Decreases in smoking during treatment for methamphetamine-use disorders: preliminary evidence.

Despite high rates of smoking (70-90%) and the severely negative impact of smoking on physical and mental health, only 12% of individuals receiving stimulant-use disorder treatment also receive smoking-cessation treatment. The aim of this investigation was to examine the effect of a contingency management (CM) intervention targeting methamphetamine (MA) use on cigarette smoking. Sixty-one adults with MA-use disorders who were smokers were assigned to CM or standard psychosocial treatment. Rates of smoking-negative breath samples (carbon monoxide <3 ppm) were compared between the two groups while controlling for baseline carbon monoxide level, marijuana use, MA use, and time. This subgroup of mostly male (59%) participants included 44 participants in the CM group and 17 participants in the standard psychosocial treatment. Tobacco smoking participants who received CM targeting MA use were 140% (odds ratio: 2.395; 95% confidence interval: 1.073-5.346) more likely to submit a smoking-negative breath sample relative to standard psychosocial treatment during the treatment period, holding constant several other prespecified covariates. This study provides evidence that a behavioral treatment for MA use results in reductions in cigarette smoking in adults with MA-use disorder.

A Randomized Controlled Trial of a Citywide Emergency Department Care Coordination Program to Reduce Prescription Opioid Related Emergency Department Visits.

BACKGROUND: Increasing prescription overdose deaths have demonstrated the need for safer emergency department (ED) prescribing practices for patients who are frequent ED users. OBJECTIVES: We hypothesized that the care of frequent ED users would improve using a citywide care coordination program combined with an ED care coordination information system, as measured by fewer ED visits by and decreased controlled substance prescribing to these patients. METHODS: We conducted a multisite randomized controlled trial (RCT) across all EDs in a metropolitan area; 165 patients with the most ED visits for complaints of pain were randomized. For the treatment arm, drivers of ED use were identified by medical record review. Patients and their primary care providers were contacted by phone. Each patient was discussed at a community multidisciplinary meeting where recommendations for ED care were formed. The ED care recommendations were stored in an ED information exchange system that faxed them to the treating ED provider when the patient presented to the ED. The control arm was subjected to treatment as usual. RESULTS: The intervention arm experienced a 34% decrease (incident rate ratios = 0.66, p < 0.001; 95% confidence interval 0.57-0.78) in ED visits and an 80% decrease (odds ratio = 0.21, p = 0.001) in the odds of receiving an opioid prescription from the ED relative to the control group. Declines of 43.7%, 53.1%, 52.9%, and 53.1% were observed in the treatment group for morphine milligram equivalents, controlled substance pills, prescriptions, and prescribers, respectively. CONCLUSION: This RCT showed the effectiveness of a citywide ED care coordination program in reducing ED visits and controlled substance prescribing.

Examining Longitudinal Stimulant Use and Treatment Attendance as Parallel Outcomes in Two Contingency Management Randomized Clinical Trials.

The primary aim of this study was to examine stimulant use and longitudinal treatment attendance in one 'parallel outcomes' model in order to determine how these two outcomes are related to one another during treatment, and to quantify how the intervention impacts these two on- and off-target outcomes differently. Data came from two multi-site randomized clinical trials (RCTs) of contingency management (CM) that targeted stimulant use. We used parallel multilevel modeling to examine the impact of multiple pre-specified covariates, including selected Addiction Severity Index (ASI) scores, age and sex, in addition to CM on concurrent attendance and stimulant use in two separate analyses, i.e., one per trial. In one trial, CM was positively associated with attending treatment throughout the trial (ß=0.060, p<0.05). In the second trial, CM predicted negative urinalysis ((-)UA) over the 12-week treatment period (ß=0.069, p<0.05). In both trials, there was a significant, positive relationship between attendance and (-)UA submission, but in the first trial a (-)UA at both baseline and over time was related to attendance over time (r=0.117; r=0.013, respectively) and in the second trial, a (-)UA submission at baseline was associated with increased attendance over time (r=0.055). These findings indicate that stimulant use and treatment attendance over time are related but distinct outcomes that, when analyzed simultaneously, portray a more informative picture of their predictors and the separate trajectories of each. This 'indirect reinforcement' between two clinically meaningful on-target (directly reinforced behavior) and off-target (indirectly reinforced behavior) outcomes is in need of further examination in order to fully exploit the potential clinical benefits that could be realized in substance use disorder treatment trials.

Nurses' Perceptions of Caring for Childbearing Women who Misuse Opioids.

PURPOSE: This study explored obstetric nurses' perceptions of providing inpatient care during labor, birth, and postpartum to pregnant and parenting women with histories of misusing opioids. Specific aims included to 1) describe common themes associated with nurses' perceptions of caring for this population, and 2) identify specific areas for intervention development. STUDY DESIGN AND METHODS: Grounded theory methods, as described by Corbin and Strauss, were used to guide data collection and to identify common themes. Initially, eight inpatient obstetric nurses working in large, urban birthing centers in Washington State were interviewed using semistructured interviews. Follow-up interviews with four of the nurses were conducted to validate emergent themes. RESULTS: Four themes were derived: needing more knowledge, feeling challenged, expressing concern for mother and infant, and knowing the truth. CLINICAL IMPLICATIONS: The four themes can have an impact on nursing practice and patient outcomes by providing specific areas for intervention development focusing on this population of vulnerable women. Nurses described several ideas for intervention development including continuing education offerings relevant to caring for mothers who misuse opioids, collaborating with providers to design education, reevaluating pain-management philosophies and practices at all levels, and working with social workers to explore available and needed community resources. Future research includes the evaluation of newly developed personalized interventions; the examination of the empirical linkages among key mother and child health outcomes; the delivery of specific nursing therapeutics; and the exploration of providers' and patients' perceptions and knowledge of opioid misuse during pregnancy, birth, and beyond.

Sleep disruption and decline in marital satisfaction across the transition to parenthood.

Despite the joy surrounding the birth of a child, numerous studies have documented a robust decline in marital satisfaction across the transition to parenthood. Various hypotheses, each supported by empirical evidence, have sought to explain this decline. This review considers the additional role of sleep loss in the postpartum decline in marital satisfaction. The authors begin by highlighting the problem of parental sleep disruption in a child's 1st year of life and then outline findings related to the affective and cognitive consequences of sleep deprivation and chronic sleep restriction. The demands brought on by the transition to parenthood are reviewed, and the ways in which the consequences of sleep disruption further exacerbate these stresses are considered. The authors suggest that clinicians working with couples who have recently had a child evaluate the extent of sleep disturbance in the family and educate couples regarding the mood and cognitive changes that co-occur with sleep loss. The authors further suggest that future research into the transition to parenthood assess level of sleep loss and that research into the consequences of sleep loss aim to identify individuals particularly vulnerable to mood and cognition changes.