1
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Marshall KD, Derse AR, Weiner SG, Joseph JW. Navigating Care Refusal and Noncompliance in Patients with Opioid Use Disorder. J Emerg Med 2024; 67:e233-e242. [PMID: 38849254 DOI: 10.1016/j.jemermed.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 01/09/2024] [Accepted: 03/06/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND For many emergency physicians (EPs), deciding whether or not to allow a patient suffering the ill effects of opioid use to refuse care is the most frequent and fraught situation in which they encounter issues of decision-making capacity, informed refusal, and autonomy. Despite the frequency of this issue and the well-known impacts of opioid use disorder on decision-making, the medical ethics community has offered little targeted analysis or guidance regarding these situations. DISCUSSION As a result, EPs demonstrate significant variability in how they evaluate and respond to them, with highly divergent understandings and application of concepts such as decision-making capacity, informed consent, autonomy, legal repercussions, and strategies to resolve the clinical dilemma. In this paper, we seek to provide more clarity to this issue for the EPs. CONCLUSIONS Successfully navigating this issue requires that EPs understand the specific effects that opioid use disorder has on decision-making, and how that in turn bears on the ethical concepts of autonomy, capacity, and informed refusal. Understanding these concepts can lead to helpful strategies to resolve these commonly-encountered dilemmas.
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Affiliation(s)
- Kenneth D Marshall
- Department of Emergency Medicine and History and Philosophy of Medicine, University of Kansas Medical Center, Kansas City, Kansas.
| | - Arthur R Derse
- Department of Emergency Medicine, Center for Bioethics and Medical Humanities, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joshua W Joseph
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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2
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Bayrakdarian ND, Bonar EE, Duguid I, Hellman L, Salino S, Wilkins C, Jannausch M, McKay JR, Staton M, Dollard K, Nahum-Shani I, Walton MA, Blow FC, Coughlin LN. Acceptability and feasibility of a mobile behavioral economic health intervention to reduce alcohol use in adults in rural areas. DRUG AND ALCOHOL DEPENDENCE REPORTS 2024; 11:100225. [PMID: 38545408 PMCID: PMC10966148 DOI: 10.1016/j.dadr.2024.100225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/26/2024] [Accepted: 02/26/2024] [Indexed: 08/27/2024]
Abstract
Background At-risk alcohol use is associated with increased adverse health consequences, yet is undertreated in healthcare settings. People residing in rural areas need improved access to services; however, few interventions are designed to meet the needs of rural populations. Mobile interventions can provide feasible, low-cost, and scalable means for reaching this population and improving health, and behavioral economic approaches are promising. Methods We conducted a pilot randomized controlled trial focused on acceptability and feasibility of a mobile behavioral economic intervention for 75 rural-residing adults with at-risk alcohol use. We recruited participants from a large healthcare system and randomized them to one of four virtually-delivered conditions reflecting behavioral economic approaches: episodic future thinking (EFT), volitional choice (VC), both EFT and VC, or enhanced usual care control (EUC). The intervention included a telephone-delivered induction session followed by two weeks of condition-consistent ecological momentary interventions (EMIs; 2x/day) and ecological momentary assessments (EMAs; 1x/day). Participants completed assessments at baseline, post-intervention, and two-month follow-up, and provided intervention feedback. Results All participants completed the telephone-delivered session and elected to receive EMI messages. Average completion rate of EMAs across conditions was 92.9%. Among participants in active intervention conditions, 89.3% reported the induction session was helpful and 80.0% reported it influenced their future drinking. We also report initial alcohol use outcomes. Discussion The behavioral economic intervention components and trial procedures evaluated here appear to be feasible and acceptable. Next steps include determination of their efficacy to reduce alcohol use and public health harms.
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Affiliation(s)
- Natalie D. Bayrakdarian
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Erin E. Bonar
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
- Injury Prevention Center, University of Michigan, Ann Arbor, MI, United States
- Michigan Innovations in Addiction Care through Research & Education, University of Michigan, Ann Arbor, MI, United States
| | - Isabelle Duguid
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Lauren Hellman
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Sarah Salino
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Chelsea Wilkins
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Mary Jannausch
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - James R. McKay
- University of Pennsylvania, Philadelphia, PA, United States
- Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States
| | - Michele Staton
- Department of Behavioral Science, University of Kentucky, Lexington, KY, United States
| | | | - Inbal Nahum-Shani
- Institute for Social Research, University of Michigan, Ann Arbor, MI, United States
| | - Maureen A. Walton
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
- Injury Prevention Center, University of Michigan, Ann Arbor, MI, United States
- Michigan Innovations in Addiction Care through Research & Education, University of Michigan, Ann Arbor, MI, United States
| | - Frederic C. Blow
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Lara N. Coughlin
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
- Injury Prevention Center, University of Michigan, Ann Arbor, MI, United States
- Michigan Innovations in Addiction Care through Research & Education, University of Michigan, Ann Arbor, MI, United States
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3
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Marshall KD, Derse AR, Weiner SG, Joseph JW. Revive and Refuse: Capacity, Autonomy, and Refusal of Care After Opioid Overdose. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024; 24:11-24. [PMID: 37220012 DOI: 10.1080/15265161.2023.2209534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Physicians generally recommend that patients resuscitated with naloxone after opioid overdose stay in the emergency department for a period of observation in order to prevent harm from delayed sequelae of opioid toxicity. Patients frequently refuse this period of observation despiteenefit to risk. Healthcare providers are thus confronted with the challenge of how best to protect the patient's interests while also respecting autonomy, including assessing whether the patient is making an autonomous choice to refuse care. Previous studies have shown that physicians have widely divergent approaches to navigating these conflicts. This paper reviews what is known about the effects of opioid use disorder on decision-making, and argues that some subset of these refusals are non-autonomous choices, even when patients appear to have decision making capacity. This conclusion has several implications for how physicians assess and respond to patients refusing medical recommendations after naloxone resuscitation.
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4
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Torres TM, Steinhauer SR, Forman SD, Forster SE. Patients with cocaine use disorder exhibit reductions in delay discounting with episodic future thinking cues regardless of incarceration history. Addict Behav Rep 2023; 18:100518. [PMID: 37955039 PMCID: PMC10632774 DOI: 10.1016/j.abrep.2023.100518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 10/25/2023] [Accepted: 10/27/2023] [Indexed: 11/14/2023] Open
Abstract
Research examining episodic future thinking (EFT; i.e., imagining oneself in future contexts) in community samples has demonstrated reduced discounting of delayed rewards when personalized event cues are included to prompt EFT related to reward latencies. While this EFT effect was recently demonstrated in individuals with substance use disorders, it is not yet known if it manifests similarly in individuals with and without a significant incarceration history-the latter being at elevated risk for negative outcomes including criminal recidivism. Individuals with cocaine use disorder (n = 35) identified personally-relevant future events and participated in a computerized delay discounting task, involving decisions between smaller immediate rewards or larger delayed rewards with and without EFT cues. Individuals with (n = 19) and without (n = 16) a significant history of incarceration were identified using the Addiction Severity Index-Lite. A significant reduction in discounting rates was observed when event cues were included to promote EFT (p = 0.02); however, there was no main effect of incarceration history on discounting behavior, or interaction between episodic future thinking condition and incarceration history. Results suggest personalized cues included to evoke EFT reduce discounting behavior in individuals with cocaine use disorder, regardless of incarceration history. EFT-based interventions may therefore have promise to reduce impulsive decision-making in individuals with cocaine use disorder with and without a significant history of incarceration, potentially supporting improved outcomes with respect to both substance use and future criminality.
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Affiliation(s)
- Taylor M. Torres
- VA Pittsburgh Healthcare System, VISN 4 Mental Illness Research, Education, & Clinical Center (MIRECC), USA
| | - Stuart R. Steinhauer
- VA Pittsburgh Healthcare System, VISN 4 Mental Illness Research, Education, & Clinical Center (MIRECC), USA
- University of Pittsburgh, Department of Psychiatry, USA
| | - Steven D. Forman
- VA Pittsburgh Healthcare System, VISN 4 Mental Illness Research, Education, & Clinical Center (MIRECC), USA
- University of Pittsburgh, Department of Psychiatry, USA
| | - Sarah E. Forster
- VA Pittsburgh Healthcare System, VISN 4 Mental Illness Research, Education, & Clinical Center (MIRECC), USA
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5
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Dick DM, Saunders T, Balcke E, Driver MN, Neale Z, Vassileva J, Langberg JM. Genetically influenced externalizing and internalizing risk pathways as novel prevention targets. PSYCHOLOGY OF ADDICTIVE BEHAVIORS 2022; 36:595-606. [PMID: 34110842 PMCID: PMC8660940 DOI: 10.1037/adb0000759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Objective: Risky substance use among college students is widespread, and associated with numerous adverse consequences. Current interventions focus primarily on students' current substance use; we hypothesize that shifting focus from current use to underlying risk factors is a complementary approach that may improve effectiveness of prevention/intervention programming. This approach aligns with the personalized medicine movement, which aims to harness knowledge about underlying etiological factors to provide individuals with specific information about their unique risk profiles and personalized recommendations, to motivate and enable individuals to better self-regulate their health. Method: Our group is building and evaluating an online Personalized Feedback Program (PFP) for college students that provides feedback about the individual's underlying genetically influenced externalizing and internalizing risk factors for substance use, along with personalized recommendations/resources. The project capitalizes on work from a university-wide research project (Spit for Science; S4S), in which > 12,000 students (˜70% of 5 years of incoming freshmen) are being followed longitudinally to assess substance use and related factors across the college years. In this article, we describe our foundational work to develop the PFP. Results: From the S4S data, we have identified risk factors across four domains (Sensation Seeking, Impulsivity, Extraversion, and Neuroticism) that are correlated with college students' substance use. We developed an online self-guided PFP, in collaboration with professionals from student affairs, and using feedback from students, with the ultimate goal of conducting a randomized clinical trial. Conclusion: The provision of personalized risk information represents a novel approach to complement and extend existing college substance use programming. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Affiliation(s)
- Danielle M. Dick
- Department of Psychology, Virginia Commonwealth
University
- Department of Human and Molecular Genetics, Virginia
Commonwealth University
| | - Trisha Saunders
- Division of Student Affairs, Virginia Commonwealth
University
| | - Emily Balcke
- Department of Psychology, Virginia Commonwealth
University
| | - Morgan N. Driver
- Department of Human and Molecular Genetics, Virginia
Commonwealth University
| | - Zoe Neale
- Department of Psychology, Virginia Commonwealth
University
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6
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Carroll ME. Voluntary exercise as a treatment for incubated and expanded drug craving leading to relapse to addiction: Animal models. Pharmacol Biochem Behav 2021; 208:173210. [PMID: 34116079 DOI: 10.1016/j.pbb.2021.173210] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 05/25/2021] [Accepted: 05/26/2021] [Indexed: 02/08/2023]
Abstract
Drug addiction is a chronic relapsing disorder, as more than 80% of former drug users relapse within a year after quit attempts have ended. This review examines incubated craving that develops over long periods of weeks to months after addictive drug use ends, when rats are given a small priming exposure to the formerly used drug, and a large amount of drug seeking occurs, reflecting large increases in craving over time. Expanded craving occurs when not only the recently-used drug, but other related or unrelated drugs of abuse elicit drug seeking that leads to relapse behavior, including common drugs like caffeine or nicotine, Thus, expanded craving is an increase in the conditions that elicit relapse, such as, a variety of drugs, and it persists weeks after drug use ends. Incubated and expanded craving occur with several drugs of abuse, and these forms of craving, can last for weeks to months and end in relapse. Voluntary physical exercise, blocked incubated cocaine craving, and expanded heroin craving elicited by multiple conditions was reduced in female and male rats. This review examines voluntary physical exercise as a long-term, self-initiated, and self-sustainable treatment that reduces long-term drug craving leading to relapse.
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Affiliation(s)
- Marilyn E Carroll
- Department of Psychiatry and Behavior Science, 621 Park Ave, University of Minnesota, Minneapolis, MN 55455, United States of America.
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7
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Schwartz LP, Silberberg A, Hursh SR. Purchase task sensitivity to drug and nondrug reinforcers in opioid-agonist treatment patients. J Exp Anal Behav 2021; 115:717-728. [PMID: 33586194 DOI: 10.1002/jeab.681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/29/2020] [Accepted: 01/19/2021] [Indexed: 11/11/2022]
Abstract
The behavioral economics of substance abuse has been increasingly recognized as a method of determining the value of abused substances for individuals who use those substances. It has been hypothesized that such analyses could serve as a clinical tool and that demand functions can be targeted predictors for the level of intervention necessary. This study evaluated the sensitivity of a demand task in 2 patient groups in a medication assisted treatment program (methadone maintenance), those who had used opioids in the last 2 months and those who had not used opioids in at least 18 months. Demand for 7 drugs and a control was assessed using hypothetical purchase tasks. Participants maintaining long-term abstinence had significantly higher α (sensitivity to price) and lower Q0 (intensity of demand) for heroin than participants who had recently used opioids. Further research is necessary to illustrate if treatment is responsible for this reduction in demand. If so, demand analyses may provide clinical utility as an aid for treatment planning or as a target for treatment.
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Affiliation(s)
- Lindsay P Schwartz
- Applied Behavioral Research, Institutes for Behavior Resources, Baltimore, MD
| | - Alan Silberberg
- Department of Psychology, American University, Washington, DC
| | - Steven R Hursh
- Applied Behavioral Research, Institutes for Behavior Resources, Baltimore, MD.,Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
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8
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Kvam PD, Romeu RJ, Turner BM, Vassileva J, Busemeyer JR. Testing the factor structure underlying behavior using joint cognitive models: Impulsivity in delay discounting and Cambridge gambling tasks. Psychol Methods 2021; 26:18-37. [PMID: 32134313 PMCID: PMC7483167 DOI: 10.1037/met0000264] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Neurocognitive tasks are frequently used to assess disordered decision making, and cognitive models of these tasks can quantify performance in terms related to decision makers' underlying cognitive processes. In many cases, multiple cognitive models purport to describe similar processes, but it is difficult to evaluate whether they measure the same latent traits or processes. In this article, we develop methods for modeling behavior across multiple tasks by connecting cognitive model parameters to common latent constructs. This approach can be used to assess whether 2 tasks measure the same dimensions of cognition, or actually improve the estimates of cognitive models when there are overlapping cognitive processes between 2 related tasks. The approach is then applied to connecting decision data on 2 behavioral tasks that evaluate clinically relevant deficits, the delay discounting task and Cambridge gambling task, to determine whether they both measure the same dimension of impulsivity. We find that the discounting rate parameters in the models of each task are not closely related, although substance users exhibit more impulsive behavior on both tasks. Instead, temporal discounting on the delay discounting task as quantified by the model is more closely related to externalizing psychopathology like aggression, while temporal discounting on the Cambridge gambling task is related more to response inhibition failures. The methods we develop thus provide a new way to connect behavior across tasks and grant new insights onto the different dimensions of impulsivity and their relation to substance use. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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9
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Coughlin LN, Bonar EE, Bickel WK. Considerations for remote delivery of behavioral economic interventions for substance use disorder during COVID-19 and beyond. J Subst Abuse Treat 2020; 120:108150. [PMID: 33298296 PMCID: PMC7532990 DOI: 10.1016/j.jsat.2020.108150] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 08/10/2020] [Accepted: 09/22/2020] [Indexed: 12/24/2022]
Abstract
The response to the COVID-19 crisis has created direct pressure on health care providers to deliver virtual care, and has created the opportunity to develop innovations in remote treatment for people with substance use disorders. Remote treatments provide an intervention delivery framework that capitalizes on technological innovations in remote monitoring of behaviors and can efficiently use information collected from people and their environment to provide personalized treatments as needed. Interventions informed by behavioral economic theories can help to harness the largely untapped potential of virtual care in substance use treatment. Behavioral economic treatments, such as contingency management, the substance-free activity session, and episodic future thinking, are positioned to leverage remote monitoring of substance use and to use personalized medicine frameworks to deliver remote interventions in the COVID-19 era and beyond. With increased remote care, there is an opportunity for virtual treatment development. Treatments can capitalize on remote technology to increase effectiveness. Behavioral economic interventions are well positioned to fill this need. Remote behavioral economic interventions can add to current treatments.
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Affiliation(s)
- Lara N Coughlin
- Addiction Center, Department of Psychiatry, University of Michigan, United States of America.
| | - Erin E Bonar
- Addiction Center, Department of Psychiatry, University of Michigan, United States of America; Injury Prevention Center, University of Michigan, United States of America
| | - Warren K Bickel
- Fralin Biomedical Research Institute at Virginia Tech, United States of America
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10
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Perry CL, Creamer MR, Chaffee BW, Unger JB, Sutfin EL, Kong G, Shang C, Clendennen SL, Krishnan-Sarin S, Pentz MA. Research on Youth and Young Adult Tobacco Use, 2013-2018, From the Food and Drug Administration-National Institutes of Health Tobacco Centers of Regulatory Science. Nicotine Tob Res 2020; 22:1063-1076. [PMID: 31127298 PMCID: PMC7457341 DOI: 10.1093/ntr/ntz059] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 04/16/2019] [Indexed: 12/21/2022]
Abstract
The Tobacco Regulatory Science Program is a collaborative research effort between the National Institutes of Health (NIH) and the Food and Drug Administration (FDA). In 2013, the NIH funded 14 Tobacco Centers of Regulatory Science (TCORS), which serve as partners in establishing research, training, and professional development programs to guide FDA. Each of the fourteen TCORS, and two other NIH-funded research programs, the Center for the Evaluation of Nicotine in Cigarettes (CENIC) and the Consortium on Methods Evaluating Tobacco (COMET), pursued specific research themes relevant to FDA's priorities. A key mandate for FDA is to reduce tobacco use among young people. This article is a review of the peer-reviewed research, including published and in-press manuscripts, from the TCORS, CENIC, and COMET, which provides specific data or other findings on youth (ages 10-18 years) and/or young adults (ages 18-34 years), from 2013 to 2018. Citations of all TCORS, CENIC, and COMET articles from September 2013 to December 2017 were collected by the TCORS coordinating center, the Center for Evaluation and Coordination of Training and Research. Additional citations up to April 30, 2018 were requested from the principal investigators. A scoring rubric was developed and implemented to assess study type, primary theme, and FDA priority area addressed by each article. The major subareas and findings from each priority area are presented. There were 766 articles in total, with 258 (34%) focusing on youth and/or young adults. Findings relevant to FDA from this review concern impact analysis, toxicity, health effects, addiction, marketing influences, communications, and behavior. IMPLICATIONS The Tobacco Centers of Regulatory Science, CENIC, and COMET have had a high output of scientific articles since 2013. These Centers are unique in that the FDA supports science specifically to guide future regulatory actions. The 258 articles that have focused on youth and/or young adults are providing data for regulatory actions by the FDA related to the key priority areas such as the addictiveness of non-cigarette products, the effects of exposure to electronic cigarette marketing on initiation and cessation, and the impact of flavored products on youth and young adult tobacco use. Future regulations to reduce tobacco use will be guided by the cumulative evidence. These Centers are one innovative mechanism to promote important outcomes to advance tobacco regulatory science.
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Affiliation(s)
- Cheryl L Perry
- School of Public Health at Austin, The University of Texas Health Science Center at Houston, Austin, TX
| | - MeLisa R Creamer
- School of Public Health at Austin, The University of Texas Health Science Center at Houston, Austin, TX
| | | | - Jennifer B Unger
- Keck School of Medicine,University of Southern California, Los Angeles, CA
| | | | | | - Ce Shang
- Oklahoma Tobacco Research Center, Stephenson Cancer Center
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Stephanie L Clendennen
- School of Public Health at Austin, The University of Texas Health Science Center at Houston, Austin, TX
| | | | - Mary Ann Pentz
- Keck School of Medicine,University of Southern California, Los Angeles, CA
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11
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Carl E, Liskiewicz A, Rivard C, Alberico R, Belal A, Mahoney MC, Quisenberry AJ, Bickel WK, Sheffer CE. Dosing parameters for the effects of high-frequency transcranial magnetic stimulation on smoking cessation: study protocol for a randomized factorial sham-controlled clinical trial. BMC Psychol 2020; 8:42. [PMID: 32357940 PMCID: PMC7193364 DOI: 10.1186/s40359-020-00403-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 04/05/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Despite the considerable success of comprehensive tobacco control efforts, tobacco use remains one of the greatest preventable causes of death and disease today. Over half of all smokers in the US make quit attempts every year, but over 90% relapse within 12 months, choosing the immediate reinforcement of smoking over the long-term benefits of quitting. Conceptual and empirical evidence supports continued investigation of high frequency repetitive transcranial magnetic stimulation (rTMS) of the left dorsolateral prefrontal cortex in reducing relapse and decreasing cigarette consumption. While this evidence is compelling, an optimal dosing strategy must be determined before a long-term efficacy trial can be conducted. The goal of this study is to determine a dosing strategy for 20 Hz rTMS that will produce the best long-term abstinence outcomes with the fewest undesirable effects. METHODS This is a fully crossed, double-blinded, sham-controlled, 3x2x2 randomized factorial study. The three factors are duration (stimulation days: 8, 12, and 16); intensity (900 or 1800 pulses per day); and sham control. Participants (n = 258) will consist of adults (18-65) who are motivated to quit smoking cigarettes and who will be followed for 6 months post-quit. Outcomes include latency to relapse, point prevalence abstinence rates, delay discounting rates, cognitive-behavioral skills acquisition, and multiple measures of potential undesirable effects that impact participant compliance. DISCUSSION This study integrates existing theoretical concepts and methodologies from neuropsychology, behavioral economics, brain stimulation, clinical psychology, and the evidence-based treatment of tobacco dependence in the development of a promising and innovative approach to treat tobacco dependence. This study will establish an optimal dosing regimen for efficacy testing. Findings are expected to have a significant influence on advancing this approach as well as informing future research on clinical approaches that combine rTMS with other evidence-based treatments for tobacco dependence and perhaps other addictions. TRIAL REGISTRATION Clinical Trials NCT03865472 (retrospectively registered). The first participant was fully enrolled on November 26, 2018. Registration was posted on March 7, 2019.
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Affiliation(s)
- Ellen Carl
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, 14203, USA.
| | | | - Cheryl Rivard
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, 14203, USA
| | - Ronald Alberico
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, 14203, USA
| | - Ahmed Belal
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, 14203, USA
| | - Martin C Mahoney
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, 14203, USA
| | | | - Warren K Bickel
- Fralin Biomedical Research Institute at Virginia Tech Carilion, Roanoke, VA, 24016, USA
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12
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Bickel WK, Athamneh LN, Snider SE, Craft WH, DeHart WB, Kaplan BA, Basso JC. Reinforcer Pathology: Implications for Substance Abuse Intervention. Curr Top Behav Neurosci 2020; 47:139-162. [PMID: 32462615 DOI: 10.1007/7854_2020_145] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The rate at which individuals discount future rewards (i.e., discounting rate) is strongly associated with their propensity for substance abuse as well as myriad other negative health behaviors. An excessive preference for immediately available rewards suggests a shortened time horizon in which immediate rewards are overvalued and future, potentially negative consequences are undervalued. This review outlines Reinforcer Pathology Theory (i.e., the interaction between excessive preference for immediately available rewards and the overvaluation of a particular commodity that offers brief, intense reinforcement), its neurobiological/behavioral underpinnings, and its implications for treating substance use disorders. In doing so, the current review provides an overview of a variety of ways in which interventions have been used to manipulate aspects of reinforcer pathology in an individual, including narrative theory, framing manipulations, and neuromodulation (e.g., working memory training, TMS) which may serve as promising avenues for the modulation of the temporal window and/or valuation of reinforcers.
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Affiliation(s)
- Warren K Bickel
- Addiction Recovery Research Center, Fralin Biomedical Research Institute, Roanoke, VA, USA. .,Center for Transformative Research on Health Behaviors, Fralin Biomedical Research Institute, Roanoke, VA, USA.
| | - Liqa N Athamneh
- Addiction Recovery Research Center, Fralin Biomedical Research Institute, Roanoke, VA, USA.,Graduate Program in Translational Biology, Medicine, and Health, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - Sarah E Snider
- Addiction Recovery Research Center, Fralin Biomedical Research Institute, Roanoke, VA, USA
| | - William H Craft
- Addiction Recovery Research Center, Fralin Biomedical Research Institute, Roanoke, VA, USA.,Graduate Program in Translational Biology, Medicine, and Health, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - William B DeHart
- Addiction Recovery Research Center, Fralin Biomedical Research Institute, Roanoke, VA, USA
| | - Brent A Kaplan
- Addiction Recovery Research Center, Fralin Biomedical Research Institute, Roanoke, VA, USA
| | - Julia C Basso
- Addiction Recovery Research Center, Fralin Biomedical Research Institute, Roanoke, VA, USA
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13
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Mellis AM, Snider SE, Deshpande HU, LaConte SM, Bickel WK. Practicing prospection promotes patience: Repeated episodic future thinking cumulatively reduces delay discounting. Drug Alcohol Depend 2019; 204:107507. [PMID: 31520923 PMCID: PMC6878183 DOI: 10.1016/j.drugalcdep.2019.06.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 05/31/2019] [Accepted: 06/03/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Delay discounting, or the preference for smaller, sooner over larger, later rewards, has been associated with alcohol use disorder and problem drinking. Episodic future thinking has been suggested as an intervention to address steep delay discounting. In the present study, we examined the effect of up to six consecutive sessions of episodic future thinking. METHODS Repeated, within-subject data were collected from current and recent problem drinkers (n = 50) over six sessions. Linear mixed-effect models were used to estimate effects of repeated sessions and manipulations. Participants completed episodic future thinking interviews at up to six sessions, in which they generated personalized future events. Participants also engaged with cues of scarcity. At each session, participants completed three delay discounting tasks under: a no-cue baseline condition, a future cue condition, and a scarcity cue condition. RESULTS Delay discounting in the no cue condition did not change over time. Discounting rates were reduced in the future cue condition, and these effects grew larger with repeated sessions. In the scarcity condition, discounting rates were slightly higher, with no effect of repeated sessions. CONCLUSIONS Episodic future thinking reduced delay discounting rate while future cues were presented, and these effects grew larger with repeated sessions. This suggests that repeated episodic future thinking may cumulatively potentiate repair of excessive preference for immediate reward.
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Affiliation(s)
| | | | | | | | - Warren K. Bickel
- Addiction Recovery Research Center, Fralin Biomedical Research Institute at VTC, Roanoke, Virginia, USA 24016
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14
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Bruce JM, Bruce AS, Lynch S, Thelen J, Lim SL, Smith J, Catley D, Reed DD, Jarmolowicz DP. Probability discounting of treatment decisions in multiple sclerosis: associations with disease knowledge, neuropsychiatric status, and adherence. Psychopharmacology (Berl) 2018; 235:3303-3313. [PMID: 30244284 DOI: 10.1007/s00213-018-5037-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 09/11/2018] [Indexed: 11/27/2022]
Abstract
RATIONALE Patients weigh risks and benefits when making treatment decisions. Despite this, relatively few studies examine the behavioral patterns underpinning these decisions. Moreover, individual differences in these patterns remain largely unexplored. OBJECTIVES The purpose of this study was to test a probability discounting model to explain the independent influences of risks and benefits when patients make hypothetical treatment decisions. Furthermore, we examine how individual differences in this probability discounting function are associated with patient demographics, clinical characteristics, disease knowledge, neuropsychiatric status, and adherence. METHODS Two hundred eight participants with relapsing-remitting multiple sclerosis (MS) indicated their likelihood (0-100%) of taking a hypothetical medication as the probability of mild side effects (11 values from .1 to 99.9%) and reported medication efficacies (11 values from .1 to 99.9%) varied systematically. They also completed a series of questionnaires and cognitive tests. RESULTS Individual components of medication treatment decision making were successfully described with a probability discounting model. High rates of discounting based on risks were associated with poor treatment adherence and less disease-specific knowledge. In contrast, high rates of discounting of benefits was associated with poorer cognitive functioning. Regression models indicated that risk discounting predicted unique variance in treatment adherence. CONCLUSIONS Insights gained from the present study represent an important early step in understanding individual differences associated with medical decision making in MS. Future research may wish to use this knowledge to inform the development of empirically supported adherence interventions.
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Affiliation(s)
- Jared M Bruce
- Department of Psychology, University of Missouri - Kansas City, 5030 Cherry Hall, Kansas City, MO, 64110, USA.
- Department of Biomedical and Health Informatics, University of Missouri - Kansas City, Kansas City, MO, USA.
| | - Amanda S Bruce
- Center for Healthy Lifestyles and Nutrition, Children's Mercy Hospital, Kansas City, MO, USA
- Department of Pediatrics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Sharon Lynch
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Joanie Thelen
- Department of Psychology, University of Missouri - Kansas City, 5030 Cherry Hall, Kansas City, MO, 64110, USA
| | - Seung-Lark Lim
- Department of Psychology, University of Missouri - Kansas City, 5030 Cherry Hall, Kansas City, MO, 64110, USA
| | - Julia Smith
- Department of Psychology, University of Missouri - Kansas City, 5030 Cherry Hall, Kansas City, MO, 64110, USA
| | - Delwyn Catley
- Center for Healthy Lifestyles and Nutrition, Children's Mercy Hospital, Kansas City, MO, USA
| | - Derek D Reed
- Department of Applied Behavior Science, University of Kansas, Lawrence, KS, USA
- Cofrin-Logan Center for Addiction Research and Treatment, Lawrence, KS, USA
| | - David P Jarmolowicz
- Department of Applied Behavior Science, University of Kansas, Lawrence, KS, USA
- Cofrin-Logan Center for Addiction Research and Treatment, Lawrence, KS, USA
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15
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Soltis KE, Acuff SF, Dennhardt AA, Borsari B, Martens MP, Murphy JG. Self-regulation as a mediator of the effects of a brief behavioral economic intervention on alcohol-related outcomes: A preliminary analysis. Exp Clin Psychopharmacol 2018; 26:347-353. [PMID: 29952619 PMCID: PMC6072594 DOI: 10.1037/pha0000213] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Behavioral economic theory suggests that increased engagement in constructive, substance-free activities that are in the service of long-term goals (e.g., college graduation, career development, health) can decrease alcohol use and related problems. However, engaging in activities such as these in the high-risk college environment requires the ability to self-regulate by avoiding rewarding but risky behaviors (e.g., drinking) while also effectively organizing behavior in the pursuit of delayed academic and career-related rewards. The current secondary data analyses evaluated self-regulation as a potential mechanism of behavior change in an alcohol intervention trial that compared a standard alcohol-focused brief motivational intervention (BMI) plus a behavioral economic substance-free activity session (SFAS) with an alcohol BMI plus relaxation training (reaction time [RT]) session (Murphy et al., 2012). Participants were 82 first-year undergraduate students (50% women; Mage = 18.5, SD = .71) who reported 2 or more past-month heavy drinking episodes. After completing a baseline assessment and an individual alcohol-focused BMI, participants were randomized to either the SFAS or the RT session. The BMI + SFAS condition reported greater mean self-regulation at 1 month compared with BMI + RT. Furthermore, self-regulation at 1 month significantly mediated the relation between condition and alcohol-related outcomes at 6-month follow-up. Although preliminary, these results suggest that brief behavioral economic intervention elements that an attempt to increase future goal pursuit and substance-free activities can enhance the short-term efficacy of standard alcohol BMIs and that this effect may be due in part to increases in self-regulation. (PsycINFO Database Record
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Affiliation(s)
- Kathryn E. Soltis
- Department of Psychology, University of Memphis, 400 Innovation Dr., Memphis, TN, 38152 United States
| | - Samuel F. Acuff
- Department of Psychology, University of Memphis, 400 Innovation Dr., Memphis, TN, 38152 United States
| | - Ashley A. Dennhardt
- Department of Psychology, University of Memphis, 400 Innovation Dr., Memphis, TN, 38152 United States
| | - Brian Borsari
- Mental Health Service (116B) San Francisco VA Health Care System, 4150 Clement Street, San Francisco, CA 94121, United States,Department of Psychiatry, University of California – San Francisco, 982 Mission St, San Francisco, CA 94103
| | - Matthew P. Martens
- Department of Educational, School, and Counseling Psychology, University of Missouri, 16 Hill Hall, Columbia, MO, 65211 United States
| | - James G. Murphy
- Department of Psychology, University of Memphis, 400 Innovation Dr., Memphis, TN, 38152 United States,Corresponding Author. Current Address: Department of Psychology, 400 Innovation Dr., Memphis, TN, 38152. E-mail Address: (James G. Murphy, PhD). Phone Number: (901) 678-2630; Fax Number: (901) 678-2579
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16
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Bickel WK, Mellis AM, Snider SE, Athamneh LN, Stein JS, Pope DA. 21st century neurobehavioral theories of decision making in addiction: Review and evaluation. Pharmacol Biochem Behav 2018; 164:4-21. [PMID: 28942119 PMCID: PMC5747999 DOI: 10.1016/j.pbb.2017.09.009] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 08/24/2017] [Accepted: 09/12/2017] [Indexed: 01/21/2023]
Abstract
This review critically examines neurobehavioral theoretical developments in decision making in addiction in the 21st century. We specifically compare each theory reviewed to seven benchmarks of theoretical robustness, based on their ability to address: why some commodities are addictive; developmental trends in addiction; addiction-related anhedonia; self-defeating patterns of behavior in addiction; why addiction co-occurs with other unhealthy behaviors; and, finally, means for the repair of addiction. We have included only self-contained theories or hypotheses which have been developed or extended in the 21st century to address decision making in addiction. We thus review seven distinct theories of decision making in addiction: learning theories, incentive-sensitization theory, dopamine imbalance and systems models, opponent process theory, strength models of self-control failure, the competing neurobehavioral decision systems theory, and the triadic systems theory of addiction. Finally, we have directly compared the performance of each of these theories based on the aforementioned benchmarks, and highlighted key points at which several theories have coalesced.
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Affiliation(s)
- Warren K Bickel
- Addiction Recovery Research Center, Virginia Tech Carilion Research Institute, Roanoke, VA, United States; Graduate Program in Translational Biology, Medicine, and Health, Roanoke, VA, United States; Department of Psychology, Virginia Polytechnic Institute and State University, Blacksburg, VA, United States; Department of Neuroscience, Virginia Polytechnic Institute and State University, United States; Faculty of Health Sciences, Virginia Polytechnic Institute and State University, United States; Department of Psychiatry and Behavioral Medicine, Virginia Tech Carilion School of Medicine, United States.
| | - Alexandra M Mellis
- Addiction Recovery Research Center, Virginia Tech Carilion Research Institute, Roanoke, VA, United States; Graduate Program in Translational Biology, Medicine, and Health, Roanoke, VA, United States
| | - Sarah E Snider
- Addiction Recovery Research Center, Virginia Tech Carilion Research Institute, Roanoke, VA, United States
| | - Liqa N Athamneh
- Addiction Recovery Research Center, Virginia Tech Carilion Research Institute, Roanoke, VA, United States; Graduate Program in Translational Biology, Medicine, and Health, Roanoke, VA, United States
| | - Jeffrey S Stein
- Addiction Recovery Research Center, Virginia Tech Carilion Research Institute, Roanoke, VA, United States
| | - Derek A Pope
- Addiction Recovery Research Center, Virginia Tech Carilion Research Institute, Roanoke, VA, United States
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17
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Verdejo-Garcia A, Chong TTJ, Stout JC, Yücel M, London ED. Stages of dysfunctional decision-making in addiction. Pharmacol Biochem Behav 2017; 164:99-105. [PMID: 28216068 DOI: 10.1016/j.pbb.2017.02.003] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 01/27/2017] [Accepted: 02/03/2017] [Indexed: 01/26/2023]
Abstract
Drug use is a choice with immediate positive outcomes, but long-term negative consequences. Thus, the repeated use of drugs in the face of negative consequences suggests dysfunction in the cognitive mechanisms underpinning decision-making. This cognitive dysfunction can be mapped into three stages: the formation of preferences involving valuation of decision options; choice implementation including motivation, self-regulation and inhibitory processes; and feedback processing implicating reinforcement learning. This article reviews behavioral studies that have examined alterations in these three stages of decision-making in people with substance use disorders. Relative to healthy individuals, those with alcohol, cannabis, stimulant and opioid use disorders value risky options more highly during the formation of preferences; have a greater appetite for superficially attractive rewards during choice implementation; and are both more efficient in learning from rewards and less efficient in learning from losses during feedback processing. These observed decision-making deficits are most likely due to both premorbid factors and drug-induced effects. Because decision-making deficits have been prospectively associated with a greater risk of drug relapse, we advocate for greater research on modulating the component stages that give rise to dysfunctional decision-making in disorders of addiction.
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Affiliation(s)
- Antonio Verdejo-Garcia
- Monash Institute of Cognitive & Clinical Neuroscience (MICCN), Monash University, Australia; School of Psychological Sciences, Monash University, Australia.
| | - Trevor T-J Chong
- Monash Institute of Cognitive & Clinical Neuroscience (MICCN), Monash University, Australia; School of Psychological Sciences, Monash University, Australia
| | - Julie C Stout
- Monash Institute of Cognitive & Clinical Neuroscience (MICCN), Monash University, Australia; School of Psychological Sciences, Monash University, Australia
| | - Murat Yücel
- Monash Institute of Cognitive & Clinical Neuroscience (MICCN), Monash University, Australia; School of Psychological Sciences, Monash University, Australia
| | - Edythe D London
- Semel Institute of Neuroscience, University of California Los Angeles, United States
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Toward Narrative Theory: Interventions for Reinforcer Pathology in Health Behavior. NEBRASKA SYMPOSIUM ON MOTIVATION 2017. [DOI: 10.1007/978-3-319-51721-6_8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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