Gerald Cochran

Caring for Opioid-dependent Pregnant Women: Prenatal and Postpartum Care Considerations.

Pregnancy is an opportune time to identify opioid dependence, facilitate conversion to opioid maintenance treatment, and coordinate care with specialists in addiction medicine, behavioral health, and social services. Comprehensive prenatal care for opioid-dependent women involves the evaluation and the management of co-occurring psychiatric disorders, polysubstance use, infectious diseases, social stressors, and counseling regarding the importance of breastfeeding, contraception, and neonatal abstinence syndrome. Although the complex psychiatric, social, and environmental factors faced by this population pose significant challenges to obstetric care providers, the development of strong patient-provider relationships can facilitate the ability to deliver efficient and effective health care during pregnancy.

An Examination of Claims-based Predictors of Overdose from a Large Medicaid Program.

Background: Health systems may play an important role in identification of patients at-risk of opioid medication overdose. However, standard measures for identifying overdose risk in administrative data do not exist. Objective: Examine the association between opioid medication overdose and 2 validated measures of nonmedical use of prescription opioids within claims data. Research Design: A longitudinal retrospective cohort study that estimated associations between overdose and nonmedical use. Subjects: Adult Pennsylvania Medicaid program 2007–2012 patients initiating opioid treatment who were: nondual eligible, without cancer diagnosis, and not in long-term care facilities or receiving hospice. Measures: Overdose (International Classification of Disease, ninth edition, prescription opioid poisonings codes), opioid abuse (opioid use disorder diagnosis while possessing an opioid prescription), opioid misuse (a composite indicator of number of opioid prescribers, number of pharmacies, and days supplied), and dose exposure during opioid treatment episodes. Results: A total of 372,347 Medicaid enrollees with 583,013 new opioid treatment episodes were included in the cohort. Opioid overdose was higher among those with abuse (1.5%) compared with those without (0.2%, P<0.001). Overdose was higher among those with probable (1.8%) and possible (0.9%) misuse compared with those without (0.2%, P<0.001). Abuse [adjusted rate ratio (ARR), 1.52; 95% confidence interval (CI), 1.10–2.10), probable misuse (ARR, 1.98; 95% CI, 1.46–2.67), and possible misuse (ARR, 1.76; 95% CI, 1.48–2.09) were associated with significantly more events of opioid medication overdose compared with those without. Conclusions: Claims-based measures can be used by health systems to identify individuals at-risk of overdose who can be targeted for restrictions on opioid prescribing, dispensing, or referral to treatment.

Pharmacists Who Screen and Discuss Opioid Misuse With Patients Future Directions for Research and Practice

Background: Prescription opioid (PO) abuse has reached epidemic proportions in the United States, and pharmacies are locations from which these medications are often diverted. This study identifies factors associated with pharmacists who currently screen and discuss PO misuse with patients. Methods: A secondary data analysis of a cross-sectional Web-based survey that was sent to pharmacists was conducted. The survey contained items that assessed whether pharmacists currently screened and discussed PO misuse with patients along with pharmacists’ attitudes and beliefs toward providing brief interventions. Multivariable models were developed which identified factors associated with pharmacists’ currently screening and discussing misuse. Results: Chain setting pharmacists (odds ratio [OR] = 6.16, 95% confidence interval [CI] = 1.16-32.72) and pharmacists interested in being directly involved in PO screening and brief intervention research projects (OR = 2.06, 95% CI = 1.35-3.15) were most likely to report current screening. Pharmacists who reported currently screening for misuse (OR = 4.27, 95% CI = 2.83-6.45) and who reported wanting to help patients who misuse POs (OR = 3.03, 95% CI = 1.50-6.15) were most likely to currently discuss abuse. Conclusions: Investigators implementing pharmacy-based screening and brief intervention studies for POs should take into account practice location and pharmacists’ interest in addressing PO issues.

Patterns and Quality of Buprenorphine Opioid Agonist Treatment in a Large Medicaid Program.

Objectives:Use of buprenorphine – an effective treatment for opioid use disorders (OUDs) – has increased rapidly in recent years and is often financed by Medicaid. We investigated predictors of buprenorphine treatment, patterns of care, and quality of care in a large state Medicaid program. Methods:Data from Pennsylvania Medicaid from 2007 to 2012 provided information regarding diagnoses, demographic characteristics, enrollment, and use of inpatient and outpatient services, and prescription drugs. We identified adult enrollees using buprenorphine, and examined prevalence of OUD diagnosis and patterns of use (duration and dose) and quality of care (physician visits, receipt of behavioral health counseling, urine drug screens, and other prescription drug use). We use a mixed logistic regression model to examine enrollee characteristics associated with buprenorphine use. Results:The share of enrollees with OUD filling prescriptions for buprenorphine increased from 2985 (9.8%) to 12,691 (25.2%) from 2007 to 2012. Between 26.2 and 32.0% of enrollees using buprenorphine had no diagnosis of OUD, depending on the year. Only 60.1% of enrollees with buprenorphine use received at least one urine drug screen, 41.0% had behavioral health counseling services, and 34.7 and 38.0% had other opioid and benzodiazepine claims, respectively, concomitant with buprenorphine use. Quality of care was lower among those with no OUD diagnosis recorded. The mean daily doses of buprenorphine decreased over time. We found wide variation in likelihood of buprenorphine use among those with OUD based upon age, sex, and race. Conclusions:Increases in buprenorphine treatment in a Medicaid population were observed across time; however, increases varied by age, sex, and rate, and the quality of care received seemed to be generally poor. The quality of the provision of buprenorphine treatment occurring in Medicaid populations should be further explored.

Medication-Assisted Treatment and Opioid Use Before and After Overdose in Pennsylvania Medicaid

Author Affiliations: Division of Cardiology, Zuckerberg San Francisco General Hospital, San Francisco, California (Kazi); Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California (Penko, Coxson); Division of General Internal Medicine, Columbia University Medical Center, New York, New York (Moran); Institute for Clinical and Economic Review, Boston, Massachusetts (Ollendorf); Department of Medicine, University of California, San Francisco (Tice, Bibbins-Domingo).

Injury-Related Consequences of Alcohol Misuse Among Injured Patients Who Received Screening and Brief Intervention for Alcohol: A Latent Class Analysis

BACKGROUND Screening and brief alcohol intervention has demonstrated efficacy in improving drinking and other risk behaviors for some patient populations. However, it is not clear that brief interventions are helpful to all injured patients who drink at risk levels. This paper identifies latent classes of intervention recipients based on injury-related consequences and risks of alcohol misuse and then determines which profiles experienced the greatest improvements in drinking. METHODS A secondary analysis was conducted using data from injured patients (N = 737) who reported heavy drinking and received a brief alcohol intervention in a Level I trauma center. Latent class analysis was used to determine patient profiles, and 7 indicators commonly associated with alcohol-related injury from the Short Inventory of Problems+6 were used to determine the latent class measurement model. Covariates were regressed onto the model to assess factors related to class membership, and drinking outcomes were analyzed to examine improvements in drinking. RESULTS Five classes emerged from the data. The classes that reported the greatest improvements in drinking following discharge were those characterized by multiple alcohol-related risks and those characterized by a history of alcohol-related accidents and injuries. Attributing the current injury to drinking was a significant predictor of class membership among those classes that reported higher levels of improvement. CONCLUSIONS This study provides tentative evidence that subclasses exist among heavy drinking injured patients who received a brief intervention in a Level I trauma center, and some subclasses experience greater drinking improvements than others. Further research is required to substantiate the findings of this secondary analysis.

Health Care Reform and the Behavioral Health Workforce

Health care reform will increase the number of individuals who have access to substance abuse services. This impending influx of consumers has the potential of overwhelming the service capacity of providers within the field. Provisions included in the reform legislation might fall short of their intended goal to expand the number of service providers needed to deliver services. This article discusses unmet treatment need in the United States, the current numbers of service providers, and provisions within the reform legislation to increase the labor force. Recommendations are set forth that could help expand the number of providers in the field.

Clinically relevant characteristics associated with early treatment drug use versus abstinence

BackgroundThis study describes early treatment drug use status and associated clinical characteristics in a diverse sample of patients entering outpatient substance abuse psychosocial counseling treatment. The goal is to more fully characterize those entering treatment with and without active use of their primary drug in order to better understand associated treatment needs and resilience factors.MethodsWe examined baseline data from a NIDA Clinical Trials Network (CTN) study (Web-delivery of Treatment for Substance Use) with an all-comers sample of patients (N = 494) entering 10 outpatient treatment centers. Patients were categorized according to self-identified primary drug of abuse (alcohol, cocaine/stimulants, opioids, marijuana) and by baseline drug use status (positive/negative) based on urine testing or self-reports of recent use (alcohol). Characteristics were examined by primary drug and early use status.ResultsClassified as drug-negative were 84%, 76%, 62%, and 33% of primary opioid, stimulant, alcohol, and marijuana users; respectively. Drug-positive versus -negative patients did not differ on demographics or rates of substance abuse/dependence diagnoses. However, those negative for active use had better physical and mental health profiles, were less likely to be using a secondary drug, and were more likely to be attending 12-step self-help meetings.ConclusionsEarly treatment drug abstinence is common among substance users entering outpatient psychosocial counseling programs, regardless of primary abused drug. Abstinence (by negative UA) is associated with better health and mental health profiles, less secondary drug use, and more days of 12-step attendance. These data highlight differential treatment needs and resiliencies associated with early treatment drug use status.Trial registrationNCT01104805.

Ethnic Differences in the Effect of Drug Use and Drug Dependence on Brief Motivational Interventions Targeting Alcohol Use

BACKGROUND We examined the effects of baseline drug use and dependence on alcohol use outcomes following brief motivational intervention for at-risk drinking (BMI-ETOH). METHODS HLM models were developed to test the interaction of drug use and dependence with BMI-ETOH for alcohol use among Hispanic (n=539), Caucasian (n=667), and black (n=287) patients admitted to a Level-1 trauma center who screened positive for alcohol misuse. RESULTS Analyses of an interaction of drug dependence and BMI-ETOH at baseline showed significant positive effects among Hispanics but not Caucasians or Blacks at six- and 12-months for percent days abstinent (6-month: B=0.27, SE=0.10, p=0.006; 12-month: B=0.41, SE=0.11, p<0.001), volume per week (6-month: B=-1.91, SE=0.77, p=0.01; 12-month: B = -2.71, SE=0.86, p=0.002), and maximum amount consumed (6-month: B = -1.08, SE=0.46, p=0.02; 12-month: B = -1.62, SE=0.52, p=0.002). CONCLUSIONS Baseline drug dependence did not negatively impact drinking outcomes. Among Hispanics, those with drug dependence at baseline who received a BMI-ETOH demonstrated consistent improvements across drinking outcomes. While the effects of drug use at baseline on drinking outcomes following BMI-ETOH varied by type of drug used and ethnicity, additional research is required.

Screening Community Pharmacy Patients for Risk of Prescription Opioid Misuse.

Objectives:This study tested screening feasibility and described the behavioral, mental, and physical health of patients filling prescriptions for opioid medications in the community pharmacy setting. Methods:We conducted a cross-sectional survey in rural/urban community pharmacies with adult noncancer patients. The survey included validated measures for opioid medication misuse risk, drug and alcohol use, and physical and mental health problems. Descriptive statistics were calculated, and bivariate and multivariable logistic regression evaluated relationships between opioid medication misuse risk and patient demographics, behavioral, mental, and physical health. Results:A total of 164 patients completed the survey (87% response rate), revealing positive screens for prescription opioid misuse risk (14.3%), illicit drug use (7.3%), hazardous alcohol use (21.4%), depression (25.8%), and posttraumatic stress disorder (PTSD; 17.1%). Bivariate analyses revealed increased odds of a positive opioid medication misuse risk score with a positive screen for illicit drug use in the previous year (odds ratio = 3.91; 95% confidence interval [CI], 1.05–14.63) and PTSD (odds ratio = 6.7; 95% CI, 2.54–17.69). In adjusted multivariable analyses, these relationships strengthened such that a positive screen for illicit drug use (adjusted odds ratio = 12.96; 95% CI, 2.18–76.9) and PTSD (adjusted odds ratio = 13.3; 95% CI, 3.48–50.66) increased odds for a positive opioid medication misuse risk score. Conclusions:Findings confirmed the feasibility of screening risk factors and positive opioid medication misuse risk among community pharmacy patients. Future research should validate these findings as a foundation to intervention development.