Daily Stress and Sleep Associations Vary by Work Schedule: A Between- and Within-Person Analysis in Nurses

Abstract Nurses experience poor sleep and high stress due to demanding work environments. Night shift work may exacerbate stress-sleep associations. We examined bidirectional associations between daily stress and sleep, and moderation by shift worker status and daily work schedule. 392 nurses (92% female, mean age = 39.54) completed 14 days of sleep diaries and actigraphy, plus daily assessments of stress and work schedule upon awakening. Nurses were classified as recent night shift workers if they worked 1+ night during the past 14 days. Greater daily stress predicted shorter diary sleep duration and lower diary sleep efficiency. Shorter diary and actigraphy sleep duration and lower diary sleep efficiency predicted higher next-day stress. Compared to recent night workers, day workers had higher stress after nights with shorter sleep. Associations did not vary by daily work schedule. Sleep disturbances and stress may unfold in a toxic cycle and are prime intervention targets among nurses.

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0225 Do Associations Between Daily Stress and Sleep Vary by Work Shift? A Within-Person Analysis in Nurses

SLEEP ◽

10.1093/sleep/zsaa056.223 ◽

2020 ◽

Vol 43 (Supplement_1) ◽

pp. A87-A87

Author(s):

J R Dietch ◽

D C Slavish ◽

B Messman ◽

S Wardle-Pinkston ◽

K Kelly ◽

...

Keyword(s):

Shift Work ◽

Sleep Disturbances ◽

Night Shift ◽

High Stress ◽

Sleep Time ◽

Daily Stress ◽

Night Shift Work ◽

Work Shift ◽

Daily Work ◽

Sleep Diaries

Abstract Introduction Longitudinal studies have shown daily stress and sleep are bidirectionally associated. Nurses are particularly likely to experience sleep disturbances and high stress due to demanding work environments. Night shift work may be a unique stressor for nurses that exacerbates associations between stress and sleep. Using a within-person design, we examined the daily bidirectional associations between stress and sleep and moderation by nightly work shift (day/off shift vs. night shift) in a large sample of nurses. Methods Participants were 393 nurses (91% female; 77% white, mean age = 38.4 years) recruited from two hospitals. Participants completed 14 days of sleep diaries and actigraphy to assess total sleep time (TST) and sleep efficiency (SE). They simultaneously completed assessments of stress on the previous day (0 = “not at all” to 4 = “extremely”) and daily work schedule (day/off shift vs. night shift [work between 9pm-6am]). Results Results indicated greater daily stress was associated with shorter diary TST (b = -9.49, p<.0001) and actigraphy TST (b = -4.48, p<.01), as well as lower diary SE (b = -0.56, p<.001). When examining reverse pathways of sleep predicting next day stress, both diary TST (b = -0.0004, p<.0001) and actigraphy TST (b = -0.0002, p = .03) predicted higher next-day stress. Lower diary SE predicted higher next-day stress (b = -0.005, p<.001). Only the association between daily stress and nightly diary SE was moderated by daily work shift: only when nurses worked a day or off shift did they have a negative association between daily stress and diary SE (b = -0.68, p<.0001). Conclusion Daily stress and sleep disturbances occurred in a bidirectional fashion for night- and day-shift working nurses. Most associations were similar regardless of daily type of work shift. Objective and subjective short TST and low subjective SE may contribute to a cycle of increased stress and are prime targets for a tailored sleep intervention in nurses. More research is needed to develop interventions to address the unique sleep health challenges faced by nurses. Support NIAID R01AI128359-01

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1097 Sleep Disturbances, Sleep Burden, And Depressive Symptoms In US Hispanics/Latinos: Results From The HCHS/SOL Sueño Study

SLEEP ◽

10.1093/sleep/zsaa056.1092 ◽

2020 ◽

Vol 43 (Supplement_1) ◽

pp. A417-A418

Author(s):

C Alcantara ◽

M Wallace ◽

D Sotres-Alvarez ◽

C Vetter ◽

A J Phillips ◽

...

Keyword(s):

Depressive Symptoms ◽

Sleep Duration ◽

Excessive Daytime Sleepiness ◽

Daytime Sleepiness ◽

Sleep Disturbances ◽

The United States ◽

Sleep Efficiency ◽

Sensitivity Analyses ◽

Poor Sleep ◽

Sleep Timing

Abstract Introduction While sleep disturbances and depression often co-occur, these associations are understudied among Hispanics/Latinos. We examined the associations of sleep disturbances and sleep burden with depressive symptoms among Hispanic/Latino adults in the United States. Methods We used cross-sectional data from the Hispanic Community Health Study/Study of Latinos Sueño Ancillary study (2010-2013). The study enrolled 2072 adults (ages 18-64; 51.5% females) who completed one-week wrist-actigraphy and sleep questionnaires. Sleep burden was operationalized as the total count of sleep disturbances across six domains (duration, efficiency, midpoint, variability, insomnia, sleepiness). Depressive symptoms were assessed using the Center for Epidemiological Studies Depression scale (CESD-10). We used weighted survey linear regressions to evaluate the association of sleep disturbances and sleep burden with elevated depressive symptoms (CESD≥10) in individual models adjusted for age, gender, site, heritage, nativity, education, income, and employment. Sensitivity analyses further adjusted for behavioral health risk factors and apnea-hypopnea index. Results An estimated 28.3% had elevated depressive symptoms, 8.0% had short sleep duration (<6 hours of sleep), 10.9% had long sleep duration (>9 hours), 45.2% exhibited a later sleep midpoint (≥4:00AM), 38.4% had high sleep timing variability (upper third tertile for between day sleep midpoint), 15.3% had insomnia (ISI≥10), 17.3% had excessive daytime sleepiness (ESS ≥10), 21.5% had poor sleep efficiency (<85%), and 77.4% had a total sleep burden count of ≥0. Insomnia (ß=0.49,95%CI:.43,.56), later sleep timing (ß=0.10,95%CI:.04,.16), excessive daytime sleepiness (ß=0.19,95%CI:.11,.27), poor sleep efficiency (ß=0.09,95%CI:.02,.17), high variability (ß=0.07, 95%CI:.01,.12), and sleep burden (ß=0.11,95%CI:.09,.13), were each positively associated with elevated depressive symptoms in individual adjusted models and sensitivity analyses. Extreme sleep durations were not associated with elevated depressive symptoms. Conclusion Multiple inter-related sleep disturbances, particularly those pertaining to sleep quality and timing, are associated with depression and may be targets for future interventions aimed at improving mood among Hispanics/Latinos. Support HL127307, HL098927, HL125748

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Improving Stress Management and Sleep Hygiene in Intelligent Homes

Sensors ◽

10.3390/s21072398 ◽

2021 ◽

Vol 21 (7) ◽

pp. 2398

Author(s):

Asterios Leonidis ◽

Maria Korozi ◽

Eirini Sykianaki ◽

Eleni Tsolakou ◽

Vasilios Kouroumalis ◽

...

Keyword(s):

Sleep Disturbances ◽

Contextual Information ◽

High Stress ◽

Sleep Hygiene ◽

Poor Sleep ◽

Health Issues ◽

Time Data ◽

Intelligent Home ◽

And Control

High stress levels and sleep deprivation may cause several mental or physical health issues, such as depression, impaired memory, decreased motivation, obesity, etc. The COVID-19 pandemic has produced unprecedented changes in our lives, generating significant stress, and worries about health, social isolation, employment, and finances. To this end, nowadays more than ever, it is crucial to deliver solutions that can help people to manage and control their stress, as well as to reduce sleep disturbances, so as to improve their health and overall quality of life. Technology, and in particular Ambient Intelligence Environments, can help towards that direction, when considering that they are able to understand the needs of their users, identify their behavior, learn their preferences, and act and react in their interest. This work presents two systems that have been designed and developed in the context of an Intelligent Home, namely CaLmi and HypnOS, which aim to assist users that struggle with stress and poor sleep quality, respectively. Both of the systems rely on real-time data collected by wearable devices, as well as contextual information retrieved from the ambient facilities of the Intelligent Home, so as to offer appropriate pervasive relaxation programs (CaLmi) or provide personalized insights regarding sleep hygiene (HypnOS) to the residents. This article will describe the design process that was followed, the functionality of both systems, the results of the user studies that were conducted for the evaluation of their end-user applications, and a discussion about future plans.

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534 Food Insecurity and Sleep Health by Race/Ethnicity and Age Group in the United States

SLEEP ◽

10.1093/sleep/zsab072.532 ◽

2021 ◽

Vol 44 (Supplement_2) ◽

pp. A211-A211

Author(s):

Nyree Riley ◽

Dana Alhasan ◽

W Braxton Jackson ◽

Chandra Jackson

Keyword(s):

Food Security ◽

Food Insecurity ◽

Sleep Duration ◽

Sleep Disturbances ◽

The United States ◽

Poor Sleep ◽

High Food ◽

Short Sleep Duration ◽

Sleep Health ◽

Falling Asleep

Abstract Introduction Food insecurity may influence sleep through poor mental health (e.g., depression) and immune system suppression. Although prior studies have found food insecurity to be associated with poor sleep, few studies have investigated the food security-sleep association among racially/ethnically diverse participants and with multiple sleep dimensions. Methods Using National Health Interview Survey data, we examined overall, age-, sex/gender-, and racial/ethnic-specific associations between food insecurity and sleep health. Food security was categorized as very low, low, marginal, and high. Sleep duration was categorized as very short (<6 hours), short (<7 hours), recommended (7–9 hours), and long (≥9 hours). Sleep disturbances included trouble falling and staying asleep, insomnia symptoms, waking up feeling unrested, and using sleep medication (all ≥3 days/times in the previous week). Adjusting for sociodemographic characteristics and other confounders, we used Poisson regression with robust variance to estimate prevalence ratios (PRs) and 95% confidence intervals (95% CI) for sleep dimensions by very low, low, and marginal vs. high food security. Results The 177,435 participants’ mean age was 47.2±0.1 years, 52.0% were women, 68.4% were Non-Hispanic (NH)-White. Among individuals reporting very low food security, 75.4% had an annual income of <$35,000 and 60.3% were ≥50 years old. After adjustment, very low vs. high food security was associated with a higher prevalence of very short (PR=2.61 [95%CI: 2.44–2.80]) and short (PR=1.66 [95% CI: 1.60–1.72]) sleep duration. Very low vs. high food security was associated with both trouble falling asleep (PR=2.21 [95% CI: 2.12–2.30]) and trouble staying asleep (PR=1.98 [95% CI: 1.91–2.06]). Very low vs. high food security was associated with higher prevalence of very short sleep duration among Asians (PR=3.64 [95% CI: 2.67–4.97]), Whites (PR=2.73 [95% CI: 2.50–2.99]), Blacks (PR=2.03 [95% CI: 1.80–2.31]), and Hispanic/Latinxs (PR=2.65 [95% CI: 2.30–3.07]). Conclusion Food insecurity was associated with poor sleep in a diverse sample of the US population. Support (if any):

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The Cycle of Daily Stress and Sleep: Sleep Measurement Matters

Annals of Behavioral Medicine ◽

10.1093/abm/kaaa053 ◽

2020 ◽

Author(s):

Danica C Slavish ◽

Justin Asbee ◽

Kirti Veeramachaneni ◽

Brett A Messman ◽

Bella Scott ◽

...

Keyword(s):

Sleep Disturbances ◽

Multilevel Models ◽

Single Channel ◽

Sleep Onset ◽

Sleep Time ◽

Sleep Diary ◽

Sleep Onset Latency ◽

Daily Stress ◽

Sleep Diaries ◽

Sleep Measurement

Abstract Background Disturbed sleep can be a cause and a consequence of elevated stress. Yet intensive longitudinal studies have revealed that sleep assessed via diaries and actigraphy is inconsistently associated with daily stress. Purpose We expanded this research by examining daily associations between sleep and stress using a threefold approach to assess sleep: sleep diaries, actigraphy, and ambulatory single-channel electroencephalography (EEG). Methods Participants were 80 adults (mean age = 32.65 years, 63% female) who completed 7 days of stressor and sleep assessments. Multilevel models were used to examine bidirectional associations between occurrence and severity of daily stress with diary-, actigraphy-, and EEG-determined sleep parameters (e.g., total sleep time [TST], sleep efficiency, and sleep onset latency, and wake after sleep onset [WASO]). Results Participants reported at least one stressor 37% of days. Days with a stressor were associated with a 14.4-min reduction in actigraphy-determined TST (β = −0.24, p = 0.030), but not with other actigraphy, diary, or EEG sleep measures. Nights with greater sleep diary-determined WASO were associated with greater next-day stressor severity (β = 0.01, p = 0.026); no other diary, actigraphy, or EEG sleep measures were associated with next-day stressor occurrence or severity. Conclusions Daily stress and sleep disturbances occurred in a bidirectional fashion, though specific results varied by sleep measurement technique and sleep parameter. Together, our results highlight that the type of sleep measurement matters for examining associations with daily stress. We urge future researchers to treat sleep diaries, actigraphy, and EEG as complementary—not redundant—sleep measurement approaches.

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Delayed Lactogenesis II is Associated With Lower Sleep Efficiency and Greater Variation in Nightly Sleep Duration in the Third Trimester

Journal of Human Lactation ◽

10.1177/0890334419830991 ◽

2019 ◽

Vol 35 (4) ◽

pp. 713-724

Author(s):

Theresa Casey ◽

Hui Sun ◽

Helen J. Burgess ◽

Jennifer Crodian ◽

Shelley Dowden ◽

...

Keyword(s):

Body Mass Index ◽

Blood Glucose ◽

Sleep Duration ◽

Body Mass ◽

Sleep Disturbances ◽

Sleep Onset ◽

Sleep Time ◽

Sleep Efficiency ◽

Delayed Onset ◽

Wrist Actigraphy

Background: Metabolic and hormonal disturbances are associated with sleep disturbances and delayed onset of lactogenesis II. Research aims: The aim of this study was to measure sleep using wrist actigraphy during gestation weeks 22 and 32 to determine if sleep characteristics were associated with blood glucose, body mass index, gestational related disease, delayed onset of lactogenesis II, or work schedule. Methods: Demographic data were collected at study intake from primiparous women who wore a wrist actigraph during gestation weeks 22 ( n = 50) and 32 ( n = 44). Start and end sleep time, total nighttime sleep, sleep efficiency, wake after sleep onset, and sleep fragmentation were measured. Night to night variability was assessed with the root mean square of successive difference. Blood glucose levels, body mass index, and gestational disease data were abstracted from medical charts. Timing of lactogenesis II was determined by survey. Results: Between gestation week 22 and 32, sleep efficiency decreased and fragmentation increased ( p < .05). During gestation week 32, blood glucose was negatively correlated with sleep duration, and positively related to fragmentation ( p < .05). Women who experienced delayed lactogenesis II had lower sleep efficiency and greater fragmentation ( p < .05), and greater night-to-night variability in sleep start and end time, efficiency, and duration during gestation week 32 ( p < .05). Conclusion: Women with better sleep efficiency and more stable nightly sleep time are less likely to experience delayed onset of lactogenesis II. Interventions to improve sleep may improve maternal health and breastfeeding adequacy.

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601 Comparison of Sleep Parameters in Children with Achondroplasia and Trisomy 21

SLEEP ◽

10.1093/sleep/zsab072.599 ◽

2021 ◽

Vol 44 (Supplement_2) ◽

pp. A236-A237

Author(s):

Jodi Gustave ◽

Kaelyn Gaza ◽

Jennifer Marriner ◽

Seema Rani ◽

Abigail Strang ◽

...

Keyword(s):

Sleep Quality ◽

Rem Sleep ◽

Trisomy 21 ◽

Sleep Disturbances ◽

Sleep Latency ◽

Sleep Efficiency ◽

Sleep Architecture ◽

Poor Sleep ◽

Arousal Index ◽

Sleep Parameters

Abstract Introduction Children with achondroplasia and Trisomy 21 (T21) have increased incidence of sleep disturbances including sleep disordered breathing. Abnormal sleep architecture has been documented in children with T21. It is important to continue to analyze sleep parameters in both groups since poor sleep quality is associated with neurocognitive impairment. Methods Following IRB approval, we performed a retrospective chart review of patients at Nemours/A.I. duPont Hospital for Children in Wilmington, DE with achondroplasia and T21 who underwent an initial polysomnogram (PSG) between 2015 and 2020. We compared sleep architecture parameters between the groups including sleep efficiency, total sleep time (TST), sleep latency, arousal index and concentration of N3 and REM sleep. Results In patients with achondroplasia (n=49, mean age 5.8 months and 63.3% male), 12% reported restless sleep. PSG data revealed TST of 392 minutes, mean sleep efficiency of 82%, mean sleep latency of 9.4 min, mean arousal index of 40, 22% REM sleep and 32% N3 sleep. In the patients with T21 (n=32, mean age 17.8 months and 50% male), 59% reported restless sleep. PSG data revealed TST of 393 minutes, mean sleep efficiency of 82%, mean sleep latency of 14 minutes, arousal index of 35, 15% REM sleep and 40% N3 sleep. The differences in REM and N3 sleep between the two groups were statistically significant (p-values of 0.001 and 0.04, respectively), but the differences in arousal index, TST and sleep efficiency were not. Conclusion Our study showed that children with T21 subjectively noted more restless sleep compared to patients with achondroplasia although TST and sleep efficiency were similar. Patients with achondroplasia had a higher arousal index that was not statistically significant. Children with achondroplasia had a shorter sleep latency and more robust REM concentration, likely due to their younger age. There was a higher concentration of N3 sleep in patients with T21. This is likely due to the decrease in REM concentration. In conclusion, it is important to establish expected sleep parameters in patients with achondroplasia and T21 to maximize sleep quality and mitigate negative neurocognitive effects of poor sleep. Support (if any):

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0785 Associations Between Circadian Preference And Sleep-related Thoughts: Data From The 2015 Sleep In America Poll

SLEEP ◽

10.1093/sleep/zsaa056.781 ◽

2020 ◽

Vol 43 (Supplement_1) ◽

pp. A298-A299

Author(s):

B Jeon ◽

F S Luyster ◽

E R Chasens

Keyword(s):

Sleep Disturbance ◽

Sleep Duration ◽

Sleep Disturbances ◽

Secondary Analysis ◽

Logistic Models ◽

Poor Sleep ◽

Sleep Habits ◽

Circadian Preference ◽

Physical Consequences ◽

The Impact

Abstract Introduction Evening types of sleep tend to have poorer sleep quality and sleep habits than morning types. Maladaptive beliefs or thoughts about sleep can affect one’s sleep and may differ between evening and morning types. We examined the association between the circadian preference and sleep-related thoughts in U.S adults. Methods A secondary analysis used survey data from the 2015 National Sleep Foundation’s Sleep in America Poll. Questions included normal bedtime and wake-up time for week/work days and weekend/non-work days. Circadian preference was determined by midpoint of sleep calculated as midpoint of sleep on weekends corrected for average nightly sleep duration. Participants were excluded if their sleep midpoint was from noon to midnight. Midpoint of sleep was divided into two groups using median split (“earlier” vs. “later”). Sleep-related thoughts were “worry about getting a good sleep”, “overwhelming thoughts about getting enough sleep”, “motivation to get sleep”, and “concern about serious physical consequences due to poor sleep”; responded often/always or extremely to somewhat for these items were coded as maladaptive. Logistic regression analysis controlling for socio-demographics, sleep duration, and sleep disturbance (PROMIS Scale; higher scores = greater sleep disturbance) was conducted to examine the relationships between midpoint of sleep and sleep-related thoughts. Results The sample (N = 1011) was primarily White (73.6%), male (50.9%), college educated (62.2%), married/partnered (67.6%) with a mean age of 51.65 ± 17.05 years. Mean midpoint of sleep in “earlier” type was 2:33AM and 5:29AM in “later” type. “Later” type had shorter sleep duration on weekdays and longer sleep duration on weekends than “earlier” type (p < .01), but average sleep duration was similar between two types. “Later” type had more “worry” and “overwhelming thoughts” (p < .05) about sleep. In logistic models, midpoint of sleep was significant only for “concern” (p = .02). Conclusion In this study, late chronotype was associated with increased sleep disturbances and greater variability in sleep duration. The relationship between the timing of sleep and thoughts about the impact of impaired sleep remains unclear and an area for further study with objective measures. Support

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Regional neurodegeneration correlates with sleep–wake dysfunction after stroke

SLEEP ◽

10.1093/sleep/zsaa054 ◽

2020 ◽

Vol 43 (9) ◽

Author(s):

Elie Gottlieb ◽

Natalia Egorova ◽

Mohamed S Khlif ◽

Wasim Khan ◽

Emilio Werden ◽

...

Keyword(s):

White Matter ◽

Sleep Duration ◽

A Priori ◽

Sleep Efficiency ◽

Poor Sleep ◽

Subcortical Structures ◽

Whole Brain ◽

Brain Volumes ◽

Regional Brain ◽

Long Sleep

Abstract Sleep–wake disruption is a key modifiable risk factor and sequela of stroke. The pathogenesis of poststroke sleep dysfunction is unclear. It is not known whether poststroke sleep pathology is due to focal infarction to sleep–wake hubs or to accelerated poststroke neurodegeneration in subcortical structures after stroke. We characterize the first prospective poststroke regional brain volumetric and whole-brain, fiber-specific, white matter markers of objectively measured sleep–wake dysfunction. We hypothesized that excessively long sleep (>8 h) duration and poor sleep efficiency (<80%) measured using the SenseWear Armband 3-months poststroke (n = 112) would be associated with reduced regional brain volumes of a priori-selected sleep–wake regions of interest when compared to healthy controls with optimal sleep characteristics (n = 35). We utilized a novel technique known as a whole-brain fixel-based analysis to investigate the fiber-specific white matter differences in participants with long sleep duration. Stroke participants with long sleep (n = 24) duration exhibited reduced regional volumes of the ipsilesional thalamus and contralesional amygdala when compared with controls. Poor sleep efficiency after stroke (n = 29) was associated with reduced ipsilesional thalamus, contralesional hippocampus, and contralesional amygdala volumes. Whole-brain fixel-based analyses revealed widespread macrostructural degeneration to the corticopontocerebellar tract in stroke participants with long sleep duration, with fiber reductions of up to 40%. Neurodegeneration to subcortical structures, which appear to be vulnerable to accelerated brain volume loss after stroke, may drive sleep–wake deficiencies poststroke, independent of lesion characteristics and confounding comorbidities. We discuss these findings in the context of the clinicopathological implications of sleep-related neurodegeneration and attempt to corroborate previous mechanistic-neuroanatomical findings.

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1110 Characteristics Of Untreated Sleep Disturbance During Intensive Outpatient Treatment For Substance Use Disorders: Preliminary Results From A Longitudinal Study

SLEEP ◽

10.1093/sleep/zsaa056.1105 ◽

2020 ◽

Vol 43 (Supplement_1) ◽

pp. A422-A422

Author(s):

A K Wilkerson ◽

D J Taylor ◽

G L Sahlem ◽

R O Simmons ◽

A Russell ◽

...

Keyword(s):

Substance Use ◽

Sleep Disturbance ◽

Substance Use Disorders ◽

Sleep Problems ◽

Post Treatment ◽

Sleep Efficiency ◽

Poor Sleep ◽

Sleep Complaints ◽

Sleep Diaries ◽

Intensive Outpatient

Abstract Introduction Previous studies have shown that sleep problems are commonly reported during treatment for substance use disorders (SUDs) and sleep complaints have been linked to subsequent relapse. However, most of these findings were in well-controlled clinical trials and may not generalize to the public. Little is known about the natural progression of sleep complaints during treatment in community clinics, the most common treatment approach for SUDs. The aim of this study is to longitudinally assess prevalence of clinically significant sleep disturbance at baseline and post-treatment in a community-based intensive outpatient (IOP) SUD treatment program using a multi-method approach with well-validated measures of sleep. Methods Adults beginning IOP SUD treatment completed the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Nightmare Disorder index (NDI), and one week of actigraphy and sleep diaries. Measures were repeated following treatment (approximately 5 weeks later). Results Preliminary analyses on 21 adults who have been enrolled thus far revealed 85.6% of participants experienced sleep disturbance (PSQI > 5) at baseline. 28.5% of participants reached cutoff for moderate-to-severe insomnia symptoms (ISI > 15) and 42.9% reported nightmares more than once per week. Sleep parameters taken from actigraphy and sleep diaries revealed mean sleep efficiency was 77.5% (TST M = 6.2 hours; TIB M = 7.9 hours). These variables did not improve from baseline to post-treatment. Further, most measures indicated a worsening of sleep, though this did not reach significance (all ps > .05). Conclusion This preliminary data show a high prevalence of self-reported sleep complaints and objectively measured poor sleep efficiency that do not improve over the course of treatment. Data collection is ongoing and expected to at least double. More robust analyses, including differences between SUD type (e.g., cannabis vs. opioid) and relationship to relapse at post-treatment, will then be completed. Support K12DA031794

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