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Kleinman MB, Anvari MS, Seitz-Brown CJ, Bradley VD, Tralka H, Felton JW, Belcher AM, Greenblatt AD, Magidson JF. Psychosocial challenges affecting patient-defined medication for opioid use disorder treatment outcomes in a low-income, underserved population: Application of the social-ecological framework. J Subst Use Addict Treat 2023; 149:209046. [PMID: 37061189 DOI: 10.1016/j.josat.2023.209046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 11/27/2022] [Accepted: 04/11/2023] [Indexed: 04/17/2023]
Abstract
INTRODUCTION Successful engagement with medication treatment for opioid use disorder is an important focus in reducing mortality associated with the opioid crisis. Mortality remains at unacceptably high levels, pointing to a need for improved understanding of factors that affect medication for opioid use disorder outcomes. This study aims to understand how barriers co-occur and interact to interfere with outcomes in methadone treatment for a low-income, underserved patient population with opioid use disorder. METHODS This study was conducted at a community-based drug treatment center that serves a predominately low-income, racially diverse population. Guided by the social-ecological framework, we analyzed semi-structured interviews and focus groups with patients and providers working in opioid use disorder care and recovery across Baltimore City (N = 32) to assess factors that influence methadone treatment outcomes, and how barriers co-occur and interact to worsen treatment outcomes. The study used patient-centered definitions to describe successful treatment outcomes. RESULTS Barriers described by both patients and providers fit into several broad levels: individual, interpersonal, institutional, community, and stigma. Participants described co-occurrence of many barriers. Further, the study identified potential interactive effects, such that interrelated barriers were seen as fueling one another and having a deleterious effect on treatment outcomes. Specifically, interrelationships between barriers were described for 1) unstable housing with social influences and mental health factors; 2) transportation with poor physical health and other competing responsibilities; 3) treatment program policies and schedule with competing responsibilities; and 4) stigma with poor physical and mental health. CONCLUSIONS Understanding barriers to successful medication for opioid use disorder outcomes and considering their co-occurrence may help to identify and promote interventions to mitigate their impact. This work is intended to guide future research to adapt conceptual frameworks for understanding psychosocial and structural barriers affecting opioid use disorder treatment and ultimately intervention efforts to improve treatment outcomes.
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Affiliation(s)
- Mary B Kleinman
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA.
| | - Morgan S Anvari
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
| | - C J Seitz-Brown
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
| | - Valerie D Bradley
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
| | - Hannah Tralka
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
| | | | - Annabelle M Belcher
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Aaron D Greenblatt
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jessica F Magidson
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
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2
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Belcher AM, Cole TO, Massey E, Billing AS, Wagner M, Wooten W, Epstein DH, Hoag SW, Wickwire EM, Greenblatt AD, Colloca L, Rotrosen J, Magder L, Weintraub E, Wish ED, Kaptchuk TJ. Effectiveness of Conditioned Open-label Placebo With Methadone in Treatment of Opioid Use Disorder: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e237099. [PMID: 37043203 PMCID: PMC10099063 DOI: 10.1001/jamanetworkopen.2023.7099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023] Open
Abstract
Importance Methadone treatment is the most effective evidence-based treatment for opioid use disorder (OUD), but challenges related to dosing and premature treatment dropout argue for adjunct interventions to improve outcomes. One potential behavioral intervention with low risk involves harnessing placebo effects. Objective To determine the effect of a pharmacologically conditioned open-label placebo (C-OLP) on 90-day methadone dose, retention, drug use, withdrawal, craving, quality of life, and sleep. Design, Setting, and Participants This 2-arm, open-label, single-blind randomized clinical trial was conducted between December 5, 2017, and August 2, 2019, in an academically affiliated community opioid treatment program. Analyses were conducted between October 1, 2019, and April 30, 2020. A total of 320 newly enrolled adults seeking treatment for moderate to severe OUD were assessed for study eligibility; 131 met eligibility criteria, provided informed consent, and were randomized to either C-OLP or treatment as usual (TAU) in an unequal-block (3:2) manner. Exclusion criteria were pregnancy, hospital/program transfers, and court-ordered treatment. Interventions Participants randomized to C-OLP received pharmacologic conditioning and a placebo pill and methadone, and participants randomized to TAU were given methadone only. Participants met with the study team 5 times: at baseline (treatment intake) and 2, 4, 8, and 12 weeks postbaseline. Interactions were balanced between the 2 groups. Main Outcomes and Measures Outcomes included 90-day methadone dose (primary) and treatment retention, drug use, withdrawal, craving, quality of life, and sleep quality (secondary). Analyses were conducted as intention-to-treat. Results Of the 131 people enrolled in the study, 54 were randomized to TAU and 77 to C-OLP. Mean (SD) age was 45.9 (11.2) years; most of the participants were Black or African American (83 [63.4%]) and male (84 [64.1%]). No significant group differences were observed in the mean (SD) 90-day methadone dose (83.1 [25.1] mg for group TAU, 79.4 [19.6] mg for group C-OLP; t = 0.621991; P = .43), but the groups differed significantly in their retention rates: 33 (61.1%) for TAU and 60 (77.9%) for C-OLP (χ21 = 4.356; P = .04; number needed to treat for the beneficial outcome of 3-month treatment retention, 6; 95% CI, 4-119). C-OLP participants also reported significantly better sleep quality. Conclusions and Relevance In this randomized clinical trial, C-OLP had no effect on the primary outcome of 90-day methadone dose. However, C-OLP participants were significantly more likely to remain in treatment. These findings support the use of C-OLP as a methadone treatment adjunct, but larger trials are needed to further examine the use of C-OLP. Trial Registration ClinicalTrials.gov Identifier: NCT02941809.
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Affiliation(s)
- Annabelle M Belcher
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore
| | - Thomas O Cole
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore
| | - Ebonie Massey
- Center for Substance Abuse Research, University of Maryland, College Park
| | - Amy S Billing
- Center for Substance Abuse Research, University of Maryland, College Park
| | - Michael Wagner
- Center for Substance Abuse Research, University of Maryland, College Park
| | - William Wooten
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - David H Epstein
- Real-World Assessment, Prediction, and Treatment Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, Maryland
| | - Stephen W Hoag
- Applied Pharmaceutics Lab, University of Maryland School of Pharmacy, Baltimore
| | - Emerson M Wickwire
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore
- Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore
| | - Aaron D Greenblatt
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore
| | - Luana Colloca
- Pain and Translational Symptom Science, University of Maryland School of Nursing, Baltimore
| | - John Rotrosen
- Department of Psychiatry, NYU Grossman School of Medicine, New York, New York
| | - Lawrence Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Eric Weintraub
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore
| | - Eric D Wish
- Center for Substance Abuse Research, University of Maryland, College Park
| | - Ted J Kaptchuk
- Program in Placebo Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Kleinman MB, Anvari MS, Bradley VD, Felton JW, Belcher AM, Seitz-Brown CJ, Greenblatt AD, Dean D, Bennett M, Magidson JF. "Sometimes you have to take the person and show them how": adapting behavioral activation for peer recovery specialist-delivery to improve methadone treatment retention. Subst Abuse Treat Prev Policy 2023; 18:15. [PMID: 36879304 PMCID: PMC9990281 DOI: 10.1186/s13011-023-00524-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 02/22/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND Despite efficacy of medication for opioid use disorder, low-income, ethno-racial minoritized populations often experience poor opioid use disorder treatment outcomes. Peer recovery specialists, individuals with lived experience of substance use and recovery, are well-positioned to engage hard-to-reach patients in treatment for opioid use disorder. Traditionally, peer recovery specialists have focused on bridging to care rather than delivering interventions. This study builds on research in other low-resource contexts that has explored peer delivery of evidence-based interventions, such as behavioral activation, to expand access to care. METHODS We sought feedback on the feasibility and acceptability of a peer recovery specialist-delivered behavioral activation intervention supporting retention in methadone treatment by increasing positive reinforcement. We recruited patients and staff at a community-based methadone treatment center and peer recovery specialist working across Baltimore City, Maryland, USA. Semi-structured interviews and focus groups inquired about the feasibility and acceptability of behavioral activation, recommendations for adaptation, and acceptability of working with a peer alongside methadone treatment. RESULTS Participants (N = 32) shared that peer recovery specialist-delivered behavioral activation could be feasible and acceptable with adaptations. They described common challenges associated with unstructured time, for which behavioral activation could be particularly relevant. Participants provided examples of how a peer-delivered intervention could fit well in the context of methadone treatment, emphasizing the importance of flexibility and specific peer qualities. CONCLUSIONS Improving medication for opioid use disorder outcomes is a national priority that must be met with cost-effective, sustainable strategies to support individuals in treatment. Findings will guide adaptation of a peer recovery specialist-delivered behavioral activation intervention to improve methadone treatment retention for underserved, ethno-racial minoritized individuals living with opioid use disorder.
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Affiliation(s)
- Mary B Kleinman
- Department of Psychology, University of Maryland at College Park, College Park, Maryland, USA.
| | - Morgan S Anvari
- Department of Psychology, University of Maryland at College Park, College Park, Maryland, USA
| | - Valerie D Bradley
- Department of Psychology, University of Maryland at College Park, College Park, Maryland, USA
| | - Julia W Felton
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI, USA
| | - Annabelle M Belcher
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - C J Seitz-Brown
- Department of Psychology, University of Maryland at College Park, College Park, Maryland, USA
| | - Aaron D Greenblatt
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Dwayne Dean
- Department of Psychology, University of Maryland at College Park, College Park, Maryland, USA
| | - Melanie Bennett
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jessica F Magidson
- Department of Psychology, University of Maryland at College Park, College Park, Maryland, USA
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Kozak Z, Ciccarone D, Thrul J, Cole TO, Pappas AL, Greenblatt AD, Welsh C, Yoon M, Gann D, Artigiani EE, Wish ED, Belcher AM. Harm reduction behaviors are associated with carrying naloxone among patients on methadone treatment. Harm Reduct J 2023; 20:17. [PMID: 36788601 PMCID: PMC9928141 DOI: 10.1186/s12954-023-00745-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 01/31/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Despite the widespread availability of naloxone, US opioid overdose rates continue to rise. The "Cascade of Care" (CoC) is a public health approach that identifies steps in achieving specific outcomes and has been used to identify gaps in naloxone carriage among individuals with opioid use disorder (OUD). We sought to apply this framework to a treatment-seeking population with OUD that may be more inclined to engage in harm reduction behaviors. METHODS Patients were recruited from an urban methadone program to complete a survey. We assessed naloxone familiarity, availability, obtainability, training, and possession, as well as naloxone carriage rates, demographics, and harm reduction behaviors. A multivariable logistic regression examined associations between naloxone carriage and individual-level factors. RESULTS Participants (n = 97) were majority male (59%), with a mean age of 48 (SD = 12), 27% had college education or higher, 64% indicated injection drug use, and 84% reported past naloxone training. All participants endorsed familiarity with naloxone, but only 42% regularly carried naloxone. The following variables were associated with carrying naloxone: White race (aOR = 2.94, 95% CI 1.02-8.52), college education (aOR = 8.11, 95% CI 1.76-37.47), and total number of self-reported harm reduction behaviors (aOR = 1.45, 95% CI 1.00-2.11). CONCLUSION We found low rates of naloxone carriage among methadone-treated patients. Methadone programs provide opportunities for naloxone interventions and should target racial/ethnic minorities and individuals with lower education. The spectrum of harm reduction behaviors should be encouraged among these populations to enhance naloxone carriage.
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Affiliation(s)
- Zofia Kozak
- grid.411024.20000 0001 2175 4264Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, 1001 W. Pratt Street, Baltimore, MD 21223 USA
| | - Daniel Ciccarone
- grid.266102.10000 0001 2297 6811Department of Family and Community Medicine, University of California, San Francisco School of Medicine, San Francisco, CA USA
| | - Johannes Thrul
- grid.21107.350000 0001 2171 9311Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD USA ,grid.280502.d0000 0000 8741 3625Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD USA ,grid.1018.80000 0001 2342 0938Centre for Alcohol Policy Research, La Trobe University, Melbourne, Australia
| | - Thomas O. Cole
- grid.411024.20000 0001 2175 4264Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, 1001 W. Pratt Street, Baltimore, MD 21223 USA
| | - Alexander L. Pappas
- grid.411024.20000 0001 2175 4264Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, 1001 W. Pratt Street, Baltimore, MD 21223 USA ,grid.478157.8Present Address: Venice Family Clinic, Venice, CA USA
| | - Aaron D. Greenblatt
- grid.411024.20000 0001 2175 4264Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, 1001 W. Pratt Street, Baltimore, MD 21223 USA
| | - Christopher Welsh
- grid.411024.20000 0001 2175 4264Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, 1001 W. Pratt Street, Baltimore, MD 21223 USA
| | - Mark Yoon
- grid.411024.20000 0001 2175 4264Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, 1001 W. Pratt Street, Baltimore, MD 21223 USA ,grid.21107.350000 0001 2171 9311Division of Medical Psychology, Department of Psychiatry & Behavioral Sciences, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, 21287 USA
| | - Donald Gann
- grid.411024.20000 0001 2175 4264Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, 1001 W. Pratt Street, Baltimore, MD 21223 USA
| | - E. Erin Artigiani
- grid.164295.d0000 0001 0941 7177Center for Substance Abuse Research, University of Maryland, College Park, MD USA
| | - Eric D. Wish
- grid.164295.d0000 0001 0941 7177Center for Substance Abuse Research, University of Maryland, College Park, MD USA
| | - Annabelle M. Belcher
- grid.411024.20000 0001 2175 4264Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, 1001 W. Pratt Street, Baltimore, MD 21223 USA
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5
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Abidogun TM, Cole TO, Massey E, Kleinman M, Greenblatt AD, Seitz-Brown CJ, Magidson JF, Belcher AM. Patient experiences of COVID-19-induced changes to methadone treatment in a large community-based opioid treatment program in Baltimore. J Subst Use Addict Treat 2023; 145:208946. [PMID: 36880915 PMCID: PMC9822549 DOI: 10.1016/j.josat.2022.208946] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/05/2022] [Accepted: 12/30/2022] [Indexed: 04/13/2023]
Abstract
INTRODUCTION Following the March 2020 federal declaration of a COVID-19 public health emergency, in line with recommendations for social distancing and decreased congregation, federal agencies issued sweeping regulation changes to facilitate access to medications for opioid use disorder (MOUD) treatment. These changes allowed patients new to treatment to receive multiple days of take-home medications (THM) and to use remote technology for treatment encounters-allowances that previously had been reserved exclusively for "stable" patients who met minimum adherence and time-in-treatment criteria. The impact of these changes on low-income, minoritized patients (frequently the largest recipients of opioid treatment program [OTP]-based addiction care), however, is not well characterized. We aimed to explore the experiences of patients who were enrolled in treatment prior to COVID-19 OTP regulation changes, with the goal of understanding patients' perceptions of the impact of these changes on treatment. METHODS This study included semistructured, qualitative interviews with 28 patients. We used a purposeful sampling method to recruit individuals who were active in treatment just before COVID-19-related policy changes went into effect, and who were still in treatment several months later. To ensure a diverse array of perspectives, we interviewed individuals who either had or had not experienced challenges with methadone medication adherence from 3/24/21 to 6/8/21, approximately 12-15 months following the onset of COVID-19. Interviews were transcribed and coded using thematic analysis. RESULTS Participants were majority male (57 %), Black/African American (57 %), with a mean age of 50.1 (SD = 9.3). Fifty percent received THM prior to COVID-19, which increased to 93 % during the pandemic. COVID-19 program changes had mixed effects on treatment and recovery experiences. Themes identified convenience, safety, and employment as reasons for preferring THM. Challenges included difficulty with managing/storing medications, experiencing isolation, and concern about relapse. Furthermore, some participants reported that telebehavioral health encounters felt less personal. CONCLUSIONS Policymakers should consider patients' perspectives to foster a more patient-centered approach to methadone dosing that is safe, flexible, and accommodating to a diverse array of patients' needs. Additionally, technical support should be provided to OTPs to ensure interpersonal connections are maintained in the patient-provider relationship beyond the pandemic.
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Affiliation(s)
- Tolulope M Abidogun
- Department of Psychology, University of Maryland, College Park, United States of America
| | - Thomas O Cole
- Division of Addiction Research and Treatment, Department of Psychiatry, School of Medicine, University of Maryland, Baltimore, United States of America
| | - Ebonie Massey
- Department of Psychology, University of Maryland, College Park, United States of America
| | - Mary Kleinman
- Department of Psychology, University of Maryland, College Park, United States of America
| | - Aaron D Greenblatt
- Division of Addiction Research and Treatment, Department of Psychiatry, School of Medicine, University of Maryland, Baltimore, United States of America
| | - C J Seitz-Brown
- Department of Psychology, University of Maryland, College Park, United States of America
| | - Jessica F Magidson
- Department of Psychology, University of Maryland, College Park, United States of America
| | - Annabelle M Belcher
- Division of Addiction Research and Treatment, Department of Psychiatry, School of Medicine, University of Maryland, Baltimore, United States of America.
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6
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Deutsch-Link S, Belcher AM, Massey E, Cole TO, Wagner MA, Billing AS, Greenblatt AD, Weintraub E, Wish ED. Race-based differences in drug use prior to onset of opioid use disorder. J Ethn Subst Abuse 2023; 22:89-105. [PMID: 33554763 PMCID: PMC9573766 DOI: 10.1080/15332640.2021.1879702] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Rates of opioid use disorder (OUD) have increased dramatically over the past two decades, a rise that has been accompanied by changing demographics of those affected. Early exposure to drugs is a known risk factor for later development of opioid use disorder; but how and whether this risk factor may differ between racial groups is unknown. Our study seeks to identify race differences in self-report of current and past substance use in OUD-diagnosed treatment-seeking individuals. Patients (n = 157) presenting for methadone maintenance treatment at a racially diverse urban opioid treatment program were approached and consented for study involvement. Participants were administered substance use history questionnaires and urine drug screening at intake. Chi-square, t-tests, and rank-sum were used to assess race differences in demographic variables. Logistic and linear regressions assessed the relationship between race and substance use for binary and continuous variables, respectively. 61% of the population identified as Black and 39% as White. Black participants were significantly older; age was thus included as a covariate. Logistic regressions demonstrated that despite similar urine toxicology at intake, White participants were significantly more likely to report having used prescription opioids and psychedelic, stimulant, and sedative substance classes prior to their first use of non-pharmaceutical opioids. Compared to Black participants, White treatment-seeking OUD-diagnosed individuals reported using a wider range of substances ever and prior to first use of non-pharmaceutical opioids. There were no differences, however, in presentation for OUD treatment, suggesting different pathways to OUD, which may carry important clinical implications.
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Affiliation(s)
| | | | | | - Thomas O. Cole
- University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | | | - Eric Weintraub
- University of Maryland School of Medicine, Baltimore, MD, USA
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7
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Magidson JF, Kleinman MB, Bradley V, Anvari MS, Abidogun TM, Belcher AM, Greenblatt AD, Dean D, Hines A, Seitz-Brown CJ, Wagner M, Bennett M, Felton JW. Peer recovery specialist-delivered, behavioral activation intervention to improve retention in methadone treatment: Results from an open-label, Type 1 hybrid effectiveness-implementation pilot trial. Int J Drug Policy 2022; 108:103813. [PMID: 35932644 PMCID: PMC9590100 DOI: 10.1016/j.drugpo.2022.103813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/13/2022] [Accepted: 07/22/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite the efficacy of methadone to treat opioid use disorder (OUD), retention is an urgent priority, particularly among low-income, minoritized populations. Peer recovery specialists are well-positioned to engage vulnerable patients, particularly when trained in an evidence-based intervention to promote retention. This hybrid effectiveness-implementation pilot trial aimed to demonstrate the proof of concept of a peer recovery specialist-delivered behavioral activation and problem solving-based approach (Peer Activate) to improve methadone retention. METHODS Implementation outcomes included feasibility, acceptability, and fidelity. Feasibility and acceptability were defined by the percentage of participants who initiated the intervention (≥75%) and completed ≥75% of core sessions, respectively. Fidelity was assessed via independent rating of a randomly selected 20% of sessions. The primary effectiveness outcome was methadone retention at three-months post-intervention vs. a comparison cohort initiating methadone during the same time period. Secondary outcomes included methadone adherence, substance use frequency, and substance use-related problems. RESULTS Benchmarks for feasibility and acceptability were surpassed: 86.5% (32/37) initiated the intervention, and 81.3% of participants who initiated attended ≥75% of core sessions. The mean independent rater fidelity score was 87.9%, indicating high peer fidelity. For effectiveness outcomes, 88.6% of participants in Peer Activate were retained in methadone treatment at three-months post-intervention-28.9% higher than individuals initiating methadone treatment alone in the same time period [χ2(1) = 10.10, p = 0.001]. Among Peer Activate participants, urine-verified methadone adherence reached 97% at post-intervention, and there was a significant reduction in substance use frequency from 48% of past two-week days used at baseline to 31.9% at post-intervention [t(25) = 1.82, p = .041]. Among participants who completed the core Peer Activate sessions (n = 26), there was a significant reduction in substance use-related problems [t(21) = 1.84, p = 0.040]. CONCLUSION Given the rapid scale-up of peer recovery specialist programs nationwide and the urgent need to promote methadone retention, these results, although preliminary, have important potential clinical significance. The next steps are to conduct a Type 1 hybrid effectiveness-implementation randomized trial with a larger sample size and longer-term follow-up to further establish the implementation and effectiveness of the Peer Activate approach.
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Affiliation(s)
- Jessica F Magidson
- Department of Psychology, University of Maryland, College Park, MD, USA.
| | - Mary B Kleinman
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Valerie Bradley
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Morgan S Anvari
- Department of Psychology, University of Maryland, College Park, MD, USA
| | | | | | | | - Dwayne Dean
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Abigail Hines
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - C J Seitz-Brown
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Michael Wagner
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Melanie Bennett
- Department of Psychiatry, University of Maryland, Baltimore, MD, USA
| | - Julia W Felton
- Center for Health Policy & Health Services Research, Henry Ford Health System, Detroit, MI, USA
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8
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Huffman M, Cloeren M, Ware OD, Frey JJ, Greenblatt AD, Mosby A, Oliver M, Imboden R, Bazell A, Clement J, Diaz-Abad M. Poor Sleep Quality and Other Risk Factors for Unemployment Among Patients on Opioid Agonist Treatment. Subst Abuse 2022; 16:11782218221098418. [PMID: 35645566 PMCID: PMC9130817 DOI: 10.1177/11782218221098418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/17/2022] [Indexed: 12/01/2022]
Abstract
Purpose: Patients with opioid use disorder (OUD) face high rates of unemployment,
putting them at higher risk of treatment nonadherence and poor outcomes,
including overdose death. The objective of this study was to investigate
sleep quality and its association with other biopsychosocial risk factors
for unemployment in patients receiving opioid agonist treatment (OAT) for
OUD. Methods: Using a cross-sectional survey design, participants from 3 OAT programs for
OUD completed questionnaires to measure sleep quality (Pittsburgh Sleep
Quality Index [PSQI]); pain disability; catastrophic thinking; injustice
experience; quality of life; and self-assessed disability. Spearman’s rank
correlation was used to test for associations between sleep quality and
other study variables. Results: Thirty-eight participants completed the study, with mean age
45.6 ± 10.9 years, 27 (71.1%) males, and 16 (42.1%) reporting a high school
diploma/equivalent certification as the highest level of academic
attainment. Poor sleep quality (defined as PSQI > 5) was identified in 29
participants (76.3%) and was positively correlated with pain disability
(r = 0.657, P < .01), self-assessed
disability (r = 0.640, P < .001),
symptom catastrophizing (r = 0.499,
P < .001), and injustice experience
(r = 0.642, P < .001), and negatively
correlated with quality of life (r = −0.623,
P < .001). Conclusions: There was a high prevalence of poor sleep quality in patients with OUD on OAT
and this was associated with multiple known risk factors for unemployment.
These findings warrant the consideration of regular screening for sleep
problems and the inclusion of sleep-related interventions to improve sleep
quality, decrease the unemployment rate, and enhance the recovery process
for individuals with OUD undergoing OAT.
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Affiliation(s)
- Margo Huffman
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Marianne Cloeren
- Division of Occupational and Environmental Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Orrin D Ware
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jodi J Frey
- University of Maryland School of Social Work, Baltimore, MD, USA
| | - Aaron D Greenblatt
- Departments of Psychiatry and Family & Community Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Amanda Mosby
- University of Maryland School of Social Work, Baltimore, MD, USA
| | - Marc Oliver
- Division of Occupational and Environmental Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rachel Imboden
- University of Maryland School of Social Work, Baltimore, MD, USA
| | - Alicia Bazell
- University of Maryland School of Social Work, Baltimore, MD, USA
| | - Jean Clement
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Montserrat Diaz-Abad
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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9
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Cole TO, Robinson D, Kelley-Freeman A, Gandhi D, Greenblatt AD, Weintraub E, Belcher AM. Patient Satisfaction With Medications for Opioid Use Disorder Treatment via Telemedicine: Brief Literature Review and Development of a New Assessment. Front Public Health 2021; 8:557275. [PMID: 33553083 PMCID: PMC7859509 DOI: 10.3389/fpubh.2020.557275] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 12/17/2020] [Indexed: 01/30/2023] Open
Abstract
Telemedicine is increasingly being used to treat patients with opioid use disorder (OUD). It has particular value in rural areas of the United States impacted by the opioid crisis as these areas have a shortage of trained addiction medicine providers. Patient satisfaction significantly impacts positive clinical outcomes in OUD treatment and thus is of great clinical interest. Yet little is known regarding patient satisfaction with the increasingly important platform of telemedicine-delivered medications for opioid use disorder (tMOUD). The goal of this review is to provide a summary of the existing literature regarding patient satisfaction with tMOUD. We also submit a novel survey based on an existing framework designed to assess tMOUD satisfaction, and present pilot data (N = 14) acquired from patients engaged in rural tMOUD care. Telemedicine provides a feasible method for delivering MOUD in rural areas, and our survey provides a useful assessment to measure patient satisfaction with tMOUD. In light of the pressing need for innovative and technology-driven solutions to the opioid epidemic (especially in light of the COVID-19 pandemic), future research should focus on the development and refinement of tools to assess the important implementation goal of patient satisfaction.
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Affiliation(s)
- Thomas O. Cole
- Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Darlene Robinson
- Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, United States
| | | | - Devang Gandhi
- Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Aaron D. Greenblatt
- Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Eric Weintraub
- Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Annabelle M. Belcher
- Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, United States
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10
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Weintraub E, Greenblatt AD, Chang J, Welsh CJ, Berthiaume AP, Goodwin SR, Arnold R, Himelhoch SS, Bennett ME, Belcher AM. Outcomes for patients receiving telemedicine-delivered medication-based treatment for Opioid Use Disorder: A retrospective chart review. Heroin Addict Relat Clin Probl 2021; 23:5-12. [PMID: 33551692 PMCID: PMC7861202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
This report builds on a previous study that describes the collaboration between an urban academic medical center and a rural drug treatment center, the goal of which is to provide medication-based treatment to individuals with OUD via videoconferencing. We describe results of a retrospective chart review of 472 patients treated in the program between August 2015 and April 2019. We examined several demographic and substance use variables for individuals who consented to telemedicine treatment, retention in treatment over time, and opioid use over time to understand further the impact of prescribing buprenorphine and naltrexone via telemedicine to patients in a rural OUD treatment setting. Our findings support the effectiveness of prescribing medications via telemedicine. The inclusion of more than three times as many patients as in our prior report revealed retention rates and toxicology results that are comparable to face-to-face treatment. These findings have implications for policymakers and clinicians considering implementation of similar programs.
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Affiliation(s)
- Eric Weintraub
- Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Aaron D. Greenblatt
- Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Joy Chang
- Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Christopher J. Welsh
- Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Alexandra P. Berthiaume
- Medical School Training Program, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Shelby R. Goodwin
- Division of Psychiatric Services Research, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Rachel Arnold
- Division of Psychiatric Services Research, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Seth S. Himelhoch
- Department of Psychiatry, University of Kentucky College of Medicine, Lexington, KY 40509, USA
| | - Melanie E. Bennett
- Division of Psychiatric Services Research, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Annabelle M. Belcher
- Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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11
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Greenblatt AD, Magidson JF, Belcher AM, Gandhi D, Weintraub E. Overdue for an Overhaul: How Opioid Treatment Programs Can Learn From COVID-19. Mayo Clin Proc 2020; 95:2076-2078. [PMID: 33012340 PMCID: PMC7447258 DOI: 10.1016/j.mayocp.2020.08.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/20/2020] [Accepted: 08/10/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Aaron D Greenblatt
- Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, Baltimore; Department of Family & Community Medicine, University of Maryland School of Medicine, Baltimore.
| | | | - Annabelle M Belcher
- Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, Baltimore
| | - Devang Gandhi
- Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, Baltimore
| | - Eric Weintraub
- Division of Addiction Research and Treatment, Department of Psychiatry, University of Maryland School of Medicine, Baltimore
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12
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Belcher AM, Cole TO, Greenblatt AD, Hoag SW, Epstein DH, Wagner M, Billing AS, Massey E, Hamilton KR, Kozak ZK, Welsh CJ, Weintraub E, Wickwire EM, Wish ED, Kaptchuk TJ, Colloca L. Open-label dose-extending placebos for opioid use disorder: a protocol for a randomised controlled clinical trial with methadone treatment. BMJ Open 2019; 9:e026604. [PMID: 31230007 PMCID: PMC6596949 DOI: 10.1136/bmjopen-2018-026604] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 04/08/2019] [Accepted: 05/09/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION More than 2 million individuals in the USA have an opioid use disorder (OUD). Methadone maintenance treatment is the gold standard of medication-based treatment for OUD, but high-dose methadone is associated with cardiotoxicity and respiratory complications, among other side effects. These adverse effects make enhancing the effectiveness of lower doses of methadone an attractive therapeutic goal. Long recognised for its capacity to enhance treatment outcomes for a wide range of neuropsychiatric disorders including pain, the placebo effect offers an as-yet untested avenue to such an enhancement. This approach is particularly compelling given that individuals with substance use disorder tend to have higher salience attribution and may thereby be more sensitive to placebo effects. Our study combines two promising clinical methodologies-conditioning/dose-extension and open-label placebo-to investigate whether placebo effects can increase the effective potency of methadone in treatment-seeking OUD patients. METHODS AND ANALYSIS A total of 120 newly enrolled treatment-seeking OUD patients will be randomly assigned to one of two different groups: either methadone plus daily placebo dose-extension (PDE; treatment group) or methadone/treatment as usual (control). Participants will meet with study team members five times over the course of 3 months of treatment with methadone (baseline, 2 weeks, and 1, 2 and 3 months postbaseline). Throughout this study time period, methadone dosages will be adjusted by an addiction clinician blind to patient assignment, per standard clinical methods. The primary outcome is methadone dose at 3 months. Secondary outcomes include self-report of drug use; 3-month urine toxicology screen results; and treatment retention. Exploratory outcomes include several environmental as well as personality factors associated with OUD and with propensity to demonstrate a placebo effect. ETHICS AND DISSEMINATION Human subjects oversight for this study is provided by the University of Maryland, Baltimore and University of Maryland, College Park Institutional Review Boards. Additionally, the study protocol is reviewed annually by an independent Data and Safety Monitoring Board. Study results will be disseminated via research conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT02941809.
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Affiliation(s)
- Annabelle M Belcher
- Department of Psychiatry, Division of Addiction Research and Treatment, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Thomas O Cole
- Department of Psychiatry, Division of Addiction Research and Treatment, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Aaron D Greenblatt
- Department of Psychiatry, Division of Addiction Research and Treatment, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Stephen W Hoag
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - David H Epstein
- Real-world Assessment, Prediction and Treatment Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, Maryland, USA
| | - Michael Wagner
- University of Maryland Center for Substance Abuse Research, College Park, Maryland, USA
| | - Amy S Billing
- University of Maryland Center for Substance Abuse Research, College Park, Maryland, USA
| | - Ebonie Massey
- University of Maryland Center for Substance Abuse Research, College Park, Maryland, USA
| | - Kristen R Hamilton
- Department of Psychology, University of Maryland, College Park, Maryland, USA
| | - Zofia K Kozak
- Medical School Training Program, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Christopher J Welsh
- Department of Psychiatry, Division of Addiction Research and Treatment, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Eric Weintraub
- Department of Psychiatry, Division of Addiction Research and Treatment, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Emerson M Wickwire
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Eric D Wish
- University of Maryland Center for Substance Abuse Research, College Park, Maryland, USA
| | - Ted J Kaptchuk
- Program in Placebo Studies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Luana Colloca
- Department of Pain and Translational Symptom Science, University of Maryland School of Nursing, Baltimore, Maryland, USA
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13
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Cai NS, Quiroz C, Bonaventura J, Bonifazi A, Cole TO, Purks J, Billing AS, Massey E, Wagner M, Wish ED, Guitart X, Rea W, Lam S, Moreno E, Casadó-Anguera V, Greenblatt AD, Jacobson AE, Rice KC, Casadó V, Newman AH, Winkelman JW, Michaelides M, Weintraub E, Volkow ND, Belcher AM, Ferré S. Opioid-galanin receptor heteromers mediate the dopaminergic effects of opioids. J Clin Invest 2019; 129:2730-2744. [PMID: 30913037 DOI: 10.1172/jci126912] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Identifying non-addictive opioid medications is a high priority in medical sciences, but μ-opioid receptors mediate both the analgesic and addictive effects of opioids. We found a significant pharmacodynamic difference between morphine and methadone that is determined entirely by heteromerization of μ-opioid receptors with galanin Gal1 receptors, rendering a profound decrease in the potency of methadone. This was explained by methadone's weaker proficiency to activate the dopaminergic system as compared to morphine and predicted a dissociation of therapeutic versus euphoric effects of methadone, which was corroborated by a significantly lower incidence of self-report of "high" in methadone-maintained patients. These results suggest that μ-opioid-Gal1 receptor heteromers mediate the dopaminergic effects of opioids that may lead to a lower addictive liability of opioids with selective low potency for the μ-opioid-Gal1 receptor heteromer, exemplified by methadone.
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Affiliation(s)
| | | | - Jordi Bonaventura
- Biobehavioral Imaging and Molecular Neuropsychopharmacology Unit, and
| | - Alessandro Bonifazi
- Medicinal Chemistry Section, National Institute on Drug Abuse (NIDA), Intramural Research Program (IRP), NIH, Baltimore, Maryland, USA
| | - Thomas O Cole
- Division of Alcohol and Drug Abuse, Department of Psychiatry, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Julia Purks
- Massachusetts General Hospital, Departments of Psychiatry and Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | - Amy S Billing
- Center for Substance Abuse Research, University of Maryland, College Park, Maryland, USA
| | - Ebonie Massey
- Center for Substance Abuse Research, University of Maryland, College Park, Maryland, USA
| | - Michael Wagner
- Center for Substance Abuse Research, University of Maryland, College Park, Maryland, USA
| | - Eric D Wish
- Center for Substance Abuse Research, University of Maryland, College Park, Maryland, USA
| | | | | | - Sherry Lam
- Biobehavioral Imaging and Molecular Neuropsychopharmacology Unit, and
| | - Estefanía Moreno
- Department of Biochemistry and Molecular Biomedicine, University of Barcelona, Barcelona, Spain
| | - Verònica Casadó-Anguera
- Department of Biochemistry and Molecular Biomedicine, University of Barcelona, Barcelona, Spain
| | - Aaron D Greenblatt
- Division of Alcohol and Drug Abuse, Department of Psychiatry, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | | | | | - Vicent Casadó
- Department of Biochemistry and Molecular Biomedicine, University of Barcelona, Barcelona, Spain
| | - Amy H Newman
- Medicinal Chemistry Section, National Institute on Drug Abuse (NIDA), Intramural Research Program (IRP), NIH, Baltimore, Maryland, USA
| | - John W Winkelman
- Massachusetts General Hospital, Departments of Psychiatry and Neurology, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Eric Weintraub
- Division of Alcohol and Drug Abuse, Department of Psychiatry, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | | | - Annabelle M Belcher
- Division of Alcohol and Drug Abuse, Department of Psychiatry, School of Medicine, University of Maryland, Baltimore, Maryland, USA
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