Brian Houle

Development and validation of the Current Opioid Misuse Measure

Abstract Clinicians recognize the importance of monitoring aberrant medication‐related behaviors of chronic pain patients while being prescribed opioid therapy. The purpose of this study was to develop and validate the Current Opioid Misuse Measure (COMM) for those pain patients already on long‐term opioid therapy. An initial pool of 177 items was developed with input from 26 pain management and addiction specialists. Concept mapping identified six primary concepts underlying medication misuse, which were used to develop an initial item pool. Twenty‐two pain and addiction specialists rated the items on importance and relevance, resulting in selection of a 40‐item alpha COMM. Final item selection was based on empirical evaluation of items with patients taking opioids for chronic, noncancer pain (N = 227). One‐week test–retest reliability was examined with 55 participants. All participants were administered the alpha version of the COMM, the Prescription Drug Use Questionnaire (PDUQ) interview, and submitted a urine sample for toxicology screening. Physician ratings of patient aberrant behaviors were also obtained. Of the 40 items, 17 items appeared to adequately measure aberrant behavior, demonstrating excellent internal consistency and test–retest reliability. Cutoff scores were examined using ROC curve analysis and reasonable sensitivity and specificity were established. To evaluate the COMM’s ability to capture change in patient status, it was tested on a subset of patients (N = 86) that were followed and reassessed three months later. The COMM was found to have promise as a brief, self‐report measure of current aberrant drug‐related behavior. Further cross‐validation and replication of these preliminary results is pending.

Prevalence of HIV among those 15 and older in rural South Africa

A greater knowledge of the burden of HIV in rural areas of Southern Africa is needed, especially among older adults. We conducted a cross-sectional biomarker survey in the rural South African Agincourt Health and Socio-demographic Surveillance site in 2010–2011 and estimated HIV prevalence and risk factors. Using an age–sex stratified random sample of ages 15+, a total of 5037 (65.7%) of a possible 7662 individuals were located and 4362 (86.6%) consented to HIV testing. HIV prevalence was high (19.4%) and characterized by a large gender gap (10.6% for men and 23.9% for women). Rates peaked at 45.3% among men and 46.1% among women – both at ages 35–39. Compared with a similar study in the rural KwaZulu-Natal Province, South Africa, peak prevalence occurred at later ages, and HIV prevalence was higher among older adults – with rates above 15% for men and 10% for women through to age 70. High prevalence continues to characterize Southern Africa, and recent evidence confirms that older adults cannot be excluded from policy considerations. The high prevalence among older adults suggests likely HIV infection at older ages. Prevention activities need to expand to older adults to reduce new infections. Treatment will be complicated by increased risk of noncommunicable diseases and by increasing numbers of older people living with HIV.

Internet surveillance: content analysis and monitoring of product-specific internet prescription opioid abuse-related postings.

ObjectivesThis study describes the development of a systematic approach to the analysis of Internet chatter as a means of monitoring potentially abusable opioid analgesics. MethodsMessage boards dedicated to drug abuse were selected using specific inclusion criteria. Threaded discussions containing 48,293 posts were captured. A coding system was created to compare content of posts related to 3 opioid analgesics: Kadian, Vicodin, and OxyContin. ResultsThe number of posts containing mentions of the target drugs were significantly different [OxyContin (1813)>Vicodin (940)>Kadian (27), P<0.001]. Analyses revealed that these differences were not simply a reflection of the availability of each product (ie, number of prescriptions written). Reliability tests indicated that the content coding system achieved good interrater reliability coefficients (average κ across all categories=0.76, range=0.52 to 1.0). Content analysis of a sample of 234 randomly selected posts indicated that the proportion of Internet posts endorsing abuse of Kadian was statistically significantly less than OxyContin (45.5% vs. 68.4%, P=0.036, not adjusted for multiple comparisons). DiscussionThese results suggest that a systematic approach to postmarketing surveillance of Internet chatter related to pharmaceutical products is feasible and yields reliable information about the quantity of discussion of specific products and qualitative information regarding the nature of the discussions. Kadian was associated with fewer Internet mentions than either OxyContin or Vicodin. This investigation stands as a first attempt to establish systematic methods for conducting Internet surveillance.

Update on Prescription Monitoring in Clinical Practice: A Survey Study of Prescription Monitoring Program Administrators

OBJECTIVE Prescription drug abuse and undertreatment of pain are public health priorities in the United States. Few options to manage these problems are balanced, in simultaneously supporting pain relief and deterring prescription drug abuse. Prescription monitoring programs (PMPs) potentially offer a balanced approach; however, the medical/scientific communities are not well informed about their current status and potential risks/benefits. The purpose of this study was to provide a benchmark of the current status of PMPs for healthcare providers upon which to engage PMP administrators. DESIGN A Web survey of current PMP directors with a telephone follow-up conducted in June-July 2006 regarding goals, data captured, data sharing procedures, healthcare provider training, and evaluation efforts. RESULTS Eighteen of 23 states with operating PMPs at that time participated. Eleven programs allowed physician access to PMP data. Data were delivered by mail (N = 6), fax (N = 8), e-mail (N = 1), and Websites (N = 8). Eight programs provided data to providers within 1 hour. Three states have developed provider PMP usage guidelines. Eight states developed or are developing educational programs. Two states completed or are conducting evaluations of the public health impact of PMP implementation. Five states have begun utilizing PMP data as an epidemiological tool. CONCLUSIONS Initial public safety orientation of PMPs is evolving to include improving public health and patient care. Beginning with efforts to engage healthcare providers through data sharing and education, and progressively including program evaluation on public health and patient care, our results suggest a rapid movement in the direction of utilization of PMPs to improve health care.

Young Children's Probability of Dying Before and After Their Mother's Death: A Rural South African Population-Based Surveillance Study

Brian Houle and colleagues examine the temporal relationship between mother and child death by using 15 years of data (1994–2008) from household surveys conducted in the Agincourt sub-district of South Africa.

The unfolding counter-transition in rural South Africa: mortality and cause of death, 1994-2009.

The HIV pandemic has led to dramatic increases and inequalities in adult mortality, and the diffusion of antiretroviral treatment, together with demographic and socioeconomic shifts in sub-Saharan Africa, has further changed mortality patterns. We describe all-cause and cause-specific mortality patterns in rural South Africa, analyzing data from the Agincourt health and socio-demographic surveillance system from 1994 to 2009 for those aged 5 years and older. Mortality increased during that period, particularly after 2002 for ages 30–69. HIV/AIDS and TB deaths increased and recently plateaued at high levels in people under age 60. Noncommunicable disease deaths increased among those under 60, and recently also increased among those over 60. There was an inverse gradient between mortality and household SES, particularly for deaths due to HIV/AIDS and TB and noncommunicable diseases. A smaller and less consistent gradient emerged for deaths due to other communicable diseases. Deaths due to injuries remained an important mortality risk for males but did not vary by SES. Rural South Africa continues to have a high burden of HIV/AIDS and TB mortality while deaths from noncommunicable diseases have increased, and both of these cause-categories show social inequalities in mortality.

Household context and child mortality in rural South Africa: the effects of birth spacing, shared mortality, household composition and socio-economic status

Background Household characteristics are important influences on the risk of child death. However, little is known about this influence in HIV-endemic areas. We describe the effects of household characteristics on children’s risk of dying in rural South Africa. Methods We use data describing the mortality of children younger than 5 years living in the Agincourt health and socio-demographic surveillance system study population in rural northeast South Africa during the period 1994–2008. Using discrete time event history analysis we estimate children’s probability of dying by child characteristics and household composition (other children and adults other than parents) (N = 924 818 child-months), and household socio-economic status (N = 501 732 child-months). Results Children under 24 months of age whose subsequent sibling was born within 11 months experience increased odds of dying (OR 2.5; 95% CI 1.1–5.7). Children also experience increased odds of dying in the period 6 months (OR 2.1; 95% CI 1.2–3.6), 3–5 months (OR 3.0; 95% CI 1.5–5.9), and 2 months (OR 11.8; 95% CI 7.6–18.3) before another household child dies. The odds of dying remain high at the time of another child’s death (OR 11.7; 95% CI 6.3–21.7) and for the 2 months following (OR 4.0; 95% CI 1.9–8.6). Having a related but non-parent adult aged 20–59 years in the household reduces the odds (OR 0.6; 95% CI 0.5–0.8). There is an inverse relationship between a child’s odds of dying and household socio-economic status. Conclusions This detailed household profile from a poor rural setting where HIV infection is endemic indicates that children are at high risk of dying when another child is very ill or has recently died. Short birth intervals and additional children in the household are further risk factors. Presence of a related adult is protective, as is higher socio-economic status. Such evidence can inform primary health care practice and facilitate targeting of community health worker efforts, especially when covering defined catchment areas.

Smoker-free workplace policies: developing a model of public health consequences of workplace policies barring employment to smokers

A marked shift in tobacco-related workplace health promotion intervention involves the adoption of policies barring employment to smokers. We discuss the potential public health consequences of these policies on those affected—smokers, their families, the surrounding community and society at large. We find a lack of published evidence evaluating the effectiveness and consequences of these policies. By developing a model of policy effects, we outline possible unintended consequences. With such large gaps in the evidence base and the potential for deleterious consequences, we argue for increased discussion about the use of smoker-free employment policies as a public health intervention and for increased engagement of employers by the public health community in worksite health promotion.

The impacts of maternal mortality and cause of death on children's risk of dying in rural South Africa: evidence from a population based surveillance study (1992-2013).

BackgroundMaternal mortality, the HIV/AIDS pandemic, and child survival are closely linked. This study contributes evidence on the impact of maternal death on children’s risk of dying in an HIV-endemic population in rural South Africa.MethodsWe used data for children younger than 10 years from the Agincourt health and socio-demographic surveillance system (1992 – 2013). We used discrete time event history analysis to estimate children’s risk of dying when they experienced a maternal death compared to children whose mother survived (N=3,740,992 child months). We also examined variation in risk due to cause of maternal death. We defined mother’s survival status as early maternal death (during pregnancy, childbirth, or within 42 days of most recent childbirth or identified cause of death), late maternal death (within 43-365 days of most recent childbirth), any other death, and mothers who survived.ResultsChildren who experienced an early maternal death were at 15 times the risk of dying (RRR 15.2; 95% CI 8.3–27.9) compared to children whose mother survived. Children under 1 month whose mother died an early (p=0.002) maternal death were at increased risk of dying compared to older children. Children whose mothers died of an HIV/AIDS or TB-related early maternal death were at 29 times the risk of dying compared to children with surviving mothers (RRR 29.2; 95% CI 11.7–73.1). The risk of these children dying was significantly higher than those children whose mother died of a HIV/AIDS or TB-related non-maternal death (p=0.017).ConclusionsThis study contributes further evidence on the impact of a mother’s death on child survival in a poor, rural setting with high HIV prevalence. The intersecting epidemics of maternal mortality and HIV/AIDS – especially in sub-Saharan Africa – have profound implications for maternal and child health and well-being. Such evidence can help guide public and primary health care practice and interventions.

Validation, Replication, and Sensitivity Testing of Heckman-Type Selection Models to Adjust Estimates of HIV Prevalence

A recent study using Heckman-type selection models to adjust for non-response in the Zambia 2007 Demographic and Health Survey (DHS) found a large correction in HIV prevalence for males. We aim to validate this finding, replicate the adjustment approach in other DHSs, apply the adjustment approach in an external empirical context, and assess the robustness of the technique to different adjustment approaches. We used 6 DHSs, and an HIV prevalence study from rural South Africa to validate and replicate the adjustment approach. We also developed an alternative, systematic model of selection processes and applied it to all surveys. We decomposed corrections from both approaches into rate change and age-structure change components. We are able to reproduce the adjustment approach for the 2007 Zambia DHS and derive results comparable with the original findings. We are able to replicate applying the approach in several other DHSs. The approach also yields reasonable adjustments for a survey in rural South Africa. The technique is relatively robust to how the adjustment approach is specified. The Heckman selection model is a useful tool for assessing the possibility and extent of selection bias in HIV prevalence estimates from sample surveys.