Introduction: Race/ethnicity and sex disparities in substance use and substance use treatment completion are well documented in the literature. Previous literature has shown that participation in self-help groups is associated with higher rates of substance use treatment completion. While most of this research has focused on the completion of treatment for alcohol and stimulant use, research examining this relationship using an intersectional approach for individuals in treatment for opioid use is limited. Methods: Thus, the current study utilized responses from the Treatment Episodes Data Set–Discharges, 2015–2017 to examine disparities in the relationship between participation in self-help groups and substance use treatment completion for individuals undergoing treatment for opioid use based on sex, race, and ethnicity. Results: Results revealed a positive association between participation in self-help groups and treatment completion among those in treatment for opioid use across race, ethnicity, and sex. Further, the study found several differences in this association based on one's race, ethnicity, and sex. When compared to men of other races/ethnicities, the association between self-help group participation and treatment completion was highest among Black men. Conclusions: The results of the current study extend the knowledge-base about self-help participation's role in promoting successful substance use treatment completion to individuals in treatment for opioid use. Results also highlight the need to examine treatment outcomes with an intersectional lens.

Background: Social adversities are prevalent among those with psychiatric disorders and may be involved in poor outcomes among patients receiving treatment. Identification of social risk factors influencing outcomes will help provide targeted interventions for at-risk patients. This thesis explored the role of social and behavioural factors in relation to adverse psychiatric outcomes, specifically relapse to substance use and attempted suicide. Methods: We used scoping study methodology to perform a comprehensive review to identify the gaps in the literature examining social functioning and MMT outcomes. This review informed our primary cohort study examining the association between social factors and continued opioid use in MMT. Lastly, we conducted a case-control study to identify risk factors for suicide attempts by comparing psychiatric patients with and without suicide attempt history (cases and controls, respectively). Multivariable logistic regression analyses were conducted in both primary studies to examine the association between predictors and outcomes. Results: The review included 101 observational studies and determined the need for further research on social factors and MMT outcomes among a current sample of Canadian patients. Our cohort study included 1043 participants (mean age=38.4 years, standard deviation [SD]=11.06); 45.8% women) to investigate this and found that unemployment, criminal activity and interpersonal conflict with friends significantly increased odds of illicit opioid use. In examining risk factors for suicide attempts, we recruited 146 cases (mean age=45.18 years, SD=14.70 years; 55% female) and 104 control participants (mean age=45.01 years, SD=14.23 years; 50% female). No sociodemographic differences existed between groups, however higher impulsivity and borderline personality symptoms significantly increased odds of attempted suicide. Conclusions: Findings from these studies may indicate the need for structured monitoring of at-risk psychiatric patients. It may be important to develop tools to measure social and behavioural factors in clinical settings and promote further integration of social services in treatment settings. / Thesis / Master of Science (MSc)

<p>The opioid epidemic is an ongoing public health crisis in the United States (US). Although many treatment options exist for opioid use disorder (OUD), including evidence-based counseling, medications, rehabilitation programs, and support groups, access to care is a significant barrier. Pharmacists can play an important role in increasing patient access to OUD care; however, insufficient training is a well-documented barrier. Integrating comprehensive training into Doctor of Pharmacy coursework is a practical approach to preparing pharmacists to provide appropriate OUD care in a variety of practice settings. A shared OUD curriculum is one strategy to facilitate the integration of comprehensive training into Doctor of Pharmacy coursework.</p> <p><br></p> <p>My current research aimed to collect data from four key stakeholder groups – Doctor of Pharmacy program faculty, community pharmacists, multidisciplinary professionals, and patients experiencing OUD – to inform a shared OUD curriculum through a convergent, parallel, mixed methods study design. Specifically comprising this thesis are the quantitative findings from telephone surveys with Doctor of Pharmacy program faculty (“Study One”) and community pharmacists (“Study Two”); qualitative findings from multidisciplinary professional focus groups and patient interviews, as well as synthesized findings across quantitative and qualitative data sources, will be reported in future publications. Collectively, the results presented in this thesis provide a “snapshot” of the current pharmacy landscape with respect to the OUD education delivered to student pharmacists and opioid-related practices in community pharmacies.</p> <p><br></p> <p>The findings from Study One and Study Two indicate that OUD education in Doctor of Pharmacy programs and pharmacist-provided opioid interventions are inconsistent at best. The three main areas identified as needing future emphasis were: (1) the disease model of addiction and accompanying stigma of OUD; (2) harm reduction-, prescription-, screening-, and resource referral-related opioid interventions; and (3) skills-based, experiential education (vs. didactic education) for opioid intervention delivery and communication techniques. A shared OUD curriculum was of interest to faculty and is a viable solution to addressing OUD education gaps in Doctor of Pharmacy programs. Once qualitative data analyses are completed and findings from all four stakeholder groups are synthesized, development of the proposed shared OUD curriculum will commence.</p>

Opioid abuse and opioid related deaths continue to affect families and communities across the United States. Medication-assisted treatment shows advantages over other types of interventions for opioid use disorder (OUD) (Bart, 2012). While buprenorphine, an approved medication for the treatment of OUD, has a wide research base to support its efficacy, there is little research or guidance on behavioral interventions to use in conjunction with the medication. Investigating clients' experiences in treatment can provide helpful and necessary information for improving treatment efforts. The following qualitative study used a phenomenological approach to explore the client experience of group therapy with buprenorphine for OUD. Results showed the importance of supportive, genuine relationships in recovery, as well as the need for accountability and a safe space for self-disclosure. This research highlights the importance of the therapeutic alliance, the 11 therapeutic factors of groups, and the necessity of building authentic relationships in treatment. / Doctor of Philosophy / As opioid overdoses continue to rise in the United States, it is essential that we improve addiction treatment. Medication-assisted treatment (MAT) combines the use of medications and counseling to treat the whole person. This type of approach shows advantages over counseling only interventions for opioid use disorder (OUD) (Bart, 2012). While MAT shows promise over counseling only approaches, there is little research or guidance on how to implement counseling with the medication. Investigating clients’ experiences in treatment can provide helpful and necessary information for improving counseling in MAT. The following qualitative study used in-depth interviews with participants who are currently in a MAT program to better understand their experiences in treatment. Results showed the importance of supportive, genuine relationships in recovery, as well as the need for accountability and a safe space for sharing. This research helps further knowledge of treatment for OUD to better serve those affected by addiction, as well as adding to the gaps in group therapy and addiction’s literature.

The region of Appalachia in the United States is a diverse region that is full of beauty, mountains, art, and culture. Due to a history of abuse from large corporations, the impact of the decline in coal mining and generational poverty, the region is currently on a road toward recovery. Substance misuse rates are disproportionality high, and there are limited resources available to address the issue. Literature suggests that church leaders may be a potential resource. The goal of the study was to provide a better understanding of the substance misuse epidemic through the eyes of church leaders. Interpretative Phenomenological Analysis guided this qualitative study. Church leaders (n = 10) were interviewed and four significant themes emerged: narratives used to describe their experiences with substance misuse, the stigma associated with substance misuse, the community impact that substance misuse has on Appalachia, and the lack of understanding and need for training on substance misuse for church leaders and healthcare practitioners. The results of the study are discussed and connected to discussions of the implications for clinical practice, recommendations for further research, and limitations of the study. / Doctor of Philosophy / Appalachia is a mountain range located in the eastern portion of the United States. It is a diverse region that is full of beauty, mountains, art, and culture. Due to a history of abuse from large corporations, the impact of the decline in coal mining and generational poverty, the region is currently on a road toward recovery. Substance misuse rates are disproportionality high, and there are limited healthcare resources available to address the issue. The goal of the presented study was to provide a better understanding of the substance misuse epidemic through the experiences of church leaders, which are abundant in the region. Church leaders, a sample of 10, were interviewed and four significant topics emerged from their stories shared: narratives used to describe their experiences with substance misuse, the stigma associated with substance misuse, the community impact that substance misuse has on Appalachia, and the lack of understanding and need for training on substance misuse for church leaders and healthcare practitioners. The results of this study suggest that church leaders may be used as a resource to help lower the impact of substance misuse. The experiences of the church leaders gained from this study can help provide training to church leaders and healthcare providers on ways to work together and lower substance misuse in Appalachia.

It is well known that people who use drugs (PWUD) leave the hospital via patient directed discharge (“PDD”; also known as against medical advice “AMA”) more often than people who do not use drugs. The introduction of xylazine – a veterinary tranquilizer – into the United States (US) synthetic opioid supply has only exacerbated this situation. The following paper reviews the literature on xylazine, hospitalization with opioid use disorder (OUD), and how xylazine has changed the experience of hospitalization with OUD. The research revealed that xylazine causes respiratory depression, sedation, and the formation of necrotic wounds. There is currently no treatment for xylazine dependence, overdose, or withdrawal. The literature further revealed that inadequate management of withdrawal and pain, along with stigma from health professionals, are major reasons why PWUD leave the hospital PDD before completing treatment. The difficulty the health system faces with the management of xylazine withdrawal and the necrotic wounds it produces only exacerbates this problem and necessitates increased attention to this topic. Using opioid agonists to treat withdrawal decreases rates of PDD for PWUD in the hospital. This paper will argue that the treatment of PWUD in the hospital with opioid agonists in order to address withdrawal and pain is ethically necessary; and that the introduction of xylazine into the synthetic opioid supply in the US only further necessitates the collective adoption of this viewpoint. / Urban Bioethics

Opioid use disorder (OUD) and opioid overdose are pervasive public health problems in the U.S. Medications for opioid use disorder (MOUD) have been shown effective to reduce OUD morbidity and mortality. Two distinct approaches to MOUD are currently used: agonist therapy (methadone or buprenorphine) or antagonist therapy (naltrexone). Limited information is available about the patterns of use, adherence to therapy, and characteristics of those who use agonist vs. antagonist therapy. The objective of this study is to assess recent trends in MOUD, adherence in use of MOUD, and the characteristics of those who use agonist vs. antagonist therapy in a nationally representative population of commercially insured patients in the U.S. This retrospective descriptive study utilized data from Truven Marketscan Commercial Claims and Encounters database from years 2011 to 2016. All individuals aged 18 years and older who have a diagnosis of OUD and utilize MOUD at any point during the study period were included. Demographic characteristics of interest included age, gender, geographic region, and type of insurance coverage. Clinical characteristics of interest included diagnosis of OUD and type of MOUD used, including extended – release naltrexone for injection, oral naltrexone, buprenorphine in combination with naloxone, and buprenorphine alone. Descriptive analyses were employed to understand utilization patterns and trends over time and proportion of days covered was used to measure adherence. Frequency and percentage are presented for categorical variables. Adherence of MOUD will be estimated by measuring proportion of days covered. As this study uses de-identified commercial health claims data, it has been determined as not human subjects research by the University of Kentucky’s Office of Research Integrity. Agonist therapy with buprenorphine or buprenorphine/naloxone was the most common treatment, representing 75.7% of those receiving treatment. Between 2011 and 2016, the percentage of individuals receiving treatment with partial agonist therapy decreased 16.5% to 9.2%, respectively. Meanwhile, the percentage of individuals receiving treatment with antagonist treatment increased from 0.1% in 2011 to 0.3% in 2016. In the analysis of proportion of days covered, all MOUD reported a decrease at both 180 and 365 days. In the commercial population, younger female patients were more likely to be treated with injectable naltrexone. Specifically, in the North Central geographic region, commercial adult patients were more likely to be treated with buprenorphine monotherapy. Overall, this study found a decrease in use of agonist therapy from 2011 through 2016, with an increase in use of antagonist therapy in the same time period. However, the increase in use of antagonist therapy does not fully account for the decrease in use of agonist therapy, suggesting that since 2011 many patients with OUD still remain untreated. All MOUD types were analyzed and saw a decrease in proportion of days covered, as a measure of adherence, from 2011 to 2016 putting patients at an increased risk for relapse, further complications, emergency visits, and hospitalizations. More information is needed about characteristics of patients who not only seek out treatment for OUD, but also maintain their treatment overtime.

Prevention, social work, and community awareness programs have not led to the successful reduction of opioid overdose deaths nationwide, and particularly in Ohio. This study explored social work perspectives about trauma-€informed care (TIC) for persons with opioid use disorder in Ohio. The research questions for this study examined how social workers in Ohio implemented TIC when providing outpatient treatment to opioid users and what challenges they faced when providing TIC. Using an action research methodology, data were collected through individual semistructured interviews with 5 social work professionals, selected through purposive sampling based on experience in the field of substance use in Ohio and the use of TIC. Contemporary trauma theory and TIC were chosen to frame the research project. Three themes emerged through thematic analysis of the data: appreciation for trauma-€informed opioid use disorder treatment, organizational and professional challenges to the use of trauma-€informed opioid use disorder treatment, and environmental barriers to successful trauma-€informed outpatient opioid use disorder programming. The study aligned with the social work core values of competence and principles of harm reduction. The findings from the study might bring about social change by igniting dialogue among treatment providers about how TIC interventions could support integrated treatment and holistic approaches to combatting opioid addiction in Ohio.

The COVID-19 pandemic adversely affected the lives of most Americans. People with Substance Use Disorder (SUD) were particularly vulnerable to the negative effects brought on by the pandemic. This study explored the increase in deaths due to opioid overdose during the pandemic exacerbated by factors such as increased stress, decrease in treatment options due to social distancing requirements and facility closures, social isolation, and an increase in spare time. Access to treatment for opioid use disorder (OUD) was interrupted by the measures meant to mitigate the spread of COVID-19. Through a systematic review of current literature, it was demonstrated that existing patients were able to maintain access to care, while few new patients were able to initiate treatment. Telehealth proved to be a vital means of assuring PWUD were able to access life-saving treatment amid a pandemic. Further research is needed to determine whether SUD treatment measures during the COVID-19 pandemic warrants changing the policies long term.

It is increasingly recognised that chronic exposure to opioids has been associated with neuropsychological impairment during both active use and following a period of abstinence. The overall objective of this thesis was to review the relevant prior literature in a systematic manner and subsequently to describe the effects of chronic exposure to prescribed and illicit opioids using an ambispective cohort study design. A systematic literature review was conducted to identify if chronic (defined as a period for more than 3 months) exposure to opioids (prescribed and/or illicit) was associated with measurable neuropsychological deficits. This review was conducted accordingly to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) and the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. The results were subsequently described within three cognitive domains of intelligence, executive function and memory and learning. Out of a total of 905 articles extracted between 1964 and 2009, 49 articles were considered appropriate for selection and review. Studies of current and abstinent chronic opioid users (illicit heroin users, patients prescribed methadone for illicit opioid dependence and patients taking opioids as part of the management of chronic pain) have identified performance deficits in measures of executive functioning and memory. These have included impairments within the domains of cognitive and motor impulsivity, strategic planning, cognitive flexibility, attention and memory. However other studies found no clear deficits when comparing the performance of healthy controls. The literature suggested that these neuropsychological deficits may be subject to at least partial recovery following initiation of methadone or total withdrawal from any opioids.This review also highlighted several methodological issues that affect the reliability, validity and clinical relevance of the results obtained. Subsequently a two year ambispective cohort design study was conducted which tested representative opioid exposed participants and healthy controls. Cohorts of participants with validated histories of illicit heroin use (HEROIN, n=24), stabilised methadone maintenance (METHADONE, n=29), chronic opioid prescriptions for pain (CHRONIC PAIN, n=28) and controls (HEALTHY CONTROL, n=28) were recruited. The study was designed to test neuropsychological performance in the HEALTHY CONTROL and CHRONIC PAIN groups on one occasion; and for the HEROIN and METHADONE groups on three and two occasions respectively. The intention was to describe neuropsychological performance in the HEROIN group under conditions of stable illicit heroin use, in controlled opioid withdrawal and when subsequently stabilised on methadone. For the METHADONE group, participants were tested twice, six months apart, to test for changes induced by chronic exposure to methadone. Eligible, screened and consented individuals were tested on nine tests from the CANTAB test battery. Data were analysed using univariate or repeated measures ANCOVA with a between subjects factor of GROUP. Further a priori subgroup analyses were conducted using (1) a two-group factor reflecting DEPENDENCE status and (2) a two-group factor reflecting INJECTING status separately as between subject factors. The homogeneity of variance across groups in repeated-measures design ANCOVAs was assessed by the Mauchly Sphericity Test. NART, age in years, SIMD, total Fagerström score, years in education and past alcohol use in years were used as covariates. A significance level of p<0.01 was applied due to multiple testing, in addition to the post-hoc Bonferroni correction procedure. On the Cambridge Gambling Task (CGT), HEROIN users placed higher bets earlier and risked more. They also showed increased motor impulsivity, impaired strategic planning and visuospatial memory on the Affective Go-NoGo (AGN), Stockings of Cambridge (SOC), and Delayed Matching to Sample(DMS) respectively. METHADONE users deliberated longer and placed higher bets earlier on the CGT, but did not show a tendency to risk more. METHADONE users were also more inattentive and demonstrated poor strategic planning and visuospatial memory on the Spatial Span (SSP) task. The CHRONIC PAIN participants did not exhibit significant impairment in neuropsychological performance on all the CANTAB tasks. Participants from the HEROIN, METHADONE and CHRONIC PAIN groups did not present with impaired cognitive flexibility. Chronic opioid dependence is associated with neuropsychological impairment reflected in altered performance on measures of risk taking and strategic planning. These data support the hypothesis that these neuropsychological impairments reflect an underlying trait vulnerability to drug taking and/or dependence rather than an effect of chronic exposure to opioids. Notably, motor impulsivity and visuo-spatial memory in HEROIN users improved after three weeks stability with methadone. Methadone use seems to confer improvement in some aspects of neuropsychological performance following cessation of heroin and sustains other deficits during long term stable methadone treatment. Dependence and injecting status do not contribute to the causation or deterioration of the identified neuropsychological impairments. Further long term longitudinal studies to help elucidate cognitive endophenotypes responsible for the components in the initiation, continuation and deterioration of neuropsychological deficits present in an opioid dependent population is necessary.