Psy. D., Antioch University, 2023, Antioch Seattle: Clinical Psychology

This study utilized Primary Care Provider (PCP) perspectives to unveil major barriers to prescribing buprenorphine to youth (ages 16-25) with opioid use disorder (OUD). Semi-structured interviews were conducted with seven PCPs recruited through convenience and snowball sampling. Interviews were conducted and recorded via Zoom video conferencing. Transcripts were generated and analyzed for themes using a Constructivist Grounded Theory (CGT) approach. The CGT of the present study describes four major barriers that limit PCP prescription of buprenorphine to youth: 1) PCPs Feel Overwhelmed, 2) PCPs Feel Ill Equipped to Treat Youth Patients with OUD, 3) PCPs Hold and Observe Stigma toward Patients with OUD—Especially Youth, and 4) Structural and Systemic Barriers. Each major barrier consists of related subcategories and sub-subcategories. Findings offer stakeholders suggestions for targeting individual, relational, clinical, and systemic level changes to increase primary care access to buprenorphine for youth ages 16-25.

Committee: Michael J. Toohey PhD, ABPP (Committee Chair); Michelle Peavy PhD, MAC, SUDP (Committee Member); Melissa Kennedy PhD (Committee Member) Subjects: Behavioral Sciences; Health; Health Care; Medicine; Mental Health; Psychology; Public Health

PhD, University of Cincinnati, 2022, Arts and Sciences: Psychology

Opioid use disorder (OUD) is a critical public health concern. Medication for opioid use disorder (MOUD), including buprenorphine, is essential for treating OUD. Patients with OUD often present with complex treatment needs and multiple risk factors for adverse treatment outcomes. Previous research suggests that OUD severity, polysubstance use, negative emotionality, and stress levels may be associated with poor treatment outcomes. Lacking are studies to identify patient profiles (subgroupings based on co-occurring patient-level risk factors) associated with adverse outcomes for patients in buprenorphine treatment. Thus, the aim of the current study was to identify patient risk factor profiles and to examine associations with adverse treatment outcomes among OUD patients admitted to outpatient buprenorphine treatment (N = 298). Participants were patients admitted to non-intensive outpatient (OP) or intensive outpatient (IOP) buprenorphine treatment at UC Health's Addiction Sciences Division (ASD) clinic between December 1, 2016, and October 1, 2019. Only patients with a primary OUD diagnosis who completed standardized intake assessment measures were eligible for inclusion. Using chart abstraction of electronic medical records, this study examined intake risk factors of OUD severity, polysubstance use, negative emotionality, and stress levels to create a clustering/subgrouping risk-level variable and examine subgroup membership in association with adverse treatment outcomes. Treatment outcomes included: (a) non-initiation of treatment programming following admission (e.g., reduced odds of initiating buprenorphine); (b) non-responsiveness to treatment while engaged in treatment (e.g., elevated rate of continued substance use); (c) treatment disengagement (e.g., lower proportion of required treatment encounters attended among patients retained in treatment at one-month); and (d) attrition (e.g., greater odds of not being retained in treatment one-month and six-months fo (open full item for complete abstract)

Committee: Jennifer Brown Ph.D. (Committee Member); T. Winhusen Ph.D. (Committee Member); Kristen Jastrowski Mano Ph.D. (Committee Member) Subjects: Psychology

Doctor of Nursing Practice, Mount St. Joseph University , 2023, Department of Nursing

Historically, a visit to the medical director was not consistently provided to each new patient at the TriHealth Outpatient Alcohol Drug Treatment Program (TOADTP). This resulted in patients being dispossessed of access to care such as evaluation and comprehensive treatment of co-occurring mental health diagnoses, the initiation of pharmacotherapy, and initiation of medication-assisted treatment for persons living with substance use disorders. This project centered on development and implementation of a standardized intake process for TOADTP patients with the goal of increasing referrals to the medical director to expand access to these lifesaving interventions. Over an eight-week period, pre-intervention data were collected. During this pre-intervention period, only one of the 12 new patients was referred to the medical director. Development, education, and mobilization of the new standardized intake process included: analyzing the old intake process for variances, educating the direct care team about the benefits of practicing from an evidence-based platform, developing a new intake process that included a hard stop in the electronic health record, and educating the TOADTP team about it. The process then was mobilized. Post-intervention outcome measures were collected over an 8-week period. These measures revealed that 17 out the 24 new patients were referred to the medical director. In sum, the implementation of a standardized referral process to the medical director increased referrals from 8.4% to 70.8%, thus expanding access to life-saving evidence-based care for people living with substance use disorders.

Committee: Rachel Baker Dr. (Advisor) Subjects: Mental Health; Nursing

Doctor of Philosophy, Case Western Reserve University, 2021, Nursing

The Impact of Resilience, Spirituality, and Self-Regulation on the Quality of Life of Adults with Opioid Use Disorder in the Gulf State of Oman Abstract By HAMED MUBARAK AL BATTASHI Substance use is currently recognized as a chronic brain disease and a significant public health concern. In Oman, the percentage of individuals seeking substance use treatment in 2017 increased by 44% when compared to 2016. A total of 64% of the individuals who reported substance use problems are below 35 years old. Easy access to alcohol and other substances, family histories of substance use, and traumatic experiences during childhood were some of the primary risk factors reported by individuals in Oman who are substance users. Individual and family self-management theory and the bio-psycho-social-spiritual model of addiction were used as theoretical frameworks to guide the development and implementation of the study. The study addressed the following aims: (1) explore the variability and extent of resilience, spirituality, self-regulation, and quality of life (QOL), (2) investigate the impact of resilience and spirituality on self-regulation, (3) examine the impact of self-regulation on QOL, and (4) assess how does self-regulation mediates how resilience and spirituality predict QOL. This descriptive, cross-sectional study utilized a convenience sampling technique to recruit 109 adult participants diagnosed with opioid use disorder or polysubstance use including opioids. The study was implemented in two treatment centers in Oman. Data xiii were collected using the Resilience Research Center-Adult Resilience Measure (PRCARM), Spiritual Involvement and Beliefs Scale (SIBS), Cognitive-Emotion Regulation Questionnaire (CERQ), Emotional Self-Efficacy Scale (ESES), and the World Health Organization Quality of Life (WHOQOL) Scale (WHOQOL-BREF). The SPSS 25 statistical package was used to analyze descriptive data and conduct various multiple linear regressions. The le (open full item for complete abstract)

Committee: Faye Gary Dr. (Committee Chair); Christopher Burant Dr. (Committee Member); Dianna Morris Dr. (Committee Member); Mary Dolansky Dr. (Committee Member); Sharon Milligan Dr. (Committee Member) Subjects: Behaviorial Sciences; Cognitive Psychology; Cognitive Therapy; Counseling Psychology; Health Care; Mental Health; Nursing

Doctor of Philosophy (PhD), Ohio University, 2020, Translational Biomedical Sciences

More than 47,000 people died in 2017 due to opioid-involved overdoses. In addition, fatal overdoses from non-methadone synthetic opioids like fentanyl have risen dramatically over the past 7 years. The heavy flow of opioid-related overdoses in hospitals have pressured healthcare professionals to adapt to new treatment modalities while following state and federally mandated prescribing guidelines. However, even when evidence-based practices are followed, patients may be negatively affected by opioid and opioid use disorder (OUD) stigma. The importance of addressing opioid-related stigma among healthcare providers has emerged during this time as a way to decrease barriers faced by patients in need of treatment for substance use disorders (SUDs) and improve general patient outcomes. Health professional students will, one day, be on the front line of the opioid epidemic, and thus, multidisciplinary opioid-focused education is needed. Developing education to address opioid-related stigma early in training may be valuable, though limited research has focused on this approach. The research detailed in this dissertation aimed to address the opioid epidemic by leveraging health professional students' opioid-related knowledge, perceptions, beliefs, and experiences toward the development of an educational intervention to reduce opioid and OUD stigma. The first study provided a quantitative analysis of health professional students' opioid-related beliefs, experiences, and postgraduate intentions. In general, nurse practitioner (NP) students perceived the epidemic as more severe compared to other health professional students. NP students had more clinical experiences than their physician assistant (PA) and doctor of osteopathy (DO) student counterparts, and these experiences were associated with increased confidence in caring for patients with OUD. The second study aimed to explore health professional students' perceived impact of the opioid epidemic on their future profes (open full item for complete abstract)

Committee: Elizabeth Beverly PhD (Advisor); Dawn Graham PhD (Advisor); Sebastian Diaz PhD, JD (Committee Member); Holly Raffle PhD (Committee Member); Janet Simon PhD (Committee Chair); Charman Miller DNP (Committee Member) Subjects: Behavioral Sciences; Education; Educational Evaluation; Health Care; Medicine

Psy. D., Antioch University, 2019, Antioch Santa Barbara: Clinical Psychology

While psychiatric medications have been categorized as the same as substances of abuse in Alcoholics Anonymous (AA), medications for common medical disorders were not affected by this disapproval of medication. It may be time for a new dialogue (Woody, 2015). According to Gjersing and Bretteville (2018), there has been a concerning increase in overdose deaths in the last decade. This includes a threefold increase in overdose deaths from prescription narcotics and six-fold increase in overdose deaths from heroin in the United States. When prescription opioid users find difficulty in obtaining pills, they may move on to heroin, which is much more readily available on the streets, in an effort to avoid painful opioid withdrawal. For this study, individuals who had previously achieved long-term abstinence from alcohol or substance use but relapsed after a significant amount of time sober were interviewed in order to better understand their experience with relapse as well as their experience returning to at least partial remission. Thematic analysis was conducted on interview data. The results from this phenomenological analysis of interviews with eight participants identified several themes regarding the experience of being a long-timer, relapsing after a substantial amount of time abstinent, and challenges to as well as factors in returning to AA. These themes are organized as long-term recovery, relapse, and a new beginning. Long-term recovery is further explored as acute treatment only, treatment did not utilize evidence-based interventions, treatment did not address emotional issues, contact with mental health, long-timer, and complacency and drifting. Relapse is further explored as medical issues, new trauma, and justification of the use of medication or marijuana. A new beginning is further explored as recovery challenges such as feelings of ostracism, age-related issues, and shame as well as recovery factors such as finding acceptance and love within the fellowsh (open full item for complete abstract)

Committee: Brett Kia-Keating Ed.D (Committee Chair); Ron Pilato Psy.D (Committee Member); Janice Stimson Psy.D (Committee Member) Subjects: Behavioral Psychology; Clinical Psychology; Cognitive Psychology; Health Care Management; Medical Ethics; Mental Health; Psychology; Psychotherapy

PHD, Kent State University, 2016, College of Arts and Sciences / Department of Psychological Sciences

Use of licit and illicit drugs, including opioids, during pregnancy is a major public health concern. In the United States, there has been an estimated 4 fold increase in the incidence of maternal opiate use at delivery, and a 3 fold increase in the incidence of neonatal abstinence syndrome (NAS) in the past decade (Patrick et al., 2012; Jones et al., 2014). Substance use during pregnancy contributes to numerous potential deleterious effects and complications, including pre-term delivery, low birth weight, smaller head size, miscarriages and damage to the infant's nervous system (Brown, Frank, & Zuckerman, 1994). Substance abuse treatment outcomes for substance dependent pregnant women are poor, with high rates of treatment dropout and drug relapse (Jones et al., 2004; Haller et al., 1993; Jones, Velez, McCaul, &Svikis, 1999). One potential explanation for poor treatment outcomes may be the failure of existent substance use treatment to address underlying mental health issues/psychiatric comorbidities. Given that the comorbidity of substance abuse/dependence with posttraumatic stress disorder (PTSD) is high (up to 43%: Breslau, Davis, & Schultz, 2003; Deering et al., 1996; Friedman, 1991; Friedman & Yehuda, 1995; Kessler et al., 1995), it is imperative that treatment addresses both substance use and mental health issues concurrently. The current study investigates the relationship between substance use disorders (SUD) and PTSD in substance dependent pregnant women who present for opioid addiction treatment services and attempts to identify relevant targets for clinical intervention in this group.

Committee: Douglas Delahanty PhD (Advisor) Subjects: Clinical Psychology; Psychology; Public Health

Doctor of Philosophy (PhD), Ohio University, 2024, Counselor Education (Education)

Society and researchers acknowledge that substance use disorders impact the entire family, not just the user. Most research focuses on alcoholism within families and rarely deviates specifically to other substances such as opioids, cocaine, meth, or marijuana. At times, parents with substance use disorders, such as opioids, are not present, whether physically or emotionally, for their children. The parents' absences can impact their children's experiences, such as how they create and maintain interpersonal relationships during childhood and adulthood. Despite this acknowledgment, little research exists on the experiences of children living with parental opioid use disorders from their perspective, instead utilizing the user's perspective of how they believe their substance use disorder impacts their children. To better understand the resulting impact of parental opioid use disorders, the researcher used a phenomenological research design to explore the first-hand experiences of adults who lived with parental opioid use disorders and the different interpersonal relationships experienced during childhood and adolescence. This study identified patterns of shared experiences and encouraged more research related to the long-term effects of parental opioid use disorders in adults, its impact on their interpersonal relationships, and identifying and understanding the counseling needs of clients affected by their parent's opioid use disorder.

Committee: Bilal Urkmez (Committee Chair); Yuchun Zhou (Committee Member); Tamarine Foreman (Committee Member); Christine S. Bhat (Committee Member) Subjects: Cognitive Therapy; Counseling Education; Counseling Psychology; Developmental Psychology; Families and Family Life; Mental Health; Social Research; Sociology

PhD, University of Cincinnati, 2024, Nursing: Nursing - Doctoral Program

Background: Many children are directly and indirectly affected by the opioid epidemic and the consequences of opioid use during pregnancy through prenatal opioid exposure. Prenatal opioid exposure is associated with adverse neonatal and long-term outcomes and may develop into neonatal opioid withdrawal syndrome. Although recent reviews largely suggest negative outcomes after prenatal opioid exposure, they are limited by the heterogeneity of identification methods used to ascertain exposure. The impact of varying identification methods on the prevalence and outcomes of exposure is not clearly understood. The use of big data and larger data linkages in nursing science may help illuminate the impact of varying identification methods used to ascertain prenatal opioid exposure. Aims: This three-manuscript dissertation aimed to (1) discuss the use and potential of big data for nurse scientists, (2) conduct a scoping review of the varying identification methods in current literature, and (3) perform a secondary data analysis of a large integrated data to explore the prevalence of prenatal opioid exposure across identification methods to inform research, practice, and support children and families impacted by prenatal opioid exposure. Methods: The first manuscript was a discursive paper that provided an introductory guide for leveraging big data in nursing research. The second manuscript was a scoping review that synthesized the various identification methods used to ascertain opioid exposure in the United States over the last decade. Insights from the scoping review generated three identification methods leveraged in the third dissertation manuscript: (1) Maternal data (e.g., toxicology and diagnoses), (2) Infant data (e.g., toxicology and diagnoses), and (3) Combined method using maternal and infant data. The third manuscript was a secondary data analysis of a large perinatal linkage database in the Midwest to explore the prevalence of prenatal opioid expo (open full item for complete abstract)

Committee: Joshua Lambert Ph.D. (Committee Chair); Sara Arter Ph.D. R.N. (Committee Member); Nichole Nidey Ph.D. (Committee Member); Samantha Boch Ph.D. R.N. (Committee Member) Subjects: Nursing

PHD, Kent State University, 2024, College of Arts and Sciences / School of Biomedical Sciences

As of 2022, three million people in the US, and sixteen million worldwide were estimated to suffer from opioid use disorder (OUD). Despite widespread efforts to increase the public availability of medical therapies for OUD, only 2.28% of people suffering from OUD will seek out and be able to sustain abstinence for at least five years. The core objectives of this work were to 1) evaluate the dose- and sex-dependent effects of fentanyl to induce rewarding states, 2) the extent to which D-Cysteine ethylester (D-CYSee) alters affective state and the acquisition of fentanyl-induced reward seeking, 3) how the timing and concentration of fentanyl administration impacts the intrinsic Ca2+ activity of neurons and astroglia from the prefrontal cortex (PFC), and 4) the extent to which D-CYSee alters intrinsic Ca2+ activity in both the presence and absence of fentanyl. To evaluate the effects of fentanyl in the presence and absence of D-CYSee on Ca2+ signaling dynamics in PFC neurons and astrocytes, this work details the development of new methods in real-time fluorescent imaging of intrinsic Ca2+ activity using a non-genetic chemical indicator in cells isolated from the rat PFC in combination with post-hoc live-cell labeling for neurons and astroglia, and a customizable cell-type informed statistical analysis pipeline with backend support for data visualization and meta-analysis. Furthermore, a general characterization of the intrinsic Ca2+ activity in this PFC preparation was conducted; first by examining the involvement of extracellular Ca2+ sources and sodium channel conductance's, followed by a deeper evaluation of the role(s) of voltage-gated L, T, & N/P/Q-Type Ca2+ channels and an assessment of NMDA, AMPA receptor, and GABAA receptor signaling in the expression of intrinsic Ca2+ activity. The findings here support: 1) that fentanyl induces reward seeking in a concentration- and sex-dependent manner, 2) that D-CYSee could be an effective co-treatment with prescribed opioi (open full item for complete abstract)

Committee: Devin Mueller, Ph.D. (Advisor); Derek S. Damron, Ph.D. (Advisor); Stephen J. Lewis, Ph.D. (Committee Member); Colleen Novak, Ph.D. (Committee Member); Robert Clements, Ph.D. (Committee Member); Rafaela S. C. Takeshita, D.Sc., (Other) Subjects: Behavioral Psychology; Behavioral Sciences; Cellular Biology; Neurosciences

Ph.D., Antioch University, 2023, Leadership and Change

The United States continues to experience unprecedented deaths related to the opioid epidemic. Efforts to address the epidemic remain hampered by war-on-drugs policies that stigmatize people who use drugs and create barriers to accessing evidence-based treatments, particularly methadone maintenance treatments (MMT). Despite 50 years of research regarding MMT, it remains highly regulated, and arguably the most stigmatized treatment. The punitive regulatory structure of MMT remained unchanged until emergency waivers were initiated during the COVID-19 pandemic. The study used an exploratory, critical phenomenological approach to examine the intersection of culture and regulation on the lived experiences of 26 addiction counselors who provide treatment for opioid use disorder employing MMT. The phenomenon is examined through lenses of structural competency, cultural healthcare capital, structural racism, and self-determination theories. Using individual interviews, the study investigated whether counselors perceived, conveyed, or enacted stigma in treating those receiving MMT. The study explored whether the pandemic-era regulatory changes shifted counselors' perceptions of the treatment. Findings indicated that counselors enacted and mitigated stigma, two-thirds expressed moderate to high levels of stigma. Counselors perceived and enacted stigma by expressing frustrations regarding programs that embraced harm reduction strategies fearing approaches enabled symptomatic behaviors. They also expressed frustrations with patients' symptomatic behavior as reflected in paternalistic attitudes and feeling compelled to surveil patients' behaviors. A number of factors aligned with counselors' stigmatizing beliefs and attitudes: their pre-career negative experiences with methadone, personal abstinence-based recovery, recovery- oriented training, and/or their lack of exposure to information about the origins of the methadone regulatory structure. Stigmatization was enacted through (open full item for complete abstract)

Committee: J. Beth Mabry PhD (Committee Chair); Lemuel Watson EdD (Committee Member); Declan Barry PhD (Committee Member) Subjects: Health; Health Education; Mental Health; Public Health; Public Policy; Social Psychology; Social Research; Social Structure; Sociology

Doctor of Philosophy, University of Toledo, 2023, Psychology - Clinical

Posttraumatic stress disorder (PTSD) and substance use disorders frequently co-occur. There is also evidence that emotion dysregulation underlies the development and maintenance of co-occurring PTSD and substance use disorders, including opioid use disorder (OUD). Thus, interventions designed to specifically target emotion dysregulation may have utility in addressing this co-occurrence. The aim of this study was to adapt an existing treatment that targets emotion dysregulation (emotion regulation group therapy) to a brief individualized protocol and assess its preliminary efficacy for reducing PTSD symptoms, emotion regulation difficulties, negative affect, and substance-use related outcomes. Using a multiple baseline experimental design, the intervention was evaluated in a patient sample of adults in medication-assisted treatment for OUD (N = 4) with probable PTSD. Participants completed daily assessments during a 2- or 4-week baseline phase, a 4-week treatment phase, and 4-week post-intervention phase. Results demonstrate that by the end of the treatment phase, two participants demonstrated reliable decreases in emotion regulation difficulties, two participants demonstrated reliable decreases in negative affect, two participants demonstrated reliable decreases in craving, and one participant demonstrated a reliable increase in medication adherence self-efficacy. By the end of the follow-up period, three participants demonstrated reliable decreases in PTSD symptoms, one participant demonstrated a further reliable decrease in emotion regulation difficulties, one participant demonstrated a reliable improvement in medication adherence, one participant demonstrated a reliable improvement in medication adherence self-efficacy, two participants demonstrated further reliable decreases in negative affect, one participant demonstrated a further reliable decrease in craving, and one participant demonstrated a reliable decrease in substance use. Results provide preliminary e (open full item for complete abstract)

Committee: Kamala London-Newton (Committee Chair); Matthew Tull (Committee Member); Kim Gratz (Committee Member); Wesley Bullock (Committee Member); Jason Rose (Committee Member); Shannon Sauer-Zavala (Committee Member) Subjects: Clinical Psychology

BS, Kent State University, 2023, College of Arts and Sciences / Department of Biological Sciences

The opioid epidemic is a major health crisis in the U.S., resulting in an estimated 80,816 deaths in 2021. Overdose results in Opioid-Induced Respiratory Depression (OIRD) often treated by administration of competitive opioid receptor antagonists such as naloxone. However, these drugs are not effective against highly potent synthetic opioids (e.g., fentanyl) and are poorly suited for the prevention and/or treatment of opioid-craving or addiction. D-cysteine ethyl ester (D-CYSee) has been shown to prevent OIRD and disrupt the acquisition of fentanyl-induced seeking behaviors in rats. The Hippocampus (Hipp) has been established as a vital region for the encoding of drug-associated cues and contexts. Thus, the effects of D-CYSee and fentanyl on intrinsic calcium activity in heterogeneous cell cultures derived from the Hipp of P0 Sprague Dawley rat pups were observed. Males and females were cultured separately so sex differences in the cellular response to fentanyl and D-CYSee could be determined. Cells were cultured for 12-days, loaded with a fluorescent Ca2+ probe, Cal-520 AM, and imaged on an inverted microscope. It was found that fentanyl induced a transient Ca2+ peak in neurons derived from males but not females and in astrocytes derived from both sexes. Pretreatment with D-CYSee prevented this peak in neurons but only modulated it in astrocytes. This demonstrated not only a cellular basis for D-CYSee's ability to prevent drug seeking behavior, but also a clear sexual dimorphism in cellular responding to exogenous opioids within the hippocampus.

Committee: Derek Damron (Advisor); Elda Hegmann (Committee Member); Aleisha Moore (Committee Member); Soumitra Basu (Committee Member) Subjects: Biology; Cellular Biology; Neurosciences; Pharmacology

Doctor of Philosophy (Ph.D.), Bowling Green State University, 2022, Biological Sciences

Substance use disorder (SUD) is a debilitating chronic disorder with enormous social and economic impact. According to the brain disease model of addiction (BDMA), this affliction progresses following three recurring stages: binge and intoxication, withdrawal and negative affect, and preoccupation. Each stage is hallmarked by changes in particular brain circuits, mediated by specific molecular effectors, and results in distinct behavioral characteristics. The opioid epidemic is a global health concern and opioid use disorder (OUD) leads all other types of SUD in drug overdose deaths. Human imaging studies in patients with OUD, along with preclinical research in animal models, continue to expand our understanding of the pathophysiology and etiology of this disorder. While treatments are available, their efficacy and availability are limited. Most addictive drugs are plant secondary metabolites (PSM) that evolved as chemical defenses against insect herbivory. PSMs interfere with reward, learning, and feeding mechanisms in insects, the same mechanisms hijacked in humans with SUD. In this study, we examine Drosophila's sensitivity to morphine, in efforts to establish this valuable model organism for the study of OUD. Indeed, flies show a dose-dependent behavioral sensitivity to morphine,measured by feeding, activity, and choice assays. In this study, we highlight the sequence similarities between two related families of receptors - human somatostatin/opioid receptors and Allatostatin C (AstC) receptors in Drosophila.s. Using the Gal4/UAS system, we show that neuronal knockdown of AstC receptors modulates the behavioral sensitivities of flies to morphine. This study demonstrates proof-of-concept evidence on the importance of taking a phylogenetic approach in SUD research. Our results suggest that Drosophila offers a useful model for the study of OUD, and that allatostatin C receptors, as their phylogenetic ancestral forms, play a key role in a flies' sensitivity to opioi (open full item for complete abstract)

Committee: Robert Huber Ph.D. (Committee Chair); Jessica Kiss M.Ed., Ph.D. (Other); Raymond Larsen Ph.D. (Committee Member); Jon Sprague Ph.D. (Committee Member); Moira Van Staaden Ph.D. (Committee Member) Subjects: Behaviorial Sciences; Biology; Genetics; Medicine; Neurosciences; Physiology; Psychobiology

Master of Arts in Medical Ethics and Humanities, Northeast Ohio Medical University, 2021, College of Graduate Studies

Despite the Anti-Drug Abuse Act of 1986 that declared a “war on drugs”, criminalized substance abuse, and opened up treatment programs specific to pregnant women, the number of pregnant women using opioids increased five-fold from 2000 to 2009, skyrocketing the related costs for state Medicaid programs (Patrick et al., 2012). Unfortunately, this law has had a pervasive effect on the public's attitudes and clinicians' treatment toward opioid use disorder (OUD) in pregnancy. My analysis according to the principles of biomedical ethics has outlined several ethical dilemmas that have been created by criminalization of substance abuse, mandatory reporting laws, stigma toward OUD and its treatments, and little understanding of the social determinants of health. This ethical framework alone does not emphasize the relational aspect of pregnancy, support patient-centered care, or address the intersectionality of this patient population. I will argue how using a care and justice ethics approach to treatment of women with OUD who would like to carry a fetus to birth is the preferable ethical approach to guide physician and public health treatment of this issue. I will discuss how this framework revives the idea of using Ulysses contracts for this patient population and how Ohio has successfully implemented caring structures already. Finally, I will envision how Ohio can continue to expand its wraparound services and fight stigma against OUD in pregnancy, which stymies clinicians' potential to form caring relationships.

Committee: Rebecca Fischbein (Advisor); Julie Aultman (Committee Member) Subjects: Ethics; Medicine; Neurosciences; Psychobiology; Public Health; Public Policy; Womens Studies

Master of Arts (MA), Wright State University, 2020, Applied Behavioral Science: Criminal Justice and Social Problems

The study examines adverse childhood experiences among individual who use illicit opioids, focusing on emotional, physical, and sexual abuse. The study uses data collected from a sample of 357 individuals with opioid use disorder who were recruited in the Dayton area between May 2017 and October 2018. The study builds on the life course and social learning theories to examine the association between childhood experiences and drug use behaviors in later life. The key aims of the study are to: 1) assess the prevalence of adverse childhood experiences in the community-recruited sample of individuals with opioid use disorder; 2) analyze the relationship between adverse childhood experiences and family history when growing up, including economic hardship and parental history of mental and substance use problems, and 3) analyze the associations between adverse childhood experiences and selected drug use characteristics, such as age of first use, frequency of use, and whether or not they inject. Participants were recruited used targeted and respondent-driven sampling. Structured interviews were conducted by trained interviewers and covered history and patterns of drug use, sociodemographic characteristics, and adverse childhood experiences (ACE). Descriptive statistics and univariate analyses were used to characterize the sample. Chi-square test was used for categorical variables. One-way ANOVA was used to assess differences in drug use characteristics (continuous variables) between those who experienced childhood abuse and those who did not. Multiple linear regression analysis was used to assess the relationships between age heroin initiation (dependent variable) and childhood abuse experiences (independent variable), controlling for socio-demographics and family history when growing up. Multivariate Logistic Regression analyses were used to assess the association between a) early initiation of alcohol use (dependent variable) and childhood abuse experiences (independent) (open full item for complete abstract)

Committee: Raminta Daniulaityte Ph.D. (Advisor); La Fleur Small Ph.D. (Committee Member); Karen Lahm Ph.D. (Committee Member) Subjects: Behavioral Sciences; Early Childhood Education; Families and Family Life; Health Education; Mental Health

Doctor of Philosophy, Case Western Reserve University, 2021, Molecular Virology

The gut microenvironment is a complex ecosystem that is modulated by alterations in i) the gut microbiome, ii) the intestinal epithelial cell layer, and iii) the immune system. Opioid use disorder (OUD) is a chronic disease associated with gastrointestinal complications including opioid-induced bowel dysfunction (OIBD), a debilitating side effect. First, we focused on understanding the modulatory effects of methadone maintenance treatment (MMT) on the gut microbiome, bacterial metabolite profile, and intestinal barrier integrity. We found that methadone-treated individuals have alterations in key bacterial communities responsible for bacterial metabolite production and intestinal barrier homeostasis. Coupled with the observed dysbiosis, the bacterial metabolite content was decreased and correlated with markers of inflammation. Finally, bacterial compounds within Akkermansia muciniphila spent media in combination with methadone treatment are able to modulate intestinal barrier integrity via tight junction proteins in vitro. Additional studies are needed to understand the direct effects of the gut microbiota and gastrointestinal motility in the context of chronic opioid use. The second component of this work focuses on the effect of Crohn's disease (CD) treatment on the gut microbiota. Previous studies have shown the alterations in the gut microbiota of CD individuals from North America and Europe, but most reports lack information on treatment types, which could be an additional confounder in their findings. Interestingly, we found that CD treatment type affects the gut microbiota distinctly, where certain organisms like Proteobacteria are increased with anti-TNF treatment. Another remarkable finding for this study is the correlation between Chao1, a measure of species richness, and time since diagnosis in both treatment groups – suggesting that bacterial richness decreases with time as patients experience CD symptoms regardless of treatment type. Overall, the dys (open full item for complete abstract)

Committee: Arne Rietsch PhD (Committee Chair); Jason Brenchley PhD (Committee Member); Stanley Hazen MD, PhD (Committee Member); Grace McComsey MD (Committee Member); Alan Levine PhD (Advisor) Subjects: Bioinformatics; Biomedical Research; Immunology; Microbiology; Molecular Biology; Virology

Doctor of Philosophy, University of Akron, 2020, Counselor Education and Supervision

The purpose of this study was to investigate the effects of mindfulness-based relapse prevention (MBRP) aftercare program on participants who were in court-ordered opioid addiction treatment. This study utilized a mixed-methods ex post facto single group pretest posttest research design and analyzed archival data to determine (1) the results of changes in mindfulness, self-compassion, and impulsivity, and (2) the findings of clients' experiences, and (3) the meta-inferences which could were drawn from integrating both quantitative results and qualitative findings. Archival data was from a previous MBRP aftercare program and included adult women (n=15) and men (n=9) in a court-ordered opioid addiction treatment program in northeast Ohio. Three instruments were used for quantitative data from (N=24) participants including the Five Factor Mindfulness Questionnaire, the Self-Compassion Scale – Short Form, and the Barratt Impulsiveness Scale. Semi-structured interviews were conducted with nine of the participants. Results included one statistically significant increase (p < .05) in the nonreacting component of mindfulness from pretest to posttest. All other quantitative results, while not reaching statistical significance, showed a change in mean scores for increased mindfulness and self-compassion, and decreased impulsivity from pretest to posttest. Qualitative findings showed three types of client experiences emerged from the data: engaged, transitional, and disengaged. These experiences were comprised of five facets: sentiment, attitude, motivation, learning and relationships. Convergence was found between quantitative results and qualitative findings for mindfulness, self-compassion, and impulsivity. Implications for counselor practice, counselor trainees, counselor educators and supervisors, and future research were discussed.

Committee: Robert Schwartz (Committee Chair); Kristin Koskey (Committee Member); Varunee Faii Sangganjanavanich (Committee Member); Victor Pinheiro (Committee Member); Seungbaum Lee (Committee Member) Subjects: Counseling Education; Counseling Psychology; Mental Health; Public Health; Therapy

PhD, University of Cincinnati, 2020, Medicine: Epidemiology (Environmental Health)

The association between opioid prescribing and opioid use disorder (OUD) is complex, not well characterized, and yet the need to treat pain remains high. This is particularly true for emergency departments (EDs), that have 136.9 million visits annually (43% for pain) and prescribe opioids to 17% of discharged patients. My objectives were to use clinically obtained data in electronic medical records (EMRs) and apply modern machine learning techniques to 1) evaluate the effect of an ED opioid prescription on diagnosis of OUD and 2) develop a predictive model to identify those at risk for OUD in an ED patient population. Objective 1 Case-control study of adult (=18 years), non-cancer, discharged ED patients without pre-existing OUD. Each patient's first ED visit (10/2014-9/2019) was identified and designated as “index”. Propensity score (PS) weights were calculated using machine learning to simulate random treatment assignment. OUD was defined as diagnosis of an opioid use disorder or unintentional opioid overdose. A Cox proportional hazards model was used to estimate the PS weighted, adjusted hazard ratio (aHR) of OUD (adjusted for: age, sex, race, history of non-opioid substance use disorder and mental health condition), in patients prescribed an opioid at index compared to those who were not, and then stratified by other medical exposures to evaluate modifying effects. Objective 2 Develop and test an OUD predictive model in adult emergency department (ED) patients (1/2013-10/2019). Medications and diagnostic codes were used to construct two machine learning models (random forest and LASSO regression). Potential predictors included: age, race, sex, insurance type, number of opioid prescriptions, and 161 diagnostic codes (ICD-10 code categories, excluding OUD outcome codes and categories occurring in < 1% of patients). Only medications and diagnoses that occurred prior to first OUD diagnosis or last ED visit in the system (for those without an OUD diagnosis) we (open full item for complete abstract)

Committee: Jane Khoury Ph.D. (Committee Chair); Scott Langevin Ph.D. (Committee Member); Michael Lyons M.D. (Committee Member) Subjects: Epidemiology

PhD, University of Cincinnati, 2019, Education, Criminal Justice, and Human Services: Health Education

In the last decade, we have witnessed a marked shift in the value placed on vocational services in treatment planning for substance use disorder because of the “opioid epidemic in the Midwest.”(Center for Substance Abuse Services (2000). Because of this, the welfare reform act has placed stricter requirements to obtain public assistance for those with disabilities, along with the elimination of federal disability benefits for addiction alone. As a result, employment has become increasingly important. Recovery can work and people in recovery want to work. Studies show that people with chronic disorders specifically “substance use disorders” can and do often want to work if for no other reason than maintaining their basic needs and social interaction to maintain sobriety in spite of the addiction. Employment is an essential element for most individuals and sometimes for people with substance use disorders (Platt & Metzger, 1985). Unemployed clients in substance abuse treatment programs face many challenges and barriers in getting and keeping jobs after recovery. These clients will need help identifying these barriers that may prevent them from gaining employment and solving stresses in the work environment to maintain employment. Nevertheless, services such vocational services are not available in treatment programs (Goldenburg, 1972). Vocational services for individuals with a disability is a mandate, to empower individuals with disabilities to maximize employment, economic self-sufficiency, independence, and inclusion and integration into society (Rehabilitation Act of 1973). According to a survey sponsored by the National Institute on Drug Abuse (NIDA), most treatment programs provide no vocational services; half of the programs reported had no full-time vocational staff and no budget for vocational services (Hubbard & Hardwood, 1981). Employment before or during substance use disorder treatment could be related to both longer retention in treatment and (open full item for complete abstract)

Committee: Rebecca Vidourek Ph.D. (Committee Chair); Keith King Ph.D. (Committee Member); Ashley Merianos Ph.D. (Committee Member) Subjects: Health Education