Evaluation of peer recovery services for substance use disorder in Minnesota: Impact of peer recovery initiation on SUD treatment and recovery.

Substance use disorder (SUD) remains one of the most persistent public health challenges across the nation and in Minnesota. One intervention to help people with SUD is peer recovery services (PRS). PRS is a form on non-clinical support where trained individuals who are more established in recovery come alongside people currently in the recovery journey and provide guidance in the treatment process, help in accessing resources, and offer an empathetic ear. In combination with other services in the continuum of care, PRS seeks to reduce harm from disordered use. In 2018, Minnesota made PRS for SUD a Medicaid reimbursable service. While prior literature demonstrates promising effects of PRS for SUD, especially in treatment retention and participant experience, most studies evaluated PRS in limited settings, rather than in a large-scale implementation. Our retrospective, matched-cohort study used administrative data to estimate the impact of initiating Medicaid-reimbursable PRS for SUD on treatment, overdose, and mortality. Our results align, in some dimensions, with prior literature evaluating smaller-scale programs with positive impacts on treatment completion. We also find, however, that PRS at scale did not produce other positive outcomes that past studies have documented, particularly around overdose and inpatient treatment. This suggests that PRS follows a common challenge of implementing promising ideas at scale.

Association of Project ECHO Training With Buprenorphine Prescribing by Primary Care Clinicians in Minnesota for Treating Opioid Use Disorder.

Importance: Buprenorphine is an approved medication for opioid use disorder (MOUD); however, prescribing buprenorphine is limited by a requirement to obtain a waiver to prescribe it (hereinafter, "DATA [Drug Abuse Treatment Act]-waiver") and a lack of knowledge of the best practices among clinicians. Objective: To examine how Project ECHO (Extension for Community Healthcare Outcomes) telementoring is associated with changes in DATA-waiver attainment and buprenorphine prescribing among primary care clinicians in Minnesota. Design, Setting, and Participants: In this retrospective matched-cohort study of 918 clinicians, ECHO-trained clinicians were enrolled on the date they first attended ECHO (January 3, 2018, to June 11, 2020); comparison clinicians were assigned an enrollment date from the distribution of the first ECHO sessions. The baseline period was 12 months preceding enrollment, with follow-up for 18 months or until June 30, 2020. The ECHO-trained clinicians were a population-based sample of primary care clinicians who treated Medicaid patients in Minnesota 12 months prior to the initiation of ECHO training. This analysis used propensity score matching to select comparison clinicians who were similar across demographic and clinical practice characteristics at baseline in a 2:1 ratio. Follow-up was available for 167 ECHO-trained clinicians (54.6%) and 330 comparison clinicians (53.9%) at 18 months. Exposures: ECHO-trained clinicians attended at least 1 weekly, hour-long ECHO session. Comparison clinicians never participated in any ECHO sessions. Main Outcomes and Measures: DATA-waiver attainment, any buprenorphine prescribing, and the percentage of patients with opioid use disorder (OUD) who were prescribed buprenorphine. Results: The final sample included 918 clinicians (ECHO-trained [306]; comparison [612]), of whom 620 (67.5%) practiced outside the metropolitan Twin Cities (Minneapolis-St Paul) region. The mean (SD) age of the ECHO-trained clinicians was 46.0 (12.1) years and that of the comparison clinicians was 45.7 (12.3) years. Relative to the changes among the matched comparison clinicians, the ECHO-trained clinicians were more likely to obtain a DATA-waiver (difference-in-differences, 22.7 percentage points; 95% CI, 15.5-29.9 percentage points; P < .001) and prescribe any buprenorphine (16.5 percentage points; 95% CI, 10.4-22.5 percentage points; P < .001) after 6 quarters of follow-up. ECHO-trained clinicians prescribed buprenorphine to a greater share of patients with OUD (a difference of 7.6 percentage points per month; 95% CI, 4.6-10.6 percentage points per month; P < .001), relative to that prescribed by the comparison clinicians. Conclusions and Relevance: According to the findings of this matched-cohort study, ECHO telementoring may be associated with greater prescribing of buprenorphine by primary care clinicians. These findings suggest that Project ECHO training could be a useful tool for expanding access to MOUD.

Control strategies for rapid, visually guided adjustments of the foot during continuous walking.

When walking over stable, complex terrain, visual information about an upcoming foothold is primarily utilized during the preceding step to organize a nearly ballistic forward movement of the body. However, it is often necessary to respond to changes in the position of an intended foothold that occur around step initiation. Although humans are capable of rapidly adjusting foot trajectory mid-swing in response to a perturbation of target position, such movements may disrupt the efficiency and stability of the gait cycle. In the present study, we consider whether walkers sometimes adopt alternative strategies for responding to perturbations that interfere less with ongoing forward locomotion. Subjects walked along a path of irregularly spaced stepping targets projected onto the ground, while their movements were recorded by a full-body motion-capture system. On a subset of trials, the location of one target was perturbed in either a medial-lateral or anterior-posterior direction. We found that subjects were best able to respond to perturbations that occurred during the latter half of the preceding step and that responses to perturbations that occurred during a step were less successful than previously reported in studies using a single-step paradigm. We also found that, when possible, subjects adjusted the ballistic movement of their center of mass in response to perturbations. We conclude that, during continuous walking, strategies for responding to perturbations that rely on reach-like movements of the foot may be less effective than previously assumed. For perturbations that are detected around step initiation, walkers prefer to adapt by tailoring the global, pendular mechanics of the body.

The pickup of visual information about size and location during approach to an obstacle.

The present study investigated differences in the pickup of information about the size and location of an obstacle in the path of locomotion. The main hypothesis was that information about obstacle location is most useful when it is sampled at a specific time during the approach phase, whereas information about obstacle size can be sampled at any point during the last few steps. Subjects approached and stepped over obstacles in a virtual environment viewed through a head-mounted display. In Experiment 1, a horizontal line on the ground indicating obstacle location was visible throughout the trial while information about obstacle height and depth was available only while the subject was passing through a viewing window located at one of four locations along the subject's path. Subjects exhibited more cautious behavior when the obstacle did not become visible until they were within one step length, but walking behavior was at most weakly affected in the other viewing window conditions. In Experiment 2, the horizontal line indicating obstacle location was removed, such that no information about the obstacle (size or location) was available outside of the viewing window. Subjects adopted a more cautious strategy compared to Experiment 1 and differences between the viewing window conditions and the full vision control condition were observed across several measures. The differences in walking behavior and performance across the two experiments support the hypothesis that walkers have greater flexibility in when they can sample information about obstacle size compared to location. Such flexibility may impact gaze and locomotor control strategies, especially in more complex environments with multiple objects and obstacles.

Visual regulation of gait: Zeroing in on a solution to the complex terrain problem.

We examine the theoretical understanding of visual gait regulation that has emerged from decades of research since the publication of Lee, Lishman, and Thompson's (1982) classic study of elite long jumpers. The first round of research identified specific informational variables, parameters of the action system, and laws of control that capture the coupling of perception and action in this context, but left unanswered important questions about why visual information is sampled in an intermittent manner and how the strategies that actors adopt ensure stability and energetic efficiency. More recent developments lead to a refined view according to which visual information is used at a specific phase of the gait cycle to modify the parameters that govern the passive dynamics of the body. We then present the results of a new experiment designed to test the prediction that when the terrain offers multiple foothold options for a given step, walkers' choices will be constrained by a strong preference for not interfering with the natural, ballistic movement of the body throughout the single support phase of that step. The findings are consistent with this prediction and support a view of visual gait regulation that is concordant with contemporary accounts of how actors use both active and passive modes of control. (PsycINFO Database Record

The critical phase for visual control of human walking over complex terrain.

To walk efficiently over complex terrain, humans must use vision to tailor their gait to the upcoming ground surface without interfering with the exploitation of passive mechanical forces. We propose that walkers use visual information to initialize the mechanical state of the body before the beginning of each step so the resulting ballistic trajectory of the walker's center-of-mass will facilitate stepping on target footholds. Using a precision stepping task and synchronizing target visibility to the gait cycle, we empirically validated two predictions derived from this strategy: (1) Walkers must have information about upcoming footholds during the second half of the preceding step, and (2) foot placement is guided by information about the position of the target foothold relative to the preceding base of support. We conclude that active and passive modes of control work synergistically to allow walkers to negotiate complex terrain with efficiency, stability, and precision.

The biomechanics of walking shape the use of visual information during locomotion over complex terrain.

The aim of this study was to examine how visual information is used to control stepping during locomotion over terrain that demands precision in the placement of the feet. More specifically, we sought to determine the point in the gait cycle at which visual information about a target is no longer needed to guide accurate foot placement. Subjects walked along a path while stepping as accurately as possible on a series of small, irregularly spaced target footholds. In various conditions, each of the targets became invisible either during the step to the target or during the step to the previous target. We found that making targets invisible after toe off of the step to the target had little to no effect on stepping accuracy. However, when targets disappeared during the step to the previous target, foot placement became less accurate and more variable. The findings suggest that visual information about a target is used prior to initiation of the step to that target but is not needed to continuously guide the foot throughout the swing phase. We propose that this style of control is rooted in the biomechanics of walking, which facilitates an energetically efficient strategy in which visual information is primarily used to initialize the mechanical state of the body leading into a ballistic movement toward the target foothold. Taken together with previous studies, the findings suggest the availability of visual information about the terrain near a particular step is most essential during the latter half of the preceding step, which constitutes a critical control phase in the bipedal gait cycle.