Accessibility of Opioid Treatment Programs Based on Conventional vs Perceived Travel Time Measures.

Importance: Transportation barriers have long been associated with poorer health outcomes; this burden is especially acute for individuals with opioid use disorder (OUD), a chronic disease often associated with low socioeconomic status. Conventional travel time analyses may not fully account for experiential components of travel, thereby understating the true travel burden and overstating treatment accessibility to opioid treatment programs (OTPs). Objective: To develop a metric of feels-like accessibility for those using public transit to access OTPs that accounts for the realistic travel burden on individuals with OUD. Design, Setting, and Participants: This cross-sectional study integrated high-resolution transit schedules and operating hours of OTPs to measure feels-like accessibility. Feels-like accessibility considers the differential outcomes of out-of-vehicle travel components and more realistically reflects individuals' transportation burden than conventional accessibility measures. Gini indices and spatial regression models were used to investigate inequities in accessibility. Geocoded data for residential addresses of 1018 overdose fatalities in Connecticut in 2019 were used as a proxy for the treatment needs of individuals with OUD. Data were analyzed between May and August 2023. Main Outcomes and Measures: Conventional and feels-like accessibility scores. Exposures: Fluctuations in public transit frequencies over the course of the day and the limited operating hours of the OTPs. Results: Of the 1018 individuals in the study, the mean (SD) age at death was 43.7 (12.6) years, 784 individuals (77%) were men, 111 (11%) were African American, and 889 (87%) were White, with other racial and ethnic categories including 18 individuals (2%). A total of 264 individuals in the sample (26%) could not access an OTP within 180 minutes. For those who could access these facilities, the average 1-way travel time was 45.6 minutes, with individuals spending approximately 70% of their trip duration on out-of-vehicle travel components. The conventional accessibility metric underestimates individuals' travel burden to OTPs as well as the inequity in accessibility compared with the feels-like accessibility metric. For example, the median (range) conventional accessibility score, defined as the number of OTPs within 120 minutes of transit travel time, was 5.0 (0.0-17.0); the median (range) feels-like accessibility score, defined as the number of OTPs within 120 minutes of transit travel time weighted to account for in- and out-of-vehicle segments, was 1.0 (0.0-10.0). There is a considerable temporal variation in travel time and accessibility depending on the departure times. Conclusions and Relevance: In this cross-sectional study of travel burdens, the calculated feels-like accessibility scores, which consider the differential outcomes of out-of-vehicle travel components (eg, walking and waiting), could better and more realistically reflect passengers' transportation burden. Policy recommendations derived from the conventional accessibility metric could be misleading, and decision-makers should use feels-like accessibility metrics that adequately capture individuals' travel burdens. In the context of access to OTPs, the findings from this study suggest that opening new OTP sites to address gaps in access due to distance to services or extending hours of operation at existing sites may ameliorate the travel burden for individuals.

Expanding access to methadone treatment in Ohio through federally qualified health centers and a chain pharmacy: A geospatial modeling analysis.

BACKGROUND: In the United States, methadone provision for opioid use disorder (OUD) occurs at opioid treatment programs (OTPs). Ohio recently enacted a policy to expand methadone administration to Federally Qualified Health Centers (FQHC). We compared how the provision of methadone at current OTPs or the proposed expansion to FQHCs and pharmacies meets the urban and rural need for OUD treatment. METHODS: Cross-sectional geospatial analysis of zip codes within Ohio with at least one 2017 opioid overdose death stratified by Rural-Urban Commuting Area codes. Our primary outcome was the proportion of need by zip code (using opioid overdose deaths as a proxy for need) within a 15- or 30- minute drive time of an OTP. RESULTS: Among 581 zip codes, sixty four percent of treatment need was within a 15-minute drive time and 81 %, within a 30-minute drive time. The proportion of need within a 15-minute drive decreased with increasing rural classification (urban 78 %, suburban 20 %, large rural 9%, and small rural 1%;p<.001). The portion of need within a 15-minute drive time increased with the addition of FQHCs (96 %) and the addition of chain pharmacies (99 %) relative to OTPs alone among all zip codes and for all urban-rural strata (p<.001). CONCLUSION: Over one-third of OUD treatment need was not covered by existing OTPs and coverage decreased with rural classification of zip codes. Most of the gap between supply and need could be mitigated with FQHC methadone provision, which would expand both urban and rural access.

Veterans' compensation claims beliefs predict timing of PTSD treatment use relative to compensation and pension exam.

INTRODUCTION: In this study we developed the Disability Beliefs Scale to assess Veterans' beliefs that engaging in treatment, as well as other behaviors, would affect the likelihood of a Veteran's being awarded disability-related benefits. We posited that Veterans with stronger beliefs that attending mental health treatment would facilitate a service-connection award would be more likely to attend PTSD treatment before their compensation and pension examinations for PTSD. METHODS: Electronic health records for 307 post-9/11-era Veterans applying for compensation and pension for service-connected PTSD and engaging in a clinical trial of a treatment-referral intervention were analyzed for PTSD-specific and more general mental health treatment use around the time of their compensation examinations. All participants completed the Disability Beliefs Scale and other baseline assessments. Multilevel models assessed change in treatment use as a function of time relative to the C&P exam, compensation examination status (before or after), and the interaction between examination status and beliefs about treatment benefits. RESULTS: No main effects of time or examination status were observed. As hypothesized, beliefs about treatment benefits moderated the effect of examination status on PTSD treatment use. Veterans believing more strongly that mental health treatment would help a claim differentially attended PTSD treatment before the examination than after. The effect was not observed for general mental health treatment use. CONCLUSION: The association between Veterans' use of PTSD treatment and their service-connection examination status was moderated by beliefs that receiving treatment affects the service-connection decision. This suggests that factors reported to motivate seeking service-connection-finances, validation of Veterans' experiences, and the involvement of significant others-might also help motivate Veterans' use of effective PTSD treatments. However, the results reflect correlations that could be explained in other ways, and service-connection was one of many factors impacting PTSD treatment engagement.

Effortless awareness: using real time neurofeedback to investigate correlates of posterior cingulate cortex activity in meditators' self-report.

Neurophenomenological studies seek to utilize first-person self-report to elucidate cognitive processes related to physiological data. Grounded theory offers an approach to the qualitative analysis of self-report, whereby theoretical constructs are derived from empirical data. Here we used grounded theory methodology (GTM) to assess how the first-person experience of meditation relates to neural activity in a core region of the default mode network-the posterior cingulate cortex (PCC). We analyzed first-person data consisting of meditators' accounts of their subjective experience during runs of a real time fMRI neurofeedback study of meditation, and third-person data consisting of corresponding feedback graphs of PCC activity during the same runs. We found that for meditators, the subjective experiences of "undistracted awareness" such as "concentration" and "observing sensory experience," and "effortless doing" such as "observing sensory experience," "not efforting," and "contentment," correspond with PCC deactivation. Further, the subjective experiences of "distracted awareness" such as "distraction" and "interpreting," and "controlling" such as "efforting" and "discontentment," correspond with PCC activation. Moreover, we derived several novel hypotheses about how specific qualities of cognitive processes during meditation relate to PCC activity, such as the difference between meditation and "trying to meditate." These findings offer novel insights into the relationship between meditation and mind wandering or self-related thinking and neural activity in the default mode network, driven by first-person reports.

Real-time fMRI links subjective experience with brain activity during focused attention.

Recent advances in brain imaging have improved the measure of neural processes related to perceptual, cognitive and affective functions, yet the relation between brain activity and subjective experience remains poorly characterized. In part, it is a challenge to obtain reliable accounts of participant's experience in such studies. Here we addressed this limitation by utilizing experienced meditators who are expert in introspection. We tested a novel method to link objective and subjective data, using real-time fMRI (rt-fMRI) to provide participants with feedback of their own brain activity during an ongoing task. We provided real-time feedback during a focused attention task from the posterior cingulate cortex, a hub of the default mode network shown to be activated during mind-wandering and deactivated during meditation. In a first experiment, both meditators and non-meditators reported significant correspondence between the feedback graph and their subjective experience of focused attention and mind-wandering. When instructed to volitionally decrease the feedback graph, meditators, but not non-meditators, showed significant deactivation of the posterior cingulate cortex. We were able to replicate these results in a separate group of meditators using a novel step-wise rt-fMRI discovery protocol in which participants were not provided with prior knowledge of the expected relationship between their experience and the feedback graph (i.e., focused attention versus mind-wandering). These findings support the feasibility of using rt-fMRI to link objective measures of brain activity with reports of ongoing subjective experience in cognitive neuroscience research, and demonstrate the generalization of expertise in introspective awareness to novel contexts.

Mindfulness training for smoking cessation: moderation of the relationship between craving and cigarette use.

BACKGROUND: Smoking is the leading cause of preventable death in the US, while abstinence rates remain modest. Smoking has been shown to be perpetuated by operant conditioning, notably negative reinforcement (e.g., smoking to relieve negative affective states). Mindfulness training (MT) shows promise for smoking cessation, by potentially altering an individual's tendency to smoke in response to craving. The purpose of this study was to examine the effects of MT and mindfulness practice on the relationship between smoking and craving after receiving four weeks of MT. METHODS: 33 adults received MT as part of a randomized trial for smoking cessation. Individuals in the MT condition recorded formal and informal mindfulness practice during treatment using daily diaries. RESULTS: Analyses showed that strong correlations between craving and smoking at baseline (r=0.582) were attenuated at the end of treatment (r=0.126). Mindfulness home practice significantly predicted cigarette use (formal: B=-1.21, p=0.007; informal: B=-1.52, p<0.0001) and informal practice moderated the relationship between craving and smoking at the end of treatment (B=0.52, p=0.03). CONCLUSIONS: These findings suggest that MT may be effective as a treatment for smoking cessation and that informal mindfulness practice predicts a decoupling of the association between craving and smoking.