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Substance use is a serious and growing problem in the U.S. The impact of substance use disorders is vast and can affect more than the person with the disorder. Drug overdose deaths and related hospitalizations are positively associated with a rise in foster care case nationwide. When a child is removed from a home, social workers see first if there are biological family members who could provide a suitable home for the child as to make the transition less disruptive for the child. The average age of a kin caregiver was 59 years old in 2018, so this likely means grandparents are stepping in the caregiver role. Appalachia specifically has been hit hard by the opioid epidemic, and its rates of both overdose deaths and foster care cases have greatly increased. However, no research has analyzed the association between rates of grandparents as primary caregivers of children and county-level drug overdose mortality rates in Appalachia specifically and then compared that to the same association for non-Appalachian areas. Thus, this study decided to examine the association between those variables with a national dataset made from county-level data from multiple sources, mainly the CDC National Center for Health Statistics and the U.S. Census Bureau American Communities Survey (ACS). A cross-sectional analysis of 5-year estimates for drug overdose mortality on a county-level associated with the ACS data on grandparents acting as primary caregivers of grandchildren under the age of 18 was performed. There were three hypotheses: 1) counties with higher rates of drug overdose mortality will have higher rates of grandparents acting as primary caregivers of children under 18 years old, 2) the rate of grandparents serving as primary guardians of children under 18 years old will be higher in Appalachian counties than in non-Appalachian counties, 3) the correlation between grandparents serving as primary caregivers of children under 18 years old and drug overdose mortality will be stronger in Appalachian counties as opposed to non. For each hypothesis, a bivariate analysis was run independently, and by using multivariate modeling, the association between grandparents as primary caregivers and overdose mortality was evaluated. Running these analyses determined some statistically significant results: as overdose rates increase, rates of grandparent guardians increase; the rate of grandparent caregivers is higher in Appalachian counties than non-Appalachian counties; and there is a stronger correlation between overdose mortality rate increases and grandparents as caregivers increases in Appalachian counties as opposed to non-Appalachian counties. This is useful as there is a lack of research discussing this specific relationship, especially in rural areas such as in Appalachia. Furthermore, these results could help inform policies and programs to support grandparent guardians and help lessen the impacts of parental substance use for children.

Substance use disorders are a prominent issue within the United States that must be addressed given the high prevalence, economic cost, and negative health consequences of these medical conditions. Current treatments are inadequate due to the limited success of behavioral therapies and the lack of pharmacological interventions geared towards preventing the neuroplastic changes initiated by substances of abuse that lead to addiction. Sigma-1 receptors represent promising pharmacological targets for treatment of substance use disorders involving cocaine and methamphetamine use. A review of recent studies suggests that sigma-1 receptors contribute to the underlying mechanisms of action utilized by cocaine. Yet the use of sigma-1 receptor antagonists shows promising results of mitigating the physiological effects induced by cocaine. In contrast to cocaine, sigma-1 receptors have yet to be linked to the underlying mechanisms of action utilized by methamphetamine. However studies indicate that the use of sigma-1 receptors agonists creates a neuroprotective effect against the physiological effects induced by methamphetamine. Currently the pharmacological targeting of sigma-1 receptors is not utilized to treat substance use disorders. A review of literature was conducted in order to elucidate the mechanistic role that sigma-1 receptors play in mediating the physiological effects induced by cocaine and methamphetamine that lead to addiction. Using this information, the potential use of sigma-1 receptors as therapeutic targets was discussed in order to provide insight about the benefits and limitations of utilizing such an intervention as treatment for substance use disorders involving cocaine and methamphetamine use.

In 2017, approximately 8.5% of pregnant women nationwide used illicit substances during their pregnancies, up from 6.3% just one year prior (NSDUH, 2017). The trends associated with substance misuse and pregnancy are alarming given the risks to both the mother and her child (Behnke et al., 2013). Pregnant women with substance use disorders (SUDs) are thus in critical need of support during the prenatal period (American Society of Addiction Medicine, 2011). However, they also contend with stigma and the possibility of punitive responses (Terplan et al, 2015), which can result in avoidance of treatment. Prenatal care and positive patient-provider relationships are essential to improved health outcomes (Lori et al, 2011). Yet, little is known about the patient-provider relationship for pregnant women with SUDs and what facilitates trust and women’s willingness to engage in care. Informed by recognition theory and intersectionality, this qualitative study aims to fill that gap, emphasizing the ways patients and providers develop and maintain their relationships, as well as their perceptions of each other. Semi-structured interviews were conducted with N=19 postpartum women with SUDs and N=10 prenatal care providers (not matched pairs). Using a two-layered thematic analytical approach – both data- and theory-driven – this research offers a comprehensive examination of prenatal care in the context of SUDs. Women entered into prenatal care feeling ambivalent about their pregnancy, with co-existing emotions such as guilt and excitement. They were also newly motivated to protect their child, and in need of clear medical information that was free of moral judgment. Women and providers identified provider traits that facilitated trust and connection in the patient-provider relationship, such as being nonjudgmental and supportive. Women also emphasized the value of being fully acknowledged as having worth and dignity. Finally, providers discussed the challenges of working with pregnant patients with SUDs, including the limits of their compassion, as well as the limitations of the health care system. Cumulatively, these findings highlight critical needs in prenatal care for women with SUDs, such as acknowledging women’s dignity, and supporting providers with comprehensive training and a health care system better suited to meet their patients’ needs.

Substance use disorders represent a consistent threat to our health care and financial resources. Although mental health professionals are likely to encounter individuals diagnosed with substance use disorders, they are less likely to receive formal graduate training in the area. Furthermore, 12-step groups like Alcoholics Anonymous and Narcotics Anonymous are popular, evidence-based recovery options, yet little is known about perceptions of such groups among clinical trainees. In addition, quantitative evaluations of substance use training modules have seldom been conducted, including a notable lack of methodologically rigorous approaches. To fill these gaps in the literature, the current study examined the efficacy of a brief computer-mediated training intervention, or e-training, designed to increase future clinicians' knowledge and intentions to engage in 12-step-related professional activities (e.g., making an appropriate referral to a 12-step group). Secondary outcomes were beliefs and attitudes about 12-step groups. Fifty participants were randomly assigned to receive the e-training, a brief audio/visual presentation reviewing 12-step recovery philosophy but focusing on academic 12-step literature. Fifty-three participants were randomly assigned to read comparison materials, which were comprised of online readings geared toward professionals, made available by Alcoholics Anonymous and Narcotics Anonymous. Outcomes were assessed at pretest, posttest (i.e., immediately following exposure to intervention or comparison materials), and 4-week follow-up periods. Results of random effects regression analyses showed that the e-training led to significantly greater increases in 12-step recovery knowledge than comparison readings, and that these gains were maintained through follow-up. An intervention effect on intentions to perform 12-step-related professional activities also emerged by follow-up. Exploratory moderation analyses revealed that the intentions effect was more pronounced for women and for trainees who had never attended a 12-step meeting. Secondarily, the e-training led to significantly greater increases in 12-step-positive beliefs and attitudes, though the beliefs effect attenuated by follow-up. Taken together, these data suggest that future clinicians may benefit from a brief e-training about 12-step recovery. More broadly, the study supports the notion that e-trainings are easily disseminated and may help address current limitations in graduate-level substance use clinical training.

Indiana University-Purdue University Indianapolis (IUPUI) / Pregnant and postpartum women with substance use disorders (SUDs) are likely to experience adverse health care encounters that contribute to poor health outcomes for them and their infants. The purpose of this dissertation is to describe the health care encounters of pregnant and postpartum women with SUDs. This dissertation includes two studies. The first study is a metasynthesis of published qualitative studies using a metasummary approach to classify the types of health care encounters experienced by pregnant and postpartum women with SUDs. A taxonomy of health care encounters was developed. Five types of adverse encounters were identified and labeled as (a) judgmental, (b) disparaging, (c) scrutinizing, (d) disempowering, and (e) deficient care. Three types of beneficial encounters were identified and labeled as (a) recovery-based, (b) accepting, and (c) effective care. The second study was a qualitative descriptive study conducted to describe factors that influence the formation of trusting relationships between maternity nurses and pregnant and postpartum women with SUDs. Interviews with 15 maternity nurses and 10 pregnant and postpartum women with SUDs were conducted. Content analysis of the participant narratives revealed a number of characteristics of maternity nurses and pregnant and postpartum women with SUDs that helped or hindered trusting relationships. Six characteristics of maternity nurses were identified and labeled as (a) rapport-building with women, (b) demeanor toward women, (c) provision of care, (d) provision of information, (e) attitude toward substance use, and (f) addiction expertise. Five characteristics of the women were identified and labeled as (a) engagement with nurses, (b) demeanor toward nurses, (c) acceptance of care, (d) investment in recovery, and (e) bonding with infant. Adverse encounters were often associated with provider stigma related to substance use during pregnancy and limited provider knowledge related to addiction. The findings will contribute to the development of strategies to improve the health care encounters of this population by promoting stigma awareness and communication skills training.

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Bipolar spectrum disorders (BSDs) and substance use disorders (SUDs) are highly co-occurring and both are associated with dysfunction in neural networks that mediate reward processing and motivated behavior. Furthermore, despite their high comorbidity rate, limited research into their shared neural mechanisms or potential prospective risk factors exists. This study attempted to elucidate common neural pathways for these disorders, and adds to the small but growing literature on possible prospective predictors of these disorders. We employed a task-based functional magnetic resonance imaging (fMRI) study to examine regions-of-interest (ventral striatum [VS], orbitofrontal cortex [OFC], ventromedial prefrontal cortex [vmPFC], dorsolateral prefrontal cortex [dlPFC]) and connectivity (VS-OFC, VS-vmPFC, vmPFC-dlPFC) analyses to examine neural reward processing as potential predictors of future substance and mood symptoms, and to explore differences among groups of participants with and without BSDs and SUDs. Results from this study provided evidence that blunted activation in the VS and dlPFC and greater negative connectivity between the vmPFC and dlPFC, key reward and control circuits, is implicated in prospective substance use. However, we did not find evidence to support our hypothesis that reward-related neural responses predict BSD symptoms or could differentiate individuals with co-occurring BSDs and SUDs from healthy volunteers. The study highlights the importance of larger, longitudinal studies to more fully probe neurodevelopmental trajectories in mood, substance, and related disorders. We also conducted an extensive review of the neural reward literature in BSDs and SUDs to understand possible pre-existent mechanisms. Results of the review provided support for an equifinality/multifinality perspective in that similar neural reward processing dysfunctions can lead to both BSDs and SUDs and different neural reward processing abnormalities can lead to a single outcome (e.g., SUDs). Taken together, results from the dissertation address an important gap in the literature on BSD-SUD comorbidity, suggest possible shared mechanisms that predispose to both disorders, and provide a backdrop for future work in this area to inform more theoretically-targeted interventions and prevention. / Psychology

Youth with co-occurring mental illness and substance use disorders are at higher risk for vocational rehabilitation exclusion. This study aimed to (a) explore the personal factors associated with vocational outcomes of youth with co-occurring mental illness and substance use disorders and (b) highlight services that have shown the greatest promise for this population in the state-federal rehabilitation program in the United States. Our analytic sample was extracted from the Rehabilitation Services Administration's Case Service Report data set for 2013, 2014, and 2015 fiscal years. Multiple regression analyses results identified personal factors such as gender, race/ethnicity, level of education, and severity of disability as predictors of the achievement of competitive employment, hours worked, and income. The receipt of vocational rehabilitation services such as job search support, job placement assistance, vocational training, and on-the-job support are significantly associated with the achievement of competitive employment, higher work hours, and income. These finding have implications for vocational rehabilitation practice as they highlight who is at higher risk for poor outcomes, effective services, and additional factors to consider when working with youth with co-occurring mental illness and substance use disorders.