Mindfulness-Oriented Recovery Enhancement for Veterans and Military Personnel on Long-Term Opioid Therapy for Chronic Pain: A Randomized Clinical Trial.

OBJECTIVE: This randomized clinical trial evaluated the efficacy of Mindfulness-Oriented Recovery Enhancement (MORE) among past and present U.S. military personnel with prescriptions for long-term opioid therapy for chronic pain. METHODS: In this clinical trial, 230 past and present military personnel with prescriptions for long-term opioid therapy were randomized in a 1:1 ratio to MORE or supportive psychotherapy (initially delivered in person and then via videoconferencing after the onset of the COVID-19 pandemic). Primary outcomes were chronic pain, measured by the Brief Pain Inventory, and aberrant drug-related behaviors, measured by the Current Opioid Misuse Measure, through 8 months of follow-up. Opioid dose was a key secondary outcome. Other outcomes included psychiatric symptoms, catastrophizing, positive affect, ecological momentary assessments of opioid craving, and opioid attentional bias. RESULTS: MORE was superior to supportive psychotherapy through the 8-month follow-up in reducing pain-related functional interference, pain severity, and opioid dose. MORE reduced daily opioid dose by 20.7%, compared with a dose reduction of 3.9% with supportive psychotherapy. Although there was no overall between-group difference in opioid misuse, the in-person MORE intervention outperformed supportive psychotherapy for reducing opioid misuse. MORE reduced anhedonia, pain catastrophizing, craving, and opioid attentional bias and increased positive affect to a greater extent than supportive psychotherapy. MORE also modulated therapeutic processes, including mindful reinterpretation of pain sensations, nonreactivity, savoring, positive attention, and reappraisal. CONCLUSIONS: Among past and present U.S. military personnel, MORE led to sustained decreases in chronic pain, opioid use, craving, and opioid cue reactivity. MORE facilitated opioid dose reduction while preserving adequate pain control and preventing mood disturbances, suggesting its utility for safe opioid tapering.

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.

Assessing the Potential Efficacy of an Intervention for Incarcerated People With Mental Illness.

OBJECTIVE: This preliminary study tested the efficacy of an evidence-based correctional intervention (Thinking for a Change) with an adapted delivery to incarcerated people with mental illness. METHODS: A small-scale randomized controlled trial (N=47 men) was conducted. Outcomes were changes in aggression, number of behavioral infractions, and days in administrative segregation. Treatment targets were impulsivity, interpersonal problem-solving skills, and attitudes supportive of crime. Linear mixed-effects models were used to examine within-person and between-group differences over time, and nonparametric tests were used to examine between-group differences in criminal legal outcomes postintervention. RESULTS: Statistically significant within-person differences were found for all treatment targets and for one study outcome (aggression). Statistically significant differences in impulsivity were found between the experimental and control groups (B=-7.10, p=0.02). CONCLUSIONS: Existing evidence-based correctional interventions can affect the lives of people with mental illness. Accelerated research in this area may benefit people with mental illness at high risk for criminal legal system involvement.

Feasibility of recruiting in prisons during a randomized controlled trial with people with serious mental illness.

BACKGROUND: Successful participant recruitment is vital to the feasibly of intervention research. In the behavioral and social sciences, intervention researchers face a myriad of recruitment barriers, many of which stem from working in real-world settings and among hard-to-access populations. Optimizing recruitment efforts requires being intentional about study planning and resource allocation, carefully documenting the outcomes of recruitment efforts, and developing and implementing procedures and strategies to overcome anticipated recruitment barriers. METHODS: The current article presents recruitment flowcharts to illustrate (a) the multistep recruitment process and (b) the points of potential participant attrition during recruitment from a two-phase group-based intervention study conducted among individuals with serious mental illness incarcerated in a state prison system in the U.S. In addition, qualitative methods are used to examine strategies employed during the study to support recruitment efforts. RESULTS: Despite challenges, this study was able to achieve recruitment goals. Analyses found the majority of potential participant attrition occurred prior to informed consent, highlighting the need for studies to track recruitment efforts in more detail than is currently recommended by commonly used guidelines. Strategies to optimize recruitment efforts included maximizing recruiter availability, developing a responsive communication approach, demonstrating respect for facility procedures and operations, and ensuring peak preparedness. CONCLUSION: Careful documentation of recruitment efforts and the early deployment of recruitment strategies is vital to the feasibility of intervention studies conducted in real-world settings with hard-to-access populations. The publication of recruitment procedures and outcomes can help future researchers anticipate recruitment challenges and inform recruitment goals, timelines, and strategies.

The Relationship Between a Lifetime History of Sexual Victimization and Perinatal Depression: A Systematic Review and Meta-Analysis.

BACKGROUND: The association between a lifetime history of sexual victimization and the well-being of women during the perinatal period has received increasing attention. However, research investigating this relationship has yet to be systematically reviewed or quantitatively synthesized. AIM: This systematic review and meta-analysis aims to calculate the pooled effect size estimate of the statistical association between a lifetime history of sexual victimization and perinatal depression (PND). METHOD: Four bibliographic databases were systematically searched, and reference harvesting was conducted to identify peer-reviewed articles that empirically examined associations between a lifetime history of sexual victimization and PND. A random effects model was used to ascertain an overall pooled effect size estimate in the form of an odds ratio and corresponding 95% confidence intervals (CIs). Subgroup analyses were also conducted to assess whether particular study features and sample characteristic (e.g., race and ethnicity) influenced the magnitude of effect size estimates. RESULTS: This review included 36 studies, with 45 effect size estimates available for meta-analysis. Women with a lifetime history of sexual victimization had 51% greater odds of experiencing PND relative to women with no history of sexual victimization (OR = 1.51, 95% CI [1.35, 1.67]). Effect size estimates varied considerably according to the PND instrument used in each study and the racial/ethnic composition of each sample. CONCLUSION: Findings provide compelling evidence for an association between a lifetime history of sexual victimization and PND. Future research should focus on screening practices and interventions that identify and support survivors of sexual victimization perinatally.

Mindfulness-Oriented Recovery Enhancement for Addictive Behavior, Psychiatric Distress, and Chronic Pain: A Multilevel Meta-Analysis of Randomized Controlled Trials.

Objectives: Mindfulness-Oriented Recovery Enhancement (MORE) is an integrative intervention designed to ameliorate addiction, chronic pain, and psychiatric symptoms. Although multiple randomized controlled trials (RCTs) have examined the clinical efficacy of MORE, no study has quantitatively synthesized this body of research. Thus, we conducted a meta-analysis of RCTs examining the effects of MORE on addictive behaviors, craving, opioid dose, pain, and psychiatric symptoms. Methods: Relevant manuscripts were identified through comprehensive searches of four bibliographic databases. Two- and three-level random-effects models were used to generate synthesized effect size estimates, and meta-regressions were performed to examine whether study and sample characteristics influenced the magnitude of aggregate effect sizes. Results: Our search identified 16 manuscripts reporting data from eight RCTs (N = 816). Moderate to small effects in favor of MORE were observed for addictive behaviors (SMC = - .54, p = .007), craving (SMC = - .42, p = .010), opioid dose (MC = - 17.95, p < .001), chronic pain (SMC = - .60, p < .001), and psychiatric symptoms (SMC = - .34, p < .001). MORE's effects on psychiatric symptoms and craving were not moderated by participant race, gender, age, or income. Conclusions: Study findings provide empirical evidence of MORE's efficacy for a wide diversity of individuals, and as such, MORE should now be disseminated broadly throughout the healthcare system. Supplementary Information: The online version contains supplementary material available at 10.1007/s12671-022-01964-x.

Mindfulness-Oriented Recovery Enhancement reduces opioid craving, pain, and negative affect among chronic pain patients on long-term opioid therapy: An analysis of within- and between-person state effects.

Mindfulness-Oriented Recovery Enhancement (MORE) is an integrative treatment that simultaneously addresses chronic pain and opioid misuse. MORE has been found to produce sustained reductions in opioid craving, pain, and negative affect-key risk mechanisms precipitating opioid misuse for patients on long-term opioid therapy (LTOT). However, less is known about MORE's impact on state measures of acute symptoms. We examined the impact of MORE versus a supportive psychotherapy group (SG) among chronic pain patients on LTOT. Mixed models examined session and momentary effects of MORE (n = 50) versus SG (n = 45) on state measures of craving, pain, and negative affect. Decentering, curiosity, and time spent engaging in daily mindfulness practice were examined as session effect predictors. For session effects, statistically significant medium-to-large effects of treatment group were observed in favor of MORE for craving, pain, and negative affect. Higher levels of curiosity predicted improvements in craving, whereas greater decentering and mindfulness practice were associated with improvements in negative affect. For momentary effects, a significant group by time interaction was observed for craving and pain. Findings suggest that MORE provides immediate symptom relief on therapeutic targets in daily life among chronic pain patients receiving LTOT.

Emotional distress and pain catastrophizing predict cue-elicited opioid craving among chronic pain patients on long-term opioid therapy.

BACKGROUND: Individuals who use illicit substances exhibit cue-elicited craving and autonomic cue-reactivity when exposed to cues associated with past drug use. However, little is known about this phenomenon among chronic pain patients on long-term opioid therapy (LTOT). Negative cognitive-emotional reactivity in general (e.g., distress) and cognitive-emotional reactivity specific to pain (e.g., pain catastrophizing) might drive cue-reactivity independent of pain severity. Here we examined emotional distress and pain catastrophizing as predictors of cue-reactivity among a sample of chronic pain patients receiving LTOT. We also tested whether associations between distress, catastrophizing, and cue-reactivity differed as a function of opioid misuse status. MATERIALS AND METHODS: Patients receiving LTOT (N = 243) were classified as exhibiting aberrant behavior consistent with opioid misuse (MISUSE+, n = 145) or as using opioids as prescribed (MISUSE-, n = 97). Participants completed assessments of pain catastrophizing and emotional distress and then participated in an opioid cue-reactivity task one week later. Cue-elicited opioid craving and autonomic cue-reactivity were measured with craving ratings and high-frequency heart rate variability (HRV), respectively. RESULTS: Distress and catastrophizing predicted cue-elicited craving and HRV, whereas pain severity did not. Misuser status moderated the relationship between emotional distress and self-reported craving, such that higher levels of distress predicted craving among the MISUSE+ group, but not among the MISUSE- group. No moderating effects were found for catastrophizing. CONCLUSIONS: Findings suggest that although opioids are prescribed for analgesia, the exacerbating influence of negative cognitive-emotional reactivity, both in general and specific to pain, on cue-elicited opioid craving extends beyond the effects of pain severity alone.

The impact of sexual victimization on substance use disorder treatment completion: A systematic review and meta-analysis.

Background:A significant proportion of individuals seeking treatment for substance use disorders (SUDs) have experienced sexual victimization, which has been shown to disrupt the efficacy of SUD treatment services. Objective: To evaluate the relationship between lifetime sexual victimization and SUD treatment completion. Methods: Relevant literature was identified through a systematic, computerized search of nine electronic databases (May 2018) and reference harvesting, yielding 15 peer-reviewed articles published between 1992 and 2017. Two authors independently conducted title and abstract screens, full-text reviews, data abstraction, and methodological appraisals. Risk of bias was assessed using a modified mixed-methods appraisal tool. Only nine studies met criteria for the meta-analysis, which used a random-effects model. Results: Included studies yielded mixed results regarding the impact of sexual victimization on treatment completion. The meta-analysis yielded a non-significant trend of survivors of sexual victimization having slightly lower odds of completing treatment. Conclusions: Findings from this systematic review and meta-analysis did not support the impact of sexual victimization on treatment completion. Methodological limitations of the extant literature limit cross-study comparisons. Future studies should document program-related factors to improve the ability to understand relationships affecting treatment completion.

Patterns in Medicaid Coverage and Service Utilization Among People with Serious Mental Illnesses.

Disruptions in Medicaid adversely affect service use and outcomes among individuals with serious mental illnesses (SMI). A retrospective longitudinal study examined Medicaid coverage and service utilization patterns among individuals with SMI (N = 8358) from 2007 to 2010. Only 36% of participants were continuously enrolled in Medicaid and 20% experienced multiple enrollment disruptions. Mental health diagnosis did not predict continuous coverage; however, individuals with schizophrenia were 19% more likely to have multiple coverage disruptions than those with depression (b = - 0.21; p < 0.01). Single and multiple coverage disruptions were associated with decreased rates of outpatient service days utilized (IRR = 0.77 and 0.65, respectively, p < 0.001) and decreased odds of not using acute care services (OR  0.26 and 0.19, respectively, p < 0.001). Future research should explore mechanisms underlying Medicaid stability and develop interventions that facilitate insurance stability and service utilization.

A Systematic Review of Interventions Targeting Criminogenic Risk Factors Among Persons With Serious Mental Illness.

OBJECTIVE: Individuals with serious mental illness are overrepresented in the criminal justice system. Research has found that interventions targeting risk factors for recidivism (i.e., criminogenic risks) reduce justice involvement in the general correctional population. However, more needs to be learned regarding use of these interventions among individuals with serious mental illness. To this end, this systematic review synthesized research on interventions that target criminogenic risk factors and are delivered to justice-involved individuals with serious mental illness. METHODS: A systematic search of six computerized bibliographic databases from inception to 2021 yielded 8,360 potentially relevant studies. Title and abstract screening, full-text reviews, and data extraction were performed independently, and discrepancies were resolved through discussion. To identify additional articles meeting inclusion criteria, experts in the field were contacted, and reference-harvesting techniques were used. Study quality was assessed with the Mixed Methods Appraisal Tool. RESULTS: Twenty-one studies were identified that evaluated nine interventions delivered to justice-involved individuals with serious mental illness. All identified programs targeted criminogenic risk factors, were group based, and used cognitive-behavioral strategies. Study quality was moderate to high. Interventions were associated with improvements in recidivism, violence, and criminogenic risk factors. CONCLUSIONS: This review is the first to evaluate interventions targeting criminogenic risks among justice-involved individuals with serious mental illness. Findings suggest that outcomes associated with these interventions are promising. Given the overrepresentation of persons with serious mental illness in the criminal justice system, these findings provide an important step toward identifying services that curb justice involvement in this population.

Accountability in Intervention Research: Developing a Fidelity Checklist of a Mental Health Intervention in Prisons.

Adherence to intervention content and delivery protocols is vital in establishing the efficacy of treatment programs for mental illnesses. Using a fidelity tool during interventions can substantially increase the likelihood of clients receiving the most scientifically rigorous treatment. This article outlines the steps taken to develop a fidelity checklist to measure treatment adherence of a two-part intervention delivered in a prison setting. Researchers followed the five-step guide by Feely et al. (Child and Adolescent Social Work Journal, 35(2), 139-152: 2018) and describe the process of developing a fidelity tool to measure treatment adherence to a newly adapted CBT-based intervention designed to maximize uptake for participants with serious mental illnesses. Key decision points are discussed, along with final decisions and contextual considerations. A 26-item checklist was developed to measure treatment adherence related to process, content, and adaptations of the intervention. The checklist follows the structure of the CBT intervention, as well as provides flexibility for the delivery adaptations. Pilot testing of the checklist revealed all sessions were implemented with at least 85% fidelity, and 90% of sessions were implemented with at least 90% fidelity. Raters agreed on the fidelity of a session in 99.6% of sessions. Contextual considerations included the highly secure study setting, reconciling the constant monitoring of a group and creating a treatment environment, the flexibility mandated by the intervention, the relative newness of the intervention, and the limitations based on study aims and resources. These results illustrate how study specific considerations and challenges can be successfully navigated in the development and deployment of a fidelity tool in a real-world setting. The fidelity checklist achieved our goal of measuring treatment adherence for this intervention. In the development of a fidelity tool, we recommend leaving space for raters to note specific considerations that disrupt facilitators' ability to deploy the intervention precisely. Measuring fidelity is imperative for mental health interventions to ensure that the treatment is responsible for the changes observed in clients.

Impact of Intimate Partner Violence on Parenting and Children's Externalizing Behaviors: Transactional Processes Over Time.

This study used longitudinal data to examine the transactional associations between mothers' spanking and mother-child relationship quality with children's externalizing behaviors in the context of intimate partner violence (IPV). Data came from a sample of 1,152 low-income mothers with children age 10-14 years. Results showed that past-year IPV triggered transactional associations by increasing children's externalizing behaviors which, in turn, increased spanking and subsequently more externalizing behaviors. Transactional associations were also found for relationship quality. All outcomes used were mothers-reported except relationship quality. Implications for practice include the importance of the mother-child dyad and their reciprocal processes in assessment and treatment.

A strange case of foreign body embolism in the right lower pulmonary artery.

Foreign bodies in the pulmonary circulation have been documented in the literature, with almost all cases being iatrogenic, involving venous catheters, or due to penetrating foreign body emboli. Foreign body pulmonary emboli are often difficult to diagnose due to their varied clinical presentation, the nature of the embolizing material and dubious radiological features. We describe the case of a patient who experienced episodes of massive hemoptysis with inconclusive radiological findings, who underwent a thoracotomy with the discovery of a wooden object of 7 cm in length in the right lower lobe artery, with no apparent mechanism of injury.

The relationship between substance misuse and complicated grief: A systematic review.

Complicated grief is a prolonged, bereavement-specific disorder with significant psychological and physical consequences. Although complicated grief represents a risk to individuals with substance misuse, this relationship is poorly understood. Consequently, this systematic literature review examined empirical findings regarding the relationship between substance misuse and complicated grief. We searched 11 databases to identify pertinent quantitative studies published in English. Our search yielded 12 peer-reviewed journal articles (N = 1749) published between 1997 and 2017. Included studies evaluated the prevalence, assessment, etiology, correlates, risk factors, and treatment of complicated grief and substance misuse among individuals with one or both conditions. Our review found evidence of a positive relationship between complicated grief and substance misuse. Individuals with substance misuse were at increased risk for subsequent development of complicated grief, particularly when increases in substance consumption preceded bereavement. Conversely, complicated grief predicted increases in smoking and alcohol dependence. Multiple risk factors for individuals with complicated grief and substance misuse were identified and discussed. An existing complicated grief assessment performed well among individuals with substance misuse, and grief interventions were effective in reducing symptoms of complicated grief and substance misuse simultaneously. Given the severity of consequences associated with both conditions, more research is needed to understand this relationship, identify effective assessment tools, and evaluate intervention strategies to improve outcomes.

Who gets to decide for the older patient with a limited decision-making capacity: a review of surrogacy laws in the European Union.

Family members of older incompetent patients are increasingly playing an essential role in the decision-making process relating to medical treatment. Furthermore, rights of patients and carers and the extent of their legal involvement vary widely across the European Union. Starting with an illustrative case within the Italian legal framework, this review focuses on statutory laws in the European Union to analyse the role and the rights of surrogates on behalf of older incompetent patients. The authors have identified two main essential areas of surrogate's law in Europe, in the absence of the advance directives: the role of family members automatically accepted as surrogates by law and a legal representative appointed by a court.

A case of oesophageal cancer with low back pain: the accidental finding of skeletal muscle metastasis.

Skeletal muscle metastasis is a very rare event in patients with oesophageal cancer. We herein report and discuss a case of a 65 years old man with history of gastro-esophageal reflux disease referred to our department for pyrosis associated to persistent low back pain. Oesophageal endoscopy and transesophageal endo-sonography showed a tumour localized in the lower third of the esophagus, histologically proved to be adenocarcinoma. Clinical staging procedures detected a two centimetres vascularized nodular lesion placed into right para-vertebral muscles at the level of L4 as the only sign of potential distant disease (versus a differential diagnosis of primitive sarcoma). The muscle lesion was completely removed and confirmed as secondary adenocarcinoma. Due to this evidence a chemotherapy protocol was initiated. After nine months the patient underwent transhiatal oesophagectomy. To the best of our knowledge this is the first reported case of a soft tissue metastasis from oesophageal cancer resected with radical intent.

Osteoporosis and psoriatic arthritis.

Osteoporosis (OP) is a skeletal disorder characterized by compromised bone strength that predisposes to an increased risk of fracture. The prevalence of OP in the general population is very high as established in several studies, and OP represents one of the possible aspects of bone involvement in arthritis. In psoriatic arthritis this involvement is particularly complex because it affects not only mechanisms of bone loss but also of bone formation. We will discuss these aspects and the available epidemiological data.