Prevention of Opioid Use and Disorder Among Youth Involved in the Legal System: Innovation and Implementation of Four Studies Funded by the NIDA HEAL Initiative

Youth involved in the legal system (YILS) experience rates of opioid and substance use disorders (OUD/SUDs) and overdose that is well above those in the general population. Despite the dire need, and the existing programs that focus on treatment of these problems in YILS, research on opioid initiation, and OUD prevention, including feasibility and sustainability, are severely limited. We present four studies testing interventions that, while not necessarily novel as SUD treatments, test novel structural and interpersonal strategies to prevent opioid initiation/OUD precursors: (1) ADAPT (Clinical Trial No. NCT04499079) provides real-time feedback using community-based treatment information system data to create a more effective mental health and SUD treatment cascade to prevent opioid use; (2) HOME (Clinical Trial No. NCT04135703) provides youth experiencing homelessness, including YILS, with direct access to shelter in independent living without prerequisites as an opioid initiation prevention strategy; (3) LeSA (Clinical Trial No. NCT04678960) uses the Trust-Based Relational Intervention® to equip YILS and their caregivers with self-regulatory and communication skills during the transition from secure confinement to reduce opioid initiation/re-initiation; and (4) POST (Clinical Trial No. NCT04901312) tests two interventions integrating interpersonal/drinking and drug refusal skills, case management, and goal setting among YILS in transitioning out of secure detention as opioid initiation prevention strategies. We discuss early implementation barriers and facilitators, including complexities of prevention research with YILS and adaptations due to COVID-19. We conclude by describing anticipated end products, including implementation of effective prevention interventions and integration of data from multiple projects to address larger, multi-site research questions.

The Perpetual Blind Spot in Public Health Surveillance

The jail population is disproportionately affected by poor health outcomes compared with the general population. Despite this, many jail systems do not have adequate surveillance of various health indicators, making it difficult to identify and address health concerns within this setting. In this commentary, the authors highlight four public health crises within the jail setting and identify gaps in data surveillance. The public health domains discussed in this commentary are HIV, suicide, overdose, and COVID-19. Authors also explore current barriers to data collection and reporting within the jail setting and provide recommendations for improved surveillance efforts.

Adolescent suicide assessment and management in primary care

Background

To understand how suicide management occurs within the primary care setting in terms of follow-up assessments and referral practices.

Methods

At an initial primary care visit, adolescents (aged 12–20 years old) completed electronic screening. Data were focused on youth who endorsed a suicidal risk item while completing screening at two Midwestern primary care clinics. Data were collected through retrospective chart reviews to analyze actions taken by the primary care physician at the youth’s initial visit and follow-up visit within the next 12 months.

Results

At initial visits 200 adolescents endorsed a suicidal risk item and 39 (19.5%) were considered to be concerning by their primary care physician. The average age was 14.7 years old (SD ± 2.0). Seventy-two percent (n = 144) were female, and 65% (n = 129) identified as Black. At initial visits, significant differences between suicidal concern groups were found in reporting active suicidal ideation, past suicide attempts, those who were referred to behavioral health counseling, and those who had a diagnosis of depression. Interestingly, only 13% (n = 25) of all patients who endorsed the suicide item were asked whether or not there were weapons in their home and primary care providers asked only 7% (n = 13) of all patients whether they had a safety plan.

Conclusions

There was inconsistent follow-up for adolescents with a history of suicide concerns. At this time, national guidelines do not exist regarding primary care follow-up of youth with suicide concerns. Guidelines are a necessary precursor for practice improvement.

Trial Registration

Clinical Trials Registry: NCT02244138. Registration date, September 1, 2014.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03454-4.

Sex-specific frontal-striatal connectivity differences among adolescents with externalizing disorders

BACKGROUND

Sex-specific neurobiological underpinnings of impulsivity in youth with externalizing disorders have not been well studied. The only report of functional connectivity (FC) findings in this area demonstrated sex differences in fronto-subcortical connectivity in youth with attention-deficit/hyperactivity disorder (ADHD).

METHODS

The current study used functional magnetic resonance imaging(fMRI) to examine sex differences in resting-state seed-based FC, self-rated impulsivity, and their interactions in 11-12-year-old boys (n = 43) and girls (n = 43) with externalizing disorders. Generalized linear models controlling for pubertal development were used. Seeds were chosen in the ventral striatum, medial prefrontal cortex, middle frontal gyrus and amygdala.

RESULTS

Impulsivity scores were greater in boys than girls (p < 0.05). Boys showed greater positive connectivity within a ventromedial prefrontal-ventral striatal network. In addition, boys demonstrated weaker connectivity than girls within two medial-lateral prefrontal cortical networks. However, only boys showed greater medial-lateral prefrontal connectivity correlated with greater impulsivity.

CONCLUSIONS

The findings provide evidence supporting sex differences in both ventral striatal-ventromedial prefrontal and medial-lateral prefrontal functional networks in youth with externalizing disorders. These important networks are thought to be implicated in impulse control. Medial-lateral prefrontal connectivity may represent a male-specific biomarker of impulsivity.

Implementation of a Brief Dialectical Behavioral Therapy (DBT) Skills Group in High Schools for At-Risk Youth: Protocol for a Mixed-Methods Study (Preprint)

Background

Adolescence is a developmental period marked by engagement in risk-taking behaviors, especially among impulsive or emotionally dysregulated youth. Thus, interventions that teach skills to reduce the risk of negative outcomes associated with emotional dysregulation are required. Social and emotional learning (SEL) programs have been developed to address both adolescent emotional dysregulation and risk-taking behaviors; however, current programs have mostly been implemented among younger youth and are used as a tier 1 universal intervention rather than a targeted tier 2 intervention for youth identified with emotional regulation difficulties.

Objective

This study aimed to address the need for SEL programming that can be delivered in schools, particularly for older youth who have difficulties with emotional or behavioral dysregulation, to reduce the risk of health-risk behaviors among this population.

Methods

Here, we outline the implementation of an SEL intervention titled Going 4 Goals, a 9-session adaptation of the Dialectical Behavioral Therapy for Adolescents (DBT-A) program delivered to at-risk high school students in a school setting. The primary objectives of the study are to test whether participating in the skills group intervention produces significant increases in the core DBT-A skills of mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness, while also producing significant decreases in substance use and risky behaviors. These primary outcomes are based on changes in participant scores between baseline and after the intervention and follow-ups at 1, 3, and 6 months compared with a control group of youth participating in the school’s health curriculum at the same time points. Qualitative interviews will also be conducted with intervention participants and school staff to examine acceptability and facilitators of and barriers to the intervention.

Results

A total of 171 participants across 13 groups had been enrolled in the intervention, with data collection ending December 2021. Data analysis will begin in the spring of 2022, with expected results to be published in the spring of 2023.

Conclusions

This paper describes the protocol of the 9-session school-based adaptation of the DBT-A intervention and discusses the strengths and limitations of the study and future directions.

International Registered Report Identifier (IRRID)

DERR1-10.2196/32490

Functional connectivity in frontostriatal networks differentiate offspring of parents with substance use disorders from other high-risk youth

BACKGROUND

Family history (FH) of substance use disorders (SUDs) is known to elevate SUD risk in offspring. However, the influence of FH SUDs has been confounded by the effect of externalizing psychopathologies in the addiction risk neuroimaging literature. Thus, the current study aimed to assess the association between parental SUDs and offspring functional connectivity in samples matched for psychopathology and demographics.

METHODS

Ninety 11-12-year-old participants with externalizing disorders were included in the study (48 FH+, 42 FH-). We conducted independent component analyses (ICA) and seed-based analyses (orbitofrontal cortex; OFC, nucleus accumbens (NAcc), dorsolateral prefrontal cortex) with resting state data.

RESULTS

FH+ adolescents showed stronger functional connectivity between the right lateral OFC seed and anterior cingulate cortex compared to FH- adolescents (p < 0.05, corrected). Compared to FH-, FH+ adolescents showed stronger negative functional connectivity between the left lateral OFC seed and right postcentral gyrus and between the left NAcc seed and right middle occipital gyrus (p < 0.05, corrected). Poorer emotion regulation was associated with more negative connectivity between right occipital/left NAcc among FH+ adolescents based on the seed-based analysis. FH- adolescents had stronger negative functional connectivity between ventral attention/salience networks and dorsal attention/visuospatial networks in the ICA.

CONCLUSIONS

Both analytic methods found group differences in functional connectivity between brain regions associated with executive functioning and regions associated with sensory input (e.g., postcentral gyrus, occipital regions). We speculate that families densely loaded for SUD may confer risk by altered neurocircuitry that is associated with emotion regulation and valuation of external stimuli beyond what would be explained by externalizing psychopathology alone.

Family and Peer Influences on Substance Attitudes and Use among Juvenile Justice-Involved Youth

Juvenile justice-involved youth experience high rates of substance use, which is concerning given associated negative consequences, including health and functional deficits. Family and peer factors are associated with a high risk of substance use among justice-involved youth. It is hypothesized that this risk process operates through pro-drug attitudes. However, limited research has been conducted on the mechanisms through which family and peer factors increase risk for substance use among juvenile justice involved youth. The current study examined both the direct and indirect effects of family and peer substance use on youth's substance use (alcohol and illicit drug use). We also examined whether this relationship differs by race. 226 detained youth (81.9% male; 74.3% Black) were recruited from an urban county in the Midwest and completed a clinical interview and substance use assessment battery. A direct effect of family/peer risk on illicit drug use was found for all youth, though the effect was stronger among White youth. Results also supported the indirect effect pathway from family/peer risk to both illicit drug use and alcohol use through pro-drug attitudes. This pathway did not vary by race. These findings suggest that interventions should focus on targeting both family/peer risk and pro-drug attitudes to reduce substance use. Given the racial difference in the direct effect of family/peer risk on illicit drug use, there may be other factors that influence risk more strongly for White youth, which warrants further investigation.

PTSD Symptoms Mediate the Relationship Between Sexual Abuse and Substance Use Risk in Juvenile Justice-Involved Youth

Juvenile justice-involved youth face disproportionate rates of sexual abuse, which increases the risk of post-traumatic stress disorder (PTSD) and substance use disorders (SUDs), both of which are associated with poor long-term outcomes. The present study tested two mediation and moderation models, controlling for age, race, and history of physical abuse, with gender as a moderator, to determine whether PTSD symptoms serve as a risk factor and/or mechanism in the relationship between sexual abuse and substance use. Data were examined for 197 juvenile justice-involved youth (mean age = 15.45, 68.9% non-White, 78.4% male) that completed court-ordered psychological assessments. Results indicated that PTSD symptoms significantly mediated the relationship between sexual abuse and drug (β = 3.44, confidence interval [CI] [0.26, 7.41]; test for indirect effect z = 2.41, p = .02) and alcohol use (β = 1.42, CI [0.20, 3.46]; test for indirect effect z = 2.23, p = .03). PTSD symptoms and gender were not significant moderators. Overall, PTSD symptoms mediate the relationship between sexual abuse and SUDs in juvenile justice-involved youth, which suggests viability of targeting PTSD symptoms as a modifiable risk factor to reduce the effects of sexual abuse on substance use in this high-risk population.

Conduct Disorder Symptoms and Illicit Drug Use in Juvenile Justice Involved Youth: The Reciprocal Relationship Between Positive Illicit Drug-Use Attitudes and Illicit Drug Use

Conduct disorder (CD) symptoms cooccur at high rates with illicit drug use in juvenile justice involved youth, which results in poorer outcomes; however, research has not identified where best to intervene in this relationship, limiting the identification of modifiable risk factors to reduce negative effects of CD symptoms. Two mediation models were examined to investigate the potential for CD symptoms to influence a reciprocal relationship between illicit drug use and positive drug attitudes, controlling for age, gender, and race. Data were examined for 245 juvenile justice involved youth (mean age = 15.46, SD = 1.30, range 12-18, 64.9% Black, 80.4% male) who completed court-ordered psychological assessments. Findings indicate: (1) Positive attitudes toward illicit drug use significantly mediated the relationship between CD symptoms and illicit drug use (β = 0.16, CI 0.09-0.27; test for indirect effect z = 4.17, p < .001) and (2) illicit drug use significantly mediated the relationship between CD symptoms and positive attitudes toward illicit drug use (β = 0.20, CI 0.12-0.32; test for indirect effect z = 4.87, p < .001). Overall, the present study suggests that CD symptoms impart risk for illicit drug use both indirectly, through more positive attitudes toward illicit drug use, and directly, which further strengthens positive attitudes toward illicit drug use.

Differences in risk behaviours, HIV/STI testing and HIV/STI prevalence between men who have sex with men and men who have sex with both men and women in China

Differences in risk behaviours between men who have sex with men (MSM) and men who have sex with both men and women (MSMW) have important implications for HIV and sexually transmitted infection (STI) transmission. We examined differences in risk behaviours, HIV/STI testing, self-reported HIV/STI diagnoses, and linkage to HIV care between MSM and MSMW across China. Participants were recruited through three MSM-focused websites in China. An online survey containing items on socio-demographics, risk behaviours, testing history, self-reported HIV/STI diagnosis, and linkage to and retention in HIV care was completed from September to October 2014. Chi square tests and logistic regression analyses were conducted. MSMW were less likely to use a condom during last anal sex (p ≤ 0.01) and more likely to engage in group sex (p ≤ 0.01) and transactional sex (p ≤ 0.01) compared to MSM. Self-reported HIV/STI testing and positivity rates between MSM and MSMW were similar. Among HIV-infected MSM, there was no difference in rates of linkage to or retention in antiretroviral therapy when comparing MSM and MSMW. Chinese MSM and MSMW may benefit from different HIV and STI intervention and prevention strategies. Achieving a successful decrease in HIV/STI epidemics among Chinese MSM and MSMW will depend on the ability of targeted and culturally congruent HIV/STI control programmes to facilitate a reduction in risk behaviours.

Intimate Partner Violence and Correlates With Risk Behaviors and HIV/STI Diagnoses Among Men Who Have Sex With Men and Men Who Have Sex With Men and Women in China: A Hidden Epidemic

BACKGROUND

Intimate partner violence (IPV) research has primarily focused on heterosexual couples but has largely ignored IPV among men who have sex with men (MSM). We examined IPV prevalence among MSM and men who have sex with men and women (MSMW) in China.

METHODS

Men who have sex with men older than 16 years were recruited through 3 MSM-focused Web sites in China. An online survey containing items on sociodemographics, risk behaviors, IPV, and self-reported HIV or sexually transmitted infection diagnosis was completed. Multivariate regression was used to examine associations between IPV and risk behaviors and an HIV or sexually transmitted infection diagnosis.

RESULTS

Among 610 participants, 182 (29.8%) reported experiencing at least 1 type of IPV. Men who have sex with both men and women were at significantly greater risk for IPV (adjusted odds ratio [AOR], 1.65; 95% confidence interval [CI], 1.08-2.53) compared with MSM. Men who had experienced IPV were more likely to have participated in group sex (AOR, 1.86; 95% CI, 1.08-3.21), to have had sex in exchange for gifts or money (AOR, 5.06; 95% CI, 2.47-10.35), and to report a positive HIV diagnosis (AOR, 2.59; 95% CI, 1.22-5.51).

CONCLUSIONS

There is a hidden epidemic of IPV among MSM in China, especially among MSMW. The hidden nature of MSM and MSMW suggests the need for a clinical environment more conducive to disclosure. Research is needed to understand the pathways linking IPV and HIV risk among MSM to optimize the design of effective interventions.

Barriers and facilitators to treatment participation by adolescents in a community mental health clinic

An estimated 40-60% of children in mental health treatment drop out before completing their treatment plans, resulting in increased risk for ongoing clinical symptoms and functional impairment, lower satisfaction with treatment, and other poor outcomes. Research has focused predominately on child, caregiver, and family factors that affect treatment participation in this population and relatively less on organizational factors. Findings are limited by focus on children between 3 and 14 years of age and included only caregivers' and/or therapists' perspectives. The purpose of this descriptive qualitative study was to identify organizational factors that influenced participation in treatment, with special attention to factors that contributed to dropout in adolescents. The sample included 12 adolescent-caregiver dyads drawn from two groups in a large public mental health provider database. Analysis of focus group interview data revealed several perceived facilitators and barriers to adolescent participation in treatment and provided several practical suggestions for improving treatment participation. Implications of the findings for psychiatric mental health nurses and other clinicians who provide services to families of adolescents with mental health concerns are discussed.

Psychopathology, Psychosocial, Gender and Cognitive Outcomes in Patients With Cloacal Exstrophy

PURPOSE

Psychological functioning, as reflected in psychopathology, psychosocial functioning, gender identity, gender role and cognitive abilities, was examined in a sample of patients with cloacal exstrophy.

MATERIALS AND METHODS

Nine participants 11 to 37 years old completed the evaluation. Standardized measures were used and participant responses were compared to the norms of the various instruments. Gender reassigned participants with cloacal exstrophy were compared with nonassigned participants with cloacal exstrophy. Mean differences between the 2 groups were calculated using the t test.

RESULTS

Overall the participants with cloacal exstrophy reported good psychological functioning. Significant differences between reassigned and nonassigned participants were found in the area of depression. All participants had a stable gender identity. XY females showed more male-typical gender roles. There were no significant group differences on cognitive assessments. Reassigned and nonassigned participants did not differ in IQ.

CONCLUSIONS

Although being born with cloacal exstrophy puts patients at risk for psychopathology and psychosocial problems, it does not necessarily mean that these problems will develop. With the appropriate support these patients can have remarkably well adjusted lives.