Integrated pain care models and the importance of aligning stakeholder values

Sustained widespread deployment of clinically and cost-effective models of integrated pain care could be bolstered by optimally aligning shared stakeholder values.

Qualitative findings from a randomized trial of mindfulness-based and cognitive-behavioral group therapy for opioid-treated chronic low back pain

This article reports qualitative outcomes from a randomized controlled trial comparing eight weeks of cognitive-behavioral group therapy for chronic pain (CBT-CP) and mindfulness-based group therapy (MBT) in individuals with chronic low back pain (CLBP). Approximately 10 months post-treatment, 108 participants completed structured qualitative interviews to express how the study treatment affected their life or health. Responses were qualitatively analyzed to generate a set of themes and subthemes, with between-groups comparisons to evaluate differences (if any) in treatment-response between MBT and CBT-CP. A majority of participants (n = 88, 81.5%) across both groups reflected positively on the study intervention and outcomes, identifying benefits in pain management (31.5%), meditation and mindfulness skills (25.9%), and relaxation skills (22.2%). Perceived benefits varied widely, suggesting no one intervention may be ideal for CLBP. Future research should examine tailoring interventions to target diverse clinical presentations to achieve optimal outcomes.

Offering recovery rather than punishment: Implementation of a law enforcement-led pre-arrest diversion-to-treatment program for adults with substance use disorders

BACKGROUND

The opioid epidemic has strained the US criminal justice system. Law enforcement frequently encounters persons with substance use disorder (SUD). Law enforcement-led, pre-arrest diversion programs linking individuals with SUD to addiction treatment instead of arrest and prosecution has the potential to reduce crime, overdoses, and other community harms. We implemented a pre-arrest diversion-to-treatment program-the Madison Addiction Recovery Initiative (MARI)-from September 2017 to August 2020, and describe the key components of MARI's effective implementation.

METHODS

Adults who committed an eligible, drug use-related crime were offered a 6-month MARI participation with referral to treatment in lieu of arrest; criminal charges for that crime were "voided" upon the successful MARI completion. Formative evaluation, with stakeholder feedback and team meeting minutes, assessed key factors influencing implementation. Process evaluation consisted of tracking participant referrals, enrollment, and engagement. Police officers, MARI participants, and treatment center staff members were surveyed about program experiences and attitudes. The study used descriptive statistics to describe quantitative survey responses; thematic qualitative analysis identified major themes in qualitative responses.

RESULTS

Of 263 participants, 160 initiated program engagement, with 100 successfully completing MARI. Interim evaluations and community partner feedback informed program protocol adjustments to increase participant enrollment, retention and diversity, streamline the referral processes, and transition to telehealth during the COVID-19 pandemic.

CONCLUSION

Rigorous evaluation and community partner feedback are essential components of effective implementation and sustainability of a law enforcement-led pre-arrest diversion-to-treatment program, which has the potential to both reduce crime and overdose, and change the lives of people with SUD.

Transportation, childcare, lodging, and meals: Key for participant engagement and inclusion of historically underrepresented populations in the healthy brain and child development birth cohort

Introduction

Participant recruitment and retention (R&R) are well-documented challenges in longitudinal studies, especially those involving populations historically underrepresented in research and vulnerable groups (e.g., pregnant people or young children and their families), as is the focus of the HEALthy Brain and Child Development (HBCD) birth cohort study. Subpar access to transportation, overnight lodging, childcare, or meals can compromise R&R; yet, guidance on how to overcome these "logistical barriers" is sparse. This study's goal was to learn about the HBCD sites' plans and develop best practice recommendations for the HBCD consortium for addressing these logistical barriers.

Methods

The HBCD's workgroups developed a survey asking the HBCD sites about their plans for supporting research-related transportation, lodging, childcare, and meals, and about the presence of institutional policies to guide their approach. Descriptive statistics described the quantitative survey data. Qualitative survey responses were brief, not warranting formal qualitative analysis; their content was summarized.

Results

Twenty-eight respondents, representing unique recruitment locations across the U.S., completed the survey. The results indicated substantial heterogeneity across the respondents in their approach toward supporting research-related transportation, lodging, childcare, and meals. Three respondents were aware of institutional policies guiding research-related transportation (10.7%) or childcare (10.7%).

Conclusions

This study highlighted heterogeneity in approaches and scarcity of institutional policies regarding research-related transportation, lodging, childcare, and meals, underscoring the need for guidance in this area to ensure equitable support of participant R&R across different settings and populations, so that participants are representative of the larger community, and increase research result validity and generalizability.

Mindfulness-based Interventions for Chronic Low Back Pain: A Systematic Review and Meta-analysis

OBJECTIVE

This systematic review aimed to compile existing evidence examining the effects of mindfulness-based interventions (MBIs) for chronic low back pain (CLBP). CLBP leads to millions of disabled individuals in the United States each year. Current pharmacologic treatments are only modestly effective and may present long-term safety issues. MBIs, which have an excellent safety profile, have been shown in prior studies to be effective in treating CLBP yet remained underutilized.

DESIGN

Ovid/Medline, PubMed, Embase, and the Cochrane Library were searched for randomized controlled trials (RCTs), pilot RCTs, and single-arm studies that explored the effectiveness of MBIs in CLBP.

METHODS

Separate searches were conducted to identify trials that evaluated MBIs in reducing pain intensity in individuals with CLBP. A meta-analysis was then performed using R v3.2.2, Metafor package v 1.9-7.

RESULTS

Eighteen studies used validated patient-reported pain outcome measures and were therefore included in the meta-analysis. The MBIs included mindfulness meditation, mindfulness-based stress reduction, mindfulness-based cognitive therapy, mindfulness-oriented recovery enhancement, acceptance and commitment therapy, dialectical behavioral therapy, meditation-cognitive behavioral therapy, mindfulness-based care for chronic pain, self-compassion course, and loving-kindness course. Pain intensity scores were reported using a numerical rating scale (0 to 10) or an equivalent scale. The meta-analysis revealed that MBIs have a beneficial effect on pain intensity with a large-sized effect in adults with CLBP.

CONCLUSIONS

MBIs seem to be beneficial in reducing pain intensity. Although these results were informative, findings should be carefully interpreted due to the limited data the high variability in study methodologies, small sample sizes, inclusion of studies with high risk of bias, and reliance on pre-post treatment differences with no attention to maintenance of effects. More large-scale RCTs are needed to provide reliable effect size estimates for MBIs in persons with CLBP.

COVID-19-related flexibility in methadone take-home doses associated with decreased attrition: Report from an opioid treatment program in central Pennsylvania

INTRODUCTION

Pennsylvania saw a dramatic increase in take-home doses of methadone after the COVID-19 pandemic-related relaxation in regulations. We evaluated whether pandemic-initiated relaxation in take-home methadone dose regulations was associated with changes in attrition and urine drug test (UDT) results at one outpatient opioid treatment program (OTP) among adult patients treated with methadone for opioid use disorder (OUD).

METHODS

We analyzed aggregated, retrospective clinical practice data, using data abstracted from the OTP's electronic health record (EHR) on the number of patients treated with methadone, those allowed take-home doses, the number of take-home methadone doses dispensed, and the number and type of patient discharge ("attrition") from treatments for 12 months before (March 2019-February 2020; "pre-pandemic") and 12 months after (March 2020-February 2021; "pandemic") the regulatory changes took place. We also examined monthly aggregate data on the number of urine samples testing positive for amphetamines, cocaine, benzodiazepines or illicit opioids, and compared these findings between the pre-pandemic and pandemic periods.

RESULTS

Pre-pandemic, 229 patients were treated with methadone, compared to 278 patients during the pandemic period. They received 11,047 and 28,563 take-home daily-doses of methadone (p < 0.0001) during each assessment period, respectively. All-cause treatment attrition (discharge from the program for any reason) decreased from 27.1 % in the pre-pandemic to 15.5 % in the pandemic period (p < 0.001). Compared to pre-pandemic, during the pandemic period the urine toxicology testing showed reduced positivity rates for cocaine (26.4 % vs 18.9 %, p < 0.001), and oxycodone and morphine (1.8 % vs 1.1 %, p < 0.019), and increased for fentanyl (24.0 % vs 30.5 %, p < 0.007), without statistically significant changes for benzodiazepines or amphetamines.

CONCLUSIONS

The relaxation of regulations guiding take-home methadone doses accompanied reduced treatment attrition and favorable changes in urine toxicology results in one OTP. Allowing OTPs to apply flexible decisions regarding take-home methadone doses could improve treatment retention, outcomes, and, in turn, save lives.

Risk Factors for Self-Harm Ideation Among Persons Treated With Opioids for Chronic Low Back Pain

OBJECTIVES

Chronic pain is a significant health concern that adversely affects all aspects of life, including emotional well-being. Opioids are prescribed for the management of refractory, severe chronic pain, although they have been associated with adverse effects, including addiction and overdose. The aim of this study was to examine factors that predict thoughts of self-harm among adults with chronic pain who are prescribed opioids.

MATERIALS AND METHODS

Seven hundred sixty-five (N=765) persons with opioid-treated chronic lower back pain completed the Current Opioid Misuse Measure (COMM) and other validated questionnaires as part of a larger study. Response to 1 question from the COMM ("How often have you seriously thought about hurting yourself?") was used to assess suicide risk on a 5-point scale (0=never; 4=very often).

RESULTS

Participants were categorized into 3 groups according to their responses to the self-harm question: never (N=628; 82.1%), seldom or sometimes (N=74; 9.7%), and often or very often (N=63; 8.2%). Multivariate adjusted odds ratio (aOR) analyses indicated that reports of alcohol or drug overuse within the past month (aOR=1.41,[95% CI 1.11-1.78]), posttraumatic stress (PTSD; aOR=1.24,[1.07 to 1.44]), pain catastrophizing (aOR=1.03,[1.01 to 1.05]), not loving oneself (aOR=0.99,[.98-1.00]) and poor perceived mental health (aOR=0.94,[.92 to 97]) were most associated with thoughts of self-harm. Importantly, the ideation frequency of self-harm was highest among individuals treated with higher daily doses of opioids.

DISCUSSION

These results support the need for continued monitoring of adults treated with opioids for chronic pain, particularly among those on high-dose opioids who present with increased negative affect and concerns of substance misuse.

Shifting quality chronic pain treatment measures from processes to outcomes

OBJECTIVE

Misapplication of the 2016 Centers for Disease Control (CDC) opioid prescribing guidelines has led to overem-phasis of morphineequivalent daily dose (MEDD) as a "metric of success" in chronic noncancer pain (CNCP), resulting in unintentional harms to patients. This article reviews CNCP-related guidelines and patient preferences in order to identify pragmatic, patient-centered metrics to assess treatment response and safety in opioid-treated CNCP.

METHODS

We reviewed the clinical (CDC), research (Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials), and implementability-related guidelines (GuideLine Implementability Appraisal), along with relevant patient-identified treatment goals. From these, we summarize a guideline-concordant, patient-centered, implementable set of measures to aid the clinical management of opioid-treated CNCP.

RESULTS

We identify metrics across three domains of care: (1) treatment response metrics, which align with the CNCP care goals (pain intensity, pain interference including function and quality of life, and global impression of change); (2) risk assessment ("safety") metrics, eg, MEDD, benzodiazepine-opioid or naloxone-opioid coprescribing, and severity of mental health disorders, which evaluate the risk-benefit profile of opioid therapy; and (3) adherence ("process") metrics, which assess clinician/patient adherence to the guideline-recommended opioid therapy monitoring practices, eg, the presence of completed treatment agreement or urine toxicology testing. All metrics should be informed by implementability principles, eg, be decidable, executable, and measurable.

CONCLUSIONS

This article summarizes guideline-concordant, patient-centered, implementable metrics for assessing treatment response, safety, and adherence in opioid-treated CNCP. Regardless of which specific treatment guidelines are applied, this approach could help conceptualize and standardize the collection and reporting of CNCP-relevant metrics, compare them across health systems, and optimize care and treatment outcomes in opioid-treated CNCP.

Experiences of adults with opioid-treated chronic low back pain during the COVID-19 pandemic: A cross-sectional survey study

This study aimed to evaluate the impact of the COVID-19 pandemic on adults with opioid-treated chronic low back pain (CLBP), an understudied area. Participants in a "parent" clinical trial of non-pharmacologic treatments for CLBP were invited to complete a one-time survey on the perceived pandemic impact across several CLBP- and opioid therapy-related domains. Participant clinical and other characteristics were derived from the parent study's data. Descriptive statistics and latent class analysis analyzed quantitative data; qualitative thematic analysis was applied to qualitative data. The survey was completed by 480 respondents from June 2020 to August 2021. The majority reported a negative pandemic impact on their life (84.8%), with worsened enjoyment of life (74.6%), mental health (74.4%), pain (53.8%), pain-coping skills (49.7%), and finances (45.3%). One-fifth (19.4%) of respondents noted increased use of prescribed opioids; at the same time, decreased access to medication and overall healthcare was reported by 11.3% and 61.6% of respondents, respectively. Latent class analysis of the COVID-19 survey responses revealed 2 patterns of pandemic-related impact; those with worse pandemic-associated harms (n = 106) had an overall worse health profile compared to those with a lesser pandemic impact. The pandemic substantially affected all domains of relevant health-related outcomes as well as healthcare access, general wellbeing, and financial stability among adults with opioid-treated CLBP. A more nuanced evaluation revealed a heterogeneity of experiences, underscoring the need for both increased overall support for this population and for an individualized approach to mitigate harms induced by pandemic or similar crises.

Opioid dose risk, clinician and patient characteristics, and adherence to opioid prescribing recommendations in chronic non-cancer pain

OBJECTIVE

This study aims to assess associations between morphine-equivalent daily dose (MEDD) of opioids, clinician and patient characteristics, and prescriber adherence to guidelines for long-term opioid therapy (LTOT) in chronic noncancer pain (CNCP) and to elucidate potential relationships associated with increased-risk opioid prescribing.

DESIGN

Retrospective cross-sectional study.

SETTING

Academic health system's 33 primary care clinics.

PATIENTS

Adults (≥18 years old) prescribed LTOT (10 + outpatient prescriptions in the past year) for CNCP.

MAIN OUTCOME MEASURE(S)

Electronic health record data on prescribed opioids (for MEDD), clinician/patient characteristics, and adherence rates to LTOT guideline-concordant recommendations.

RESULTS

A total of 2,738 patients were eligible, 61.6 percent Lower, 15.7 percent Moderate, and 22.7 percent Higher Risk MEDD (<50, 50-89, and ≥90 mg/day, respectively). Higher MEDD correlated (p < 0.001) with Medicare insurance, current cigarette smoking, higher pain intensity and interference scores, and the presence of opioid use disorder diagnoses. Male clinicians more frequently prescribed (p < 0.001) and male patients were more likely to be prescribed (p < 0.001) higher MEDD compared to their female counterparts. Higher Risk MEDD was associated with higher coprescribed benzodiazepines (p = 0.015), lower depression screening (p = 0.048), urine drug testing (p = 0.003), comparable active treatment agreement (p = 0.189), opioid misuse risk screening (p = 0.619), and prescription drug monitoring checks (p = 0.203).

CONCLUSIONS

This study documented that higher MEDD was associated with risks of worse health outcomes without improved adherence to opioid prescribing guideline recommendations. Enhanced clinician awareness of factors associated with MEDD has the potential to mitigate LTOT risks and improve overall patient care.

Promoting research engagement among women with addiction: Impact of recovery peer support in a pilot randomized mixed-methods study

OBJECTIVE

The impact of involving peers on research engagement is largely unknown. The purpose of this pilot study, a part of a larger research, was to evaluate the impact of recovery peer involvement as a study team member on recruitment/retention of persons with lived experience of SUD during pregnancy and to assess participant perceptions about factors impacting engagement of this population and their children in research, especially brain magnetic resonance imaging (MRI).

METHODS

This study randomly assigned participants (1:1) to either Peer or Research Coordinator (RC) arms. Eligible participants were English-speaking adult, non-pregnant females with lived experience of substance use during pregnancy. Certified Peers were recruited word of mouth and completed study-specific training. The impact of trained, certified Peer versus RC on research engagement was assessed by between-arm comparison of retention rates. Quantitative and qualitative survey data on participant perceptions were summarized.

RESULTS

Thirty-eight individuals enrolled into the study (19 Peer, 19 RC). Peer versus RC had 7.2 times greater odds of completing Visit 2 (Fisher's exact test; 95%CI: 1.2, 81.8; p = 0.03). The majority (70.4%) of respondents identified being accompanied by a peer and getting a tour of the MRI facility/procedures as 'extremely' helpful for improving participant comfort and engagement in future studies. Motivators of future research engagement also included creating a trusting, supportive, non-judgmental research environment, and linkages to treatment and other services.

CONCLUSION

Findings support the notion that peers involved as research team members could boost research engagement among persons with substance use during pregnancy.

To be aware, or to accept, that is the question: Differential roles of awareness of automaticity and pain acceptance in opioid misuse

BACKGROUND

Individuals with chronic low back pain (CLBP) are commonly prescribed long-term opioid therapy (LTOT) for analgesia, placing this population at increased risk for opioid misuse and opioid use disorder. Acceptance of aversive experiences (e.g., chronic pain) and awareness of automatic thoughts and behaviors (i.e., automaticity) are two facets of dispositional mindfulness that may serve as protective mechanisms against opioid misuse risk. Therefore, the aim of the current study was to examine the differential contributions of these constructs to opioid misuse risk among adults with CLBP receiving LTOT.

METHODS

Data were obtained from a sample of 770 adults with opioid-treated CLBP. Bivariate correlations and hierarchical linear regression analyses were used to determine whether chronic pain acceptance and awareness of automatic thoughts and behaviors explained a statistically significant portion of variance in opioid misuse risk after accounting for the effects of other relevant confounders.

RESULTS

Hierarchical regression results revealed that chronic pain acceptance and awareness of automatic thoughts and behaviors contributed a significant portion in the variance of opioid misuse risk. Awareness of automatic thoughts and behaviors was negatively associated with opioid misuse risk, such that individuals with lower levels of awareness of automaticity were at higher risk of opioid misuse. By contrast, pain acceptance was not associated with opioid misuse.

CONCLUSIONS

Findings suggest that awareness of automaticity may buffer against opioid misuse risk. Interventions designed to strengthen awareness of automaticity (e.g., mindfulness-based interventions) might be especially efficacious among this population.

Voices of Women With Lived Experience of Substance Use During Pregnancy: A Qualitative Study of Motivators and Barriers to Recruitment and Retention in Research

Despite concerns about negative neurocognitive effects of in utero substance exposure on child and brain development, research in this area is limited. This study gathered perspectives of persons with lived experience of substance use (eg, alcohol, prescription and illicit opioids, and other illicit substances) during a previous pregnancy to determine facilitators and barriers to research engagement in this vulnerable population. We conducted structured, in-depth, individual interviews and 2 focus groups of adult persons with lived experience of substance use during a previous pregnancy. Questions were developed by clinical, research, bioethics, and legal experts, with input from diverse stakeholders. They inquired about facilitators and barriers to research recruitment and retention, especially in long-term studies, with attention to bio-sample and neuroimaging data collection and legal issues. Interviews and focus groups were audio-recorded, transcribed, and analyzed using inductive coding qualitative analysis methods. Ten participants completed in-depth interviews and 7 participated in focus groups. Three main themes emerged as potential barriers to research engagement: shame of using drugs while pregnant, fear of punitive action, and mistrust of health care and research professionals. Facilitative factors included trustworthiness, compassion, and a nonjudgmental attitude among research personnel. Inclusion of gender-concordant recovery peer support specialists as research team members was the most frequently identified facilitator important for helping participants reduce fears and bolster trust in research personnel. In this qualitative study, persons with lived experience of substance use during a previous pregnancy identified factors critical for engaging this population in research, emphasizing the involvement of peer support specialists as research team members.

External Validation of the COVID-NoLab and COVID-SimpleLab Prognostic Tools

Our objective was to externally validate 2 simple risk scores for mortality among a mostly inpatient population with COVID-19 in Canada (588 patients for COVID-NoLab and 479 patients for COVID-SimpleLab). The mortality rates in the low-, moderate-, and high-risk groups for COVID-NoLab were 1.1%, 9.6%, and 21.2%, respectively. The mortality rates for COVID-SimpleLab were 0.0%, 9.8%, and 20.0%, respectively. These values were similar to those in the original derivation cohort. The 2 simple risk scores, now successfully externally validated, offer clinicians a reliable way to quickly identify low-risk inpatients who could potentially be managed as outpatients in the event of a bed shortage. Both are available online (https://ebell-projects.shinyapps.io/covid_nolab/ and https://ebell-projects.shinyapps.io/COVID-SimpleLab/).

Risks of Severe COVID-19 Outcomes Among Patients With Diabetic Polyneuropathy in the United States

CONTEXT

Diabetic neuropathy (DN) affects more than 50% of diabetic patients who are also likely to have compromised immune system and respiratory function, both of which can make them susceptible to the SARS-CoV-2 virus.

OBJECTIVE

To assess the risk of severe COVID-19 illness among adults with DN, compared with those with no DN and those with no diabetes.

SETTING

The analysis utilized electronic health records from 55 US health care organizations in the TriNetX research database.

DESIGN

A retrospective cohort study.

PARTICIPANTS

The analysis included 882 650 adults diagnosed with COVID-19 in January 2020 to June 2021, including 16 641 with DN, 81 329 with diabetes with no neuropathy, and 784 680 with no diabetes.

OUTCOME MEASURES

The presence of health care utilization (admissions to emergency department, hospital, intensive care unit), 30-day mortality, clinical presentation (cough, fever, hypoxemia, dyspnea, or acute respiratory distress syndrome), and diagnostic test results after being infected affected by COVID-19.

RESULTS

The DN cohort was 1.19 to 2.47 times more likely than the non-DN cohorts to utilize care resources, receive critical care, and have higher 30-day mortality rates. Patients with DN also showed increased risk (1.13-2.18 times) of severe symptoms, such as hypoxemia, dyspnea, and acute respiratory distress syndrome.

CONCLUSIONS

Patients with DN had a significantly greater risk of developing severe COVID-19-related complications than those with no DN. It is critical for the public health community to continue preventive measures, such as social distancing, wearing masks, and vaccination, to reduce infection rates, particularly in higher risk groups, such as those with DN.

Provider and patient sex disparities in opioid prescribing and patient outcomes

OBJECTIVE

To assess sex disparities in opioid prescribing practices and patient outcomes.

DESIGN

A retrospective cross-sectional study.

SETTING

Thirty-three primary care clinics in an academic health system.

PARTICIPANTS

2,738 adults prescribed 10+ outpatient opioid prescriptions within 12 months.

MAIN OUTCOME MEASURE(S)

Patient and primary care provider (PCP) sexbased differences in clinical outcomes, opioid prescribing, and rates of adherence to guideline-concordant opioid prescribing practices.

RESULTS

Female PCPs were more likely (p < 0.001) to prescribe lower morphineequivalent daily dose (MEDD) of opioids and complete risk assessment for opioid misuse than male PCPs. PCPs did not differ by sex in adherence rates to controlled substance agreements, urine drug, depression screening, or opioid-benzodiazepine coprescribing. Female patients were more likely (all p ≤ 0.01) to be screened for opioid misuse, treated with lower MEDD, receive opioid-benzodiazepine coprescriptions, have higher pain interference, anxiety and depression diagnoses, and have an overdose diagnosis; they were less likely (all p < 0.001) to report alcohol use or have an alcohol use disorder diagnosis and utilized health care at higher rates than male patients.

CONCLUSIONS

Sex differences were found in clinician opioid-prescribing practices and adherence to opioid prescribing guidelines and patient characteristics associated with long-term opioid therapy. Strategies to identify sex-related disparities and enhance guideline-concordant opioid prescribing and monitoring could contribute to improved patient care, and clinical and safety outcomes.

Treatment with stimulants and the risk of COVID-19 complications in adults with ADHD

Adults with attention deficit hyperactivity disorder (ADHD) have shown higher infection rates and worse outcomes from COVID-19. Stimulant medications are prescribed as the first-line treatment for ADHD in adults and mitigate risk of negative ADHD-related health outcomes, but little is known about the association between stimulant medications and COVID-19 outcomes. The objective of this study was to assess the risks of severe COVID-19 outcomes among people with ADHD who were prescribed stimulant medications versus those who were not. This retrospective cohort study used electronic health records in the TriNetX research database. We assessed records of adults with ADHD diagnosed with COVID-19 between January 1, 2020 and June 30, 2021. The stimulant cohort consisted of 28,011 people with at least one stimulant prescription; the unmedicated cohort comprised 42,258 people without prescribed stimulants within 12 months prior to their COVID infection. Multiple logistic regression modeling was utilized to assess the presence of critical care services or death within 30 days after the onset of COVID diagnoses, controlling for patient demographics, and comorbid medical and mental health conditions. The stimulant cohort was less likely to utilize emergency department, hospital, and intensive care services than the unmedicated cohort, and had significantly lower 30-day mortality. Further research, including prospective studies, is needed to confirm and refine these findings.

Latent class analysis of health, social, and behavioral profiles associated with psychological distress among pregnant and postpartum women during the COVID-19 pandemic in the United States

BACKGROUND

There is a growing body of literature documenting negative mental health impacts from the COVID-19 pandemic. The purpose of this study was to identify risk and protective factors associated with mental health and well-being among pregnant and postpartum women during the pandemic.

METHODS

This was a cross-sectional, anonymous online survey study distributed to pregnant and postpartum (within 6 months) women identified through electronic health records from two large healthcare systems in the Northeastern and Midwestern United States. Survey questions explored perinatal and postpartum experiences related to the pandemic, including social support, coping, and health care needs and access. Latent class analysis was performed to identify classes among 13 distinct health, social, and behavioral variables. Outcomes of depression, anxiety, and stress were examined using propensity-weighted regression modeling.

RESULTS

Fit indices demonstrated a three-class solution as the best fitting model. Respondents (N = 616) from both regions comprised three classes, which significantly differed on sleep- and exercise-related health, social behaviors, and mental health: Higher Psychological Distress (31.8%), Moderate Psychological Distress (49.8%), and Lower Psychological Distress (18.4%). The largest discriminatory issue was support from one's social network. Significant differences in depression, anxiety, and stress severity scores were observed across these three classes. Reported need for mental health services was greater than reported access.

CONCLUSIONS

Mental health outcomes were largely predicted by the lack or presence of social support, which can inform public health decisions and measures to buffer the psychological impact of ongoing waves of the COVID-19 pandemic on pregnant and postpartum women. Targeted early intervention among those in higher distress categories may help improve maternal and child health.

The relationship between police contacts for drug use-related crime and future arrests, incarceration, and overdoses: a retrospective observational study highlighting the need to break the vicious cycle

BACKGROUND

Individuals with substance use disorder often encounter law enforcement due to drug use-related criminal activity. Traditional policing approaches may not be effective for reducing recidivism and improving outcomes in this population. Here, we describe the impact of traditional policing approach to drug use-related crime on future recidivism, incarceration, and overdoses.

METHODS

Using a local Police Department (PD) database, we identified individuals with a police contact with probable cause to arrest for a drug use-related crime ("index contact"), including for an opioid-related overdose, between September 1, 2015, and August 31, 2016 (Group 1, N = 52). Data on police contacts, arrests, and incarceration 12 months before and after the index contact were extracted and compared using Fisher's exact or Wilcoxon signed-rank tests. County-level data on fatal overdoses and estimates of time spent by PD officers in index contact-related responses were also collected. To determine whether crime-related outcomes changed over time, we identified a second group (Group 2, N = 263) whose index contact occurred between September 1, 2017, and August 31, 2020, and extracted data on police contacts, arrests, and incarceration during the 12 months prior to their index contact. Pre-index contact data between Groups 1 and 2 were compared with Fisher's exact or Mann-Whitney U tests.

RESULTS

Comparison of data during 12 months before and 12 months after the index contact showed Group 1 increased their total number of overdose-related police contacts (6 versus 18; p = 0.024), incarceration rate (51.9% versus 84.6%; p = 0.001), and average incarceration duration per person (16.2 [SD = 38.6] to 50 days [SD = 72]; p < 0.001). In the six years following the index contact, 9.6% sustained a fatal opioid-related overdose. For Group 1, an average of 4.7 officers were involved, devoting an average total of 7.2 h per index contact. Comparison of pre-index contact data between Groups 1 and 2 showed similar rates of overdose-related police contacts and arrests.

CONCLUSIONS

The results indicated that the traditional policing approach to drug use-related crime did not reduce arrests or incarceration and was associated with a risk of future overdose fatalities. Alternative law enforcement-led strategies, e.g., pre-arrest diversion-to-treatment programs, are urgently needed.

Mindfulness-Based Stress Reduction Live Online During the COVID-19 Pandemic: A Mixed Methods Feasibility Study

Objectives: To assess the feasibility, acceptability, and effects of Mindfulness Based Stress Reduction (MBSR) live online during the COVID-19 shutdown. Design: Mixed-methods study using a sequential explanatory design. Settings/location: Cohorts 1-4 took place in-person and Cohorts 5-6 took place over Zoom following the onset of the COVID-19 pandemic. Subjects: Participants were paying members of the general public enrolled in one of six live MBSR courses. Interventions: All MBSR courses followed the standard 8-week MBSR curriculum, led by experienced instructors. Outcome measures: Feasibility measured via class attendance, acceptability measured via the adapted Treatment Satisfaction Survey, and MBSR course effects measured by a focus group with Cohort 5, and the following assessments completed by all cohorts: Perceived Stress Scale-10, Generalized Anxiety Disorder-7, Patient Health Questionnaire-9 and the 36-item Short Form Survey. Results: 73 adults participated in six live MBSR courses (48 in the four in-person courses; 25 in the two online courses). Most of the participants identified as white, non-Hispanic, middle-aged females, with annual household income >$100,000. Course completion, defined as at least 6/8 classes attended, did not differ between in-person and online cohorts (84.1% versus 67.6%, respectively, p = 0.327). Participants in Cohort 5 who completed the course (n = 10) rated it as very important and useful for stress coping, and reported high likelihood of continuing their mindfulness practice (all ratings: between 8 and 10 on a 1-10 Likert scale), with open-ended responses corroborating their numerical ratings. Focus group (n = 6) responses indicated that online MBSR was positively received, reduced perceived loss of control, and improved quality of life and morale during the pandemic. Conclusions: Delivering MBSR live online can be feasible and acceptable for the general public, and is potentially beneficial, including during the social upheaval of the COVID-19 pandemic. Online delivery could help expand access to MBSR and address health inequities.

Adjunctive osteopathic therapy for hospitalized COVID-19 patients: A feasibility-oriented chart review study with matched controls

Background

Osteopathic manipulative treatment (OMT) may improve outcomes during COVID-related respiratory distress - the most common cause of death from novel coronavirus (SARS-CoV-2). Outcomes from OMT treatments of respiratory distress during the COVID-19 pandemic have not been reported.

Objective

Assess adjunctive OMT in hospitalized patients with SARS-CoV-2 and respiratory distress.

Design

Feasibility oriented retrospective observational cohort study.

Setting

COVID-19 (non-ICU) ward in a tertiary academic medical center.

Methods

Inpatients received daily OMT treatments of rib raising, abdominal diaphragm doming, thoracic pump and pedal pump. Primary outcomes were procedural acceptance, satisfaction, side effects, and adverse events. Secondary outcomes were patient-reported clinical change after therapy; number of hospital days; need during hospitalization for high-flow oxygen, C-PAP/BiPAP or intensive care; need for supplementary oxygen at discharge; and discharge disposition.

Participants

Hospitalized adults with SARS-CoV-2 infection and respiratory distress.

Results

OMT (n = 27) and Control (n = 152) groups were similar in demographics and most laboratory studies. 90% of patients accepted OMT and reported high satisfaction (4.26/±0.71 (maximum 5)), few negative effects, no adverse events, and positive clinical change (5.07 ± 0.96 (maximum 7)). Although no significant differences were found in secondary outcomes, OMT patients trended towards fewer hospital days than Controls (p = 0.053; Cohen's d = 0.22), a relationship that trended towards correlation with number of co-morbidities (p = 0.068).

Conclusion

Hospitalized patients with respiratory distress and COVID-19 reported acceptance, satisfaction, and greater ease of breathing after a four-part OMT protocol, and appear to have a shorter length of hospitalization. Randomized controlled trials are needed to confirm these results.

Development and Validation of a Two-Step Predictive Risk Stratification Model for Coronavirus Disease 2019 In-hospital Mortality: A Multicenter Retrospective Cohort Study

Objectives

An accurate prognostic score to predict mortality for adults with COVID-19 infection is needed to understand who would benefit most from hospitalizations and more intensive support and care. We aimed to develop and validate a two-step score system for patient triage, and to identify patients at a relatively low level of mortality risk using easy-to-collect individual information.

Design

Multicenter retrospective observational cohort study.

Setting

Four health centers from Virginia Commonwealth University, Georgetown University, the University of Florida, and the University of California, Los Angeles.

Patients

Coronavirus Disease 2019-confirmed and hospitalized adult patients.

Measurements and Main Results

We included 1,673 participants from Virginia Commonwealth University (VCU) as the derivation cohort. Risk factors for in-hospital death were identified using a multivariable logistic model with variable selection procedures after repeated missing data imputation. A two-step risk score was developed to identify patients at lower, moderate, and higher mortality risk. The first step selected increasing age, more than one pre-existing comorbidities, heart rate >100 beats/min, respiratory rate ≥30 breaths/min, and SpO₂ <93% into the predictive model. Besides age and SpO₂, the second step used blood urea nitrogen, absolute neutrophil count, C-reactive protein, platelet count, and neutrophil-to-lymphocyte ratio as predictors. C-statistics reflected very good discrimination with internal validation at VCU (0.83, 95% CI 0.79-0.88) and external validation at the other three health systems (range, 0.79-0.85). A one-step model was also derived for comparison. Overall, the two-step risk score had better performance than the one-step score.

Conclusions

The two-step scoring system used widely available, point-of-care data for triage of COVID-19 patients and is a potentially time- and cost-saving tool in practice.

'Us-Versus-Them': Othering in COVID-19 public health behavior compliance

Objective

We explored public perceptions about the COVID-19 pandemic to learn how those attitudes may affect compliance with health behaviors.

Methods

Participants were Central Pennsylvania adults from diverse backgrounds purposively sampled (based on race, gender, educational attainment, and healthcare worker status) who responded to a mixed methods survey, completed between March 25–31, 2020. Four open-ended questions were analyzed, including: “What worries you most about the COVID-19 pandemic?” We applied a pragmatic, inductive coding process to conduct a qualitative, descriptive content analysis of responses.

Results

Of the 5,948 respondents, 538 were sampled for this qualitative analysis. Participants were 58% female, 56% with ≥ bachelor’s degree, and 50% from minority racial backgrounds. Qualitative descriptive analysis revealed four themes related to respondents’ health and societal concerns: lack of faith in others; fears of illness or death; frustration at perceived slow societal response; and a desire for transparency in communicating local COVID-19 information. An “us-versus-them” subtext emerged; participants attributed non-compliance with COVID-19 behaviors to other groups, setting themselves apart from those Others.

Conclusion

Our study uncovered Othering undertones in the context of the COVID-19 pandemic, occurring between groups of like-minded individuals with behavioral differences in ‘compliance’ versus ‘non-compliance’ with public health recommendations. Addressing the ‘us-versus-them’ mentality may be important for boosting compliance with recommended health behaviors.

Lower Intent to Comply with COVID-19 Public Health Recommendations Correlates to Higher Disease Burden in Following 30 Days

OBJECTIVES

We sought to determine whether self-reported intent to comply with public health recommendations correlates with future coronavirus disease 2019 (COVID-19) disease burden.

METHODS

A cross-sectional, online survey of US adults, recruited by snowball sampling, from April 9 to July 12, 2020. Primary measurements were participant survey responses about their intent to comply with public health recommendations. Each participant's intent to comply was compared with his or her local COVID-19 case trajectory, measured as the 7-day rolling median percentage change in COVID-19 confirmed cases within participants' 3-digit ZIP code area, using public county-level data, 30 days after participants completed the survey.

RESULTS

After applying raking techniques, the 10,650-participant sample was representative of US adults with respect to age, sex, race, and ethnicity. Intent to comply varied significantly by state and sex. Lower reported intent to comply was associated with higher COVID-19 case increases during the following 30 days. For every 3% increase in intent to comply with public health recommendations, which could be achieved by improving average compliance by a single point for a single item, we estimate a 9% reduction in new COVID-19 cases during the subsequent 30 days.

CONCLUSIONS

Self-reported intent to comply with public health recommendations may be used to predict COVID-19 disease burden. Measuring compliance intention offers an inexpensive, readily available method of predicting disease burden that can also identify populations most in need of public health education aimed at behavior change.

Developing and testing an automated qualitative assistant (AQUA) to support qualitative analysis

Qualitative research remains underused, in part due to the time and cost of annotating qualitative data (coding). Artificial intelligence (AI) has been suggested as a means to reduce those burdens, and has been used in exploratory studies to reduce the burden of coding. However, methods to date use AI analytical techniques that lack transparency, potentially limiting acceptance of results. We developed an automated qualitative assistant (AQUA) using a semiclassical approach, replacing Latent Semantic Indexing/Latent Dirichlet Allocation with a more transparent graph-theoretic topic extraction and clustering method. Applied to a large dataset of free-text survey responses, AQUA generated unsupervised topic categories and circle hierarchical representations of free-text responses, enabling rapid interpretation of data. When tasked with coding a subset of free-text data into user-defined qualitative categories, AQUA demonstrated intercoder reliability in several multicategory combinations with a Cohen’s kappa comparable to human coders (0.62–0.72), enabling researchers to automate coding on those categories for the entire dataset. The aim of this manuscript is to describe pertinent components of best practices of AI/machine learning (ML)-assisted qualitative methods, illustrating how primary care researchers may use AQUA to rapidly and accurately code large text datasets. The contribution of this article is providing guidance that should increase AI/ML transparency and reproducibility.

Using electronic health record's data to assess daily dose of opioids prescribed for outpatients with chronic non-cancer pain

This research intended to examine electronic health record (EHR) based methods for automated estimation of morphine equivalent daily dose (MEDD) of prescribed opioids in primary care research and practice. The study leveraged the health system’s audit of adults treated with long-term opioids for chronic non-cancer pain to compare two EHR-based automated MEDD calculation methods: RxSignature (active prescriptions’ signature information) and RxQuantity (quantity dispensed for prescriptions issued within the past 90 days). Prescribed opioid EHR data were extracted from the target population at a large US academic health system in a 2-year assessment period. Forty-five ‘target patients’ were selected by the health system for a manual audit by an expert physician who then ‘manually’ calculated the actual MEDD over the past 90 days (RxAudit) for those with discrepancies in the MEDD calculated with RxSignature and RxQuantity. Paired samples t-test compared the MEDD generated by the RxSignature and RxQuantity methods by opioid type in the target population. The audit (n=45) revealed the RxSignature and RxQuantity methods yielded comparable MEDD results for 20 patients and discrepant results for 25 patients. The former group had opioid prescriptions issued at regular intervals for stable, scheduled doses of opioids; the latter group had opioid prescriptions issued irregularly or for changed daily dosing regimen, for as-needed use, or had changes in the dosing regimen or inactive prescriptions mislabeled as active. RxAudit of the EHR of those with discrepant MEDD results (n=25) produced consistent results with those yielded by the RxQuantity, but not the RxSignature, method. Significant differences in MEDD were found for most opioid types when the MEDD was calculated for the target population using the RxSignature and RxQuantity methods. In conclusion, different EHR-based methods for MEDD calculation can lead to vastly different estimates, with implications for research and clinical care outcomes. Standardising data extraction and MEDD calculation algorithms could overcome these challenges, enabling a more accurate and reproducible approach to the dose calculation for prescribed opioids, improving the quality of research and patient safety.

COVID-19 outcomes among adult patients treated with long-term opioid therapy for chronic non-cancer pain in the USA: a retrospective cohort study

OBJECTIVE

Patients treated with long-term opioid therapy (LTOT) are known to have compromised immune systems and respiratory function, both of which make them particularly susceptible to the SARS-CoV-2 virus. The objective of this study was to assess the risk of developing severe clinical outcomes among COVID-19 non-cancer patients on LTOT, compared with those without LTOT.

DESIGN AND DATA SOURCES

A retrospective cohort design using electronic health records in the TriNetX research database.

PARTICIPANTS AND SETTING

418 216 adults diagnosed with COVID-19 in January-December 2020 from 51 US healthcare organisations: 9558 in the LTOT and 408 658 in the control cohort. They did not have cancer diagnoses; only a small proportion might have been treated with opioid maintenance for opioid use disorder.

RESULTS

Patient on LTOT had a higher risk ratio (RR) than control patients to visit an emergency department (RR 2.04, 95% CI 1.93 to 2.16) and be hospitalised (RR 2.91, 95% CI 2.69 to 3.15). Once admitted, LTOT patients were more likely to require intensive care (RR 3.65, 95% CI 3.10 to 4.29), mechanical ventilation (RR 3.47, 95% CI 2.89 to 4.15) and vasopressor support (RR 5.28, 95% CI 3.70 to 7.53) and die within 30 days (RR 1.96, 95% CI 1.67 to 2.30). The LTOT group also showed increased risk (RRs from 2.06 to 3.98, all significant to 95% CI) of more-severe infection (eg, cough, dyspnoea, fever, hypoxaemia, thrombocytopaenia and acute respiratory distress syndrome). Statistically significant differences in several laboratory results and other vital signs appeared clinically negligible.

CONCLUSION

COVID-19 patients on LTOT were at higher risk of increased morbidity, mortality and healthcare utilisation. Interventions to reduce the need for LTOT and to increase compliance with COVID-19 protective measures may improve outcomes and reduce healthcare cost in this population. Prospective studies need to confirm and refine these findings.

Mindfulness-based interventions for substance use disorders

BACKGROUND

Substance use disorders (SUDs) are highly prevalent and associated with a substantial public health burden. Although evidence-based interventions exist for treating SUDs, many individuals remain symptomatic despite treatment, and relapse is common.Mindfulness-based interventions (MBIs) have been examined for the treatment of SUDs, but available evidence is mixed.

OBJECTIVES

To determine the effects of MBIs for SUDs in terms of substance use outcomes, craving and adverse events compared to standard care, further psychotherapeutic, psychosocial or pharmacological interventions, or instructions, waiting list and no treatment.

SEARCH METHODS

We searched the following databases up to April 2021: Cochrane Drugs and Alcohol Specialised Register, CENTRAL, PubMed, Embase, Web of Science, CINAHL and PsycINFO. We searched two trial registries and checked the reference lists of included studies for relevant randomized controlled trials (RCTs).

SELECTION CRITERIA

RCTs testing a MBI versus no treatment or another treatment in individuals with SUDs. SUDs included alcohol and/or drug use disorders but excluded tobacco use disorders. MBIs were defined as interventions including training in mindfulness meditation with repeated meditation practice. Studies in which SUDs were formally diagnosed as well as those merely demonstrating elevated SUD risk were eligible.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Forty RCTs met our inclusion criteria, with 35 RCTs involving 2825 participants eligible for meta-analysis. All studies were at high risk of performance bias and most were at high risk of detection bias. Mindfulness-based interventions (MBIs) versus no treatment Twenty-four RCTs included a comparison between MBI and no treatment. The evidence was uncertain about the effects of MBIs relative to no treatment on all primary outcomes: continuous abstinence rate (post: risk ratio (RR) = 0.96, 95% CI 0.44 to 2.14, 1 RCT, 112 participants; follow-up: RR = 1.04, 95% CI 0.54 to 2.01, 1 RCT, 112 participants); percentage of days with substance use (post-treatment: standardized mean difference (SMD) = 0.05, 95% CI -0.37 to 0.47, 4 RCTs, 248 participants; follow-up: SMD = 0.21, 95% CI -0.12 to 0.54, 3 RCTs, 167 participants); and consumed amount (post-treatment: SMD = 0.10, 95% CI -0.31 to 0.52, 3 RCTs, 221 participants; follow-up: SMD = 0.33, 95% CI 0.00 to 0.66, 2 RCTs, 142 participants). Evidence was uncertain for craving intensity and serious adverse events. Analysis of treatment acceptability indicated MBIs result in little to no increase in study attrition relative to no treatment (RR = 1.04, 95% CI 0.77 to 1.40, 21 RCTs, 1087 participants). Certainty of evidence for all other outcomes was very low due to imprecision, risk of bias, and/or inconsistency. Data were unavailable to evaluate adverse events. Mindfulness-based interventions (MBIs) versus other treatments (standard of care, cognitive behavioral therapy, psychoeducation, support group, physical exercise, medication) Nineteen RCTs included a comparison between MBI and another treatment. The evidence was very uncertain about the effects of MBIs relative to other treatments on continuous abstinence rate at post-treatment (RR = 0.80, 95% CI 0.45 to 1.44, 1 RCT, 286 participants) and follow-up (RR = 0.57, 95% CI 0.28 to 1.16, 1 RCT, 286 participants), and on consumed amount at post-treatment (SMD = -0.42, 95% CI -1.23 to 0.39, 1 RCT, 25 participants) due to imprecision and risk of bias. The evidence suggests that MBIs reduce percentage of days with substance use slightly relative to other treatments at post-treatment (SMD = -0.21, 95% CI -0.45 to 0.03, 5 RCTs, 523 participants) and follow-up (SMD = -0.39, 95% CI -0.96 to 0.17, 3 RCTs, 409 participants). The evidence was very uncertain about the effects of MBIs relative to other treatments on craving intensity due to imprecision and inconsistency. Analysis of treatment acceptability indicated MBIs result in little to no increase in attrition relative to other treatments (RR = 1.06, 95% CI 0.89 to 1.26, 14 RCTs, 1531 participants). Data were unavailable to evaluate adverse events.

AUTHORS' CONCLUSIONS

In comparison with no treatment, the evidence is uncertain regarding the impact of MBIs on SUD-related outcomes. MBIs result in little to no higher attrition than no treatment. In comparison with other treatments, MBIs may slightly reduce days with substance use at post-treatment and follow-up (4 to 10 months). The evidence is uncertain regarding the impact of MBIs relative to other treatments on abstinence, consumed substance amount, or craving. MBIs result in little to no higher attrition than other treatments. Few studies reported adverse events.

Impact of a community-policing initiative promoting substance use disorder treatment over criminal charges on arrest recidivism

BACKGROUND

Overdose deaths, addiction, and drug-related crime have increased in the United States over the past decade. Treatment improves outcomes, including reducing crime, but few individuals with addiction receive treatment. Here, we determine whether the Madison Addiction Recovery Initiative (MARI), a community policing program implemented by the City of Madison (Wisconsin) Police Department (MPD) that diverts adults who committed a non-violent, drug use-related crime from criminal prosecution to addiction treatment, reduces the risk of recidivism (i.e., an arrest) in the 6-month period following the index crime.

METHODS

Observational data were collected by the MPD for 12 months before through 6 months after an index crime from participants in the MARI program (n = 263) who referred to MARI between September 1, 2017 and August 31, 2020 and a Historical Comparison group (n = 52) who committed a comparable crime between September 1, 2015 and August 31, 2016. Average effects were estimated using intention-to-treat (ITT), a per-protocol, and a complier average causal effects (CACE) analyses, adjusted for covariates.

RESULTS

ITT analysis did not show that MARI assignment lowered adjusted odds of 6-month recidivism (aOR = 0.59 [0.32, 1.12], p = 0.11). Per-protocol analysis showed that completing MARI lowered the adjusted odds of 6-month recidivism (aOR = 0.23 [0.10, 0.52], p < 0.001). CACE analysis indicated that assignment to MARI among individuals who would complete the MARI program if assigned to the program lowered the adjusted odds of 6-month recidivism (aOR = 0.85 [0.80, 0.90], p < 0.001).

CONCLUSIONS

Diverting adults who committed a non-violent, drug use-related crime from criminal prosecution to addiction treatment may reduce 6-month recidivism.

A socioecological framework for engaging substance-using pregnant persons in longitudinal research: Multi-stakeholder perspectives

OBJECTIVE

Understanding the impact of substance use during pregnancy on fetal development and child health is essential for designing effective approaches for reducing prenatal substance exposures and improving child outcomes. Research on the developmental impacts of prenatal substance exposure has been limited by legal, ethical, and practical challenges. This study examined approaches to engage substance-using (with an emphasis on opioids) pregnant persons in longitudinal research, from multi-stakeholder perspectives.

METHODS

The present study solicited the expertise of 1) an advisory group of community stakeholders, including people with lived experienced of opioid/substance use; and 2) an online survey with content experts. Qualitative analysis examined facilitators and barriers to recruiting and retaining substance-using pregnant persons through a socioecological lens at the individual, interpersonal, organizational, community, and policy levels.

RESULTS

Stakeholders (N = 19) prioritized stigma, loss of confidentiality, legal consequences, and instability (e.g., homelessness and poverty) as important barriers that prevent substance-using persons from enrolling in research studies. Of 70 survey respondents, most self-identified as researchers (n = 37), followed by clinicians (n = 19), and 'others' (n = 14). Survey respondents focused on retention strategies that build trusting relationships with participants, including incentives (e.g., transportation and childcare support), participant-friendly study design, and team-related factors, (e.g., attitudes and practices).

CONCLUSION

The stakeholder input and survey data offer key insights strengthening our understanding of facilitators and barriers to research participation, and ways to overcome barriers among substance-using pregnant persons. A socioecological framework can be used to identify and address these factors to increase recruitment and long-term retention of high-risk populations.

Mindfulness-based therapy compared to cognitive behavioral therapy for opioid-treated chronic low back pain: Protocol for a pragmatic randomized controlled trial

OBJECTIVE

Chronic low back pain (CLBP) is disabling and costly. Existing therapies have proven suboptimal, with many patients resorting to long-term opioid therapy, which can cause harms. Cognitive behavioral (CBT) and mindfulness-based (MBT) therapies can be effective and offer unique skills for safe pain coping. This article describes the protocol for a study evaluating comparative effectiveness of CBT and MBT in adults with opioid-treated CLBP.

DESIGN

Pragmatic, multi-center randomized controlled trial (RCT).

SETTINGS

Community and outpatient care.

PARTICIPANTS

Planned enrollment of 766 adults (383/group) with CLBP treated with long-term opioids (≥3 months; ≥15 mg/day morphine-equivalent dose).

INTERVENTIONS

CBT or MBT consisting of eight weekly therapist-led, two-hour group sessions, and home practice (≥30 min/day, 6 days/week) during the 12-month study.

MAIN OUTCOME MEASURES

Main outcome measures, collected by self-report at baseline, then three, six, nine and 12 months post-entry, include co-primary measures: pain intensity (Numeric Rating Scale) and function (Oswestry Disability Index), and secondary measures: quality of life (Medical Outcomes Study) and average daily opioid dose (Timeline Followback). Baseline scores of depression, anxiety, and opioid misuse questionnaires will be assessed as potential contributors to the heterogeneity of treatment response. Intention-to-treat, linear mixed-effects analysis will examine treatment effectiveness. Qualitative data will augment the quantitative measures.

CONCLUSIONS

This will be the largest RCT comparing CBT and MBT in opioid-treated CLBP. It will provide evidence on the impact of these interventions, informing clinical decisions about optimal therapy for safe, effective care, improving quality of life and decreasing opioid-related harm among adults with refractory CLBP.

Knowledge, Perceptions, and Preferred Information Sources Related to COVID-19 Among Central Pennsylvania Adults Early in the Pandemic: A Mixed Methods Cross-Sectional Survey

PURPOSE

To explore public knowledge, understanding of public health recommendations, perceptions, and trust in information sources related to COVID-19.

METHODS

A cross-sectional survey of central Pennsylvanian adults evaluated self-reported knowledge, and a convergent, mixed methods design was used to assess beliefs about recommendations, intended behaviors, perceptions, and concerns related to infectious disease risk, and trust of information sources.

RESULTS

The survey was completed by 5,948 adults. The estimated probability of correct response for the basic knowledge score, weighted with confidence, was 0.79 (95% CI, 0.79-0.80). Knowledge was significantly higher in patients with higher education and nonminority race. While the majority of respondents reported that they believed following CDC recommendations would decrease the spread of COVID-19 in their community and intended to adhere to them, only 65.2% rated social isolation with the highest level of belief and adherence. The most trusted information source was federal public health websites (42.8%). Qualitative responses aligned with quantitative data and described concerns about illness, epidemiologic issues, economic and societal disruptions, and distrust of the executive branch's messaging. The survey was limited by a lack of minority representation, potential selection bias, and evolving COVID-19 information that may impact generalizability and interpretability.

CONCLUSIONS

Knowledge about COVID-19 and intended adherence to behavioral recommendations were high. There was substantial distrust of the executive branch of the federal government, however, and concern about mixed messaging and information overload. These findings highlight the importance of consistent messaging from trusted sources that reaches diverse groups.

Recruitment and retention of pregnant women in prospective birth cohort studies: A scoping review and content analysis of the literature

Longitudinal cohort studies present unique methodological challenges, especially when they focus on vulnerable populations, such as pregnant women. The purpose of this review is to synthesize the existing knowledge on recruitment and retention (RR) of pregnant women in birth cohort studies and to make recommendations for researchers to improve research engagement of this population. A scoping review and content analysis were conducted to identify facilitators and barriers to the RR of pregnant women in cohort studies. The search retrieved 574 articles, with 38 meeting eligibility criteria and focused on RR among English-speaking, adult women, who are pregnant or in early postpartum period, enrolled in birth cohort studies. Selected studies were birth cohort (including longitudinal) (n = 20), feasibility (n = 14), and other (n = 4) non-interventional study designs. The majority were from low-risk populations. Abstracted data were coded according to emergent theme clusters. The majority of abstracted data (79%) focused on recruitment practices, with only 21% addressing retention strategies. Overall, facilitators were reported more often (75%) than barriers (25%). Building trusting relationships and employing diverse recruitment methods emerged as major recruitment facilitators; major barriers included heterogeneous participant reasons for refusal and cultural factors. Key retention facilitators included flexibility with scheduling, frequent communication, and culturally sensitive practices, whereas participant factors such as loss of interest, pregnancy loss, relocation, multiple caregiver shifts, and substance use/psychiatric problems were cited as major barriers. Better understanding of facilitators and barriers of RR can help enhance the internal and external validity of future birth/pre-birth cohorts. Strategies presented in this review can help inform investigators and funding agencies of best practices for RR of pregnant women in longitudinal studies.

Norovirus Infections Drop 49% in the United States with Strict COVID-19 Public Health Interventions

Norovirus is a substantial burden on the U.S. We compared norovirus outbreaks before and during COVID-19. There were fewer norovirus outbreaks during COVID-19 compared to a similar time period in 2019 (326 versus 638, P<0.001). CONCLUSION: COVID-19 public health interventions may be considered to decrease the burden of norovirus. This demonstrates the ability of more restrictive interventions to decrease other outbreaks of known or emerging viruses.

Pre-arrest diversion to addiction treatment by law enforcement: protocol for the community-level policing initiative to reduce addiction-related harm, including crime

BACKGROUND

Despite evidence that treatment reduces addiction-related harms, including crime and overdose, only a minority of addiction-affected individuals receive it. Linking individuals who committed an addiction-related crime to addiction treatment could improve outcomes.

METHODS

The aim of this city-wide, pre-arrest diversion program, Madison Addiction Recovery Initiative (MARI) is to reduce crime and improve health (i.e., reduce the overdose deaths) among adults who committed a minor, non-violent, drug use-related offense by offering them a referral to treatment in lieu of arrest and prosecution of criminal charges. This manuscript outlines the protocol and methods for the MARI program development and implementation. MARI requires its participants to engage in the recommended treatment, without reoffending, during the six-month program, after which the initial criminal charges are "voided" by the law enforcement agency. The project, implemented in a mid-size U.S. city, has involved numerous partners, including law enforcement, criminal justice, public health, and academia. It includes training of the police officer workforce and collaboration with clinical partners for treatment need assessment, treatment placement, and peer support. Program evaluation includes formative, process, outcome (participant-level) and exploratory impact (community-level) assessments. For outcome evaluation, we will compare crime (primary outcome), overdose-related offenses, and incarceration-related data 12 months before and 12 months after the index crime between participants who completed (Group 1), started but not completed (Group 2), and were offered but did not start (Group 3) the program, and adults who would have been eligible should MARI existed (Historical Comparison, Group 4). Clinical characteristics will be compared at baseline between Groups 1-2, and pre-post the program within Group 1. Participant baseline data will be assessed as potential covariates. Surveys of police officers and program completers, and community-level indicators of crime and overdose pre- versus post-program will provide additional data on the program impact.

DISCUSSION

By offering addiction treatment in lieu of arrest and prosecution of criminal charges, this pre-arrest diversion program has the potential to disrupt the cycle of crime, reduce the likelihood of future offenses, and promote public health and safety.

Characteristics and Outcomes Among Hospitalized COVID-19-Positive Patients in a Nonurban Environment

INTRODUCTION

Virtually all hospitalized coronavirus disease-2019 (COVID-19) outcome data come from urban environments. The extent to which these findings are generalizable to other settings is unknown. Coronavirus disease-2019 data from large, urban settings may be particularly difficult to apply in military medicine, where practice environments are often semi-urban, rural, or austere. The purpose of this study is compare presenting characteristics and outcomes of U.S. patients with COVID-19 in a nonurban setting to similar patients in an urban setting.

MATERIALS AND METHODS

This is a retrospective case series of adults with laboratory-confirmed COVID-19 infection who were admitted to Hershey Medical Center (HMC), a 548-bed tertiary academic medical center in central Pennsylvania serving semi-urban and rural populations, from March 23, 2020, to April 20, 2020 (the first month of COVID-19 admissions at HMC). Patients and outcomes of this cohort were compared to published data on a cohort of similar patients from the New York City (NYC) area.

RESULTS

The cohorts had similar age, gender, comorbidities, need for intensive care or mechanical ventilation, and most vital sign and laboratory studies. The NYC's cohort had shorter hospital stays (4.1 versus 7.2 days, P < .001) but more African American patients (23% versus 12%, P = .02) and higher prevalence of abnormal alanine (>60U/L; 39.0% versus 5.9%, P < .001) and aspartate (>40U/L; 58.4% versus 42.4%, P = .012) aminotransferase, oxygen saturation <90% (20.4% versus 7.2%, P = .004), and mortality (21% versus 1.4%, P < .001).

CONCLUSIONS

Hospitalists in nonurban environments would be prudent to use caution when considering the generalizability of results from dissimilar regions. Further investigation is needed to explore the possibility of reproducible causative systemic elements that may help improve COVID-19-related outcomes. Broader reports of these relationships across many settings will offer military medical planners greater ability to consider outcomes most relevant to their unique settings when considering COVID-19 planning.

Language Matters: It Is Time We Change How We Talk About Addiction and its Treatment

The way we communicate about addiction, its treatment, and treatment outcomes matters to individuals affected by addiction, their families, and communities. Stigmatizing language can worsen addiction-related stigma and outcomes. Although non-professional terminology may be used by individuals with addiction, the role of clinicians, educators, researchers, policymakers, and community and cultural leaders is to actively work toward destigmatization of addiction and its treatment, in part through the use of non-stigmatizing language. Role-modeling better approaches can help us move away from the inaccurate, outdated view of addiction as a character flaw or moral failing deserving of punishment, and toward that of a chronic disease requiring long-term treatment. Non-stigmatizing, non-judgmental, medically-based terminology and the adoption of person-first language can facilitate improved communication as well as patient access to and engagement with addiction care. Person-first language, which shifts away from defining a person through the lens of disease (eg, the term "a person with addiction" is recommended over the terms "addict" or "addicted patient"), implicitly acknowledges that a patient's life extends beyond a given disease. While such linguistic changes may seem subtle, they communicate that addiction, chronic pain and other diseases are only one aspect of a person's health and quality of life, and can promote therapeutic relationships, reduce stigma and health and disparities in addiction care. This article provides examples of stigmatizing terms to be avoided and recommended replacements to facilitate the dialogue about addiction in a more intentional, therapeutic manner.

Increasing system-wide implementation of opioid prescribing guidelines in primary care: findings from a non-randomized stepped-wedge quality improvement project

Background

Clinician utilization of practice guidelines can reduce inappropriate opioid prescribing and harm in chronic non-cancer pain; yet, implementation of “opioid guidelines” is subpar. We hypothesized that a multi-component quality improvement (QI) augmentation of “routine” system-level implementation efforts would increase clinician adherence to the opioid guideline-driven policy recommendations.

Methods

Opioid policy was implemented system-wide in 26 primary care clinics. A convenience sample of 9 clinics received the QI augmentation (one-hour academic detailing; 2 online educational modules; 4–6 monthly one-hour practice facilitation sessions) in this non-randomized stepped-wedge QI project. The QI participants were volunteer clinic staff. The target patient population was adults with chronic non-cancer pain treated with long-term opioids. The outcomes included the clinic-level percentage of target patients with a current treatment agreement (primary outcome), rates of opioid-benzodiazepine co-prescribing, urine drug testing, depression and opioid misuse risk screening, and prescription drug monitoring database check; additional measures included daily morphine-equivalent dose (MED), and the percentages of all target patients and patients prescribed ≥90 mg/day MED. T-test, mixed-regression and stepped-wedge-based analyses evaluated the QI impact, with significance and effect size assessed with two-tailed p < 0.05, 95% confidence intervals and/or Cohen’s d.

Results

Two-hundred-fifteen QI participants, a subset of clinical staff, received at least one QI component; 1255 patients in the QI and 1632 patients in the 17 comparison clinics were prescribed long-term opioids. At baseline, more QI than comparison clinic patients were screened for depression (8.1% vs 1.1%, p = 0.019) and prescribed ≥90 mg/day MED (23.0% vs 15.5%, p = 0.038). The stepped-wedge analysis did not show statistically significant changes in outcomes in the QI clinics, when accounting for the comparison clinics’ trends. The Cohen’s d values favored the QI clinics in all outcomes except opioid-benzodiazepine co-prescribing. Subgroup analysis showed that patients prescribed ≥90 mg/day MED in the QI compared to comparison clinics improved urine drug screening rates (38.8% vs 19.1%, p = 0.02), but not other outcomes (p ≥ 0.05).

Conclusions

Augmenting routine policy implementation with targeted QI intervention, delivered to volunteer clinic staff, did not additionally improve clinic-level, opioid guideline-concordant care metrics. However, the observed effect sizes suggested this approach may be effective, especially in higher-risk patients, if broadly implemented.

Trial registration

Not applicable.

Public Intent to Comply with COVID-19 Public Health Recommendations

Stay-at-home orders have been an essential component of coronavirus 2019 (COVID-19) management in the United States. As states start lifting these mandates to reopen the economy, voluntary public compliance with public health recommendations may significantly influence the extent of resurgence in COVID-19 infection rates. Population-level risk from reopening may therefore be predicted from public intent to comply with public health recommendations. We are conducting a global, convergent design mixed-methods survey on public knowledge, perceptions, preferred health information sources, and understanding of and intent to comply with public health recommendations. With over 9,000 completed surveys from every US state and over 70 countries worldwide, to our knowledge this is the largest pandemic messaging study to date. Although the study is still ongoing, we have conducted an analysis of 5,005 US surveys completed from April 9-15, 2020 on public intent to comply with public health recommendations and offer insights on the COVID-19 pandemic-related risk of reopening. We found marked regional differences in intent to follow key public health recommendations. Regional efforts are urgently needed to influence public behavior changes to decrease the risk of reopening, particularly in higher-risk areas with low public intent to comply with preventive health recommendations. [HLRP: Health Literacy Research and Practice. 2020;4(3):e160-e165.].

Mindfulness practice predicts interleukin-6 responses to a mindfulness-based alcohol relapse prevention intervention

Chronic alcohol misuse can result in chronically elevated interleukin (IL)-6, a pro-inflammatory cytokine, in the bloodstream. Given that Mindfulness-Based Relapse Prevention (MBRP) has been shown to reduce alcohol misuse, MBRP might also be effective in reducing IL-6 concentrations. Past research has found, however, that IL-6 does not respond consistently to mindfulness-based interventions. Building on prior studies, we examined whether between-person variability in engagement with mindfulness training (i.e., formal mindfulness practice time) is associated with between-person variability in changes in serum IL-6, using data from a randomized controlled trial evaluating MBRP for Alcohol Dependence (MBRP-A). Participants were 72 alcohol dependent adults (mean age = 43.4 years, 63.9% male, 93.1% White) who received a minimum dose (i.e., at least four sessions) of MBRP-A either at the start of the trial (n = 46) or after a 26-week delay (n = 26). IL-6 concentrations did not significantly change from pre- to post-intervention for the full sample. Nevertheless, greater mindfulness practice time was significantly associated with reduced IL-6 levels (r = -0.27). The association between practice time and IL-6 changes remained significant when controlling for intervention timing (i.e., immediate or after the 26-week delay), demographic characteristics, and changes in mindful awareness, obsessive-compulsive drinking, and depressive symptoms. The association between practice time and IL-6 changes was not significant when omitting the minimum treatment dose requirement. Overall, results suggest that the level of engagement in mindfulness training may predict changes in the inflammatory pathophysiology in adults with alcohol dependence.

Benefits of 8-wk Mindfulness-based Stress Reduction or Aerobic Training on Seasonal Declines in Physical Activity

Mindfulness-based stress reduction (MBSR) and aerobic exercise training (AET) programs improve health and well-being. Exercise participation has been related to mindfulness and may be altered by MBSR training.

Brief Mindfulness-Based Interventions for Acute and Chronic Pain: A Systematic Review

OBJECTIVES

Nonpharmacologic approaches have been characterized as the preferred means to treat chronic noncancer pain by the Centers for Disease Control and Prevention. There is evidence that mindfulness-based interventions (MBIs) are effective for pain management, yet the typical MBI may not be feasible across many clinical settings due to resource and time constraints. Brief MBIs (BMBIs) could prove to be more feasible and pragmatic for safe treatment of pain. The aim of the present article is to systematically review evidence of BMBI's effects on acute and chronic pain outcomes in humans.

METHODS

A literature search was conducted using PubMed, PsycINFO, and Google Scholar and by examining the references of retrieved articles. Articles written in English, published up to August 16, 2017, and reporting on the effects of a BMBI (i.e., total contact time <1.5 h, with mindfulness as the primary therapeutic technique) on a pain-related outcome (i.e., pain outcome, pain affect, pain-related function/quality of life, or medication-related outcome) were eligible for inclusion. Two authors independently extracted the data and assessed risk of bias.

RESULTS

Twenty studies meeting eligibility criteria were identified. Studies used qualitative (n = 1), within-group (n = 3), or randomized controlled trial (n = 16) designs and were conducted with clinical (n = 6) or nonclinical (i.e., experimentally-induced pain; n = 14) samples. Of the 25 BMBIs tested across the 20 studies, 13 were delivered with audio/video recording only, and 12 were delivered by a provider (participant-provider contact ranged from 3 to 80 min). Existing evidence was limited and inconclusive overall. Nevertheless, BMBIs delivered in a particular format-by a provider and lasting more than 5 min-showed some promise in the management of acute pain.

CONCLUSIONS

More rigorous large scale studies conducted with pain populations are needed before unequivocally recommending BMBI as a first-line treatment for acute or chronic pain.

Enhancing system-wide implementation of opioid prescribing guidelines in primary care: protocol for a stepped-wedge quality improvement project

Background

Systematic implementation of guidelines for opioid therapy management in chronic non-cancer pain can reduce opioid-related harms. However, implementation of guideline-recommended practices in routine care is subpar. The goal of this quality improvement (QI) project is to assess whether a clinic-tailored QI intervention improves the implementation of a health system-wide, guideline-driven policy on opioid prescribing in primary care. This manuscript describes the protocol for this QI project.

Methods

A health system with 28 primary care clinics caring for approximately 294,000 primary care patients developed and implemented a guideline-driven policy on long-term opioid therapy in adults with opioid-treated chronic non-cancer pain (estimated N = 3980). The policy provided multiple recommendations, including the universal use of treatment agreements, urine drug testing, depression and opioid misuse risk screening, and standardized documentation of the chronic pain diagnosis and treatment plan. The project team drew upon existing guidelines, feedback from end-users, experts and health system leadership to develop a robust QI intervention, targeting clinic-level implementation of policy-directed practices. The resulting multi-pronged QI intervention included clinic-wide and individual clinician-level educational interventions. The QI intervention will augment the health system’s “routine rollout” method, consisting of a single educational presentation to clinicians in group settings and a separate presentation for staff. A stepped-wedge design will enable 9 primary care clinics to receive the intervention and assessment of within-clinic and between-clinic changes in adherence to the policy items measured by clinic-level electronic health record-based measures and process measures of the experience with the intervention.

Discussion

Developing methods for a health system-tailored QI intervention required a multi-step process to incorporate end-user feedback and account for the needs of targeted clinic team members. Delivery of such tailored QI interventions has the potential to enhance uptake of opioid therapy management policies in primary care. Results from this study are anticipated to elucidate the relative value of such QI activities.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3227-2) contains supplementary material, which is available to authorized users.

Cost of opioid-treated chronic low back pain: Findings from a pilot randomized controlled trial of mindfulness meditation-based intervention

OBJECTIVE

Opioid-treated chronic low back pain (CLBP) is debilitating, costly, and often refractory to existing treatments. This secondary analysis aims to pilot-test the hypothesis that mindfulness meditation (MM) can reduce economic burden related to opioid-treated CLBP.

DESIGN

Twenty-six-week unblinded pilot randomized controlled trial, comparing MM, adjunctive to usual-care, to usual care alone.

SETTING

Outpatient.

PARTICIPANTS

Thirty-five adults with opioid-treated CLBP (≥30 morphine-equivalent mg/day) for 3 + months enrolled; none withdrew.

INTERVENTION

Eight weekly therapist-led MM sessions and at-home practice.

OUTCOME MEASURES

Costs related to self-reported healthcare utilization, medication use (direct costs), lost productivity (indirect costs), and total costs (direct + indirect costs) were calculated for 6-month pre-enrollment and postenrollment periods and compared within and between the groups.

RESULTS

Participants (21 MM; 14 control) were 20 percent men, age 51.8 ± 9.7 years, with severe disability, opioid dose of 148.3 ± 129.2 morphine-equivalent mg/d, and individual annual income of $18,291 ± $19,345. At baseline, total costs were estimated at $15,497 ± 13,677 (direct: $10,635 ± 9,897; indirect: $4,862 ± 7,298) per participant. Although MM group participants, compared to controls, reduced their pain severity ratings and pain sensitivity to heat stimuli (p < 0.05), no statistically significant within-group changes or between-group differences in direct and indirect costs were noted.

CONCLUSIONS

Adults with opioid-treated CLBP experience a high burden of disability despite the high costs of treatment. Although this pilot study did not show a statistically significant impact of MM on costs related to opioid-treated CLBP, MM can improve clinical outcomes and should be assessed in a larger trial with long-term follow-up.

A randomized matched-pairs study of feasibility, acceptability, and effectiveness of systems consultation: a novel implementation strategy for adopting clinical guidelines for Opioid prescribing in primary care

Background

This paper reports on the feasibility, acceptability, and effectiveness of an innovative implementation strategy named “systems consultation” aimed at improving adherence to clinical guidelines for opioid prescribing in primary care. While clinical guidelines for opioid prescribing have been developed, they have not been widely implemented, even as opioid abuse reaches epidemic levels.

Methods

We tested a blended implementation strategy consisting of several discrete implementation strategies, including audit and feedback, academic detailing, and external facilitation. The study compares four intervention clinics to four control clinics in a randomized matched-pairs design. Each systems consultant aided clinics on implementing the guidelines during a 6-month intervention consisting of monthly site visits and teleconferences/videoconferences. The mixed-methods evaluation employs the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Quantitative outcomes are compared using time series analysis. Qualitative methods included focus groups, structured interviews, and ethnographic field techniques.

Results

Seven clinics were randomly approached to recruit four intervention clinics. Each clinic designated a project team consisting of six to eight staff members, each with at least one prescriber. Attendance at intervention meetings was 83%. More than 80% of staff respondents agreed or strongly agreed with the statements: “I am more familiar with guidelines for safe opioid prescribing” and “My clinic’s workflow for opioid prescribing is easier.” At 6 months, statistically significant improvements were noted in intervention clinics in the percentage of patients with mental health screens, treatment agreements, urine drug tests, and opioid-benzodiazepine co-prescribing. At 12 months, morphine-equivalent daily dose was significantly reduced in intervention clinics compared to controls. The cost to deliver the strategy was $7345 per clinic. Adaptations were required to make the strategy more acceptable for primary care. Qualitatively, intervention clinics reported that chronic pain was now treated using approaches similar to those employed for other chronic conditions, such as hypertension and diabetes.

Conclusions

The systems consultation implementation strategy demonstrated feasibility, acceptability, and effectiveness in a study involving eight primary care clinics. This multi-disciplinary strategy holds potential to mitigate the prevalence of opioid addiction and ultimately may help to improve implementation of clinical guidelines across healthcare.

Trial registration

ClinicalTrials.gov (NCT02433496). https://clinicaltrials.gov/ct2/show/NCT02433496

Registered May 5, 2015

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0713-1) contains supplementary material, which is available to authorized users.

Racial discrimination mediates race differences in sleep problems: A longitudinal analysis

OBJECTIVES

To examine changes in sleep problems over a 1.5-year period among Black or African American (AA) and White or European American (EA) college students and to consider the role of racial discrimination as a mediator of race differences in sleep problems over time.

METHOD

Students attending a large, predominantly White university (N = 133, 41% AA, 57% female, mean age = 18.8, SD = .90) reported on habitual sleep characteristics and experiences of racial discrimination at baseline and follow-up assessments. A latent variable for sleep problems was assessed from reports of sleep latency, duration, efficiency, and quality. Longitudinal models were used to examine race differences in sleep problems over time and the mediating role of perceived discrimination. Covariates included age, gender, parent education, parent income, body mass index, self-rated physical health, and depressive symptoms. Each of the individual sleep measures was also examined separately, and sensitivity analyses were conducted using alternative formulations of the sleep problems measure.

RESULTS

AAs had greater increases in sleep problems than EAs. Perceived discrimination was also associated with increases in sleep problems over time and mediated racial disparities in sleep. This pattern of findings was similar when each of the sleep indicators was considered separately and held with alternative sleep problems measures.

CONCLUSIONS

The findings highlight the importance of racial disparities in sleep across the college years and suggest that experiences of discrimination contribute to group disparities. (PsycINFO Database Record

Racial and socioeconomic disparities in body mass index among college students: understanding the role of early life adversity

The role of early life adversity (ELA) in the development of health disparities has not received adequate attention. The current study examined differential exposure and differential vulnerability to ELA as explanations for socioeconomic and racial disparities in body mass index (BMI). Data were derived from a sample of 150 college students (M age  = 18.8, SD = 1.0; 45 % African American; 55 % European American) who reported on parents' education and income as well as on exposure to 21 early adverse experiences. Body measurements were directly assessed to determine BMI. In adjusted models, African American students had higher BMI than European Americans. Similarly, background socioeconomic status was inversely associated with BMI. Significant mediation of group disparities through the pathway of ELA was detected, attenuating disparities by approximately 40 %. Furthermore, ELA was more strongly associated with BMI for African Americans than for European Americans. Efforts to achieve health equity may need to more fully consider early adversity.