Experiences and opinions of health professional students participating in an opioid use disorder educational event

Introduction

The objectives of this study were to describe health professional students' experiences and opinions about patients with opioid-use disorder (OUD), to summarize evaluation results from an OUD educational event and to compare results by sex, discipline, and clinical experience.

Methods

The OUD educational event lasted 75 minutes and covered the epidemiology of the opioid epidemic, evidence-based prevention and treatment services, stigma, and recommendations on how to improve care. An anonymous pre-event survey collected information on attendees' experiences and opinions about patients with OUD. The postevent survey collected information on the attendees' evaluation of the event.

Results

Forty percent of students reported having a friend or family member who has/had an OUD. A minority (29.1%) reported that they would be uncomfortable working with patients with OUD or would prefer not to interact with patients with OUD (27.7%). Overall, the event evaluation results were very positive, and 85.5% reported that the information would change or influence their clinical practices. The open-ended responses found that the content was informative (n = 36); the attendees liked the inclusion of statistics (n = 19) and that the content was locally focused (n = 13).

Discussion

Health professional students participating in this event had fewer negative opinions of patients with OUD than previous research has found, and this may, in part, be explained by their personal experiences. Overall, health professional students want to learn more about patients with OUD.

Long-term treatment retention in West Virginia's comprehensive opioid addiction treatment (COAT) program

BACKGROUND

The United States continues to experience an opioid epidemic of unprecedented proportions despite FDA approval of life saving medications, such as buprenorphine. This paper describes a novel group-based buprenorphine treatment model and summarizes patient characteristics and treatment retention. This model, known as the Comprehensive Opioid Addiction Treatment (COAT) program, was developed in West Virginia, the epicenter of the opioid epidemic.

METHODS

Data on 454 patients actively enrolled in the COAT program were extracted from an administrative clinical data set and electronic medical records and analyzed using descriptive and quantitative analysis to determine long-term retention in treatment using frequencies and means.

RESULTS

The characteristics of the 454 patients are as follows: average age of 39, 53% female, predominantly white (94%) and Medicaid was the primary insurance provider (68%). Analysis of retention showed 37.8% of patents were retained less than one year and 14.7% were retained 10 or more years. Initiating treatment at a younger age was associated with long-term retention.

CONCLUSION

Opioid use disorder is a chronic relapsing disease and treatment models that retain patients long-term have the greatest benefit. The COAT model has been successful in retaining patients long-term in a rural setting where barriers to treatment are many.

The Impact of the Opioid Epidemic on Children and Adolescents

Although an epidemic of opioid-related overdose deaths has continued to increase in the United States for 2 decades, the impact of opioid use disorders (OUDs) on children and families receives minimal attention. The purpose of this commentary was to provide an overview of the impact of the opioid epidemic on children and adolescents, as well as to summarize challenges to improving outcomes for children. Children and adolescents who grow up in households with opioid misuse and OUDs may experience a myriad of adverse consequences, including: increased risk of mental health problems and drug use; accidental opioid poisoning; increased risk of developing a substance use disorder; and family dissolution that results from parents' incarceration, foster care placement, or loss of parent to an opioid overdose. Parental drug use may result in child neglect or deficits in parent-child attachment, and parents with an OUD may be less likely to be reunified with their children. OUD treatment is effective at reducing parental opioid use and improving child outcomes; however, stigma and cross-system collaboration may limit access to treatment and timely reunification of families. Children are the most vulnerable witnesses of the opioid epidemic, and further research is urgently needed to expand prevention interventions.

West Virginia's model of buprenorphine expansion: Preliminary results

West Virginia (WV) is situated at the epicenter of the opioid epidemic with the highest rates of overdose deaths and some of the lowest rates of access to life saving evidence-based medication assisted treatment (MAT) for patients with opioid use disorder (OUD). WV used a modified hub-and-spoke model to build organizational capacity for facilities to use buprenorphine to treat patients with OUD and to provide ongoing case consultation. The purpose of this study is to 1) describe the group-base model of buprenorphine treatment and the model used to build organizational capacity, 2) to describe the preliminary results of buprenorphine expansion in WV and 3) to report preliminary data describing and comparing the characteristics of the patients served across five hubs. A single Coordinating Center uses video conferencing to train hubs and provide ongoing case consultation, as well as clinical support. Hubs were trained to deliver a buprenorphine treatment model that is multi-disciplinary and includes group-based medication management and psychosocial therapy. Five regional hubs independently treat patients and are leading MAT expansion in their local areas by training and mentoring spokes (n = 13). As a result of the WV STR funding, 14 health care facilities have started to use buprenorphine, 56 health professionals were trained and 196 patients with OUD have been treated. There were few sociodemographic characteristic differences across patients treated at the five hubs, while there were differences in self-reported alcohol and drug use in the 30 days prior to intake. Additional research is needed to determine whether the WV modified hub-and-spoke model resulted in statistically significant improvements in buprenorphine treatment capacity; there is a need to address MAT stigma and regulatory barriers in order to ensure the long-term sustainability of the buprenorphine expansion.

Mandatory review of a prescription drug monitoring program and impact on opioid and benzodiazepine dispensing

BACKGROUND

The purpose of this study is to determine whether Ohio House Bill 341, which mandated the use of Ohio's Prescription Drug Monitoring Program (PDMP), was an effective regulatory strategy to reduce opioid and benzodiazepine dispensing.

METHOD

Secondary analysis of Ohio's PDMP data on prescription opioids and benzodiazepines dispensed from November 2014 to March 2017. An interrupted time series analysis was conducted to determine if there was a significant change in the quantity of opioids and benzodiazepines dispensed.

RESULTS

After HB341 became effective in April 2015, there was a statistically significant decrease in the monthly quantity (number of pills) opioids and benzodiazepines dispensed in Ohio. There was a modest increase in the mean days' supply of opioids and no change in the mean morphine equivalent dose.

CONCLUSIONS

Legislation in Ohio requiring prescribers to check the PDMP was effective in reducing the quantity of opioids and benzodiazepines dispensed.

Statewide cross-sectional survey of emergency departments' adoption and implementation of the Ohio opioid prescribing guidelines and opioid prescribing practices

STUDY OBJECTIVE

To evaluate the implementation of the Ohio Emergency and Acute Care Facility Opioids and Other Controlled Substances Prescribing Guidelines and their perceived impact on local policies and practice.

METHODS

The study design was a cross-sectional survey of emergency department (ED) medical directors, or appropriate person identified by the hospital, perception of the impact of the Ohio ED Opioid Prescribing Guidelines on their departments practice. All hospitals with an ED in Ohio were contacted throughout October and November 2016. Distribution followed Dillman's Tailored Design Method, augmented with telephone recruitment. Hospital chief executive officers were contacted when necessary to encourage ED participation. Descriptive statistics were used to assess the impact of opioid prescribing policies on prescribing practices.

RESULTS

A 92% response rate was obtained (150/163 EDs). In total, 112 (75%) of the respondents stated that their ED has an opioid prescribing policy, is adopting one or is implementing prescribing guidelines without a specific policy. Of these 112 EDs, 81 (72%) based their policy on the Ohio ED Opioid Prescribing Guidelines. The majority of respondents strongly agreed/agreed that the prescribing guidelines have increased the use of the prescription drug monitoring programme (86%) and have reduced inappropriate opioid prescribing (71%).

CONCLUSION

This study showed that the Ohio ED Opioid Prescribing Guidelines have been widely disseminated and that the majority of EDs in Ohio are using them to develop local policies. The majority of respondents believed that the Ohio opioid prescribing guidelines reduced inappropriate opioid prescribing. However, prescribing practices still varied greatly between EDs.

Strategies and policies to address the opioid epidemic: A case study of Ohio

OBJECTIVE

To describe the strategies and policies implemented in Ohio to improve opioid safety and to discuss the role that pharmacists can play in implementing, promoting, and enhancing the effectiveness of these policies.

SETTING

Ohio has the fifth highest rate of drug overdose deaths (24.6 deaths per 100,000) in the United States. Unintentional drug overdose has become the leading cause of injury-related death in Ohio. In 2015, there were 3050 overdose deaths in Ohio, and in 2014 there were an estimated 12,847 overdose events reversed by emergency medical services with naloxone.

PRACTICE DESCRIPTION

Not applicable.

PRACTICE POLICY INNOVATION

In 2011, the Governor's Cabinet Opiate Action Team was created to implement a multifaceted strategy, in part (1) to promote the responsible use of opioids, (2) to reduce the supply of opioids, and (3) to support overdose prevention and expand access to naloxone. Innovations to assist these goals include the development of Ohio guidelines on the responsible use of opioids, mandatory use of Ohio's prescription drug monitoring program, closing pill mills, promotion of drug take-back programs and increased access to naloxone and public health campaigns.

EVALUATION

Not applicable.

RESULTS

Since the development of the Governor's Cabinet Opiate Action Team, there were 81 million fewer doses of opioids dispensed to Ohio patients in 2015 compared with 782 million doses dispensed in 2011. As such, the proportion of unintentional drug overdose deaths involving prescription opioids has reduced from 45% in 2011 to 22% in 2015.

CONCLUSION

Strong political support was crucial in Ohio to facilitate the rapid implementation opioid overdose prevention programs and the promotion of public awareness campaigns. However, the misuse and abuse of prescription opioids are complex problems requiring a comprehensive and multifaceted approach. Pharmacists are identified as a crucial component of the state strategy to addressing opioid abuse by promoting responsible prescribing and adopting prevention practices.

Inpatient Experiences with MyChart Bedside

BACKGROUND

As technology is increasingly being integrated into hospital-based care, it is important to assess patient experiences. The purpose of this project was to conduct an evaluation of inpatient experiences with MyChart^® Bedside.

MATERIALS AND METHODS

A convenience sample of patients (n = 88) were included in this study, who responded to a Web-based self-reported survey that was embedded within the MyChart Bedside application.

RESULTS

The majority of respondents (78%) reported that MyChart Bedside was easy to use. The respondents agreed that MyChart Bedside improved communication with their nurses (74%) and with their physicians (53%), as well as helped them understand their medications (90%) during their inpatient hospitalization.

CONCLUSIONS

The study found that the majority of patients were satisfied with MyChart Bedside, and they reported that it helped them learn more about their medications, as well as communicate with their care team.

Barriers to implementation of opioid overdose prevention programs in Ohio

BACKGROUND

Nationally, overdose fatalities have reached epidemic proportions. Ohio has one of the highest overdose death rates in the country, as well as high rates of prescription opioid trafficking.

METHODS

A cross-sectional self-report survey of opioid overdose prevention programs (OOPPs) in Ohio was conducted between August and October 2014 to characterize programs and ascertain barriers to successful implementation. A 91% response rate was achieved with 18 programs participating in the study.

RESULTS

The first Ohio OOPP opened in August 2012, a second program opened in 2013, and the remaining programs began in 2014. All of the programs distribute nasal naloxone and provide overdose prevention education, and 89% (n = 16) provide overdose kits for free. Six OOPPs are funded by the Ohio Department of Health, 3 programs are funded by a local health foundation, and several other public and private funding sources were reported. The OOPPs have funding to distribute a combined total of 8,670 overdose kits and had distributed 1998 kits by October 2014. The OOPPs reported 149 overdose reversals. Fifteen programs (83%) reported implementation barriers that were categorized as stigma-, cost-, staffing-, legal, regulatory, and client-related problems. Legislative changes aimed at removing some of the obstacles to distribution and lay administration of naloxone have recently been enacted in Ohio.

CONCLUSIONS

OOPPs have rapidly expanded in Ohio during the past 3 years. Although recent legislative changes have addressed some of the reported implementation barriers, stigma and the cost of naloxone remain significant problems.

Assessing Fidelity of a Community-Based Opioid Overdose Prevention Program: Modification of the Fidelity Checklist

BACKGROUND

The evaluation and maintenance of treatment fidelity is an important methodological consideration in intervention research. Treatment fidelity is the degree to which interventions are delivered as outlined by the program developers. A lack of fidelity to the intervention model has the potential to be a large source of error, including type I and type II error. Monitoring and assuring fidelity is critical to assuring the validity of the interventions. The Fidelity Checklist is a reliable and valid tool designed to measure fidelity in a group-based parenting program. The Fidelity Checklist assesses group leaders' maintenance of the intervention protocol (adherence) and their group facilitation and process skills (competence).

OBJECTIVES

The purpose of this article is to describe the systematic process of modifying the Fidelity Checklist for use in a community-based opioid overdose prevention group educational intervention.

METHODS

A biphasic approach was used to modify the Fidelity Checklist. Phase 1 included engaging key stakeholders during a full-day meeting to determine adherence subscale components. Phase 2 included: (a) the modification of the competence subscale of the Fidelity Checklist, (b) adaptation of the coding manual defining the components of the Fidelity Checklist, and (c) creating a fidelity checklist to guide interventionists.

RESULTS

The biphasic systematic modification approach resulted in a revised Fidelity Checklist that was successfully used to measure treatment fidelity in a community-based opioid overdose prevention program.

CLINICAL RELEVANCE

The findings of this study provide information for nurse researchers and nurse educators for modifying a fidelity checklist that can be used to enhance community-based educational interventions.

Emergency Department Prescription Opioids as an Initial Exposure Preceding Addiction

STUDY OBJECTIVE

Opioid abuse and overdose constitute an ongoing health emergency. Many presume opioids have little potential for iatrogenic addiction when used as directed, particularly in short courses, as is typical of the emergency department (ED) setting. We preliminarily explore the possibility that initial exposure to opioids by EDs could be related to subsequent opioid misuse.

METHODS

This cross-sectional study surveyed a convenience sample of patients reporting heroin or nonmedical opioid use at an urban, academic ED. We estimated the proportion whose initial exposure to opioids was a legitimate medical prescription and the proportion of those prescriptions that came from an ED. Secondary measurements included the proportion of patients receiving nonopioid substances before initial opioid exposure, the source of opioids between initial exposure and onset of regular nonmedical use, and time from initial prescription to opioid use disorder.

RESULTS

Of 59 subjects, 35 (59%; 95% confidence interval [CI] 47% to 71%) reported they were first exposed to opioids by a legitimate medical prescription, and for 10 of 35 (29%; 95% CI 16% to 45%), the prescription came from an ED. Most medically exposed subjects (28/35; 80%; 95% CI 65% to 91%) reported nonopioid substance use or treatment for nonopioid substance use disorders preceding the initial opioid exposure. Emergency providers were a source of opioids between exposure and onset of regular nonmedical use in 11 of 35 cases (31%; 95% CI 18% to 48%). Thirty-one of the 35 medically exposed subjects reported the time of onset of nonmedical use; median time from exposure to onset of nonmedical use was 6 months for use to get high (N=25; interquartile range [IQR] 2 to 36), 12 months for regular use to get high (N=24; IQR 2 to 36), 18 months for use to avoid withdrawal (N=26; IQR 2 to 38), and 24 months for regular use to avoid withdrawal (N=27; IQR 2 to 48). Eleven subjects (36%; 95% CI 21% to 53%) began nonmedical use within 2 months, and 9 of 11 (82%; 95% CI 53% to 96%) reported nonopioid substance use or treatment for alcohol abuse before initial opioid exposure.

CONCLUSION

Although short-term opioid administration by emergency providers is unlikely to cause addiction by itself, ED opioid prescriptions may contribute to the development of addiction in some patients. There is an urgent need for further research to estimate long-term risks of short-course opioid therapy so that the risk of iatrogenic addiction can be appropriately balanced with the benefit of analgesia.

Risk factors for opioid overdose and awareness of overdose risk among veterans prescribed chronic opioids for addiction or pain

Rising overdose fatalities among U.S. veterans suggest veterans taking prescription opioids may be at risk for overdose. However, it is unclear whether veterans prescribed chronic opioids are aware of this risk. The objective of this study was to identify risk factors and determine awareness of risk for opioid overdose in veterans treated with opioids for chronic pain, using veterans treated with methadone or buprenorphine for opioid use disorder as a high-risk comparator group. In the current study, 90 veterans on chronic opioid medication, for either opioid use disorder or pain management, completed a questionnaire assessing risk factors, knowledge, and self-estimate of risk for overdose. Nearly all veterans in both groups had multiple overdose risk factors, although individuals in the pain management group had on average a significantly lower total number of risk factors than did individuals in the opioid use disorder group (5.9 versus 8.5, p < .0001). On average, participants treated for pain management scored slightly but significantly lower on knowledge of opioid overdose risk factors (12.1 versus 13.5, p < .01). About 70% of participants, regardless of group, believed their overdose risk was below that of the average American adult. There was no significant relationship between self-estimate of overdose risk and either number or knowledge of opioid overdose risk factors. Our results suggest that veterans in both groups underestimated their risk for opioid overdose. Expansion of overdose education to include individuals on chronic opioids for pain management and a shift in educational approaches to overdose prevention may be indicated.

Using e-technologies in clinical trials

Clinical trials have been slow to incorporate e-technology (digital and electronic technology that utilizes mobile devices or the Internet) into the design and execution of studies. In the meantime, individuals and corporations are relying more on electronic platforms and most have incorporated such technology into their daily lives. This paper provides a general overview of the use of e-technologies in clinical trials research, specifically within the last decade, marked by rapid growth of mobile and Internet-based tools. Benefits of and challenges to the use of e-technologies in data collection, recruitment and retention, delivery of interventions, and dissemination are provided, as well as a description of the current status of regulatory oversight of e-technologies in clinical trials research. As an example of ways in which e-technologies can be used for intervention delivery, a summary of e-technologies for treatment of substance use disorders is presented. Using e-technologies to design and implement clinical trials has the potential to reach a wide audience, making trials more efficient while also reducing costs; however, researchers should be cautious when adopting these tools given the many challenges in using new technologies, as well as threats to participant privacy/confidentiality. Challenges of using e-technologies can be overcome with careful planning, useful partnerships, and forethought. The role of web- and smartphone-based applications is expanding, and the increasing use of those platforms by scientists and the public alike make them tools that cannot be ignored.

Moving beyond misuse and diversion: the urgent need to consider the role of iatrogenic addiction in the current opioid epidemic

An epidemic of drug overdose deaths has led to calls for programs and policies to limit misuse and diversion of opioid medications. Any parallel call to consider the risk of iatrogenic addiction when treating pain has been muted in comparison. We have moved beyond questions of nonmedical use, abuse, and diversion to highlight the role of prescription opioids in causing addiction even when prescribed and used appropriately. Unfortunately, current evidence is insufficient, and a rapid expansion of longitudinal research is urgently needed to guide clinicians in balancing the need for opioids with the risk of adverse consequences. Meanwhile, medical education should place greater emphasis on the abuse liability of prescription opioids, and providers should endeavor to attenuate risk when possible.

Improving treatment for opioid dependence: a perspective from the Ohio Valley node of the NIDA Clinical Trials Network

PROBLEM

Rates of adoption of evidenced-based practices, including the use of medications, to treat opioid dependence are low and severely limit secondary prevention efforts to curtail the prescription drug epidemic.

PURPOSE

The goal of this article was to describe how involvement in a research clinical trials network (CTN) facilitated the adoption of medications to treat opioid dependence at two community-based treatment programs (CTPs) affiliated with the Ohio Valley Node (OVN) of the National Institute on Drug Abuse's (NIDA) CTN.

KEY POINTS

Participation in a CTN may facilitate adoption by providing the infrastructure for trialability and observability, but the most critical function may be the knowledge translation that occurs through the individual-level professional relationships that develop.

CONCLUSION

Community-based treatment providers' involvement in research networks may increase the rate of evidence-based practice (EBP) adoption and improve outcomes for patients with opioid dependence.

Topiramate for cocaine dependence during methadone maintenance treatment: a randomized controlled trial

BACKGROUND

Dual dependence on opiate and cocaine occurs in about 60% of patients admitted to methadone maintenance and negatively impacts prognosis (Kosten et al. 2003. Drug Alcohol Depend. 70, 315). Topiramate (TOP) is an antiepileptic drug that may have utility in the treatment of cocaine dependence because it enhances the GABAergic system, antagonizes the glutamatergic system, and has been identified by NIDA as one of only a few medications providing a "positive signal" warranting further clinical investigation. (Vocci and Ling, 2005. Pharmacol. Ther. 108, 94).

METHOD

In this double-blind controlled clinical trial, cocaine dependent methadone maintenance patients (N=171) were randomly assigned to one of four groups. Under a factorial design, participants received either TOP or placebo, and monetary voucher incentives that were either contingent (CM) or non-contingent (Non-CM) on drug abstinence. TOP participants were inducted onto TOP over 7 weeks, stabilized for 8 weeks at 300 mg daily then tapered over 3 weeks. Voucher incentives were supplied for 12 weeks, starting during the fourth week of TOP induction. Primary outcome measures were cocaine abstinence (Y/N) as measured by thrice weekly urinalysis and analyzed using Generalized Estimating Equations (GEE) and treatment retention. All analyses were intent to treat and included the 12-week evaluation phase of combined TOP/P treatment and voucher intervention period.

RESULTS

There was no significant difference in cocaine abstinence between the TOP vs. P conditions nor between the CM vs. Non-CM conditions. There was no significant TOP/CM interaction. Retention was not significantly different between the groups.

CONCLUSION

Topiramate is not efficacious for increasing cocaine abstinence in methadone patients.

Adolescent Substance Abuse and Mental Health: Problem Co-Occurrence and Access to Services

The purpose of this study is to identify factors associated with adolescent alcohol or drug (AOD) abuse/dependence, mental health and co-occurring problems; as well as factors associated with access to treatment. This is a secondary analysis of data from the National Survey on Drug Use and Health (NSDUH) 2000. The 12-month prevalence rate of adolescents with only mental health problems was 10.8%, 5.1% had only AOD abuse/dependence only, and 2.7% had co-occurring problems. Approximately 15% of youth reported receiving behavioral health treatment in the past 12 months. Several factors associated with having behavioral health problems and receiving treatment are presented.

Prescription drug abuse as a public health problem in Ohio: a case report

Prescription drug overdose is the leading cause of injury death in Ohio, as well as in 16 other states. Responding to the prescription drug epidemic is particularly challenging given the fragmentation of the health care system and that the consequences of addiction span across systems that have not historically collaborated. This case study reports on how Ohio is responding to the prescription drug epidemic by developing cross-system collaboration from local public health nurses to the Governor's office. In summary, legal and regulatory policies can be implemented relatively quickly whereas changing the substance abuse treatment infrastructure requires significant financial investments.

Duloxetine in the treatment of binge eating disorder with depressive disorders: a placebo-controlled trial

OBJECTIVE

This study evaluated duloxetine in the treatment of binge eating disorder (BED) with comorbid current depressive disorders.

METHOD

In this 12-week, double-blind, placebo-controlled trial, 40 patients with Diagnostic and Statistical Manual of Mental Disorders-IV-TR BED and a comorbid current depressive disorder received duloxetine (N = 20) or placebo (N = 20). The primary outcome measure was weekly binge eating day frequency.

RESULTS

In the primary analysis, duloxetine (mean 78.7 mg/day) was superior to placebo in reducing weekly frequency of binge eating days (p = .04), binge eating episodes (p = .02), weight (p = .04), and Clinical Global Impression-Severity of Illness ratings for binge eating (p = .02) and depressive disorders (p = .01). Changes in body mass index and measures of eating pathology, depression, and anxiety did not differ between the two groups.

DISCUSSION

Duloxetine may be effective for reducing binge eating, weight, and global severity of illness in BED with a comorbid current depressive disorder, but this finding needs confirmation in larger, placebo-controlled trials.

The potential impact of recruitment method on sample characteristics and treatment outcomes in a psychosocial trial for women with co-occurring substance use disorder and PTSD

BACKGROUND

Recruitment method can impact the sample composition of a clinical trial and, thus, the generalizability of the results, but the importance of recruitment method in substance use disorder trials has received little attention. The present paper sought to address this research gap by evaluating the association between recruitment method and sample characteristics and treatment outcomes in a substance use disorder trial.

METHODS

In a multi-site trial evaluating Seeking Safety (SS), relative to Women's Health Education (WHE), for women with co-occurring PTSD (either sub-threshold or full PTSD) and substance use disorders, one site assessed the method by which each participant was recruited. Data from this site (n=106), which recruited participants from newspaper advertising and clinic intakes, were analyzed.

RESULTS

Participants recruited through advertising, relative to those from the clinic, had significantly higher levels of baseline drug use and higher rates of meeting DSM-IV-TR criteria for full PTSD. Results suggest that the effectiveness of SS in decreasing PTSD symptoms was greater for participants recruited through advertising relative to those recruited from the clinic. Conversely, the results revealed a significant treatment effect in the clinic-recruited participants, not seen in the advertising-recruited participants, with SS, relative to WHE, participants being more likely to report past week drug use during the follow-up phase.

CONCLUSION

Recruitment method may impact sample composition and treatment effects. Replication of this finding would have important implications for substance use disorder efficacy trials which often utilize advertising to recruit participants.