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Objectives In a prior statewide naloxone purchase trial conducted in Massachusetts, we documented a high rate of naloxone dispensing under the state's standing order program. The purpose of this study was to understand the factors that facilitate naloxone access under the Massachusetts naloxone standing order (NSO) program and identify any remaining barriers amenable to intervention. Design Mixed methods design involving a pharmacist survey and 3 pharmacist focus groups. Setting and participants Focus groups were conducted at 3 separate professional conferences for pharmacists (n = 27). The survey was conducted among Massachusetts pharmacists (n = 339) working at a stratified random sample chain and independent retail pharmacies across Massachusetts. All data were collected between September 2018 and November 2019. Outcome measures Facilitators and barriers to NSO implementation and naloxone dispensing and pharmacists' attitudes and beliefs regarding naloxone and opioid use. Results Most pharmacists described NSO implementation as being straightforward, although differences were reported by pharmacy type in both the survey and focus groups. Facilitators included centralized implementation at chain pharmacies, access to Web-based resources, regularly stocking naloxone, and use of naloxone-specific intake forms. Barriers included patient confidentiality concerns and payment/cost issues. Only 31% of surveyed pharmacists reported always providing naloxone counseling; the most commonly cited barriers were perceived patient discomfort (21%) and time limitations (14%). Confidential space was also more of a concern for independent (vs. chain) pharmacists (18% vs. 6%, P = 0.008). A majority of pharmacists held supportive attitudes toward naloxone, although some reported having moral/ethical concerns about naloxone provision. Conclusion We documented several facilitators to NSO implementation and naloxone dispensing. Areas for improvement include addressing stigma and misconceptions around opioids and naloxone use. These remain important targets for improving pharmacy-based naloxone dispensing, although our overall positive results suggest Massachusetts' experience with NSO implementation can inform other states' efforts to expand pharmacy-based naloxone access.

BACKGROUND: Mobile health (mHealth) interventions have the potential to improve substance use treatment engagement and outcomes, and to reduce risk behaviors among people who inject drugs (PWID). However, there are few studies assessing mobile technology use among PWID and none have investigated continuity of mobile phone use. METHODS: We surveyed 494 PWID. We used bivariate (independent-sample t- and chi-square tests) and multivariate (logistic regression) analyses to determine whether mobile phone and/or internet use differed as a function of participant- and/or injection-related characteristics. RESULTS: Most participants (77%) had a mobile phone, with 67% having a phone that was free of charge. Participants with a phone were significantly less likely to be homeless (OR=0.28), to have shared syringes (OR=0.53), and to have reused syringes (OR=0.26) in the past 3 months. We observed high rates of phone and number turnover, with more than half reporting that they got a new phone (57%) and/or number (56%) at least once within the past 3 months. Most participants were familiar with using the internet (80% ever use), though participants who had ever used the internet were younger (OR=0.89), were less likely to be homeless (OR=0.38), were less likely to have shared syringes (OR=0.49), and were more likely to have injected methamphetamine by itself (OR=2.49) in the past 3 months. CONCLUSIONS: Overall, mobile technology and internet use was high among our sample of PWID. Several factors should be considered in recruiting diverse samples of PWID to minimize bias in mHealth study outcomes, including mobile phone access and protocol type (text- vs internet-based).

Skin and soft tissue infections (SSTIs) are the most common medical complication of injection drug use in the United States, though little work has been done assessing SSTI treatment among people who inject drugs (PWID). We examined past-3-month abscess characteristics, treatment utilization, and barriers to medical treatment among N = 494 community-recruited PWID. We used descriptive statistics to determine the frequencies of self-treatment and medical treatment for their most recent past-3-month abscess as well as barriers to seeking medical treatment. We then used bivariate and multivariate logistic regression to identify factors associated with having an abscess in the past 3 months. Overall, 67% of participating PWID ever had an abscess and 23% had one in the past 3 months. Only 29% got medical treatment for their most recent abscess whereas 79% self-treated. Methods for self-treatment included pressing the pus out (81%), applying a hot compress (79%), and applying hydrogen peroxide (67%). Most (91%) self-treated abscesses healed without further intervention. Barriers to medical treatment included long wait times (56%), being afraid to go (49%), and not wanting to be identified as a PWID (46%). Factors associated independently with having an abscess in the past 3 months were injecting purposely into muscle tissue (adjusted odds ratio [AOR] = 2.64), having difficulty finding a vein (AOR = 2.08), and sharing injection preparation equipment (AOR = 1.74). Our findings emphasize the importance of expanding community-based access to SSTI education and treatment services, particularly at syringe service programs where PWID may be more comfortable seeking resources.

OBJECTIVES: Massachusetts was among the first states to allow standing orders to facilitate pharmacy-based naloxone purchase and reduce opioid overdose deaths. We conducted a unique purchase trial to establish a valid measure of standing order naloxone in Massachusetts, using purchasers from two high priority populations to determine whether naloxone is less accessible to those who use illicit opioids than other potential purchasers. METHODS: A random sample of 200 retail pharmacies was selected from a statewide list. Each pharmacy underwent two purchase attempts - one by a person who used illicit opioids (PWUIO) and one by a potential bystander who did not use illicit opioids but had a relationship with someone at risk of opioid overdose. Purchases were conducted in accordance with a detailed purchase protocol between May 2018 and April 2019. Matched pairs analysis was used to identify statistically significant differences in purchase outcomes and experiences by purchaser type. RESULTS: Overall, 322 of 397 purchase attempts (81%) were successful, with no significant difference between PWUIO and bystanders (p=.221). Most purchases (93%) resulted in acquisition of single-step nasal naloxone (NARCAN; median cost $133.38). Forty percent of purchases included state-mandated verbal counseling, and PWUIO were significantly less likely to receive counseling than bystanders (30% vs. 51%, p$150 (25%), and requiring a prescription (15%). Chain pharmacies were significantly more likely to sell naloxone than independent pharmacies (86% vs. 53%, p

BackgroundThe concurrent use of cigarettes with other tobacco products, such as smokeless tobacco (SLT), is increasingly common. Extant work with cigarette smokers who also use SLT is based heavily on retrospective reports and between-group comparisons. The purpose of this study was to assess prospectively the patterns of dual users’ product use and nicotine exposure on days when cigarettes were smoked exclusively (single use) versus concurrently with SLT (dual use).DesignForty-six dual cigarette-SLT users recorded their product use in real time via ecological momentary assessment for a 2-week longitudinal design. They responded to questions about situational factors (eg, location, mood) using this same diary, and collected saliva samples each night for later cotinine measurement. At the end of this 2-week period, users reported on their reasons for and beliefs about SLT use.ResultsCotinine levels were significantly higher on dual versus single use days (mean±SEM=374.48±41.08 ng/mL vs 300.17±28.13 ng/mL, respectively; pConclusionsResults support the idea of product supplementation rather than replacement among this convenience sample of dual users. For smokers whose primary motivation for SLT use involves situations where they would otherwise be tobacco free, the potential benefits of clean indoor air laws may be diminished.

INTRODUCTION: Electronic cigarettes (ECIGs) vary greatly in their ability to deliver nicotine, which suggests they may also vary in their ability to produce dependence. This study examined individual and combined ECIG device features, and also user behaviors, as predictors of dependence in never-smoking ECIG users. METHODS: Data were collected from 711 current ECIG users who had smoked

Traumatic brain injury (TBI) affects 2.8 million people annually in the United States, with significant populations suffering from ongoing cognitive dysfunction. Impairments in decision-making can have major implications for patients and their caregivers, often enduring for years to decades, yet are rarely explored in experimental TBI. In the current study, the Rodent Gambling Task (RGT), an Iowa Gambling Task analog, was used to assess risk-based decision-making and motor impulsivity after TBI. During testing, rats chose between options associated with different probabilities of reinforcement (sucrose) or punishment (timeout). To determine effects of TBI on learned behaviors versus the learning process, rats were trained either before, or after, a bilateral frontal controlled cortical impact TBI, and then assessed for 12 weeks. To evaluate the degree to which monoamine systems, such as dopamine, were affected by TBI, rats were given an amphetamine challenge, and behavior recorded. Injury immediately and chronically decreased optimal decision-making, and biased rats towards both riskier, and safer (but suboptimal) choices, regardless of prior learning history. TBI also increased motor impulsivity across time, reflecting ongoing neural changes. Despite these similarities in trained and acquisition rats, those that learned the task after injury demonstrated reduced effects of amphetamine on optimal decision-making, suggesting a lesser role of monoamines in post-injury learning. Amphetamine also dose-dependently reduced motor impulsivity in injured rats. This study opens up the investigation of psychiatric-like dysfunction in animal models of TBI and tasks such as the RGT will be useful in identifying therapeutics for the chronic post-injury period.

Introduction Cigarette smoking rates among individuals with opioid use disorder (OUD) are notoriously high and may be improved by considering the timing of treatment integration for these two substances. The current study examined the feasibility of a method for assessing the timing of integrating smoking cessation pharmacotherapy within three different phases of outpatient treatment with medication for OUD (MOUD). Methods Seventy-four buprenorphine-maintained smokers were enrolled in a quasi-experimental study across three MOUD treatment phases: 0–90 (Phase 1), 91–365 (Phase 2), and > 365 days of MOUD treatment (Phase 3). During a 12-week varenicline-based intervention, the study assessed outcomes daily via text messages (cigarette smoking, varenicline adherence, side effects) or monthly at in-person visits (quit motivation and carbon monoxide levels). Results Thirty-five participants completed the study, with a lower retention rate in Phase 1 (37.5%) relative to Phases 2 (53.5%) or 3 (57.1%). A trend occurred for Phase 1 participants to report aversive side effects (e.g., abnormal dreams, gastrointestinal distress) on more study days. Among completers, adherence to text messaging and varenicline use was high and independent of MOUD treatment phase. Participants in all phases reported declines in cigarette smoking and increases in quit motivation over time; the study observed biochemically verified tobacco abstinence among only a few participants from Phases 2 or 3. Conclusions This feasibility study demonstrates a method to evaluate the timing of treatment integration for cigarette smoking and MOUD. Method strengths include a study schedule that coincided with the MOUD clinic schedule and use of text messaging to encourage varenicline adherence and evaluate outcomes regularly.

Prior work suggests that prospective measurement of cigarette use may be more reliable and valid than retrospective self-reports. Despite several studies comparing retrospective and prospective methods, there are a myriad of prospective methods that have not been directly compared, including spent cigarette filters that are returned to the laboratory by participants and diary logs of cigarette use on an electronic device via ecological momentary assessment. The current secondary data analysis compared the reliability of retrospective global self-report, returned cigarette filters, and electronic diary logs among a sample of cigarette smokers that also use smokeless tobacco (SLT; N = 51) over two consecutive weeks. CPD values also were compared to salivary cotinine levels to determine whether any method was associated more strongly with nicotine/tobacco exposure. Results indicated that CPD values via global self-report were significantly larger than returned filter and diary log daily averages across both weeks (t(50) = 8.28 to 9.35; p < .001). Both prospective measures showed less digit bias and more variation in smoking behavior across days than global self-reports. Only returned CPD values were correlated significantly with salivary cotinine levels (r(593) = 0.09, p = .024). Importantly, most reliability outcomes for returned filters and logged CPD did not differ significantly, suggesting that they may be comparable prospective methods for measuring cigarette use. Because returned filters and diary logs did not differ from one another, researchers' selection of a prospective measurement method should rely on considerations of participant compliance, protocol burden, and specific research questions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Traumatic brain injury (TBI) affects millions of individuals every year. Many of these injuries lead to lasting effects, particularly impairments in domains broadly classified as executive functions, such as impulse control and decision-making. While these impairments have been historically associated with frontal brain damage, other injuries such as concussion or parietal injury also contribute to similar dysfunction. However, it is unknown whether animal models of TBI would replicate these broad effects that are observed in human patients. In the current study, we delivered a unilateral parietal controlled cortical impact injury and assessed the performance of rats on a motoric task (rotarod) and a test of decision-making and impulsivity (rodent gambling task). TBI rats demonstrated significant motor impairments on the rotarod task; however, this did not extend to difficulties inhibiting motor actions (impulsivity). In addition, TBI caused chronic alterations to risk-based decision-making, extending out to 12 weeks post-injury. Specifically, rats with TBI preferred the riskiest, and most suboptimal option over all others. The current data suggest that models of unilateral TBI are sufficient for replicating some aspects of executive dysfunction (risky decision-making), while others are limited to frontal damage (impulsivity). These models may be used to develop therapeutics targeted at the chronic post-injury period when these symptoms often manifest in patients, a critically understudied area in preclinical TBI research.

Research methods are needed that can predict whether the availability of potential modified risk tobacco products (MRTPs) may influence smokers' quit-related motivation, choice, and behavior. This pilot study assessed the primary outcomes of feasibility and adherence to address this need using an electronic cigarette (ECIG) as a model MRTP. Cigarette smokers were randomly assigned to use only their own brand of cigarettes (OB-only) or a second-generation ECIG (18 ng/ml nicotine) plus their OB cigarettes (ECIG+OB) ad libitum for four weeks. Participants logged products using a mobile device, collected used cigarette filters, and provided saliva samples every day for analysis of cotinine. They returned to the lab once per week to provide a breath sample and accept or decline a choice to quit all tobacco products (i.e., cigarettes and/or ECIGs). They also returned for a one-month follow-up visit. Of those participants randomized (n = 60), 56.7% completed the 4-week intervention and 40.0% completed the follow-up visit. The primary reason for withdrawal was poor adherence with mobile device use. Comparable numbers of participants in each group chose to make a quit attempt, although more OB-only participants chose to quit during the first two weeks and more ECIG+OB participants during the last two weeks. With protocol modifications to reduce participation burden, the current method might ultimately be used by regulators to predict how smokers' quit-related motivation, choice, and behavior are influenced by current and future MRTPs.

Stroke is a world-wide leading cause of death and long-term disability with concurrent secondary consequences that are largely comprised of mood dysfunction, as well as sensory, motor, and cognitive deficits. This review focuses on the cognitive deficits associated with stroke specific to executive dysfunction (including decision making, working memory, and cognitive flexibility) in humans, non-human primates, and additional animal models. Further, we review some of the cellular and molecular underpinnings of the individual components of executive dysfunction and their neuroanatomical substrates after stroke, with an emphasis on the changes that occur during biogenic monoamine neurotransmission. We concentrate primarily on changes in the catecholaminergic (dopaminergic and noradrenergic) and serotonergic systems at the levels of neurotransmitter synthesis, distribution, re-uptake, and degradation. We also discuss potential secondary stroke-related behavioral deficits (specifically, post-stroke depression as well as drug-abuse potential and addiction) and their relationship with stroke-induced deficits in executive function, an especially important consideration given that the average age of the human stroke population is decreasing. In the final sections, we address pharmacological considerations for the treatment of ischemia and the subsequent functional impairment, as well as current limitations in the field of stroke and executive function research.

Fixating on the present moment rather than considering future consequences of behavior is considered to be a hallmark of drug addiction. As an example, cigarette smokers devalue delayed consequences to a greater extent than nonsmokers, and former smokers devalue delayed consequences more than nonsmokers, but less than current smokers. Further, cigarette smokers have higher norepinephrine levels than nonsmokers, which is indicative of poor future health outcomes. It is unclear how duration of cigarette smoking may impact these associations. The current secondary analysis of publicly available data investigated whether extent of future thinking is associated with smoking duration, as well as norepinephrine level, in a large national US sample (N = 985) of current, former, and never smokers. Individuals scoring lower on future thinking tended to smoke for longer durations and had higher norepinephrine levels relative to individuals scoring higher on future thinking. In addition, duration of cigarette abstinence interacted significantly with future thinking and smoking duration for former smokers. Specifically, the mediation relationship between future thinking, smoking duration, and norepinephrine level for former smokers was strongest at shorter durations of cigarette abstinence and decreased as a function of increasing duration of cigarette abstinence. Overall, results from this study suggest the potential importance of implementing smoking cessation treatments as early as possible for smokers and support future thinking as a potential therapeutic target for smoking cessation treatment.

Snus tobacco characteristics may attract non-tobacco users, including relatively low, but pharmacologically active, doses of nicotine. Lower nicotine doses may limit adverse drug effects while also producing a physiologically active response.This pilot study is the first to profile the acute effects of snus on physiological and subjective assessments in a sample of never-tobacco users.Eleven never-tobacco users (five women;100 uses/lifetime) were recruited from the community via university-approved advertisements. Using a within-subject design, participants consumed six pouches in ascending dose order (0, 1.6, 3.2, 4.8, 6.4, and 8.0 mg nicotine) within one session. The start of each snus bout was separated by 45 minutes, and pre- and post-pouch assessments included ratings of drug effects and physiological response.The average heart rate and systolic blood pressure increased significantly from pre- to post-pouch use as a function of dose, though these increases were reliable for 8.0 mg nicotine only (p.05). Collapsed across time, diastolic blood pressure was significantly higher for 8.0 mg nicotine than for all other doses (p.05). Subjective ratings for "excessive salivation" and "satisfying" increased significantly from pre- to post-pouch use (p.05), independent of dose.Significant increases in physiological response at some doses suggest that users were exposed to pharmacologically active doses of nicotine. The lack of reliable subjective effects may be the product of the dosing regimen or the relatively small sample size. Findings highlight the need for identification of doses of snus that may promote abuse among naïve users.