completely substitute their preferred MCA for their UBMC for 1 week and complete daily diaries documenting adherence and subjective effects. At the final lab visit, participants completed concurrent choice and cross-price elasticity tasks with their substitute product and UBMC as the comparator. RESULTS: Most (65%) participants chose mRYO as their preferred product, followed by NMC and mFLC. Adherence to MCA was high for all products across the week (range: 63%-88%). Positive subjective effects for mRYO decreased over time but remained numerically higher than the other MCA products; craving reduction also decreased for NMC across phases. In the progressive ratio task, participants chose their UBMC in 61.7% of choices; this did not differ by preferred MCA, although the median breakpoint was highest for mRYO and similar for mFLC and NMC. Cross-price elasticity comparing UBMC and the preferred product indicated high substitutability of each MCA at phase 3 (I values -0.70 to -0.82). CONCLUSIONS AND RELEVANCE: mRYOs were the most preferred MCA among the study products, but all MCAs were acceptable substitutes for UBMC using behavioural and economic measures in a short-term trial period.Trial registration number NCT04844762.

A Survey of Staff Training and Performance Management Practices: An Update.

The field of behavior analysis has experienced marked growth in the number of credentialed professionals over the last decade. This growth may have implications for the quality of staff training, performance management, and supervision practices provided in human service settings. The purpose of this survey was to extend DiGennaro Reed and Henley (2015) by surveying credentialed and aspiring behavior analytic professionals on the staff training, performance management, and supervision practices available at their current place of employment. Three main differences were observed in relation to the findings of DiGennaro Reed and Henley. The current findings indicate notable changes in the demographic characteristics of survey respondents. In addition, we observed modest increases in the use of best practices for initial and ongoing training and performance management. Results also indicate several areas of concern regarding the provision of supervisory skills training. • Results revealed improvements in the percentage of respondents who received initial or preservice training compared to DiGennaro Reed and Henley (2015). However, employers primarily rely on instructions and modeling to train their employees. • Findings revealed greater reliance on asynchronous and synchronous online training modalities compared to DiGennaro Reed and Henley (2015). • Results revealed a slight shift in the percentage of respondents who reported receiving ongoing training compared to DiGennaro Reed and Henley (2015). In the present study, BCaBAs and RBTs generally received ongoing training; however, fewer BCBAs reported receiving ongoing training. • The reported use of performance management practices improved compared to DiGennaro Reed and Henley (2015). That is, a higher percentage of respondents reported being observed at work while carrying out their job responsibilities. • Of the respondents who supervise staff, less than half of them reported receiving supervisory skills training. And only half of those respondents reported that their training prepared them to supervise others.

Contingency management interventions for abstinence from cigarette smoking in pregnancy and postpartum: A systematic review and meta-analysis.

Contingency management is one of the most effective treatments for substance use disorders in not-pregnant people. The most recent quantitative review of its efficacy among pregnant and postpartum women who smoke cigarettes concluded with moderate certainty that those receiving contingent financial incentives were twice as likely to be abstinent compared with controls. We aimed to update and extend previous reviews. Five databases were systematically searched for randomized controlled trials (RCTs) published before December 2022 that assessed the effectiveness of incentives for abstinence from substance use. Data from trials of smoking abstinence were pooled using a random-effects meta-analysis model (restricted maximum likelihood). Results are reported as risk-ratios (RRs) with 95% confidence intervals (CIs). This study is registered with PROSPERO, CRD42022372291. Twelve RCTs (3136) pregnant women) were included. There was high certainty evidence that women receiving incentives were more likely to be abstinent than controls at the last antepartum assessment (12 RCTs; RR = 2.43, 95% CI 2.04-2.91, n = 2941, I2 = 0.0%) and moderate certainty evidence at the longest postpartum assessment while incentives were still available (five RCTs; RR = 2.72, 1.47-5.02, n = 659, I2 = 44.5%), and at the longest postpartum follow-up after incentives were discontinued (six RCTs; RR = 1.93, 1.08-3.46, n = 1753, I2 = 51.8%). Pregnant women receiving incentives are twice as likely to achieve smoking abstinence during pregnancy suggesting this intervention should be standard care for pregnant women who smoke. The results also demonstrate that abstinence continues into the postpartum period, including after incentives are discontinued, but more trials measuring outcomes in the postpartum period are needed to strengthen this conclusion.

The fourth wave of the overdose crisis: Examining the prominent role of psychomotor stimulants with and without fentanyl.

The current overdose and broader public health crisis involving illicit drug use is often referred to as the "opioid" or "fentanyl" crisis. Clearly there is extensive data on the profound damage done by opioids over the past 20 years and specifically by fentanyl in the past 5 years. However, there is an extensive array of data that suggests there is more to the current crisis than opioids/fentanyl. Much recent evidence indicates that methamphetamine and cocaine are playing a substantial and increasing role in the illicit drug crisis in the US-the 4th wave. This paper reviews data that illustrate the role of psychomotor stimulants in fatal overdoses, nonfatal overdoses, and emergency department visits. Despite the major detrimental role that stimulants are having on the public health in the US in 2023, there is virtually no evidence-based treatment available in practice for people with stimulant use disorder (StimUD). Although there are no medications with FDA-approval for the treatment of StimUD, there is a behavioral treatment, contingency management (CM), with over 3 decades of robust research supporting its efficacy for individuals with StimUD. Despite the overwhelming evidence supporting CM, it is not being widely used in routine treatment outside the VA healthcare system. This paper reviews some of the (a) evidence for CM, (b) CM protocol design elements that require consideration, (c) current obstacles to the widespread implementation of CM, and (d) strategies for addressing these obstacles. Overcoming these obstacles is a priority to allow routine use of CM as a treatment for StimUD.

Smoking cessation interventions for US adults with disabilities: protocol for a systematic review.

INTRODUCTION: People with disabilities have a higher prevalence of cigarette smoking than people without disabilities. However, little information exists on smoking cessation interventions tailored to address the unique needs of people with disabilities. This paper describes a systematic review protocol to identify and evaluate tobacco smoking cessation interventions designed to improve outcomes for people with disabilities. METHODS AND ANALYSIS: We will conduct a systematic review of the literature using the procedures outlined by Cochrane. We will search four electronic databases (CINAHL Plus (EBSCO), Embase (Ovid), Medline (Ovid) and PsycINFO (Ovid)) with no date restriction to identify tobacco cessation interventions tailored to meet the needs of people with disabilities. We will extract data and assess risk of bias using the RoB2 and ROBINS-I for included studies using Covidence systematic review software. Quantitative and qualitative syntheses will summarise key study characteristics and outcomes with text, tables and forest plots; a meta-analysis will be conducted, if appropriate. ETHICS AND DISSEMINATION: Ethical approval is not required as there are no primary data associated with the study. Data will be disseminated through a peer-reviewed articles and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42022337434.

Contingency Management for Stimulant Use Disorder: Progress, Challenges, and Recommendations.

The United States is currently in the fourth wave of the overdose crisis wherein stimulants together with fentanyl are the major drivers of overdose deaths. To date, there has been limited effort outside the US Veterans Administration Health System health system to disseminate evidence-based treatment for people with stimulant use disorder. Contingency management, a behavioral intervention in which positive reinforcement is provided for a target behavior indicating treatment progress, has decades of empirical support but limited implementation in real-world, non-US Veterans Administration Health System settings. The purpose of the report is to provide an overview of contingency management, the barriers to adoption, and recommendations for overcoming these barriers.

Addiction potential of combustible menthol cigarette alternatives: a randomised cross-over trial.

INTRODUCTION: The Food and Drug Administration (FDA) has issued proposed product standards banning menthol as a characterising flavour in cigarettes and cigars. The public health benefits of these product standards may be attenuated by the role of plausible substitutes in the marketplace. Therefore, the present study examined the addiction potential of plausible combustible menthol alternatives compared with usual brand menthol cigarettes (UBMC). METHODS: Ninety-eight adult menthol cigarette smokers completed four visits, smoking their UBMC at the first session and three menthol cigarette alternatives in random order at the subsequent visits: (1) a preassembled menthol roll-your-own (mRYO) cigarette using menthol pipe tobacco and mentholated cigarette tube, (2) a menthol filtered little cigar (mFLC) and (3) a non-menthol cigarette (NMC). Measures of smoking topography, exhaled carbon monoxide (CO), craving and withdrawal, subjective effects and behavioural economic demand indices were assessed. RESULTS: Compared with UBMC, menthol cigarette alternatives resulted in different puffing topography and CO exposure (except mRYO), and lower levels of positive subjective experience and behavioural economic demand indices. Among the alternative products, participants reported the highest level of positive subjective experience and higher demand for mRYO, compared with mFLC and NMC. Similarly, participants were significantly more likely to want to try again, purchase and use the mRYO product regularly compared with mFLC and NMC. CONCLUSIONS AND RELEVANCE: mRYO cigarettes were the most highly rated cigarette alternative among study products, suggesting their potential appeal as a menthol cigarette substitute and needed inclusion of menthol pipe tobacco and cigarette tubes in FDA's proposed ban.

A review of research on cigarette smoking in Preventive Medicine in recognition of the journal's 50th anniversary.

This report reviews the literature on cigarette smoking published in Preventive Medicine over the past 50 years. The goal is twofold. First, to acknowledge the 50th anniversary of Preventive Medicine and its role in disseminating research on cigarette smoking by providing an abridged summary of smoking research published in the journal from inception through June 23, 2022. Second, to review experimental reports to identify contributions to innovations in tobacco control and regulatory efforts to reduce cigarette smoking. We searched PubMed using the search terms cigarette/cigarettes, tobacco products, smoking, smoking cessation, Preventive Medicine. Titles and abstracts were reviewed in duplicate, excluding reports not addressing cigarette smoking. Included reports were categorized by study type (original study, commentary, review). Experimental articles were assessed for impact using iCite, a National Institutes of Health web application that provides bibliometric information for articles in defined topic areas. The review identified 1181 articles on cigarette smoking: 1018 original studies (86.2%), 107 literature reviews (9.1%), and 56 commentaries (4.7%); 166 of the 1018 original studies (16%) were experimental reports. In the iCite analysis these 166 experimental articles received 6366 total citations, a mean (standard error) citation rate/article of 38.35 (±3.21) and mean relative citation ratio of 1.85 (±0.17) which is at the 73rd percentile for NIH-funded field- and time-normalized reports. Overall, this review demonstrates an ongoing and impactful contribution of Preventive Medicine to efforts to reduce cigarette smoking, the most preventable cause of premature death.

Leveraging the cigarette purchase task to understand relationships between cumulative vulnerabilities, the relative reinforcing effects of smoking, and response to reduced nicotine content cigarettes.

We examined if the relative-reinforcing effects of smoking increase with greater cumulative vulnerability and whether cumulative vulnerability moderates response to reduced nicotine content cigarettes. Participants were 775 adults from randomized clinical trials evaluating research cigarettes differing in nicotine content (0.4, 2.4, 15.8 mg/g). Participants were categorized as having low (0-1), moderate (2-3), or high (≥4) cumulative vulnerability. Vulnerabilities included rural residence, opioid use disorder, affective disorder, low educational attainment, poverty, unemployment, and physical disability. We used the cigarette purchase task (CPT) to assess the relative-reinforcing effects of participants' usual-brand cigarettes at baseline and study cigarettes during the 12-week trial. The CPT is a behavioral-economic task wherein participants estimate likely smoking (demand) over 24 h under escalating cigarette price. Demand is characterized by two factors: Amplitude (demand volume at zero/minimal price) and Persistence (demand sensitivity to price). Greater cumulative vulnerability was associated with greater demand Amplitude (F[2709] = 16.04,p < .0001) and Persistence (F[2709] = 8.35,p = .0003) for usual-brand cigarettes. Demand Amplitude for study cigarettes increased with increasing cumulative vulnerability (F[2619] = 19.59, p < .001) and decreased with decreasing nicotine content ([4879] = 5.45, p < .001). The only evidence of moderation was on demand Persistence (F[8867] = 2.00,p = .04), with larger reductions at the 0.4 mg/g compared to 15.8 mg/g doses among participants with low compared to moderate or high cumulative vulnerability. The relative-reinforcing effects of smoking clearly increase with greater cumulative vulnerability. Reducing nicotine content would likely reduce demand Amplitude across cumulative-vulnerability levels but reductions in demand Persistence may be more limited among those with greater cumulative vulnerability.

Technology-based contingency management for walking to prevent prolonged periods of workday sitting.

Sedentary behavior is an emerging public health issue. Frequent, brief bouts of walking are recommended by experts to reduce the health risks correlated with physical inactivity and prolonged sedentary periods. The purpose of the current study was to extend the literature by evaluating a remote, technology-based contingency management (CM) intervention that reinforced frequent, brief bouts of walking to decrease prolonged periods of sitting during the workday. A packaged intervention consisting of a contingency contract, monetary incentives, goal setting, textual prompts, and performance feedback was implemented with individuals with sedentary job responsibilities working from home during the COVID-19 pandemic. The intervention increased the number of physically active intervals to mastery for 4 participants, thereby disrupting prolonged periods of sedentary time. For 2 participants, the intervention did not meaningfully increase the number of physically active intervals. Results suggest that a remote, digital CM intervention can decrease sedentary behavior in home office environments.

Effects of a Systems-Level Intervention to Improve Trainer Integrity in a Behavioral Healthcare Organization.

Objectives: Direct support professionals (DSPs) play a critical role in health-related outcomes for individuals with intellectual and developmental disabilities (IDD) who reside in congregate living settings. Large behavioral healthcare organizations often rely on staff to function as peer trainers for newly hired DSPs. Organizations should adopt empirically supported training techniques to prepare peer trainers for their role and develop systems to ensure ongoing integrity of the training system. The purpose of this program description is to summarize consultation activities that attempted to create these systems. Methods: Staff members were trained to function as peer trainers, an assessment was conducted to determine the barriers to training in the natural environment, and a systems-level intervention informed by the assessment was implemented to improve peer trainer integrity. Results: The assessment revealed peer trainers were often unaware when they were expected to train and did not receive feedback or programmed consequences for training newly hired DSPs. A systems-level intervention containing a prompt (reminder) about upcoming training and feedback plus a monetary incentive produced improvements in trainer integrity. Conclusions: A systems-level intervention based on an assessment can improve peer trainer integrity. Ensuring peer trainer integrity increases the likelihood that newly hired DSPs will implement health-related protocols with individuals with IDD.

Training human service staff to implement behavioral skills training using a video-based intervention.

The current study evaluated the efficacy of a video-based training to teach 4 staff working in a human service setting to use behavioral skills training (BST) to teach job-related skills to others. Low levels of BST integrity were observed during baseline. Immediately after viewing a 13-min training video, 2 participants implemented BST at mastery (i.e., 100% integrity). The remaining 2 participants required brief supplemental performance feedback to reach criterion performance. The effects of the training generalized to training 2 novel skills and maintained in follow-up probes conducted 1 to 4 weeks posttraining. A social validity measure indicated high levels of satisfaction with the video-based training and high acceptability of BST. Implications of these findings for organizational training practices and directions for future research are discussed.

A Survey Assessing Privacy Concerns of Smart-Home Services Provided to Individuals with Disabilities.

Privacy has been identified as a primary concern among stakeholders (i.e., service recipients, advocates, administrators, family) when using technology to provide residential services to individuals in need. This paper summarizes a study that distributed a survey to agencies that provide services (e.g., clinical, recreational) and resources (e.g., advocacy groups) to people with various types of disabilities (e.g., physical, sensory, intellectual, developmental) across the United States. The results led to several recommendations about how smart-home service providers can use technology in a way that promotes client privacy. In addition, we make several suggestions for how remote staff (i.e., individuals monitoring the information gathered by technology) can assist in the process of ensuring client privacy.

Enhancing the training integrity of human service staff using pyramidal behavioral skills training.

This experiment used a pyramidal training model to evaluate the effects of behavioral skills training (BST), delivered in a 1-time group-training format, on the extent to which 25 human service staff implemented BST when training others how to implement behavioral procedures. Results indicated that (a) the training workshop increased BST integrity to mastery levels for the majority of participants with varying levels of education, organizational positions, and training experience, (b) the training effects generalized to teaching an untrained skill, and (c) high levels of BST integrity maintained at follow-up 4 to 6 weeks after training for all 3 participants with whom probes were conducted. Moreover, participants indicated high levels of satisfaction with both the training workshop and BST as a training procedure.

A brief review of technology-based antecedent training procedures.

This brief review summarizes recent research on technology-based antecedent staff training procedures, highlights key methodological components, and concludes with potential directions for future research.

Operant renewal of desirable behavior in a simulated workplace: A translational model.

Organizational settings are replete with changing stimulus contexts and contingencies, which makes relapse a particularly relevant framework for understanding the ways in which controlling stimuli influence employee responding. The purpose of the current study was to develop a translational model to assess renewal of desirable behavior in a simulated workplace with neurotypical adults. Experiment 1 assessed renewal of desirable behavior using a computerized check processing task. Experiment 2 extended the findings and the translational utility of the experimental arrangement to implementation of a behavior-analytic teaching procedure. Results across both experiments demonstrated renewal of desirable behavior. Overall, the current methodology and findings extend the human operant literature on renewal and demonstrate a translational model that brings together operant renewal and organizational behavior management.

Evidence-Based Performance Management: Applying Behavioral Science to Support Practitioners.

The science of behavior has effectively addressed many areas of social importance, including the performance management of staff working in human-service settings. Evidence-based performance management entails initial preservice training and ongoing staff support. Initial training reflects a critical first training component and is necessary for staff to work independently within an organization. However, investment in staff must not end once preservice training is complete. Ongoing staff support should follow preservice training and involves continued coaching and feedback. The purpose of this article is to bridge the research-to-practice gap by outlining research-supported initial training and ongoing staff support procedures within human-serving settings, presenting practice guidelines, and sharing information about easy-to-implement ways practitioners may stay abreast of current research.