Faculty Bibliography

This article examines the symbolic work of gender as it intersects with race and class in popular media and in local community discourses surrounding the "suburban opioid epidemic," in which national drug policies, and White futures, are thought to be at stake. The study starts with an analysis of the White, middle-class, female "new face of addiction" that has been cultivated by national press coverage of prescription opioid-cum-heroin overdoses in the U.S. and then turns to interviews with community physicians in the front line of a clinical response to the "epidemic" in Staten Island, a White suburban enclave within New York City that is experiencing 3"“4 times the opioid overdose rate of any other City borough. Physicians use the language of family membership to indicate identification with their opioid addiction patients, and many go to lengths to provide holistic care and to incorporate family support for their patients despite lack of insurance reimbursement. White, educated patients describe buprenorphine as a way to maintain their professional identities, while low-income Black and Latino patients describe pharmaceutical maintenance as a socially alienating arm of the criminal justice system. Together, media and clinical responses make up strategies of White racial rescue from threatened social reproduction in an era of substance-induced White downward mobility.

Background: With both agonist and antagonist medications available to treat opioid dependence, and with these differing markedly on a spectrum of parameters - including philosophy of treatment, need for detoxification to initiate treatment, ongoing dependence and withdrawal on stopping treatment, diversion risk, community acceptability and controlled substance restrictions - it's difficult to know which approach to take. What do we tell our patients? How should we choose? Is one approach better for some patients, the other for others? Does choice matter, do patients do better with their preferred treatment than with the alternative? CTN-0051 grows out of these questions and will establish the evidence-base to inform treatment decisions. Methods: Close to a dozen designs, including no-medication treatment-as-usual conditions, SMART designs, and designs taking choice into consideration were considered. The final design was a randomized two-arm, head-to-head effectiveness trial comparing extended-release naltrexone to buprenorphine, both FDA approved treatments, in 570 patients across 8 sites. Recruitment was from inpatient detoxification and short term residential programs. We selected a flexible point of randomization to reflect community medication initiation practices. We predicted differential induction success, and included a mitigation plan to manage the detoxification hurdle. Treatment was for up to six months with follow up visits through nine months postrandomization. The primary outcome measure was timeto- relapse, defined as 7 consecutive use-days or 4 consecutive use-weeks. Secondary outcomes included successful induction, abstinence from opioids, alcohol, tobacco and other drugs, craving, subacute withdrawal, etc., and mediators and moderators of treatment response. Results: Recruitment was completed in May 2016 with 722 participants consented and 570 randomized. Treatment visits were completed in November 2016 and follow up visits in February 2017. Women made up 30% of the population; 17% were Hispanic, 26% non-white; 69% were 25-45 years old, 15% were under 25; 57% had a high school education or less, 66% were never married, 63% were unemployed; 82% identified heroin as their primary abused opioid, 16% prescription drugs; 63% were IV users; 40% were high users defined as IV use of at least 6 bags a day, a stratification variable that we predicted to influence outcome; although all participants expressed willingness to take either medication, 29% indicated that they preferred extended-release naltrexone, and 33% buprenorphine. AEs and SAEs were those expected in this population. Data lock will be in May 2017 after which we will be able to look at outcomes data. Conclusions: We expect to be able to present comparative effectiveness data on induction success, survival without relapse, time-to-relapse, abstinence from opioids and other drugs, successful completion of 24 weeks of treatment, craving, cognitive function, and adverse events including overdose during and after treatment. Findings on the role of choice in influencing outcome, and mediators and moderators of treatment success or failure will be presented. None of these data will be available until after data-lock, precluding more specific "conclusions" per se until early summer

Recent randomized controlled trials of psilocybin-assisted psychotherapy for patients with cancer suggest that this treatment results in large-magnitude reductions in anxiety and depression as well as improvements in attitudes toward disease progression and death, quality of life, and spirituality. To better understand these findings, we sought to identify psychological mechanisms of action using qualitative methods to study patient experiences in psilocybin-assisted psychotherapy. Semistructured interviews were conducted with 13 adult participants with clinically elevated anxiety associated with a cancer diagnosis who received a single dose of psilocybin under close clinical supervision. Transcribed interviews were analyzed using interpretative phenomenological analysis, which resulted in 10 themes, focused specifically on cancer, death and dying, and healing narratives. Participants spoke to the anxiety and trauma related to cancer, and perceived lack of available emotional support. Participants described the immersive and distressing effects of the psilocybin session, which led to reconciliations with death, an acknowledgment of cancer's place in life, and emotional uncoupling from cancer. Participants made spiritual or religious interpretations of their experience, and the psilocybin therapy helped facilitate a felt reconnection to life, a reclaiming of presence, and greater confidence in the face of cancer recurrence. Implications for theory and clinical treatment are discussed.

Experiences of discrimination, or social marginalization and ostracism, may lead to the formation of social networks characterized by inequality. For example, those who experience discrimination may be more likely to develop drug use and sexual partnerships with others who are at increased risk for HIV compared to those without experiences of discrimination. This is critical as engaging in risk behaviors with others who are more likely to be HIV positive can increase one's risk of HIV. We used log-binomial regression models to examine the relationship between drug use, racial and incarceration discrimination with changes in the composition of one's risk network among 502 persons who use drugs. We examined both absolute and proportional changes with respect to sex partners, drug use partners, and injecting partners, after accounting for individual risk behaviors. At baseline, participants were predominately male (70%), black or Latino (91%), un-married (85%), and used crack (64%). Among those followed-up (67%), having experienced discrimination due to drug use was significantly related to increases in the absolute number of sex networks and drug networks over time. No types of discrimination were related to changes in the proportion of high-risk network members. Discrimination may increase one's risk of HIV acquisition by leading them to preferentially form risk relationships with higher-risk individuals, thereby perpetuating racial and ethnic inequities in HIV. Future social network studies and behavioral interventions should consider whether social discrimination plays a role in HIV transmission.

Screening, brief intervention, and referral to treatment (SBIRT) has been widely implemented as a method to address substance use disorders in general medical settings, and some evidence suggests that its use is associated with decreased societal costs. In this paper, we investigated the economic impact of SBIRT using data from Screening, Motivational Assessment, Referral, and Treatment in Emergency Departments (SMART-ED), a multisite, randomized controlled trial. Utilizing self-reported information on medical status, health services utilization, employment, and crime, we conduct a benefit-cost analysis. Findings indicate that neither of the SMART-ED interventions resulted in any significant changes to the main economic outcomes, nor had any significant impact on total economic benefit. Thus, while SBIRT interventions for substance abuse in Emergency Departments may be appealing from a clinical perspective, evidence from this economic study suggests resources could be better utilized supporting other health interventions.

Research activity on the potential clinical value of classic hallucinogens and other psychedelics has increased markedly in the past two decades, and promises to continue to expand. Experimental study of hallucinogen-assisted treatment, and any future clinical use, requires the development of psychotherapeutic models that are appropriate to the disorder being treated and effectively integrated with the pharmacologic component of the treatment. To provide a framework for thinking about possible treatment models, we provide an overview of the history of psychedelic-assisted treatment, review what is known about the therapeutic mechanisms of these treatments, and consider the various purposes of psychotherapy in the context of both research and clinical use of psychedelic-assisted treatment. We then provide a description of a therapy model we have developed and are currently using in a trial of psilocybin-assisted treatment for alcoholism. Finally, we discuss advantages and disadvantages of a range of alternative models, emphasizing the need for research to determine the most effective treatment models for any indications for which efficacy becomes established.

The psychological mechanisms of action involved in psilocybin-assisted psychotherapy are not yet well understood. Despite a resurgence of quantitative research regarding psilocybin, the current study is the first qualitative study of participant experiences in psilocybin-assisted psychotherapy. Semistructured interviews were carried out with 13 adult participants aged 22 to 69 years (M = 50 years) with clinically elevated anxiety associated with a cancer diagnosis. Participants received a moderate dose of psilocybin and adjunctive psychotherapy with an emphasis on the process of meaning-making. Verbatim transcribed interviews were analyzed by a five-member research team using interpretative phenomenological analysis. General themes found in all or nearly all transcripts included relational embeddedness, emotional range, the role of music as conveyor of experience, meaningful visual phenomena, wisdom lessons, revised life priorities, and a desire to repeat the psilocybin experience. Typical themes found in the majority of transcripts included the following: exalted feelings of joy, bliss, and love; embodiment; ineffability; alterations to identity; a movement from feelings of separateness to interconnectedness; experiences of transient psychological distress; the appearance of loved ones as guiding spirits; and sharing the experience with loved ones posttreatment. Variant themes found in a minority of participant transcripts include lasting changes to sense of identity, synesthesia experiences, catharsis of powerful emotion, improved relationships after treatment, surrender or letting go, forgiveness, and a continued struggle to integrate experience. The findings support the conclusion that psilocybin-assisted psychotherapy may provide an effective treatment for psychological distress in cancer patients. Implications for theory and treatment are discussed.

The US 'War on Drugs' has had a profound role in reinforcing racial hierarchies. Although Black Americans are no more likely than Whites to use illicit drugs, they are 6-10 times more likely to be incarcerated for drug offenses. Meanwhile, a very different system for responding to the drug use of Whites has emerged. This article uses the recent history of White opioids - the synthetic opiates such as OxyContin(R) that gained notoriety starting in the 1990s in connection with epidemic prescription medication abuse among White, suburban and rural Americans and Suboxone(R) that came on the market as an addiction treatment in the 2000s - to show how American drug policy is racialized, using the lesser known lens of decriminalized White drugs. Examining four 'technologies of whiteness' (neuroscience, pharmaceutical technology, legislative innovation and marketing), we trace a separate system for categorizing and disciplining drug use among Whites. This less examined 'White drug war' has carved out a less punitive, clinical realm for Whites where their drug use is decriminalized, treated primarily as a biomedical disease, and where their whiteness is preserved, leaving intact more punitive systems that govern the drug use of people of color.