Deaths from opioid overdose have increased dramatically in the past decade, representing an epidemic in the United States. For individuals with opioid use disorder (OUD), agonist medications such as methadone and buprenorphine represent an evidence-based treatment that has been shown to reduce opioid-related morbidity and mortality. Historically, the provision of buprenorphine treatment in office-based settings has relied on frequent in-person contact, which influenced patients’ access to and retention in care. However, in response to the COVID-19 pandemic, providers of office-based buprenorphine treatment rapidly adapted their care processes, increasingly relying on telemedicine visits. This dissertation employed mixed methods to study the implementation and effectiveness of telemedicine in office-based buprenorphine treatment provided in safety-net settings, or those that provide health services to patients regardless of their ability to pay. Qualitative methods were used to explore provider and patient experiences with the use of telemedicine in an office-based buprenorphine treatment clinic associated with an academic safety-net hospital, while quantitative methods were used to examine the effects of telemedicine adoption on outcomes for patients with OUD attending federally-qualified health centers (FQHCs) in Massachusetts. Results from provider interviews indicated the implementation of telemedicine in office-based buprenorphine treatment precipitated openness to more flexibility in care practices, though providers expressed concerns regarding telemedicine and related adaptations that centered around patient safety. Results from patient interviews indicated telemedicine enabled engagement in care, though patients differed in their views on: 1) the appropriateness of telemedicine based on one’s stage of recovery, 2) how telemedicine impacted their relationships with providers, and 3) their preferences for telemedicine visits moving forward. Results from both patient and provider interviews indicated safety-net patient populations experienced unique challenges when using telemedicine, particularly due to difficulties with technology and privacy. Finally, results from the quasi-experimental study of telemedicine adoption across a network of FQHCs indicated it was associated with: 1) increases in all-cause and OUD-related outpatient care engagement, 2) increases in retail buprenorphine fills and days supplied, and 3) either no changes or decreases in all-cause and OUD-related emergency department visits and inpatient admissions. These findings suggest telemedicine has the potential to improve patients’ engagement in office-based buprenorphine treatment while not compromising safety; however, qualitative data emphasizes the perceived benefits of hybrid, patient-centered approaches to care, particularly in safety-net settings. Overall, results of this dissertation support the maintenance of changes to policy and practice that facilitate the use of telemedicine in office-based buprenorphine treatment beyond the COVID-19 public health emergency. / 2025-01-03T00:00:00Z

<p>Social support is generally viewed in the addiction field as an important consideration in assessment and a potentially valuable component of a comprehensive treatment plan. The literature would suggest that strong social support can benefit individuals during many stages of the recovery process, including both active recovery and longer term maintenance. Less is known about social considerations in the initial stages of seeking support to begin recovery.</p> <p>This report seeks to explore social support considerations for a specific population, Ontario Works recipients who have identified substance use as a barrier to employment, and to do so in a hopefully reciprocal manner which values understanding context from those with lived experience. This qualitative study is informed by the principles of grounded theory in a general manner, began with no specific hypothesis, and allowed participants flexibility in their responses. Previously documented barriers facing this population were generally reflected by the circumstances revealed by this study’s participants.</p> <p>The principle findings outlined the lack of social supports currently in place for participants and their struggle to seek help. Seeking help appeared to require an emotional low point and a recognition that overcoming the substance use concern would not be realistic without additional help. Support seeking appears to be encouraged by specific nurturing characteristics of supporters. From a practice perspective the findings illustrated the need for increased focus on clinician/client engagement and a greater focus on practitioner’s appreciating the unique challenges facing this population and utilizing creative approaches to address them.</p> / Master of Social Work (MSW)

In psychological research, positive developmental outcomes in young adulthood are often conceptualized as the absence of psychological symptoms. However, positive outcome may be better understood as high levels of subjective wellbeing and adaptive interpersonal, occupational, and educational functioning. Nevertheless, a comprehensive model that takes into account multiple facets of youth behavior and transactional relations between youth and their environments as predictors of adjustment in young adulthood is lacking. Prior evidence implicates internalizing and externalizing behaviors in the development of subjective wellbeing, and emotion regulation as a reliable predictor and/or correlate of both internalizing and externalizing behaviors. Parenting behaviors in childhood and youth substance use represent other shared risk or resilience factors that likely contribute to internalizing and externalizing behaviors, as well as subjective wellbeing and adaptive functioning outcomes in young adulthood. The current study examined an existing sample of youth who were recruited at ages 10-12 and were assessed again at ages 16 and 25. Analyses aimed to (a) identify subgroups of youth who vary in frequency and quality of internalizing and externalizing symptoms and emotion regulation at ages 10-12 and 16 using latent class analyses, (b) examine stability of and transitions in class membership from classes at ages 10-12 to classes at age 16 using latent transition analysis, (c) investigate parenting behaviors as predictors of stability and transitions among classes, and (d) investigate whether classes differ in cross-sectional and prospective levels of substance use, as well as subjective wellbeing and adaptive functioning in young adulthood. Results demonstrated that a 4-class model best fit the data at both time points. Classes of youth with (a) low symptoms and high emotion regulation; (b) low internalizing, moderate externalizing, and high emotion regulation; and (c) moderate internalizing, high externalizing, and low emotion regulation emerged at both time points. The fourth class at ages 10-12 was characterized by high social withdrawal and moderate hyperactivity and emotion regulation, and the fourth class at age 16 was characterized by moderate internalizing, low externalizing, and low emotion regulation. Latent transition analyses revealed transitions from several symptom classes at ages 10-12 into the age 16 Low Symptoms/High Emotion Regulation class, and also stability and transitions to other symptom classes. Predictor analyses indicated that levels of parenting behaviors (maternal and paternal acceptance, child-centeredness, use of guilt and anxiety to control youth, lax discipline, and nonenforcement of rules) were associated with transitions among and stability within classes, but findings were dependent on levels of internalizing and externalizing symptoms among classes. Substance use differed cross-sectionally and prospectively across classes based on the substances considered. Further, subjective wellbeing was higher among age 16 classes characterized by low internalizing symptoms, low or moderate externalizing symptoms, and high emotion regulation. Adaptive functioning in select domains was also differentially associated with classes at both time points, with youth in the Low Symptoms/High Emotion Regulation classes experiencing better outcomes in certain areas. Results indicate that distinct classes of youth internalizing and externalizing symptoms and emotion regulation can be identified in late childhood and middle adolescence and are differentially associated with outcomes related to wellbeing and adaptive functioning in young adulthood. Further, the frequency and quality of co-occurring symptoms evidenced among youth may change over time as reflected in transitions from classes identified in middle childhood to adolescence. Emotion regulation and parenting may be potential targets for enhanced interventions intended to promote subjective wellbeing and adaptive functioning among youth with internalizing and externalizing symptoms. / Psychology

Among those seeking treatment for a substance use disorder (SUD), the prevalence of a concurrent anxiety disorder or posttraumatic stress disorder (PTSD) is surprisingly high, with some estimates placing the comorbidity rate at 33% to 43%. There is evidence that this comorbidity is associated with greater symptom severity, impairment, and substance use relapse than when the disorders present independently. One of the greatest challenges that clinicians face when presented with a patient with an anxiety disorder/PTSD and SUD is deciding how to approach treatment. Though the prevailing approach has been to treat the disorders sequentially, with the SUD receiving initial attention, there is a movement towards developing integrated or concurrent treatment models. The current meta-analytic study examined integrated or concurrent psychotherapies or pharmacotherapies for SUDs and anxiety disorders or PTSD. A meta-analysis on this topic is particularly important given the generally mixed findings of existing randomized controlled trials in this area of research. Our main question of interest was how integrated/concurrent treatments compared to single-target treatments. In addition, we explored whether there were outcome differences between psychotherapy and pharmacotherapy, between anxiety disorders and PTSD, and differences based on treatment setting (e.g., substance use treatment center versus other settings). Our findings suggested that integrated or concurrent treatments were superior in reducing anxiety or PTSD symptoms, compared to treatments that only targeted substance use or anxiety/PTSD. The effect, however, was small. There was no evidence that integrated or concurrent treatments improved substance use outcomes in comparison to stand alone substance use treatment. We also found evidence that treatment studies conducted at substance use inpatient or outpatient programs produced smaller anxiety/PTSD effects. A trend was found suggesting combined psychotherapy-pharmacotherapy interventions may be more effective than psychotherapy alone. No difference was found between treatments targeting PTSD versus anxiety disorders. Implications of our findings are discussed. / Psychology

Over the past three decades, the United States criminal justice system and mental health treatment providers have collaborated in ways to support more than 20.3 million individuals who are struggling with a substance use disorder (SUD), and who may also be facing drug-related offenses due to their ongoing challenges combatting addiction. Through collaborative efforts we have been fortunate to witness the establishment of adult drug treatment courts, as well as other problem-solving court processes. With more than 1,500 active adult drug treatment court programs in this country, there is a critical need to better understand the working alliance between counselors and clients who have been mandated to receive SUD treatment. Adult drug treatment court programs have been shown to have discrepant success outcomes (8% to 80%) in terms of reducing criminal recidivism; moreover, the existing literature examining the lived experiences of participants in these programs is both minimal and disheartening. This lack of empirical data is problematic for the counseling profession given that they serve as key change agents in this process. What we do know is that the process of creating treatment goal and modalities, which should be in the hands of the clients and their counselors, can be complicated by court-mandated requirements. This bi-level structure has the potential to create ruptures in the working alliance between clients and counselors providing SUD treatment to this population. Accordingly, additional research is needed to explore the client experience within the working alliance, and in so doing reveal the influences at play when working with clients who are mandated to receive SUD treatment. This qualitative study was guided by one central research question: How do clients experience the working alliance with counselors during drug court-mandated addictions treatment? Interview data from eight individuals in court-mandated SUD treatment led to the development of a constructivist grounded theory model: From compliance to alliance: A grounded theory of building rapport in mandated treatment. This model and it's components describe and define key factors when working with this population. More research is needed to understand counselors' perspectives of the working alliance with court-mandated clients. / Doctor of Philosophy / With more than 1,500 active drug court programs throughout the United States, there is a pressing need to better understand the working alliance between counselors and clients who have been mandated to receive SUD treatment. While adult drug treatment court programs have been shown to have positive outcomes in terms of reducing criminal recidivism, the existing literature examining the participants' lived experiences receiving SUD treatment is minimal and disheartening. Due to the nature of the mandated treatment relationship, the confidentiality which has historically bound and secured the therapeutic working alliance is less defined than it is in fully voluntary treatment settings. This shift in understanding what creates a healthy working alliance for mandated clients to work through presenting treatment issues is something that has yet to be explored by current research. The current study sought to explore clients' experiences of the working alliance with counselors during drug court-mandated addictions treatment. Interview data from eight individuals in court-mandated SUD treatment led to the development of a constructivist grounded theory model: From compliance to alliance: A grounded theory of building rapport in mandated treatment. This model and it's components describe and define key factors when working with this population. More research is needed to understand counselors' perspectives of the working alliance with court-mandated clients.

Drug use, overdose, and addiction has skyrocketed in the past twenty years (Centers for Disease Control and Prevention, 2020). Negative stigma towards addiction, or otherwise known as substance use disorder (SUD), has only increased since President Nixon declared the "war on drugs" in 1971 (National Public Radio, 2007). Negative public stigma of SUD creates barriers for treatment for those who are suffering, continuing to exacerbate the stigma surrounding SUD. To understand ways to reduce stigma surrounding SUD, this study will look at narrative persuasion through transportation theory to better understand the power of stories and stories of recovery as a method to reduce stigma surrounding SUD among community members. In addition to examining narrative persuasion literature, 21 semi-structured interviews from community stakeholder groups in Virginia's Department of Behavioral Health and Developmental Services region 3, were conducted. To further understand the content in the stakeholder interviews, a qualitative thematic analysis using inductive themes was conducted to determine common themes surrounding substance use disorder, stigma, and ways to reduce stigma surrounding substance use disorder through narrative persuasion. Based on participant interviews, community stakeholders hold negative perceptions of those with SUD based on personal and professional experiences but believe that positive personal narratives of SUD and recovery can reduce public stigma towards those who suffer from the disorder. / Master of Arts / Drug use, overdose, and addiction has skyrocketed in the past twenty years (Centers for Disease Control and Prevention, 2020). Negative stigma towards addiction, or otherwise known as substance use disorder (SUD), has risen since President Nixon declared the "war on drugs" in 1971 (National Public Radio, 2007). Negative public stigma of SUD creates barriers for treatment for those who are suffering, continuing to worsen the stigma surrounding SUD. To understand ways to reduce stigma surrounding SUD, this study will look at persuasive storytelling through transportation theory to better understand the power of stories and stories of recovery as a method to reduce stigma surrounding SUD among community members. In addition to examining narrative persuasion literature, 21 interviews from various community members in region 3 of Virginia were conducted. To further understand the content in the participant interviews, a thematic analysis was conducted to determine common themes and patterns surrounding substance use disorder, stigma, and ways to reduce stigma surrounding substance use disorder through persuasive storytelling. Based on participant interviews, community stakeholders hold negative perceptions of those with SUD through personal and professional experiences but believe that positive personal narratives of SUD and recovery can reduce public stigma towards those who suffer from the disorder.

Delay discounting (DD) and self-regulation are important predictors of substance use disorder (SUD) outcomes. Further, regulatory flexibility (RF; i.e., selecting, monitoring, and adapting coping techniques based on contextual demands) is related to psychological resilience. However, studies have yet to examine associations between DD, RF, and remission from SUDs. Individuals (N = 148) in SUD recovery completed the Context Sensitivity Index (CSI), the Flexible Regulation of Emotional Expression (FREE) Scale, and the Perceived Ability to Cope with Trauma (PACT) Scale to assess RF and, an Adjusting Amount Delay Discounting Task. T-tests were used to examine differences in RF and DD by remission status. Univariate linear regressions were used to examine the relationship between RF and DD. Finally, mediation models examined the dynamic relationship between DD, RF, and remission status. Remitted individuals (n=82) had significantly lower DD rates (p<0.001) and higher context sensitivity (p<0.001) and coping flexibility (p<0.001). There were significant negative associations between DD and context sensitivity (p=0.008), coping flexibility (p=0.002), and emotion regulation flexibility (p<0.001). Finally, context sensitivity (p=0.023) and coping flexibility (p=0.007) mediated the relationship between DD and SUD remission. Results suggest that individuals in recovery with broader temporal windows can better identify contextual demands and flexibly cope, contributing to improved SUD recovery outcomes. / M.S. / Preference for immediate gratification (also called delay discounting), and self-regulation (the ability to control one’s emotions) are related to addiction outcomes. Regulatory flexibility - a self-regulation process by which individuals select and adapt their coping strategies based on their situation - is related to improved mental health outcomes. However, research studies have yet to examine the relationship between regulatory flexibility and delay discounting in individuals with a history of drug and/or alcohol dependence. Using a sample from an online addiction recovery research and support community called the International Quit and Recovery Registry, the current thesis examined the relationship between delay discounting and regulatory flexibility grouped by substance use disorder clinical diagnoses amongst 148 individuals. Group comparisons suggested that individuals in remission (i.e., no longer meet criteria for clinical diagnosis of addiction) were better able to delay gratification and were better able to flexibly regulate their emotions compared to individuals who relapsed. When examining the relationship between delay discounting and regulatory flexibility, we found that individuals’ who preferred delayed rewards over immediate rewards were better able to flexibly self-regulate, suggesting that being able to delay gratification is an important component of effective coping, together contributing to improved addiction recovery outcomes.

Adolescence is a period of heightened risk for substance use and heightened vulnerability to substance exposure. Yet, little is known about how socioeconomic status (SES) influences adolescent decision making and behavior across development to add to these risks. This prospective longitudinal study used latent growth curve modeling (GCM) to examine the contributions of SES on adolescent delay discounting and substance use in a sample of 167 adolescents (52% male). Confirmatory factor analysis (CFA) was used to compute SES factor scores across three waves using a composite of parent and spouse education years and combined annual household income. Adolescent delay discounting and substance use were measured annually across three waves. The main goal of this study is to examine how SES may explain individual differences in growth trajectories of delay discounting and substance use. We used parallel process growth curve modeling with SES as a time-varying and time-invariant covariate to examine the associations between adolescent SES, delay discounting, and substance use onset as well as frequency. These results reveal that delay discounting exhibits a declining linear trend across adolescent development whereas cigarette, alcohol, marijuana, and polysubstance use exhibit increasing linear trends across adolescent development. Furthermore, low SES (as a time-invariant covariate) may lead to earlier onset adolescent alcohol and polysubstance use by way of heightened levels of delay discounting. These findings suggest that delay discounting interventions may be a promising avenue for reducing socioeconomic disparities in early onset alcohol and polysubstance use, while delay discounting development is still underway. / Master of Science / Adolescence is a period of heightened risk for substance use and heightened vulnerability to the effects of substances. Yet, little is known about how socioeconomic status (SES) influences adolescent decision making and behavior to add to these risks. This study used latent growth curve modeling (GCM) to examine the role of SES on adolescent decision making and substance use in a sample of 167 adolescents (52% male). Confirmatory factor analysis (CFA) was used to compute SES factor scores across three time points using an average of parent and spouse education years and income. Adolescent delay discounting and substance use were measured annually across three time points. The main goal of this study is to examine how SES may explain individual differences in delay discounting and substance use across adolescence. We used parallel process growth curve modeling with SES as a time-varying and time-invariant covariate to examine the links between adolescent SES, delay discounting, and substance use age of onset and frequency. These results reveal that delay discounting shows linear decreases in growth across adolescence whereas cigarette, alcohol, marijuana, and polysubstance use show increasing linear growth across adolescence. Additionally, low SES may lead to earlier onset adolescent alcohol and polysubstance use by way of heightened levels of delay discounting. These findings suggest that delay discounting interventions may help reduce socioeconomic differences in early onset alcohol and polysubstance use, while delay discounting development is still in progress.

Maladaptive habits, such as substance use, that are highly ingrained and automatized behaviors with negative long-term health consequences need effective interventions to promote change towards more healthful behaviors. Implementation intentions, the structured linking of critical situations and alternative, healthier responses, have been shown to improve health-benefiting behaviors such as eating more fruits and vegetables and being more physically active (Sheeran, Milne, Webb, and Gollwitzer, 2005). Here, a laboratory analogue for smoking relapse and a pilot clinical trial of alcohol use are assessed using implementation intention interventions to reduce these health risk behaviors. In Study 1, heavy smokers completed a smoking resistance task that is a candidate analogue for smoking relapse. Participants were exposed to an in-laboratory implementation intention and/or monetary incentive condition during each of four experimental sessions. The combined implementation intention and monetary incentive condition resulted in the greatest delay to smoking initiation. In Study 2, individuals with alcohol use disorder completed an active or control implementation intention treatment condition. Remotely, both treatment groups received a daily ecological momentary intervention, thrice daily biologic breath alcohol ecological momentary assessments, and once daily self-report ecological momentary assessment of alcohol consumption during the intervention period. The active implementation intention group was associated with a greater reduction in alcohol consumption compared to the control group. Together, these studies provide experimental and initial clinical evidence for implementation intentions, in conjunction with other effective treatments (Study 1) and technological advancements (Study 2), to intervene on and reduce substance use. This project is the first to use implementation intentions in a laboratory evaluation of smoking resistance and in an initial clinical trial to reduce alcohol consumption in a naturalistic community sample using both ecological momentary assessments and ecological momentary interventions. / Ph. D.

Positive, but distal consequences of reducing alcohol use among at-risk users may have little impact on behavior due to temporal discounting (Mazur, 1987), in which delayed rewards are devalued relative to more proximal rewards, even if such distal rewards actually provide considerably more value. Delay discounting may be manipulated using a variety of means, one of which involves utilizing prospective thinking about future autobiographical events and is termed Episodic Future Thinking (Atance and ONeill, 2001). Episodic future thinking (EFT) has been demonstrated in previous studies to be effective in reducing delay discounting relative to a variety of control conditions (Benoit, Gilbert, and Burgess, 2011; Daniel, Stanton, and Epstein, 2013a, 2013b; Lin and Epstein, 2014; Peters and Büchel, 2010) and recently among substance-abusing populations (Snider, LaConte, and Bickel, 2016; Stein et al., 2016). The present study examined EFT in a novel sample of at-risk alcohol users. Participants were randomized to EFT, episodic past thinking (EPT), or a control condition in which non-autobiographical events were recalled (CET). Immediately following intervention, results demonstrated significantly less discounting in EFT and EPT, relative to CET. At follow-up, EFT demonstrated significantly less temporal discounting and alcohol use, when compared to both EPT and CET. No differences among conditions in alcohol demand or alcohol use intentions were observed. The present study contributes a number of novel findings to the literature, most notably that engaging in EFT predicts reductions in alcohol use prospectively and that reductions in delay discounting associated with EFT persist at least a week later, without any additional intervention. Such findings suggest that EFT manipulations influence the valuation of future rewards. Additionally, findings support EFT as a useful supplement to existing empirically-supported treatments or a component of novel substance use disorder treatments. / Ph. D.