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Dunlap LJ, Zarkin GA, Orme S, Meinhofer A, Kelly SM, O'Grady KE, Gryczynski J, Mitchell SG, Schwartz RP. Re-engineering methadone-Cost-effectiveness analysis of a patient-centered approach to methadone treatment. J Subst Abuse Treat 2018; 94:81-90. [PMID: 30243422 DOI: 10.1016/j.jsat.2018.07.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 06/23/2018] [Accepted: 07/30/2018] [Indexed: 10/28/2022]
Abstract
Methadone maintenance treatment has proven effectiveness in the treatment of opioid use disorder, but significant barriers remain to treatment retention. In a randomized clinical trial, 300 newly-admitted methadone patients were randomly assigned to patient-centered methadone (PCM) v. treatment-as-usual (TAU). In PCM, participants were treated under revised program rules which permitted voluntary attendance at counseling and other changes focused on reducing involuntary discharge, and different staff roles which shifted disciplinary responsibility from the participant's counselor to the supervisor. The study found no significant differences in treatment retention, measures of opioid use, or other patient outcomes. This paper employs an activity-based costing approach to estimate the cost and cost-effectiveness of the two study conditions. We found that service use and costs were similar between PCM and TAU. Specifically, the average cost for PCM patients was $2396 compared to $2292 for standard methadone, while the average length of stay was 2 weeks longer for PCM patients. Incremental cost-effectiveness ratios (ICER) for self-reported heroin use, opioid positive urine screens, and meeting DSM-IV criteria for opioid dependence were mixed, with TAU achieving non-significantly better outcomes at lower treatment episode costs (i.e., economically dominating) for opioid positive urine screens. PCM patients reported slightly more days abstinent from heroin and fewer meet the opioid dependence criteria. While these differences are small and not statistically significant, we can still examine the cost-effectiveness implications. For days, abstinent from heroin, the ICER was $242 for one additional day of abstinence, however, there was notable uncertainty around this estimate. For opioid dependence criteria, the ICER was $1160 for a one-percentage point increase in the probability that a participant no longer met criteria for opioid dependence at follow-up. This economic study finds that patient choice concepts can be introduced into methadone treatment without significant impacts on costs or patient outcomes.
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Mitchell SG, Monico LB, Stitzer M, Matheson T, Sorensen JL, Feaster DJ, Schwartz RP, Metsch L. How patient navigators view the use of financial incentives to influence study involvement, substance use, and HIV treatment. J Subst Abuse Treat 2018; 94:18-23. [PMID: 30243412 DOI: 10.1016/j.jsat.2018.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 07/18/2018] [Accepted: 07/19/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND AIMS While patient navigation has been shown to be an effective approach for linking persons to HIV care, and contingency management is effective at improving substance use-related outcomes, Project HOPE combined these two interventions in a novel way to engage HIV-positive patients with HIV and substance use treatment. The aims of this paper are to examine patient navigator views regarding how contingency management interacted with and affected their navigation process. DESIGN Semi-structured qualitative interviews. PARTICIPANTS 22 patient navigators from the original 10 Project HOPE study sites. MEASUREMENTS Individual, semi-structured interviews lasting approximately 60 min addressed the patient navigator's professional background, descriptions of the participant population, substance use disorder versus HIV treatment entry and engagement issues, and the use of contingency management within the navigation service delivery protocol. FINDINGS Patient navigators believed that financial incentives helped motivate participant attendance at navigation sessions, particularly early in study involvement, which helped them to establish rapport and develop relationships with participants. Patient navigators often noted that financial incentives positively influenced targeted HIV health-related behaviors, such as attending medical appointments, which provided a rapid pay-off with an escalating sum. Contingency management was more complex when used by the patient navigators for substance use-related behaviors, particularly when incentives revolved around negative urine screening. Patient navigators noted that not all participants responded the same way to the contingency management and that the incentives were particularly helpful when participants were financially strained with limited resources or when internal motivation was lacking. CONCLUSIONS Overall patient navigators found the inclusion of contingency management to be helpful and affective at influencing participant behaviors, particularly concerning navigation session attendance and HIV healthcare-related participation. However, issues and concerns surrounding the inclusion of contingency management for drug-related behaviors as delivered in Project HOPE were noted. CLINICAL TRIALS REGISTRATION NCT01612169.
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Gordon MS, Blue TR, Couvillion K, Schwartz RP, O'Grady KE, Fitzgerald TT, Vocci FJ. Initiating buprenorphine treatment prior to versus after release from prison: Arrest outcomes. Drug Alcohol Depend 2018; 188:232-238. [PMID: 29783095 PMCID: PMC5999574 DOI: 10.1016/j.drugalcdep.2018.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 03/28/2018] [Accepted: 04/05/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND This secondary analysis of a randomized trial examines the association between initiation of buprenorphine treatment prior to, versus post-release, and rearrests during the 12-months following release. METHODS Official rearrest data (N = 199) for the 12-months post-release were examined. Four outcomes were measured: (1) rearrested (yes/no), (2) time to rearrest, (3) number of rearrests, and (4) severity of charges (less severe vs. severe). RESULTS A minority (43.1%) of the sample were rearrested (N = 91). There were no significant differences between study conditions in the proportion of rearrested participants [P = 0.28] nor in the mean number of arrests [P = 0.15]. Likewise, the condition was not a significant predictor of the hazard of rearrest [p = 0.10]. The mean number of days until rearrest for the in prison vs. post-release buprenorphine conditions were not significantly different (205.8 days (SD = 104.6) vs. 170.8 days (SD = 113.1), respectively; P = 0.13]. Treatment condition was not a significant predictor of the likelihood of rearrest for a severe crime compared to a less severe crime [P = 0.09]. CONCLUSION Despite the parent study finding of higher rates of post-release drug treatment entry in the group assigned to start buprenorphine treatment prior to, compared to post-release, there were no significant differences in the proportion of individuals arrested, the mean number of arrests, the time to first arrest, or the severity of their charges.
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Barbosa C, Wedehase B, Dunlap L, Mitchell SG, Dusek K, Schwartz RP, Gryzcynski J, Kirk AS, Oros M, Hosler C, O'Grady KE, Brown BS. Start-Up Costs of SBIRT Implementation for Adolescents in Urban U.S. Federally Qualified Health Centers. J Stud Alcohol Drugs 2018; 79:447-454. [PMID: 29885153 DOI: 10.15288/jsad.2018.79.447] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Understanding the costs to implement Screening, Brief Intervention, and Referral to Treatment (SBIRT) for adolescent substance use in primary care settings is important for providers in planning for services and for decision makers considering dissemination and widespread implementation of SBIRT. We estimated the start-up costs of two models of SBIRT for adolescents in a multisite U.S. Federally Qualified Health Center (FQHC). In both models, screening was performed by a medical assistant, but models differed on delivery of brief intervention, with brief intervention delivered by a primary care provider in the generalist model and a behavioral health specialist in the specialist model. METHOD SBIRT was implemented at seven clinics in a multisite, cluster randomized trial. SBIRT implementation costs were calculated using an activity-based costing methodology. Start-up activities were defined as (a) planning activities (e.g., changing existing electronic medical record system and tailoring service delivery protocols); and (b) initial staff training. Data collection instruments were developed to collect staff time spent in start-up activities and quantity of nonlabor resources used. RESULTS The estimated average costs to implement SBIRT were $5,182 for the specialist model and $3,920 for the generalist model. Planning activities had the greatest impact on costs for both models. Overall, more resources were devoted to planning and training activities in specialist sites, making the specialist model costlier to implement. CONCLUSIONS The initial investment required to implement SBIRT should not be neglected. The level of resources necessary for initial implementation depends on the delivery model and its integration into current practice.
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John WS, Zhu H, Mannelli P, Schwartz RP, Subramaniam GA, Wu LT. Prevalence, patterns, and correlates of multiple substance use disorders among adult primary care patients. Drug Alcohol Depend 2018; 187:79-87. [PMID: 29635217 PMCID: PMC5959766 DOI: 10.1016/j.drugalcdep.2018.01.035] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 01/26/2018] [Accepted: 01/27/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Addressing multiple substance use disorders (SUDs) in primary care-based screening and intervention may improve SUD treatment access, engagement, and outcomes. To inform such efforts, research is needed on the prevalence and patterns of multiple SUDs among primary care patients. METHODS Data were analyzed from a sample of 2000 adult (aged ≥ 18) primary care patients recruited for a multisite National Drug Abuse Treatment Clinical Trials Network (CTN) study (CTN-0059). Past-year DSM-5 SUDs (tobacco, alcohol, and drug) were assessed by the modified Composite International Diagnostic Interview. Prevalence and correlates of multiple versus single SUDs were examined. Latent class analysis (LCA) was used to explore patterns of multiple SUDs. RESULTS Multiple SUDs were found among the majority of participants with SUD for alcohol, cannabis, prescription opioids, cocaine, and heroin. Participants who were male, ages 26-34, less educated, and unemployed had increased odds of multiple SUDs compared to one SUD. Having multiple SUDs was associated with greater severity of tobacco or alcohol use disorder. LCA of the sample identified three classes: class 1 (83.7%) exhibited low prevalence of all SUDs; class 2 (12.0%) had high-moderate prevalence of SUDs for tobacco, alcohol, and cannabis; class 3 (4.3%) showed high prevalence of SUD for tobacco, opioids, and cocaine. LCA-defined classes were distinguished by sex, age, race, education, and employment status. CONCLUSIONS Findings suggest that primary care physicians should be aware of multiple SUDs when planning treatment, especially among adults who are male, younger, less educated, or unemployed. Interventions that target multiple SUDs warrant future investigation.
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Monico LB, Gryczynski J, Schwartz RP, Jaffe JH, O'Grady KE, Mitchell SG. Treatment outcomes among a cohort of African American buprenorphine patients: Follow-up at 12 months. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2018; 44:604-610. [PMID: 29718715 DOI: 10.1080/00952990.2018.1461877] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Although buprenorphine/naloxone (bup/nal) is well-established as a safe and effective treatment for opioid use disorders (OUDs), there are few studies reporting 12-month outcomes of patients receiving bup/nal in formerly drug-free outpatient programs. OBJECTIVES To examine 12-month outcomes by bup/nal treatment enrollment status among a cohort of African American patients enrolled in a clinical trial. METHODS This analysis builds upon a randomized trial of 300 opioid-dependent African American bup/nal patients in two outpatient programs in Baltimore, MD. A subset of participants (N = 133, n = 47 female) were tracked for a 12-month follow-up interview. RESULTS The participants receiving bup/nal at 12 months had significantly fewer opioid-positive urine screens (44% v. 73%) and days of self-reported heroin use (M [SE] = 1.13 [.34] v. 7.12 [1.44]) than the out-of-bup/nal-treatment group (both ps ≤ .001). Similarly, those receiving bup/nal reported significantly fewer days of cocaine use (M [SE] = 0.85 [0.23] v. 2.88[0.75]) and alcohol use (M [SE] = 1.44 [0.38] v. 3.69 [1.04]; both ps<.05). There were no significant differences related to criminal activity, quality of life, and most ASI composite scores. Models adjusting for the baseline value, prior treatment experience, and assigned study condition largely confirmed these findings, except that participants in treatment had fewer days of crime and higher psychological quality of life scores compared to those out-of-treatment. CONCLUSIONS Those receiving bup/nal at 12 months had significantly lower rates of illicit opioid use than those who were not. Approaches to improve bup/nal treatment retention and reengagement of patients with OUD are needed.
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Nordeck CD, Welsh C, Schwartz RP, Mitchell SG, Cohen A, O’Grady KE, Gryczynski J. Rehospitalization and substance use disorder (SUD) treatment entry among patients seen by a hospital SUD consultation-liaison service. Drug Alcohol Depend 2018; 186. [PMID: 29529456 PMCID: PMC5922267 DOI: 10.1016/j.drugalcdep.2017.12.043] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Substance use disorders (SUD) are associated with non-adherence to medical care and high utilization of hospital services. This study characterized patterns and correlates of rehospitalization among patients seen by a hospital-based SUD consultation-liaison (CL) team. METHODS This study was a retrospective medical record review of patients in a large urban academic hospital who received SUD consultation and were diagnosed with opioid, cocaine, and/or alcohol use disorder (N = 267). Data were collected on patient characteristics, substance-specific SUD diagnoses (opioids, cocaine, and alcohol), opioid agonist treatment (OAT) with methadone or buprenorphine (treatment status at admission; in-hospital initiation of OAT), and rehospitalization through 180 days post-discharge. Associations with rehospitalization were examined using bivariate tests of independence and multivariate logistic regression, with patient background and medical characteristics, substance-specific SUD diagnoses, and OAT status (at admission and in-hospital initiation) as predictors. RESULTS Rehospitalization rates were higher among patients with current opioid (38% vs. 24%; p < .05) and cocaine use disorders (39% vs. 26%; p < .05) compared to patients without these diagnoses. In multivariate logistic regression analysis, the number of medical comorbidities [Adjusted Odds Ratio (AOR) = 1.2; p < .01] and opioid use disorder (AOR = 2.4, p < .05) were independently associated with rehospitalization. CONCLUSIONS In this sample of hospital patients receiving SUD CL services, the risk of rehospitalization differed by type of SUD diagnosis. In-hospital initiation of OAT is promising for facilitating treatment linkage post-discharge, but this small study did not show differences in rehospitalization based on OAT initiation. These findings could inform services for hospital patients with comorbid SUDs.
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Gryczynski J, Schwartz RP, Fishman MJ, Nordeck CD, Grant J, Nidich S, Rothenberg S, O'Grady KE. Integration of Transcendental Meditation® (TM) into alcohol use disorder (AUD) treatment. J Subst Abuse Treat 2018; 87:23-30. [DOI: 10.1016/j.jsat.2018.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 01/10/2018] [Accepted: 01/12/2018] [Indexed: 01/22/2023]
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Gryczynski J, Carswell SB, O'Grady KE, Mitchell SG, Schwartz RP. Gender and ethnic differences in primary care patients' response to computerized vs. in-person brief intervention for illicit drug misuse. J Subst Abuse Treat 2017; 84:50-56. [PMID: 29195593 DOI: 10.1016/j.jsat.2017.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 10/17/2017] [Accepted: 10/17/2017] [Indexed: 12/19/2022]
Abstract
This study is a secondary analysis from a randomized clinical trial of computerized vs. in-person brief intervention (BI) for illicit drug misuse among adult primary care patients (N=359; 45% Female; 47% Hispanic) with moderate-risk illicit drug misuse as measured by the World Health Organization's Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). This study examined differences in response to the two brief intervention strategies (both based on motivational interviewing) on the basis of gender and ethnicity, comparing non-Hispanic males, non-Hispanic females, Hispanic males, and Hispanic females. Participants were assessed at baseline, 3-, 6-, and 12-month follow-up with the ASSIST. Trajectories in Global Continuum of Illicit Drug Risk Scores were examined using a generalized linear mixed model. There were significant differences in response to computerized vs. in-person BI over time on the basis of gender-ethnic subgroups (Gender×Ethnicity×Condition×Time interaction; p=0.03), with Hispanic males tending to respond more favorably to the computerized BI and Hispanic females tending to respond more favorably to the in-person BI. There was no clear differentiation in response to the two BIs among non-Hispanic males, while among non-Hispanic females the pattern of change converged following baseline differences. Consideration of gender and ethnic differences in future studies of BI is warranted.
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Schwartz RP, Kelly SM, Mitchell SG, Gryczynski J, O'Grady KE, Jaffe JH. When does methadone treatment reduce arrest and severity of arrest charges? An analysis of arrest records. Drug Alcohol Depend 2017; 180:385-390. [PMID: 28961545 PMCID: PMC5667939 DOI: 10.1016/j.drugalcdep.2017.08.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 08/16/2017] [Accepted: 08/23/2017] [Indexed: 11/29/2022]
Abstract
This is an analysis of the odds of arrest, severity of charges, and factors predicting these outcomes in the year after methadone treatment entry using arrest records of patients (N=289) participating in two opioid treatment programs (OTPs) in Baltimore, MD as part of a previously-reported study. Baseline Addiction Severity Index data were examined along with publicly-available dates of arrest and arrest charges from the year before and after OTP entry. Severity of charges was rated independently by three researchers using a 1-7 point scale. Data were analyzed using Generalized Estimating Equations and Multiple Regression. The majority of the patients had no arrests over both time periods (61.6% and 65.7%, respectively). Of those arrested, the majority of the sample were charged with non-severe crimes in the year before and after OTP entry (82.9% and 73.7%, respectively). There were no significant differences in the odds of arrest or severity of charges in the year before versus the year after OTP admission (both ps>0.05). Predictors of arrest following admission included an arrest in the year prior to admission (p<0.001), younger age (p<0.001), and more lifetime months of incarceration (p=0.045). Predictors of the higher severity of charges included younger age (p<0.001), African-American race (p=0.032), and more lifetime months of incarceration (p=0.018). While in this population, the odds of arrest and severity of charges did not decrease significantly in the year following OTP entry, we discuss the need to avoid generalizing findings without considering those factors that may influence the likelihood of post-OTP entry arrest.
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Kelly SM, O’Grady KE, Gryczynski J, Gwin Mitchell S, Kirk A, Schwartz RP. The concurrent validity of the Problem Oriented Screening Instrument for Teenagers (POSIT) substance use/abuse subscale in adolescent patients in an urban federally qualified health center. Subst Abus 2017; 38:382-388. [PMID: 28686545 PMCID: PMC6317511 DOI: 10.1080/08897077.2017.1351413] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The Problem Oriented Screening Instrument for Teenagers (POSIT) substance use/abuse subscale has been validated with high school students, adolescents with criminal justice involvement, and adolescent substance use treatment samples using the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III-R and DSM-IV. This study examines the concurrent validity of the POSIT's standard 17-item substance use/abuse subscale and a revised, shorter 11-item version using DSM-5 substance use disorder diagnoses. METHODS Adolescents (N = 525; 93% African American, 55% female) 12-17 years of age awaiting primary care appointments at a Federally Qualified Health Center in Baltimore, Maryland completed the 17-item POSIT substance use/abuse subscale and items from a modified World Mental Health Composite International Diagnostic Interview corresponding to DSM-5 alcohol use disorder (AUD) and cannabis use disorder (CUD). Receiver operating characteristic curves, sensitivities, and specificities were examined with DSM-5 AUD, CUD, and a diagnosis of either or both disorders for the standard and revised subscales using risk cutoffs of either 1 or 2 POSIT "yes" responses. RESULTS For the 17-item subscale, sensitivities were generally high using either cutoff (range: 0.79-1.00), although a cutoff of 1 was superior (sensitivities were 1.00 for AUD, CUD, and for either disorder). Specificities were also high using either cutoff (range: 0.81-0.95) but were higher using a cutoff of 2. For the 11-item subscale, a cutoff of 1 yielded higher sensitivities than a cutoff of 2 (ranges for 1 and 2: 0.96-1.00 and 0.79-0.86, respectively). Specificities for this subscale were higher using a cutoff of 2 (ranges for 1 and 2: 0.82-0.89 and 0.89-0.96, respectively). CONCLUSIONS Findings suggest that the POSIT's substance use/abuse subscale is a potentially useful tool for screening adolescents in primary care for AUD or CUD using a cutoff of 1 or 2. The briefer, revised subscale may be preferable to the standard subscale in busy pediatric practices.
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Wu LT, McNeely J, Subramaniam GA, Brady KT, Sharma G, VanVeldhuisen P, Zhu H, Schwartz RP. DSM-5 substance use disorders among adult primary care patients: Results from a multisite study. Drug Alcohol Depend 2017; 179:42-46. [PMID: 28753480 PMCID: PMC5599360 DOI: 10.1016/j.drugalcdep.2017.05.048] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 05/24/2017] [Accepted: 05/26/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND There are limited data about the extent of DSM-5 substance use disorders (SUDs) among primary care patients. METHODS This study analyzed data from a multisite validation study of a substance use screening instrument conducted in a diverse sample of 2000 adults aged ≥18 years recruited from five primary care practices in four states. Prevalence and correlates of 12-month DSM-5 SUDs were examined. RESULTS Overall, 75.5% of the sample used any substance, including alcohol (62.0%), tobacco (44.1%), or illicit drugs/nonmedical medications (27.9%) in the past 12 months (marijuana 20.8%, cocaine 7.3%, opioids 4.8%, sedatives 4.1%, heroin 3.9%). The prevalence of any 12-month SUD was 36.0% (mild disorder 14.2%, moderate/severe disorder 21.8%): tobacco 25.3% (mild 11.5%, moderate/severe 13.8%); alcohol 13.9% (mild 6.9%, moderate/severe 7.0%); and any illicit/nonmedical drug 14.0% (mild 4.0%, moderate/severe 10.0%). Among past 12-month users, a high proportion of tobacco or drug users met criteria for a disorder: tobacco use disorder 57.4% (26.1% mild, 31.3% moderate/severe) and any drug use disorder 50.2% (14.3% mild, 35.8% moderate/severe); a lower proportion of alcohol users (22.4%) met criteria for alcohol use disorder (11.1% mild, 11.3% moderate/severe). Over 80% of adults with opioid/heroin use disorder met criteria for a moderate/severe disorder. Younger ages, male sex, and low education were associated with increased odds of having SUD. CONCLUSION These findings reveal the high prevalence of SUDs in primary care and underscore the need to identify and address them.
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Holloway AS, Ferguson J, Landale S, Cariola L, Newbury-Birch D, Flynn A, Knight JR, Sherritt L, Harris SK, O’Donnell AJ, Kaner E, Hanratty B, Loree AM, Yonkers KA, Ondersma SJ, Gilstead-Hayden K, Martino S, Adam A, Schwartz RP, Wu LT, Subramaniam G, Sharma G, McNeely J, Berman AH, Kolaas K, Petersén E, Bendtsen P, Hedman E, Linderoth C, Müssener U, Sinadinovic K, Spak F, Gremyr I, Thurang A, Mitchell AM, Finnell D, Savage CL, Mahmoud KF, Riordan BC, Conner TS, Flett JAM, Scarf D, McRee B, Vendetti J, Gallucci KS, Robaina K, Clark BJ, Jones J, Reed KD, Hodapp RM, Douglas I, Burnham EL, Aagaard L, Cook PF, Harris BR, Yu J, Wolff M, Rogers M, Barbosa C, Wedehase BJ, Dunlap LJ, Mitchell SG, Dusek KA, Gryczynski J, Kirk AS, Oros MT, Hosler C, O’Grady KE, Brown BS, Angus C, Sherborne S, Gillespie D, Meier P, Brennan A, de Vargas D, Soares J, Castelblanco D, Doran KM, Wittman I, Shelley D, Rotrosen J, Gelberg L, Edelman EJ, Maisto SA, Hansen NB, Cutter CJ, Deng Y, Dziura J, Fiellin LE, O’Connor PG, Bedimo R, Gibert C, Marconi VC, Rimland D, Rodriguez-Barradas MC, Simberkoff MS, Justice AC, Bryant KJ, Fiellin DA, Giles EL, Coulton S, Deluca P, Drummond C, Howel D, McColl E, McGovern R, Scott S, Stamp E, Sumnall H, Vale L, Alabani V, Atkinson A, Boniface S, Frankham J, Gilvarry E, Hendrie N, Howe N, McGeechan GJ, Ramsey A, Stanley G, Clephane J, Gardiner D, Holmes J, Martin N, Shevills C, Soutar M, Chi FW, Weisner C, Ross TB, Mertens J, Sterling SA, Shorter GW, Heather N, Bray J, Cohen HA, McPherson TL, Adam C, López-Pelayo H, Gual A, Segura-Garcia L, Colom J, Ornelas IJ, Doyle S, Donovan D, Duran B, Torres V, Gaume J, Grazioli V, Fortini C, Paroz S, Bertholet N, Daeppen JB, Satterfield JM, Gregorich S, Alvarado NJ, Muñoz R, Kulieva G, Vijayaraghavan M, Adam A, Cunningham JA, Díaz E, Palacio-Vieira J, Godinho A, Kushir V, O’Brien KHM, Aguinaldo LD, Sellers CM, Spirito A, Chang G, Blake-Lamb T, LaFave LRA, Thies KM, Pepin AL, Sprangers KE, Bradley M, Jorgensen S, Catano NA, Murray AR, Schachter D, Andersen RM, Rey GN, Vahidi M, Rico MW, Baumeister SE, Johansson M, Sinadinovic C, Hermansson U, Andreasson S, O’Grady MA, Kapoor S, Akkari C, Bernal C, Pappacena K, Morley J, Auerbach M, Neighbors CJ, Kwon N, Conigliaro J, Morgenstern J, Magill M, Apodaca TR, Borsari B, Hoadley A, Scott Tonigan J, Moyers T, Fitzgerald NM, Schölin L, Barticevic N, Zuzulich S, Poblete F, Norambuena P, Sacco P, Ting L, Beaulieu M, Wallace PG, Andrews M, Daley K, Shenker D, Gallagher L, Watson R, Weaver T, Bruguera P, Oliveras C, Gavotti C, Barrio P, Braddick F, Miquel L, Suárez M, Bruguera C, Brown RL, Capell JW, Paul Moberg D, Maslowsky J, Saunders LA, McCormack RP, Scheidell J, Gonzalez M, Bauroth S, Liu W, Lindsay DL, Lincoln P, Hagle H, Wallhed Finn S, Hammarberg A, Andréasson S, King SE, Vargo R, Kameg BN, Acquavita SP, Van Loon RA, Smith R, Brehm BJ, Diers T, Kim K, Barker A, Jones AL, Skinner AC, Hinman A, Svikis DS, Thacker CL, Resnicow K, Beatty JR, Janisse J, Puder K, Bakshi AS, Milward JM, Kimergard A, Garnett CV, Crane D, Brown J, West R, Michie S, Rosendahl I, Andersson C, Gajecki M, Blankers M, Donoghue K, Lynch E, Maconochie I, Phillips C, Pockett R, Phillips T, Patton R, Russell I, Strang J, Stewart MT, Quinn AE, Brolin M, Evans B, Horgan CM, Liu J, McCree F, Kanovsky D, Oberlander T, Zhang H, Hamlin B, Saunders R, Barton MB, Scholle SH, Santora P, Bhatt C, Ahmed K, Hodgkin D, Gao W, Merrick EL, Drebing CE, Larson MJ, Sharma M, Petry NM, Saitz R, Weisner CM, Young-Wolff KC, Lu WY, Blosnich JR, Lehavot K, Glass JE, Williams EC, Bensley KM, Chan G, Dombrowski J, Fortney J, Rubinsky AD, Lapham GT, Forray A, Olmstead TA, Gilstad-Hayden K, Kershaw T, Dillon P, Weaver MF, Grekin ER, Ellis JD, McGoron L, McGoron L. Proceedings of the 14th annual conference of INEBRIA. Addict Sci Clin Pract 2017. [PMCID: PMC5606215 DOI: 10.1186/s13722-017-0087-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Gryczynski J, McNeely J, Wu LT, Subramaniam GA, Svikis DS, Cathers LA, Sharma G, King J, Jelstrom E, Nordeck CD, Sharma A, Mitchell SG, O'Grady KE, Schwartz RP. Validation of the TAPS-1: A Four-Item Screening Tool to Identify Unhealthy Substance Use in Primary Care. J Gen Intern Med 2017; 32:990-996. [PMID: 28550609 PMCID: PMC5570743 DOI: 10.1007/s11606-017-4079-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 03/16/2017] [Accepted: 04/28/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Tobacco, Alcohol, Prescription Medication, and Other Substance use (TAPS) tool is a combined two-part screening and brief assessment developed for adult primary care patients. The tool's first-stage screening component (TAPS-1) consists of four items asking about past 12-month use for four substance categories, with response options of never, less than monthly, monthly, weekly, and daily or almost daily. OBJECTIVE To validate the TAPS-1 in primary care patients. DESIGN Participants completed the TAPS tool in self- and interviewer-administered formats, in random order. In this secondary analysis, the TAPS-1 was evaluated against DSM-5 substance use disorder (SUD) criteria to determine optimal cut-points for identifying unhealthy substance use at three severity levels (problem use, mild SUD, and moderate-to-severe SUD). PARTICIPANTS Two thousand adult patients at five primary care sites. MAIN MEASURES DSM-5 SUD criteria were determined via the modified Composite International Diagnostic Interview. Oral fluid was used as a biomarker of recent drug use. KEY RESULTS Optimal frequency-of-use cut-points on the self-administered TAPS-1 for identifying SUDs were ≥ monthly use for tobacco and alcohol (sensitivity = 0.92 and 0.71, specificity = 0.80 and 0.85, AUC = 0.86 and 0.78, respectively) and any reported use for illicit drugs and prescription medication misuse (sensitivity = 0.93 and 0.89, specificity = 0.85 and 0.91, AUC = 0.89 and 0.90, respectively). The performance of the interviewer-administered format was similar. When administered first, the self-administered format yielded higher disclosure rates for past 12-month alcohol use, illicit drug use, and prescription medication misuse. Frequency of use alone did not provide sufficient information to discriminate between gradations of substance use problem severity. Among those who denied drug use on the TAPS-1, less than 4% had a drug-positive biomarker. CONCLUSIONS The TAPS-1 can identify unhealthy substance use in primary care patients with a high level of accuracy, and may have utility in primary care for rapid triage.
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Magge SN, Goodman E, Armstrong SC, Daniels S, Corkins M, de Ferranti S, Golden NH, Kim JH, Magge SN, Schwarzenberg SJ, Sills IN, Casella SJ, DeMeglio LA, Gonzalez JL, Kaplowitz PB, Lynch JL, Wintergerst KA, Bolling CF, Armstrong SC, Muth ND, Rausch JC, Rogers VW, Schwartz RP. The Metabolic Syndrome in Children and Adolescents: Shifting the Focus to Cardiometabolic Risk Factor Clustering. Pediatrics 2017; 140:peds.2017-1603. [PMID: 28739653 DOI: 10.1542/peds.2017-1603] [Citation(s) in RCA: 224] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Metabolic syndrome (MetS) was developed by the National Cholesterol Education Program Adult Treatment Panel III, identifying adults with at least 3 of 5 cardiometabolic risk factors (hyperglycemia, increased central adiposity, elevated triglycerides, decreased high-density lipoprotein cholesterol, and elevated blood pressure) who are at increased risk of diabetes and cardiovascular disease. The constellation of MetS component risk factors has a shared pathophysiology and many common treatment approaches grounded in lifestyle modification. Several attempts have been made to define MetS in the pediatric population. However, in children, the construct is difficult to define and has unclear implications for clinical care. In this Clinical Report, we focus on the importance of screening for and treating the individual risk factor components of MetS. Focusing attention on children with cardiometabolic risk factor clustering is emphasized over the need to define a pediatric MetS.
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Sharma A, Kelly SM, Mitchell SG, Gryczynski J, O'Grady KE, Schwartz RP. Update on Barriers to Pharmacotherapy for Opioid Use Disorders. Curr Psychiatry Rep 2017; 19:35. [PMID: 28526967 PMCID: PMC7075636 DOI: 10.1007/s11920-017-0783-9] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW The recent heroin and prescription opioid misuse epidemic has led to a sharp increase in the number of opioid overdose deaths in the USA. Notwithstanding the availability of three FDA-approved medications (methadone, buprenorphine, and naltrexone) to treat opioid use disorder, these medications are underutilized. This paper provides an update from the recent peer-reviewed literature on barriers to the use of these medications. FINDINGS These barriers are interrelated and can be categorized as financial, regulatory, geographic, attitudinal, and logistic. While financial barriers are common to all three medications, other barriers are medication-specific. The adverse impact of the current opioid epidemic on public health can be reduced by increasing access to effective pharmacotherapy for opioid use disorder.
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Schwartz RP, McNeely J, Wu LT, Sharma G, Wahle A, Cushing C, Nordeck CD, Sharma A, O'Grady KE, Gryczynski J, Mitchell SG, Ali RL, Marsden J, Subramaniam GA. Identifying substance misuse in primary care: TAPS Tool compared to the WHO ASSIST. J Subst Abuse Treat 2017; 76:69-76. [PMID: 28159441 PMCID: PMC5377907 DOI: 10.1016/j.jsat.2017.01.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 01/25/2017] [Accepted: 01/25/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND There is a need for screening and brief assessment instruments to identify primary care patients with substance use problems. This study's aim was to examine the performance of a two-step screening and brief assessment instrument, the TAPS Tool, compared to the WHO ASSIST. METHODS Two thousand adult primary care patients recruited from five primary care clinics in four Eastern US states completed the TAPS Tool followed by the ASSIST. The ability of the TAPS Tool to identify moderate- and high-risk use scores on the ASSIST was examined using sensitivity and specificity analyses. RESULTS The interviewer and self-administered computer tablet versions of the TAPS Tool generated similar results. The interviewer-administered version (at cut-off of 2), had acceptable sensitivity and specificity for high-risk tobacco (0.90 and 0.77) and alcohol (0.87 and 0.80) use. For illicit drugs, sensitivities were >0.82 and specificities >0.92. The TAPS (at a cut-off of 1) had good sensitivity and specificity for moderate-risk tobacco use (0.83 and 0.97) and alcohol (0.83 and 0.74). Among illicit drugs, sensitivity was acceptable for moderate-risk of marijuana (0.71), while it was low for all other illicit drugs and non-medical use of prescription medications. Specificities were 0.97 or higher for all illicit drugs and prescription medications. CONCLUSIONS The TAPS Tool identified adult primary care patients with high-risk ASSIST scores for all substances as well moderate-risk users of tobacco, alcohol, and marijuana, although it did not perform well in identifying patients with moderate-risk use of other drugs or non-medical use of prescription medications. The advantages of the TAPS Tool over the ASSIST are its more limited number of items and focus solely on substance use in the past 3months.
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Stitzer ML, Schwartz RP, Bigelow GE. Prescription opioids: New perspectives and research on their role in chronic pain management and addiction. Drug Alcohol Depend 2017; 173 Suppl 1:S1-S3. [PMID: 28363314 DOI: 10.1016/j.drugalcdep.2016.11.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 11/20/2016] [Indexed: 10/19/2022]
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Sigmon SC, Schwartz RP, Higgins ST. Buprenorphine for Persons on Waiting Lists for Treatment for Opioid Dependence. N Engl J Med 2017; 376:1000. [PMID: 28273017 PMCID: PMC5514413 DOI: 10.1056/nejmc1700539] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Schwartz RP, Kelly SM, Mitchell SG, Gryczynski J, O’Grady KE, Gandhi D, Olsen Y, Jaffe JH. Patient-centered methadone treatment: a randomized clinical trial. Addiction 2017; 112:454-464. [PMID: 27661788 PMCID: PMC5296234 DOI: 10.1111/add.13622] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 04/14/2016] [Accepted: 09/19/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS Methadone patients who discontinue treatment are at high risk of relapse, yet a substantial proportion discontinue treatment within the first year. We investigated whether a patient-centered approach to methadone treatment improved participant outcomes at 12 months following admission, compared with methadone treatment-as-usual. DESIGN Two-arm open-label randomized trial. SETTING Two methadone treatment programs (MTPs) in Baltimore, MD, USA. PARTICIPANTS Three hundred newly admitted MTP patients were enrolled between 13 September 2011 and 26 March 2014. Their mean age was 42.7 years [standard deviation (SD) = 10.1] and 59% were males. INTERVENTION Newly admitted MTP patients were assigned randomly to either patient-centered methadone treatment (PCM; n = 149), which modified the MTP's rules (e.g. counseling attendance was optional), and counselor roles (e.g. counselors were not responsible for enforcing clinic rules) or treatment-as-usual (TAU; n = 151). MEASUREMENTS The primary outcome was opioid-positive urine test at 12-month follow-up. Other 12-month outcomes included days of heroin and cocaine use, cocaine-positive urine tests, meeting DSM-IV opioid and cocaine dependence diagnostic criteria, HIV risk behavior and quality of life and retention in treatment. FINDINGS There was no significant difference between PCM and TAU conditions in opioid-positive urine screens at 12 months [adjusted odds ratio = 0.98; 95% confidence interval (CI) = 0.61, 1.56]. There were also no significant differences in any of the secondary outcome measures (all Ps > 0.05) except Quality of Life Global Score (P = 0.04; 95% CI = 0.01, 0.45). There were no significant differences between conditions in the number of individual or group counseling sessions attended. (Ps > 0.05). CONCLUSIONS Patient-centered methadone treatment (with optional counseling and the counselor not serving as the treatment program disciplinarian) does not appear to be more effective than methadone treatment-as-usual.
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Gryczynski J, Schwartz RP, O'Grady KE, Restivo L, Mitchell SG, Jaffe JH. Understanding Patterns Of High-Cost Health Care Use Across Different Substance User Groups. Health Aff (Millwood) 2017; 35:12-9. [PMID: 26733696 DOI: 10.1377/hlthaff.2015.0618] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Substance use contributes to significant societal burdens, including high-cost health care use. However, these burdens may vary by type of substance and level of involvement. Using the 2009-13 National Surveys on Drug Use and Health, we examined all-cause hospitalizations and estimated costs across substance use profiles for alcohol, marijuana, and other illicit drugs. For each substance, we characterized differences between abstainers, nondiagnostic users (people who used the substance but did not meet diagnostic criteria for substance use disorder), and people with substance use disorders. In a multivariate analysis, we found that the odds of hospitalization were 16 percent lower for nondiagnostic marijuana users and 11 percent lower for nondiagnostic alcohol users, compared to abstainers. Neither alcohol- nor marijuana-specific substance use disorders were associated with hospitalization. In contrast, substance use disorders for other illicit drugs were strongly associated with hospitalization: People with those disorders had 2.2 times higher odds of hospitalization relative to abstainers. A more detailed understanding of health care use in different substance user groups could inform the ongoing expansion of substance use services in the United States.
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Sigmon SC, Ochalek TA, Meyer AC, Hruska B, Heil SH, Badger GJ, Rose G, Brooklyn JR, Schwartz RP, Moore BA, Higgins ST. Interim Buprenorphine vs. Waiting List for Opioid Dependence. N Engl J Med 2016; 375:2504-2505. [PMID: 28002704 PMCID: PMC5373028 DOI: 10.1056/nejmc1610047] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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McNeely J, Wu LT, Subramaniam G, Sharma G, Cathers LA, Svikis D, Sleiter L, Russell L, Nordeck C, Sharma A, O'Grady KE, Bouk LB, Cushing C, King J, Wahle A, Schwartz RP. Performance of the Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS) Tool for Substance Use Screening in Primary Care Patients. Ann Intern Med 2016; 165:690-699. [PMID: 27595276 PMCID: PMC5291717 DOI: 10.7326/m16-0317] [Citation(s) in RCA: 159] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Substance use, a leading cause of illness and death, is underidentified in medical practice. OBJECTIVE The Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) tool was developed to address the need for a brief screening and assessment instrument that includes all commonly used substances and fits into clinical workflows. The goal of this study was to assess the performance of the TAPS tool in primary care patients. DESIGN Multisite study, conducted within the National Drug Abuse Treatment Clinical Trials Network, comparing the TAPS tool with a reference standard measure. (ClinicalTrials.gov: NCT02110693). SETTING 5 adult primary care clinics. PARTICIPANTS 2000 adult patients consecutively recruited from clinic waiting areas. MEASUREMENTS Interviewer- and self-administered versions of the TAPS tool were compared with a reference standard, the modified World Mental Health Composite International Diagnostic Interview (CIDI), which measures problem use and substance use disorder (SUD). RESULTS Interviewer- and self-administered versions of the TAPS tool had similar diagnostic characteristics. For identifying problem use (at a cutoff of 1+), the TAPS tool had a sensitivity of 0.93 (95% CI, 0.90 to 0.95) and specificity of 0.87 (CI, 0.85 to 0.89) for tobacco and a sensitivity of 0.74 (CI, 0.70 to 0.78) and specificity of 0.79 (CI, 0.76 to 0.81) for alcohol. For problem use of illicit and prescription drugs, sensitivity ranged from 0.82 (CI, 0.76 to 0.87) for marijuana to 0.63 (CI, 0.47 to 0.78) for sedatives; specificity was 0.93 or higher. For identifying any SUD (at a cutoff of 2+), sensitivity was lower. LIMITATIONS The low prevalence of some drug classes led to poor precision in some estimates. Research assistants were not blinded to participants' TAPS tool responses when they administered the CIDI. CONCLUSION In a diverse population of adult primary care patients, the TAPS tool detected clinically relevant problem substance use. Although it also may detect tobacco, alcohol, and marijuana use disorders, further refinement is needed before it can be recommended broadly for SUD screening. PRIMARY FUNDING SOURCE National Institute on Drug Abuse.
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Kelly SM, Gryczynski J, Mitchell SG, Kirk A, O’Grady KE, Schwartz RP. Corrigendum to "Concordance between DSM-5 and DSM-IV nicotine, alcohol, and cannabis use disorder diagnoses among pediatric patients" [Drug Alcohol Depend. 140 (2014) 213-216]. Drug Alcohol Depend 2016; 168:203. [PMID: 27697697 PMCID: PMC5586217 DOI: 10.1016/j.drugalcdep.2016.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Schwartz RP, Kelly SM, Mitchell SG, Dunlap L, Zarkin GA, Sharma A, O’Grady KE, Jaffe JH. Corrigendum to "Interim methadone and patient navigation in jail: Rationale and design of a randomized clinical trial." [Contemp. Clin. Trials 49 (2016): 21-28]. Contemp Clin Trials 2016; 51:97. [PMID: 27729206 PMCID: PMC9828321 DOI: 10.1016/j.cct.2016.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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