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Pregnant people with substance use disorders (SUD) are at high risk of potentially avoidable morbidity and mortality. In particular, pregnant people with opioid use disorder (OUD) have experienced large increases in maternal mortality, largely driven by rising rates of drug overdose. The majority of pregnant people with SUD receive health insurance through state Medicaid programs, many of which use private Medicaid managed care (MMC) plans to finance and deliver health care services rather than through the state-run fee-for-service (FFS) plan. MMC plans receive capitated payments in exchange for coverage of a defined set of benefits. Pregnant people with SUD are predictably high-cost and high-need, and MMC plans may not be able to recoup the high cost of services used over often short periods of enrollment associated with pregnancy. While capitation may incentivize MMC plans to promote access to high-value services that reduce the risk of poor maternal health outcomes, it might also incentivize plans to restrict access to certain services or alter their provider networks in ways that reduce costs. Despite being the dominant delivery vehicle of insurance coverage to this growing population, no research has examined the association between MMC enrollment and maternal health outcomes among pregnant people with any SUD or with OUD. In this Dissertation, I use the newly-available Transformed Medicaid Statistical Information System Analytic Files (TAF) across all three studies. The newly-available TAF files contain claims data for all Medicaid enrollees from all 50 states and the District of Columbia, and represent the most comprehensive data source for longitudinal inpatient and outpatient health service utilization among Medicaid enrollees. In the first study, I develop and validate an algorithm to identify live births using the TAF data. I find that using claims in both the inpatient and other services files are critical to accurately capture live births at the state-year and state-month level. In the second study, I first estimate the burden of SUD and OUD among pregnant people enrolled in Medicaid, and the prevalence of adverse maternal health outcomes in these groups. Next, I examine the association of severe maternal morbidity (SMM) and MMC enrollment among pregnant people with SUD and, separately, OUD nationally from 2016-2018. I find that SMM within six weeks of delivery is more prevalent among those with any SUD (3.2%) and OUD (3.9%) than those without either diagnosis (1.6%). Moreover, I find that enrollment in MMC (vs. Medicaid FFS) is associated with a 0.54 percentage-point (pp) and a 0.66 pp reduction in the probability of SMM among those with any SUD and among those with OUD, respectively. In the third study, I estimate the effect of MMC enrollment on adverse maternal health outcomes using data from two states (Illinois and Missouri) that expanded MMC to statewide. Using difference-in-differences models, I find that expansion of MMC did not change the probability of adverse maternal health outcomes among pregnant people with any SUD. These results suggest that at a minimum MMC has not worsened health outcomes among those with SUD, and at best, MMC may be driving incremental improvements for this group at high-risk of morbidity and mortality. / 2025-07-25T00:00:00Z

Indiana University-Purdue University Indianapolis (IUPUI) / Nicotine is one of the most widely abused drugs in the world, and most smokers begin smoking during their adolescent years. Adolescence is a unique developmental period during which vulnerability to the effects of drug exposure is especially high. This dissertation uses rodent models to investigate the persistent effects of adolescent nicotine exposure on both neurobiological and behavioral measures of drug sensitivity in adulthood. The aims of this dissertation were to 1) determine whether nicotine would be self-administered into the posterior ventral tegmental area (pVTA), a neuroanatomical component of the mesolimbic dopamine (DA) system, which is known to be involved in reward and reinforcement; 2) investigate whether adolescent nicotine exposure would alter the sensitivity of the mesolimbic DA system as measured by DA release in the nucleus accumbens (NAc) in response to nicotine microinjections into the pVTA; 3) examine the effects of adolescent nicotine exposure on behavioral sensitization to nicotine in adulthood; and 4) investigate whether adulthood alcohol drinking behavior, in both Wistar and alcohol-preferring (P) rats, would be augmented by nicotine exposure during adolescence. Results of this dissertation demonstrated that 1) the pVTA is a neuroanatomical site that supports nicotine self-administration; and that adolescent nicotine exposure results in 2) increased nicotine-stimulated DA release in the NAc during adulthood; 3) augmented behavioral sensitization to nicotine in adult animals; and 4) enhanced acquisition of alcohol drinking behavior in adult Wistar and P rats. Overall, this dissertation provides insight into the diverse and persistent changes, in both neurobiology and behavior, caused by exposure to nicotine during the critical developmental period of adolescence.

Alcohol consumption is a leading cause of morbidity and premature mortality. In the United States, consumption remains highly prevalent, and certain subgroups have been increasing alcohol risks in recent decades. Among these are women in the mid-life, who have increased rates of both alcohol consumption (vs. abstention) and binge drinking (i.e., multiple drinks in a setting). Women’s alcohol use has increased concurrent with social and economic gains. These gains in women’s social and economic status are indicative of broader declines in structural sexism, a macro-level, systematic source of gender inequality. The objective of this dissertation is to examine the associations between state-level structural sexism (e.g.., social, political, and economic gender inequality) and patterns of women’s alcohol consumption. This dissertation is presented in five chapters: first, an introduction; second, a narrative historical review of the relationship between structural sexism in the United States and women’s health outcomes, with a lens towards understanding the theoretical and epidemiologic sources of conflicting study findings; third, an empirical study of the relationship between state-level structural sexism and both alcohol consumption and binge drinking among women in the mid-life in recent cohorts; fourth, an empirical study examining structural sexism as a source of heterogeneity for relationships between women’s social positions—namely, their occupational characteristics—and both alcohol consumption and binge drinking; fifth, a discussion of findings and implications for future research. Materials and methods The narrative literature review drew from empirical studies in public health, criminology, and sociology (N=43 studies). The two empirical aims used longitudinal data from Monitoring the Future (MTF), a national survey examining substance use throughout young adulthood, using data from cohorts who were high school seniors between 1988-2006. For both empirical aims, I measured structural sexism using a factor-analytically derived score based on state-level social and economic indicators of gender inequality, and assessed occasions of alcohol consumption and probability of binge drinking as study outcomes. Both studies used three-level multilevel models to estimate associations between structural sexism and each alcohol outcome. The first empirical aim included a sample of 23,862 women surveyed between 1988-2016, and beyond the marginal association also tested the role of three mediators: depressive symptoms, college completion, and restrictive alcohol norms. The second empirical aim included a sample of 16,571 women in the MTF follow-up surveys between 1989-2016, and examined whether associations among work status, high-status careers, occupational gender composition, and both alcohol outcomes varied across levels of structural sexism using interaction models between occupational characteristics and state structural sexism. Results The review identified the divergent theoretical frameworks and measurement invariance as the most pressing threats to reconciling competing findings. In the review I also observed a dearth of empirical studies relating structural sexism to any behavioral health outcomes, including alcohol use. In the first empirical study, I demonstrated that women living in states with lower levels of structural sexism evidenced increases in both occasions of alcohol consumption (RR: 0.974, 95% CI: 0.971, 0.976) and probability of binge drinking (OR: 0.917, 95% CI: 0.909, 0.926); I showed that this relationship was specific to women (i.e., it was less pronounced among men) and that mediators of this relationship included increases in college completion and decreases in restrictive alcohol norms. In the second empirical study, I found that working women evidenced higher frequencies of alcohol consumption and higher probabilities of binge drinking than non-working women, and that these differences were most pronounced among women in low-sexism environments. At the lowest level of structural sexism, employed women reported higher occasions of consumption (2.61, 95% CI 2.57, 2.64) then unemployed women (2.32, 95% CI 2.27, 2.37). I also found that women in high-status occupations reported more occasions of alcohol consumption than those in low-status occupations, but only in low-sexism environments. Conclusions Lower levels of structural sexism are related to increases in both alcohol consumption and binge drinking among women. In low-sexism environments, working and belonging to a high-status career increases women’s alcohol use. Increases in women’s equality are positive and important social forces, but have conferred new acceptability of alcohol use that has implications for women’s health.

This non-experimental field study examined the relationship between participant reported experiences of relational depth (RD) with their individual counselors in substance use disorder (SUD) treatment and participant reported motivation to change substance use. Participants in the study were clients enrolled in inpatient and outpatient levels of substance use disorder treatment. A total of 78 clients (aged 18-77, with mean age 35.97, 80.1% Caucasian, 11.5% African-American, 3.8% Hispanic, 1.3% Asian, 1.3% multiracial, 1.3% other) with SUDs participated in the study. Results demonstrated that treatment process variables explained approximately 42% of the variance in participant recognition scores. Specifically, substance abuse community support involvement (β = .598, rs2 = .908, p < .001) and relational depth (β = .184, rs2 = .178, p = .045) were found to be significant predictors of participant recognition of a substance use problem. From these results, one may tentatively conclude that community support and the development of relational depth in SUD treatment are valuable additions to standard SUD treatment. Extended results are described and summarized using text, tables, and figures. The study has practical and clinical implications for counselors working with clients in substance use disorder treatment particularly concerning the length of individual counseling.

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abstract: Excessive drinking in adolescence is a public health issue with major consequences on both an individual and societal level. Elucidating genetic and environmental influences could be particularly informative for prevention efforts. One potential source of genetic influence is sensitivity to environmental influences. It was hypothesized that parent knowledge would interact with genetic sensitivity to the environment to indirectly reduce risk for alcohol problems through less adolescent rule breaking behavior. Participants (N=316) provided genetic data and reported their rule breaking behavior and past year frequency of heavy drinking, and participants’ custodial parents reported their perceived knowledge of their child’s activities. A novel index of genetic sensitivity to environmental influence was created using published methylation quantitative trait locus data from the frontal lobe. Study hypotheses were mostly not supported. The study results likely reflect the poor distribution of study variables and the limitations of the current study’s sensitivity gene score. The current study underscored the importance of adhering to methodological rigor and explored alternate conceptualizations and methods that future research could use to elucidate the role of inherited to sensitivity to environmental influences in adolescent drinking. / Dissertation/Thesis / Doctoral Dissertation Psychology 2020

Background. Europe and North America have low rates of mental health service use despite high rates of mental disorder. Little is known about mental health service use among South Africans. Design. A nationally representative survey of 4 351 adults. Twelve-month DSM-IV (Diagnostic and Statistical Manual, 4th edition) diagnoses, severity, and service utilisation were determined using the World Health Organization Composite International Diagnostic Interview (CIDI). Twelve-month treatment was categorised by sector and province. South Africans in households and hostel quarters were interviewed between 2002 and 2004 in all nine provinces. Outcome measures. 4 317 respondents 18 years and older were analysed. Bivariate logistic regression models predicted (i) 12-month treatment use of service sectors by gender, and (ii) 12-month treatment use by race by gender. Results. Of respondents with a mental disorder, 25.2% had sought treatment within the previous 12 months; 5.7% had used any formal mental health service. Mental health service use was highest for adults with mood and anxiety disorders, and among those with a mental disorder it varied by province, from 11.4% (Western Cape) to 2.2% (Mpumalanga). More women received treatment, and this was largely attributable to higher rates of treatment in women with mood disorders. Age, income, education and marital status were not significantly associated with mental health service use. Race was associated with the treatment sector accessed in those with a mental disorder. Conclusions. There is a substantial burden of untreated mental disorders in the South African population, across all provinces and even in those with substantial impairment. Greater allocation of resources to mental health services and more community awareness initiatives are needed to address the unmet need.

The purpose of the current study was to investigate predictors of therapeutic alliance among a sample of 46 adults with substance misuse who were convicted of felony offenses and court-mandated to attend substance use treatment as part of their probation requirements. For this study, I purposed four hypotheses: (1) older participants will report a stronger therapeutic alliance with their therapist. (2) women will form a stronger therapeutic alliance with their therapist than men, (3) higher levels of distress will be associated with lower therapeutic alliance, and (4) people with more extensive criminal and substance use histories to have poorer therapeutic alliance. Data was collected quantitatively, utilizing a questionnaire method. Bivariate correlations were run on all study variables, as well as a multiple linear regression model. Results of this study found that older participants and number of months incarcerated predicted weaker therapeutic alliance. No statistically significant findings were found in relation to the DASS-21 or gender.

Background: Obesity remains a major public health problem and a risk factor for developing chronic diseases. Substance use such as e-cigarette, marijuana, and alcohol have been associated with the risk of being obese. However, the results from previous studies have been inconsistent. The purpose of this study is to determine the association between substance use and obesity among adults in the United States. Method: Data from the 2016 Behavioral Risk Factor Surveillance System (BRFSS), an annual cross-sectional survey administered to 446,687 adults in all 50 states to collect information about their health-related risk behaviors, chronic health conditions and the use of preventive services, was used in this study. Data was collected via a self-reported questionnaire validated by CDC. A multiple logistic regression model was conducted to determine the association between exposure variables (e-cigarette, marijuana, and alcohol abuse) and obesity. The model was adjusted for possible confounders such as demographics (age, sex and race) and behaviors such as tobacco smoking and physical activity. The data was analyzed using SAS v 9.4. Results: Individuals who used marijuana during the past 30 days were 32.4% less likely (adjusted odds ratio (aOR): 0.676, 95% CI: 0.631-0.723, P<0.001) to be obese compared to those who did not. The odds of being obese among heavy alcohol drinkers was 30% less (aOR: 0.70, 95% CI: 0.679-0.721, p<0.001) compared to those who were not heavy alcohol drinkers. Conclusion: The study findings demonstrate that marijuana and heavy alcohol drinking are significantly associated with reduced likelihood of obesity. However, e-cigarette use was not significantly associated with obesity. Further longitudinal studies to explore the relationship between these substances and obesity will be beneficial.