Digital Commons Network^™

Implementation Of A Cardiomems Screening Tool To Increase Provider Awareness And Referrals In Eligible Patients, Monica Rios

DNP Projects

Background: Heart failure affects over 6 million Americans and causes more than one million hospitalizations annually. CardioMEMS, a remote pulmonary artery pressure monitoring device, effectively reduces hospitalizations, yet its use remains limited due to provider and system barriers. The purpose was to increase CardioMEMS referrals for eligible heart failure patients through targeted provider education and a standardized screening tool.

Local Problem: Kentucky experiences higher heart failure hospitalization rates than the national average, contributing to prolonged hospital stays and rising healthcare costs.

Methods: A pre—post quasi-experimental study was conducted at an academic medical center. Baseline chart review of 47 patients evaluated …

Improving Compliance With Preoperative Antibiotic Protocols For Cardiac Implanted Electronic Devices: A Quality Improvement Project, James Kaup

DNP Projects

Abstract

Background

Cardiac implantable electronic device infections remain a serious complication of permanent pacemaker implantation despite evidence-based infection prevention guidelines.

Local Problem

An academic electrophysiology laboratory identified inconsistent guideline-concordant antibiotic selection despite consistently high compliance with recommended antibiotic timing.

Methods

A nurse-led, quasi-experimental pre-post quality improvement project evaluated implementation of a standardized preoperative antibiotic prophylaxis protocol. Data from 36 permanent pacemaker implantations (16 pre-intervention, 20 postintervention) were analyzed.

Interventions

The intervention included a standardized antibiotic protocol, multidisciplinary staff education, and performance feedback.

Results

Guideline-concordant antibiotic selection improved from 37.5% to 95.0% (χ² = 11.27, P = .001). Antibiotic timing remained …

Implementing A Standardized App-Led Multidisciplinary Medication Review And Reconciliation To Improve Medication Safety Before Systemic Cancer Therapy: An Ambulatory Oncology Quality Improvement Initiative, Sarah R. Hines

DNP Projects

Background

Adult patients initiating systemic cancer therapy frequently present with pre-existing polypharmacy related to chronic comorbidities and cancer-related symptom management. The addition of anticancer therapies and supportive care medications further increases medication burden and the risk of medication-related harm. Although national organizations and institutional policies recommend comprehensive medication review before treatment initiation, implementation remains inconsistent in ambulatory oncology practice.

Purpose

To implement and evaluate a standardized Advanced Practice Provider (APP)-led multidisciplinary medication review and reconciliation process designed to identify medication medication-related safety risks before initiation of systemic cancer therapy in adult oncology patients receiving care in an ambulatory infusion center. …

Kentucky Bluegrass (Poa Pratensis L.) As A Perennial Groundcover: Establishment And Weed Management In Corn, Kiera S. Searcy

Theses and Dissertations--Plant and Soil Sciences

Perennial groundcover (PGC) systems offer a cost-effective alternative to annual cover crops, by providing continuous soil cover, reducing soil erosion, and contributing to integrated weed management (IWM) in corn (Zea mays L.) production systems. Kentucky bluegrass (Poa pratensis L.) has been proposed as a perennial groundcover for corn due to its low growth habit and seasonal dormancy; however, successful adoption is limited by challenges associated with establishment-phase weed competition and compatibility with weed management programs during corn production. The objectives of this research were to (1) evaluate weed management strategies that support Kentucky bluegrass establishment and (2) assess …

Impact Of Land Use On Soil Properties, Clay Mineralogy, And Behavior Of Ammonium Across A Precipitation Gradient, Isabel Delamater

Theses and Dissertations--Plant and Soil Sciences

Like soil texture, clay mineralogy is considered a permanent or inherent characteristic of soils reflecting the influence of soil forming factors over long periods of time. Despite the importance of clay mineralogy in providing ecosystem services, much remains unknown about whether land use (native grassland sod versus no-tillage) can modify clay mineralogy under short periods of time. Furthermore, in no-tillage agroecosystems, lower crop yields are often ascribed to immobilization of added N fertilizer where inorganic nitrogen (such as ammonium) is converted to organic nitrogen. The possible role of clay mineralogy in retaining added ammonium has been overlooked in no-tillage systems. …

Breeding For Fhb Resistance And Post-Harvest Quality In Soft Red Winter Wheat, Margaret E. Gillum

Theses and Dissertations--Plant and Soil Sciences

Soft red winter wheat (Triticum aestivum L.) is both an economically and nutritionally important crop in the global food supply. Despite its global importance, wheat is continually threatened by fungal diseases. Fusarium head blight (FHB), caused by Fusarium graminearum, is a devastating fungal disease affecting wheat worldwide, resulting in low yields, reduced test weight and mycotoxin production. The mycotoxin deoxynivalenol (DON) is toxic to humans, results in feed rejection in livestock, and is heavily monitored in the food supply. Because of wheat’s importance in the food system, post-harvest quality (milling, baking, and flavor) has been a growing area of …

Supramolecular Self-Assemblies Of Ru( Ii ) Phototherapeutics: Biological Activity Of Micro- And Nano-Particles Acting As Reservoirs, Jérôme Laisney, Sarah M. Kriger, Dmytro Havrylyuk, Jason M. Unrine, David K. Heidary, Edith C. Glazer

Chemistry Faculty Publications

Ruthenium( II) coordination complexes have many appealing properties as prodrugs, but can suffer from poor aqueous solubility and short circulation times, drastically decreasing efficiency in vivo. Nanoformulations using a variety of carriers, such as inclusion in polymers/lipids or adsorption on inorganic nanoparticles have been applied to overcome this limitation, but unfortunately, these approaches raise additional concerns regarding the fate of the carriers, with potential long-term toxicity and accumulation in vital organs. Here, we present an alternative delivery strategy with formation of pure and polymer-supported supramolecular self-assemblies of Ru(II) complexes acting as ‘‘reservoirs’’. A facile preparation of size-controlled particles was achieved …

Eco-Friendly Solvent-Based Fabrication Of Single-Layer And Polydopamine-Modified Bilayer Pvdf-Hfp Membranes, Eesh M. Kulshrestha

Theses and Dissertations--Chemical and Materials Engineering

The growing global demand for clean drinking water has intensified the need for advanced water treatment technologies capable of efficiently removing contaminants while maintaining environmental sustainability. Polymeric membrane systems have emerged as an effective approach for water separations due to their high separation efficiency, simplicity, and adaptability to a wide range of water treatment applications. However, traditional membrane fabrication processes often rely on toxic organic solvents, such as N-methyl-2-pyrrolidone (NMP) and diemethylacetamide (DMAc), which pose environmental and health risks. These concerns have led to an increase in regulatory restrictions, primarily through the Registration, Evaluation, Authorisation, and Restriction of Chemicals (REACH) …

Investigation Of Succinylated Zwitterionic Polyethylenimine/Dna Complexes: Performance In Serum, Internalization, And Intracellular Fate, Levi Lampe

Theses and Dissertations--Chemical and Materials Engineering

Gene therapy has promised to revolutionize medicine since the earliest clinical trials, but a lack of delivery methods that are both safe and efficient has hampered progress. Gene therapy with viral vectors is effective at delivering nucleic acids to cells, but is associated with dangerous immunogenic responses and cancer-causing insertions into the genome. Viral vectors are also among the most prohibitively costly therapeutics in medicine. Polymeric vectors avoid these dangers and are made from inexpensive, off-the- shelf materials, but have been hindered by poor efficiency compared to viral vectors.

A benchmark polymer for in vitro nucleic acid delivery has been …

Navigating Mental Wellness: A Peer-Led Journey Into Adult Services, Kristin G. Haberek

DSW Capstone Projects

Students with severe emotional disturbances (SED) occupy one of the most underserved intersections in American education and mental health care. As they age out of children’s services, they face abrupt service discontinuation, disrupted therapeutic relationships, and adult systems ill-equipped to meet their needs. These vulnerabilities, including heightened risks of crisis, hospitalization, homelessness, and justice involvement, constitute a central practice problem. This capstone addresses these transitions across three scholarly products: a systematic literature review, a theoretical concept paper, and a practical application paper, tracing a unified arc from diagnosing structural failures to proposing an evidence-informed, equity-oriented clinical response. Synthesizing key findings …

Preoperative Glucagon-Like Peptide-1 Therapy In Bariatric Surgery Patients With Morbid Obesity (Premo): Rationale And Study Design For A Randomized Controlled Trial, Varun Jain, Colleen A. Mcmullen, Joy I. Kimbrough, Anna K. Rockich, Daniel L. Davenport, Gregory S. Hawk, Barbara S. Nikolajczyk, Philip A. Kern, Simon J. Fisher, Joshua P. Steiner, William B. Inabnet Iii, Marlene E. Starr

Surgery Faculty Publications

Introduction: Bariatric surgery is the most effective treatment modality for individuals with morbid obesity, providing significant and durable weight loss and comorbidity resolution. Glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide receptor agonists have shown promise as weight loss drugs, in addition to their use in the treatment of metabolic disorders. While multimodal weight management is the standard of care for individuals with morbid obesity, the benefit of antecedent GLP-1 therapy prior to bariatric surgery has not been well-studied. The objective of this study is to conduct a clinical trial testing the hypothesis that preoperative treatment with a dual GLP-1/glucose-dependent insulinotropic …

Amustaline/Glutathione Pathogen-Reduced Red Cell Hemoglobin Utilization In Complex Cardiac Surgery, Ian J. Welsby, Michael E. Sekela, Edward L. Snyder, James D. Gorham, John S. Mcneil, Kathy Liu, Stanley Bentow, Thomas Gniadek, Laurence Corash, Nina Mufti, Richard J. Benjamin

Surgery Faculty Publications

Background: The ReCePI randomized, controlled trial compared amustaline/glutathione pathogen-reduced (PR) and conventional red blood cell (RBC) transfusions in cardiac surgery. Study design and methods: We performed a post-hoc analysis of hemoglobin (Hb) utilization and safety outcomes. Hb content of study RBCs was measured at manufacture. Subject Hb levels, estimated blood loss and blood product use were recorded during and for 7 days post-surgery. Acute kidney injury (AKI) incidence was graded over 7 days, and adverse events were assessed for 28 days. Results: PR-RBCs contained 5.2% less Hb (mean [SD] Test 58.1 [6.5] g; Control 61.5 [6.8] g Hb, p <.001) due to manufacturing volume losses. Four hundred fifty-six PR- and 524 conventional RBCs were transfused to 159 Test and 162 Control subjects, respectively. Mean subject baseline and post-surgery Hb levels, and blood loss were not different between groups. Test subjects tended to require fewer total RBCs (3.5 [2.7] Test vs. 4.0 [3.5] Control, p =.08) resulting in 17.6% significantly less mean total Hb transfused (Test 203.2 g; Control 246.8 g Hb, p =.01). The proportions of subjects transfused with, and the number of platelet and cryoprecipitate units transfused were not different. Test subjects received less plasma (2.3 [1.8] units Test vs. 3.5 [3.8] Control, p =.03). Overall incidence of adverse events and AKI were not clinically different. Imbalances in AKI severity (Grade III Test 15/159 [9.4%]; Control 7/162 [4.3%], p =.07) may suggest under-transfusion in the highest-risk Test subjects. Discussion: Test patients required less transfused Hb than control subjects to maintain equivalent daily hemoglobin levels following similar blood loss.

Prolonged Invasive Mechanical Ventilation Is Associated With Decreased Survival After Lung Transplantation Among Recipients With Primary Graft Dysfunction, Meghan Aversa, Shaf Keshavjee, Tereza Martinu, Marcelo Cypel, Andrew T. Sage, Joshua M. Diamond, Jonathan P. Singer, Scott M. Palmer, Krishna Pandya, Edward Cantu, Jason D. Christie, Michaela R. Anderson

Surgery Faculty Publications

Introduction: Prolonged invasive mechanical ventilation (IMV) after lung transplantation is an appealing early prognostic outcome as it can be reproducibly assessed both prospectively and retrospectively. Whether use of IMV at 72 h after lung transplantation is associated with post-transplant graft survival is unknown. Methods: We performed a retrospective cohort study of 1511 participants in the multi-center Lung Transplant Outcomes Group cohort (2011–2018). Using Cox proportional hazards models and restricted mean survival time, we investigated whether IMV at 72 h was associated with post-transplant graft survival. We secondarily evaluated whether IMV at 72 h was concordant with severe primary graft dysfunction …

Mouse Models For Post-Sepsis Syndrome, John Matthew K. Ang, Stephanie F. Mori, Erick Lewis, Maria E.C. Bruno, Arnold Stromberg, Hiroshi Saito

Surgery Faculty Publications

Background – Sepsis survivors commonly suffer from chronic Post-Sepsis Syndrome (PSS). To understand the mechanisms of PSS, it is critical to utilize appropriate animal models. While cecal ligation and puncture (CLP) is a widely used model of sepsis, a concern exists regarding its suitability for studying long-term outcomes. Alternatively, we previously optimized a highly reproducible murine cecal slurry (CS)-injection model of sepsis. The objective of this study was to compare the suitability of CS and CLP models for investigating PSS. Methods – Male 4-month-old C57BL/6 mice were divided into 7 groups: (1) Naïve control; (2) Sham: laparotomy control; (3) CL: …

Scrolling, Searching, And Self-Diagnosing: Examining How Social Media Influences Self- Diagnosis And Shapes Mental Health Literacy, Conceptualization, And Identity Development, Sara Elaine Hamilton

DSW Capstone Projects

This capstone examines the influence of social media on the growing issue of self-diagnosis of mental health disorders through three scholarly works: a systematic literature review (SLR), a conceptual paper, and practice application paper. Accessibility, anonymity, and social isolation are identified as contributing factors of self-diagnosis, as individuals increasingly prioritize convenience over traditional help-seeking methods. Research suggests that self-diagnosis is influenced by misinformation and reinforced by validation and a sense of belonging, leading individuals to internalize mental health disorders as part of their identity. Findings further indicate that social media plays a significant role in the dissemination of misinformation about …

The Impact Of Medicaid Policy Limitations On Access To Eating Disorder Treatment: Uncovering The Consequences Of A System Built To Fail, Meghan Frost

DSW Capstone Projects

Individuals who rely on Medicaid face major barriers when trying to access eating disorder (ED) treatment, reflecting broader patterns of structural disadvantage in publicly funded health care. Research shows delayed diagnosis, limited access to ED specialists, and frequent denials for recommended services. These gaps occur because Medicaid policies do not match the needs of evidence based ED care, resulting in delayed or incomplete care for many individuals with eating disorders.

This issue is highly relevant to social work practice because the policies shaping these barriers are complex and difficult for clients and ED providers to navigate. Social workers across clinics, …

Investigating Intersectionality: How Multiple Marginalized Identities And Social Perceptions Of Victims Influences The Efficacy Of Panic-Defense Narratives In Bathooms, Demitri James Aguilar

Theses and Dissertations--Psychology

Despite transgender Women of Color being the main victims of violent victimization and panic-narrative cases, very little research has investigated how race/ethnicity might impact perceptions of violence or the influence of panic-narratives. Thus, the current experiment (N = 1275) examined the social and legal ramifications of using panic-narratives against transgender and cisgender women of color (Black vs. Latino vs. White) in bathroom victimization contexts. The predictions were partially supported. Regardless of racial identity, the justification of transgender (versus cisgender) victimization via panic-narratives produced more anti-victim (e.g., increased victim guilty verdicts, sentencing, victim culpability, perceived deception, and threat) and prodefendant outcomes …

Brief Exposure Therapy With Exercise For Ptsd: A Pilot Study Using Single Case Experimental Design, Troy J.J. Hubert

Theses and Dissertations--Psychology

Posttraumatic stress disorder (PTSD) is a common and often disabling psychiatric disorder associated with an increased risk of multiple mental and physical health conditions. Exposure therapy is a gold standard treatment for PTSD, but attrition rates and treatment response are notable limitations. Animal and human research collectively indicate that aerobic exercise can enhance preclinical and experimental models of exposure by improving consolidation of fear-extinction memories. To date, only one clinical trial has attempted to translate exercise augmented exposure therapy for PTSD. The current study is an open-label pilot clinical trial aiming at gauging the effectiveness of a brief eight-session PTSD …

The Power Of A Picture: Building Visual Depictions Of The Eppm Bolstering Sunscreen Application Motivation, Ansley M. George

University of Kentucky Doctoral Dissertations

This study investigates visual depictions of efficacy skin cancer health risk messages. Using Witte's Extended Parallel Processing Model (EPPM) and existing literature on fear appeals and visual persuasion as a theoretical framework, the study aims to explore how self and response efficacy imagery impacts individuals' perceptions of health risk messages in the context of skin cancer prevention when emphasizing specific principles of design. Formative research was employed via qualitative photo sorts and participants were exposed to an assortment of images depicting efficacy in the context of skin cancer prevention where they discussed why they felt they were or were not …

Stressful Life Events And Ocd Treatment: A Thematic Analysis Of Patient Perspectives, Emily E. Fenlon

Theses and Dissertations--Psychology

Trauma exposure, including interpersonal violence (IPV), is associated with increased risk and severity of obsessive-compulsive disorder (OCD). Exposure and response prevention (ERP) is the treatment of choice for OCD, yet research suggests a history of trauma and comorbid PTSD may adversely impact treatment outcomes. No studies have yet evaluated patient perspectives on the relationship between trauma, IPV and related sequelae and OCD treatment. The present study applies reflexive thematic analysis to interviews from individuals with a history of IPV who received exposure-based therapy for OCD. Interviews explored the influence of posttraumatic distress, impairment, and psychopathology on the treatment of OCD, …

Menstrual Cycle Phase Effects On Alcohol-Impaired Driving Performance And Risk Awareness, Annie K. Griffith

Theses and Dissertations--Psychology

Growing evidence indicates that risky behavior among women is elevated during the late follicular phase of the menstrual cycle, likely due to increased estradiol levels. Furthermore, alcohol-induced impairment of women’s inhibitory control is significantly greater during the late versus early follicular phase. Consequently, cycle phase may influence outcomes of poor inhibitory control while intoxicated, such as alcohol-impaired driving. Alcohol-impaired driving risk manifests in two ways: risk-taking while driving, and risk awareness regarding the decision to drive. This dissertation tested the hypothesis that alcohol-induced increases in driver risk-taking and decreases in risk awareness would be exacerbated during the late versus early …

Daily Rhythms In Psychosocial Stress, Sleep, And Mood: A Multimethod Approach To Transdiagnostic Psychopathology Risk And Intervention, Gabriel Gilmore

Theses and Dissertations--Psychology

Rhythms are central to nearly every core physiological and psychological process and have profound influences on overall health and well-being, particularly in the context of mood disorders. This dissertation emphasizes a rhythm-centered framework for understanding transdiagnostic psychopathology, proposing that the temporal organization of psychosocial stress, sleep, and mood provides crucial information for the development and treatment of mood disorder symptomology. Current literature relies primarily on mean symptom levels, overlooking day-to-day patterns in psychosocial experiences. To address this key methodological gap, three studies are examined. Study 1 develops and validates the Psychosocial Stress Regularity Measure (PSRM), a brief single-item measure of …

Relative Utility Governs Working Memory For Drug-Associated Stimuli In A Novel Translational Paradigm, Maxwell E. Boileau

Theses and Dissertations--Psychology

Substance use disorder (SUD) remains a prevalent health concern, partially characterized by continued drug use despite aversive consequences. Contrary to accounts emphasizing cognitive deficits, drug versus non-drug choice data reflect sensitivity to reinforcement dimensions, with preference shifting systematically as a function of magnitude and probability. The present study tested whether another cognitive system, working memory, is similarly affected by relative utility. Preclinical studies have demonstrated sensitivity of working memory to reinforcement dimensions, but these are often attributed to the differential outcomes effect. Generalized matching models were fit to allomorphic choice data, allowing estimation of exchange rate parameters. A concurrent solid- …

The Relationship Between Estradiol And Progesterone Concentration Levels, Alcohol Consumption, And Inhibitory Control, Layne Elizabeth Robinson B.S.

Theses and Dissertations--Psychology

Alcohol use is increasing among women, with estimates for binge drinking having risen to levels similar to those seen in men. Despite this trend, sex differences regarding mechanisms of alcohol consumption have seldom been investigated. Our group and others have found evidence to suggest that ovarian sex hormones are associated with alcohol consumption and mechanisms that might be related to alcohol consumption, such as executive function deficits. The current study sought to extend this prior research in a larger sample with higher drinking rates and more rigorous methods, and to explore inhibitory control associations with drinking. Across the two samples …

Next-Day Effects Of Binge Drinking On Inhibitory Control In Laboratory And Naturalistic Settings, Justin Verlinden

Theses and Dissertations--Psychology

Binge drinking occurs at an alarmingly high rate, despite its negative consequences on behavior, health, and cognition. One acute cognitive consequence of binge drinking is the impairment of inhibitory control, or the ability to stop oneself from engaging in maladaptive or inappropriate behaviors. Specifically, during a binge episode, individuals display impaired inhibitory control while completing Go/NoGo or Stop Signal Tasks (SST). This impairment has been shown to be maintained for up to five hours post-drinking, even as breath alcohol concentration (BrAC) approaches zero. Evidence also suggests that binge drinking results in next-day deficits in attention, memory, and psychomotor speed. However, …

Patient Perspectives Of Psychotherapy Duration And Treatment Outcomes, Doug Terrill

Theses and Dissertations--Psychology

The duration of psychotherapeutic treatment is a longstanding and clinically consequential question in psychotherapy research. Premature dropout from therapy is common, indicating some patients do not receive adequate benefit. On the other hand, some patients remain in treatment beyond the point at which they receive significant benefit, which may delay care for those on patient waitlists. Researchers have proposed two contemporary models of the relation between treatment duration and symptom improvement; 1) the dose-effect (DE) model, which posits that patients improve at similar rates following a negatively accelerated symptom curve, suggesting treatment should end when sessions no longer provide significant …

Effects Of Transcranial Direct Current Stimulation On Urge During Cue-Exposure To Body-Focused Repetitive Behaviors, Hannah Rebecca Wild

Theses and Dissertations--Psychology

Body-focused repetitive behaviors (BFRBs) are unnecessary, repetitive grooming behaviors linked to abnormalities in sensory and reward processing, as well as top-down inhibition. The left dorsolateral prefrontal cortex (dlPFC) is implicated in these processes and plays a key role in cravings among individuals facing addiction. Transcranial direct current stimulation (tDCS) targeting the left dlPFC shows promise in reducing craving for addictive substances. Despite phenomenological similarities between BFRBs and addictive disorders, no controlled studies have examined tDCS’s effect on BFRBs. This study used a randomized, double-blind design to examine whether a single session of anodal multifocal tDCS targeting the left dlPFC reduced …

Comparing Domain- And Facet-Based Models Of Personality Disorder: Incremental Predictive Validity And Model Fit, Alexandra Hines

Theses and Dissertations--Psychology

Personality disorders (PDs) have historically been conferred using a categorical diagnostic framework (i.e., present versus absent). However, recent research supports a transition toward dimensional models of PDs wherein personality traits are measured along a continuum. Some dimensional models contain personality domains only, whereas other models contain both personality domains and facets of each of those domains. The leading models of each type are the PD model in the eleventh edition of the International Classification of Diseases (ICD-11) and the Alternative Model of Personality Disorders (AMPD) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), respectively. …

A Mixed Method Investigation On The Effects Of Information And Motivation On Self-Regulation Skills And Fruit And Vegetable Consumption, Kristen Buford

Theses and Dissertations--Psychology

Introduction: The purpose of this research study is to understand the interplay between health information and health motivation on eating behaviors in African American emerging adults. Greater knowledge of nutrition is linked to healthier eating outcomes, but the motivations that individuals possess about their ability to improve their health also play a pivotal role. However, the joint effect of such constructs (i.e., information and motivation) on eating behaviors is unknown. Emerging adults are still developing their capacities to exercise their health autonomy, and this developmental period represents an opportunity to intervene before the onset of age-related chronic diseases in middle …

Correlates Of Recovery Capital Among Women In Jails: Leveraging A Dimensional Recovery Framework, Amanda Fallin-Bennett, Martha Tillson, Jaxin Annett, Hartley Feld, Michele Staton

Nursing Faculty Publications

Background: Recovery capital encompasses internal and external factors that support recovery from substance use disorder, such as employment, social support, and physical and mental health. There is a need for more research on recovery capital among women who are incarcerated, who often face complex barriers to recovery, such as poverty, unemployment, and histories of trauma.

Methods: Women (N ¼ 900) were recruited from Kentucky jails as part of the broader NIDA-funded Kentucky Justice Community Opioid Innovation Network (JCOIN) cooperative project. Measures from baseline interviews (during incarceration) were selected in alignment with the Substance Abuse Mental Health Service Administration (SAMHSA)’s four …