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Zuccarini MM, Stiller C. The Effect of Peer Support on Treatment Engagement for Opioid Use Disorder. J Am Psychiatr Nurses Assoc 2024; 30:709-715. [PMID: 36254384 DOI: 10.1177/10783903221128062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Opioid misuse has been a growing problem in the United States that has escalated into a national public health emergency. Despite substance abuse programs that offer assistance in the treatment of opioid use disorder (OUD), keeping clients engaged in recovery treatment can be very challenging. Relapse prevention is a priority concern due to the higher risk of overdose following a period of sobriety. AIMS This research compares two different approaches to treatment of OUD to assess relative treatment adherence. The purpose of this research is to establish whether a peer support-based treatment methodology, combined with increased medication-assisted treatment, provided by an outpatient facility is more effective than treatment-as-usual in improving client engagement in recovery treatment. METHODS The research analyzed data collected over a 6-month period by a facility. The retrospective review of data compared a total of 1,570 clients enrolled in a certified recovery services (CRSs) program versus individuals engaged in treatment-as-usual program. Inclusion criteria consisted of clients with at least one diagnoses of OUD who met level of care requirements. RESULTS Statistical t-test analysis revealed greater engagement in recovery services among those enrolled in the CRS program. CONCLUSIONS The findings support the benefits of a peer support program as a treatment methodology for clients with OUD. This research will be of value in the design and development of future program policy and treatment guidelines.
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Affiliation(s)
- Michelle M Zuccarini
- Michelle M. Zuccarini, MSN, RN, PMHNP-BC, Clarion University of Pennsylvania, Clarion, PA, USA
| | - Cate Stiller
- Cate Stiller, PhD, RN, CNE, Clarion University of Pennsylvania, Clarion, PA, USA
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Mosher HJ, Hadlandsmyth K, Alexander B, Lund BC. Continuation of Buprenorphine During Hospitalization and Subsequent Retention in Therapy: an Observational Study in Veterans Administration Hospitals. J Gen Intern Med 2024; 39:207-213. [PMID: 37752303 PMCID: PMC10853128 DOI: 10.1007/s11606-023-08420-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/07/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND Inpatient hospitalization has the potential to disrupt buprenorphine therapy. OBJECTIVE Among patients receiving outpatient buprenorphine prior to admission, we determined the rate of discontinuation during medical and surgical admissions to VA hospitals and its association with subsequent post-discharge continuation of buprenorphine therapy. DESIGN AND MAIN MEASURES We conducted an observational study using Veterans Administration data from 10/1/2018 to 3/31/2020 for all medical and surgical admissions where Veterans had active buprenorphine prescriptions at the time of admission. Pre-admission buprenorphine prescriptions were categorized as either sublingual (presumed indication for opioid use disorder (OUD)) or buccal/topical (presumed indication for pain). The primary measure of post-discharge buprenorphine receipt was any outpatient buprenorphine prescription dispensed between 1 day prior to discharge and 60 days following discharge. KEY RESULTS A total of 830 unique inpatient hospitalizations to medical or surgical services occurred among Veterans receiving sublingual (48.3%) or buccal/topical (51.7%) buprenorphine prior to admission. Fewer than half (43.9%) of these patients received buprenorphine at some point during the medical or surgical portion of their hospital stay. Among the 766 patients discharged from a medical or surgical unit, 74.3% received an outpatient buprenorphine prescription within the 60 days following discharge (80.2% sublingual and 69.1% buccal/topical). Among patients who had received buprenorphine during the final 36 h prior to discharge, subsequent outpatient buprenorphine receipt was observed in 94.0%, compared to only 63.7% among those not receiving buprenorphine during the final 36 h (χ2 = 83.5, p < 0.001). CONCLUSION Inpatient buprenorphine administrations near the time of discharge were highly predictive of continued outpatient therapy and a significant subset of patients did not continue or reinitiate buprenorphine therapy following discharge. As recommendations for perioperative and inpatient management of buprenorphine coalescence around continuation, efforts are needed to optimize hospital-based buprenorphine practices.
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Affiliation(s)
- Hilary J Mosher
- Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, USA
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Katherine Hadlandsmyth
- Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, USA.
- Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, IA, USA.
| | - Bruce Alexander
- Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, USA
| | - Brian C Lund
- Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, IA, USA
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Nowels MA, Duberstein PR, Crystal S, Treitler P, Miles J, Olfson M, Samples H. Suicide within 1 year of non-fatal overdose: Risk factors and risk reduction with medications for opioid use disorder. Gen Hosp Psychiatry 2024; 86:24-32. [PMID: 38061284 PMCID: PMC10880030 DOI: 10.1016/j.genhosppsych.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/15/2023] [Accepted: 11/03/2023] [Indexed: 01/27/2024]
Abstract
OBJECTIVE Individuals with substance use disorders and overdoses have high risk of suicide death, but evidence is limited on the relationship between interventions following the initial overdose and subsequent suicide death. METHODS National Medicare data were used to identify Medicare disability beneficiaries (MDBs) with inpatient or emergency care for non-fatal opioid overdoses from 2008 to 2016. Data were linked with National Death Index (NDI) to obtain dates and causes of death for the sample. Cox proportional hazards models estimated the associations between exposure to interventions (mechanical ventilation, MOUD) and suicide death. RESULTS The sample (n = 81,654) had a suicide rate in the year following a non-fatal overdose of 566 per 100,000 person-years. Post-overdose MOUD was associated with an adjusted hazard ratio of 0.20 (95%CI: 0.05,0.85). Risk of suicide was elevated for those whose initial overdoses required mechanical ventilation as part of the treatment (aHR: 1.86, 95%CI:[1.48,2.34]). CONCLUSIONS The year following a non-fatal opioid overdose is a very high-risk period for suicide among MDBs. Those receiving MOUD had an 80% reduction in the hazards of suicide, while those whose overdose treatment involved mechanical ventilation had 86% higher hazards of death by suicide. Our findings highlight the importance of psychiatric intervention in this high-risk population. Efforts are needed to initiate and retain more patients in MOUD.
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Affiliation(s)
- Molly A Nowels
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, 683 Hoes Lane West, Piscataway, NJ 08854, USA; Institute for Health, Health Care Policy, and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ 08901, USA.
| | - Paul R Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, 683 Hoes Lane West, Piscataway, NJ 08854, USA
| | - Stephen Crystal
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ 08901, USA
| | - Peter Treitler
- School of Social Work, Boston University, 264 Bay State Road, Boston, MA 02215, USA
| | - Jennifer Miles
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ 08901, USA
| | - Mark Olfson
- New York Psychiatric Institute, Columbia University, 1051 Riverside Drive, New York, NY 10032, USA
| | - Hillary Samples
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, 683 Hoes Lane West, Piscataway, NJ 08854, USA; Institute for Health, Health Care Policy, and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ 08901, USA
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DeSisto CL, Terplan M, Kacha-Ochana A, Green JL, Mueller T, Cox S, Ko JY. Buprenorphine use and setting type among reproductive-aged women self-reporting nonmedical prescription opioid use. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 155:209083. [PMID: 37245854 PMCID: PMC10676438 DOI: 10.1016/j.josat.2023.209083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 04/11/2023] [Accepted: 05/23/2023] [Indexed: 05/30/2023]
Abstract
INTRODUCTION Screening for opioid misuse and treatment for opioid use disorder are critical for reducing morbidity and mortality. We sought to understand the extent of self-reported past 30-day buprenorphine use in various settings among women of reproductive age with self-reported nonmedical prescription opioid use being assessed for substance use problems. METHODS The study collected data from individuals being assessed for substance use problems using the Addiction Severity Index-Multimedia Version in 2018-2020. We stratified the sample of 10,196 women ages 12-55 self-reporting past 30-day nonmedical prescription opioid use by buprenorphine use and setting type. We categorized setting types as: buprenorphine in specialty addiction treatment, buprenorphine in office-based opioid treatment, and diverted buprenorphine. We included each woman's first intake assessment during the study period. The study assessed number of buprenorphine products, reasons for using buprenorphine, and sources of buprenorphine procurement. The study calculated frequency of reasons for using buprenorphine to treat opioid use disorder outside of a doctor-managed treatment, overall and by race/ethnicity. RESULTS Overall, 25.5 % of the sample used buprenorphine in specialty addiction treatment, 6.1 % used buprenorphine prescribed in office-based treatment, 21.7 % used diverted buprenorphine, and 46.7 % reported no buprenorphine use during the past 30 days. Among women who reported using buprenorphine to treat opioid use disorder, but not as part of a doctor-managed treatment, 72.3 % could not find a provider or get into a treatment program, 21.8 % did not want to be part of a program or see a provider, and 6.0 % reported both; a higher proportion of American Indian/Alaska Native women (92.1 %) reported that they could not find a provider or get into a treatment program versus non-Hispanic White (78.0 %), non-Hispanic Black (76.0 %), and Hispanic (75.0 %) women. CONCLUSIONS Appropriate screening for nonmedical prescription opioid use to assess need for treatment with medication for opioid use disorder is important for all women of reproductive age. Our data highlight opportunities to improve treatment program accessibility and availability and support the need to increase equitable access for all women.
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Affiliation(s)
- Carla L DeSisto
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Chamblee, GA 30341, United States of America.
| | - Mishka Terplan
- Friends Research Institute, 1040 Park Ave, Baltimore, MD 21201, United States of America
| | - Akadia Kacha-Ochana
- Office of Strategy and Innovation, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Chamblee, GA 30341, United States of America
| | - Jody L Green
- Integrated Behavioral Health, Inflexxion, 2 Park Plaza, Suite 1200, Irvine, CA 92614, United States of America
| | - Trisha Mueller
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Chamblee, GA 30341, United States of America
| | - Shanna Cox
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Chamblee, GA 30341, United States of America
| | - Jean Y Ko
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Chamblee, GA 30341, United States of America
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Miller JC, Brooks MA, Wurzel KE, Cox EJ, Wurzel JF. A Guide to Expanding the Use of Buprenorphine Beyond Standard Initiations for Opioid Use Disorder. Drugs R D 2023; 23:339-362. [PMID: 37938531 PMCID: PMC10676346 DOI: 10.1007/s40268-023-00443-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 11/09/2023] Open
Abstract
Buprenorphine has become an important medication in the context of the ongoing opioid epidemic. However, complex pharmacologic properties and varying government regulations create barriers to its use. This narrative review is intended to facilitate buprenorphine use-including non-traditional initiation methods-by providers ranging from primary care providers to addiction specialists. This article briefly discusses the opioid epidemic and the diagnosis and treatment of opioid use disorder (OUD). We then describe the basic and complex pharmacologic properties of buprenorphine, linking these properties to their clinical implications. We guide readers through the process of initiating buprenorphine in patients using full agonist opioids. As there is no single recommended approach for buprenorphine initiation, we discuss the details, advantages, and disadvantages of the standard, low-dose, bridging-strategy, and naloxone-facilitated initiation techniques. We consider the pharmacology of, and evidence base for, buprenorphine in the treatment of pain, in both OUD and non-OUD patients. Throughout, we address the use of buprenorphine in children and adolescent patients, and we finish with considerations related to the settings of pregnancy and breastfeeding.
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Affiliation(s)
- James C Miller
- Psychiatry Residency Spokane, Providence Sacred Heart Medical Center and Children's Hospital, 101 W Eighth Ave, Spokane, WA, 99204, USA
| | - Michael A Brooks
- Psychiatry Residency Spokane, Providence Sacred Heart Medical Center and Children's Hospital, 101 W Eighth Ave, Spokane, WA, 99204, USA
| | - Kelly E Wurzel
- Psychiatry Residency Spokane, Providence Sacred Heart Medical Center and Children's Hospital, 101 W Eighth Ave, Spokane, WA, 99204, USA
| | - Emily J Cox
- Providence Research Network, Renton, WA, USA
| | - John F Wurzel
- Psychiatry Residency Spokane, Providence Sacred Heart Medical Center and Children's Hospital, 101 W Eighth Ave, Spokane, WA, 99204, USA.
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Seol A, Chan J, Micham B, Ye Y, Mariano ER, Harrison TK, Hunter OO. Acute pain service reduces barriers to buprenorphine/naloxone initiation by using regional anesthesia techniques. Reg Anesth Pain Med 2023; 48:425-427. [PMID: 36792313 DOI: 10.1136/rapm-2022-104317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 02/08/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Medications for opioid use disorder (MOUD) are a life-saving intervention; thus, it is important to address barriers to successful initiation. Spasticity affects many patients with spinal cord injury and can be painful and physically debilitating. Chronic painful conditions can lead to the illicit use of non-prescribed opioids, but fear of pain is a barrier to the initiation of MOUD. In this case report, we describe the novel use of botulinum toxin A injections to treat abdominal spasticity and facilitate Acute Pain Service-led buprenorphine/naloxone initiation in a patient with opioid use disorder and severe abdominal spasticity due to spinal cord injury. CASE PRESENTATION A patient with C4 incomplete tetraplegia and opioid use disorder complicated by abdominal spasticity refractory to oral antispasmodics and self-treating with intravenous heroin was referred to the Acute Pain Service for inpatient buprenorphine/naloxone initiation. The patient began to fail initiation of buprenorphine/naloxone secondary to increased pain from abdominal spasms. The patient was offered ultrasound-guided abdominal muscle chemodenervation with botulinum toxin A, which resulted in the resolution of abdominal spasticity and facilitated successful buprenorphine/naloxone initiation. At 6 months post-initiation, the patient remained abstinent from non-prescribed opioids and compliant with buprenorphine/naloxone 8 mg/2 mg three times a day. CONCLUSIONS This case report demonstrates that inpatient buprenorphine/naloxone initiation by an Acute Pain Service can improve the success of treatment by addressing barriers to initiation. Acute Pain Service clinicians possess unique skills and knowledge, including ultrasound-guided interventions, that enable them to provide innovative and personalized approaches to care in the complex opioid use disorder population.
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Affiliation(s)
- Alice Seol
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - John Chan
- Department of Physical Medicine and Rehabilitation, Stanford University School of Medicine, Stanford, California, USA
| | - Brittni Micham
- Department of Physical Medicine and Rehabilitation, Stanford University School of Medicine, Stanford, California, USA
- Physical Medicine and Rehabilitation Service, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Ying Ye
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - T Kyle Harrison
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Oluwatobi O Hunter
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
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Jones KF, O'Reilly Jacob M, Spetz J, Hailer L, Tierney M. Eliminate the buprenorphine DEA X waiver: Justification using a policy analysis approach. J Nurs Scholarsh 2023; 55:655-664. [PMID: 36624606 PMCID: PMC10159879 DOI: 10.1111/jnu.12871] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/28/2022] [Accepted: 12/21/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Drug overdoses have reached a historic milestone of over 100,000 deaths in a single year, 75,673 related to opioids. The acceleration in opioid-related deaths coupled with stark health inequities demands a close examination of opioid use disorder (OUD) treatment barriers and swift consideration of policy changes. DESIGN The aim of this buprenorphine policy analysis is to summarize existing buprenorphine barriers and present policy solutions to improve access and actualize the contributions of Advanced Practice Registered Nurses (APRNs). METHODS The policy analysis follows five sequential steps: (1) defining the problem, (2) identifying key stakeholders, (3) assessing the landscape of relevant policies, (4) describing viable policy options, and (5) making final recommendations. RESULTS Although there are laudable efforts to improve buprenorphine access, such as the new buprenorphine guidelines issued in April 2021, without larger-scale changes to federal, state, and scope of practice laws, overdose rates will continue to rise. We recommend a multipronged policy approach to improve buprenorphine treatment access, including eliminating the DEA X waiver, improving OUD education, and adopting full practice authority for APRNs in all states. CONCLUSION Incremental change is no longer sufficient to address opioid overdose deaths. Bolder and coordinated policy action is possible and necessary to empower the full clinical workforce to apply evidence-based life-saving treatments for OUD. The critical contributions of nurses in advancing equitable access to OUD care are emphasized in the National Academy of Medicine's Report, Future of Nursing: Charting a Path to Achieve Health Equity. Nurses are named as instrumental in improving buprenorphine access. Policy changes that acknowledge and build on evidence-based treatment expansion strategies are sorely needed. CLINICAL RELEVANCE One of the most robust tools to combat opioid overdose deaths is buprenorphine, a partial opioid agonist, and gold standard medication treatment for OUD, but only 5% of the prescribing workforce possess the required Drug Enforcement Agency (DEA) X waiver. A growing body of evidence demonstrates that Advanced Practice Registered Nurses are accelerating the growth in waiver update and buprenorphine use, despite the considerable barriers and limitations described in this policy analysis.
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Affiliation(s)
- Katie Fitzgerald Jones
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Mongan Institute for Aging and Serious Illness, Boston, Massachusetts, USA
- Boston College, William F. Connell School of Nursing, Chestnut Hill, Massachusetts, USA
| | - Monica O'Reilly Jacob
- Boston College, William F. Connell School of Nursing, Chestnut Hill, Massachusetts, USA
| | - Joanne Spetz
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | | | - Matthew Tierney
- Office of Population Health, UCSF Health, University of California San Francisco, San Francisco, California, USA
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Kline A, Williams JM, Steinberg ML, Mattern D, Chesin M, Borys S, Chaguturu V. Predictors of opioid overdose during the COVID-19 pandemic: The role of relapse, treatment access and nonprescribed buprenorphine/naloxone. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 149:209028. [PMID: 37003539 PMCID: PMC10063455 DOI: 10.1016/j.josat.2023.209028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 01/17/2023] [Accepted: 03/17/2023] [Indexed: 04/03/2023]
Abstract
INTRODUCTION Emerging data indicate a disproportionate increase in overdose deaths since the onset of COVID-19. Speculation about causes for the increase center on rising drug use, illicit drug supply changes, and reduced treatment access. Possible overdose mitigation factors include reduced federal MOUD prescribing restrictions, naloxone distribution programs, and increased use of telehealth. Similarly, nonprescribed buprenorphine (NPB) use, increasingly described as a harm reduction strategy in the absence of treatment, may have moderated overdose risk. This study explored factors associated with pandemic-related overdose in people who use opioids (PWUO) in New Jersey. METHODS We surveyed 342 PWUO from March to May 2021. Approximately 50 % of our sample was treated at some time since the COVID-19 emergency declaration in March 2020. The risk and protective factors associated with overdose were identified using Pearson's chi square test and ANOVA and tested in a series of multivariable logistic regression models for the full sample and the subsample of PWUO treated during the pandemic. RESULTS Forty-eight percent of respondents increased their drug use during the pandemic, including 32 % who relapsed after previous abstinence. Fifteen percent overdosed at least once since March 2020. In the full sample, overdose was associated with Hispanic ethnicity (AOR = 3.51; 95 % CI = 1.22-10.11), pre-pandemic overdose (AOR = 6.75; 95 % CI = 3.03-15.02), lack/loss of medical insurance (AOR = 3.02; 95 % CI = 1.01-9.02), relapse (AOR = 2.94; 95 % CI = 1.36-6.36), and nonprescribed use of buprenorphine/naloxone (AOR = 3.16; 95 % CI = 1.49-6.70). The study found similar trends in the treatment sample, with the exceptions that heroin/fentanyl use also predicted overdose (AOR = 3.43; 95 % CI = 1.20-9.78) and the association of overdose with nonprescribed buprenorphine/naloxone was stronger (AOR = 4.91; 95 % CI = 2.01-12.03). Potential mitigating factors, such as take-home methadone and telehealth, were not significant. CONCLUSIONS Relapse during the pandemic was widespread and a significant contributor to overdose. Lack/loss of medical insurance further exacerbated the risk. Despite the growing literature reporting "therapeutic" use of NPB, people using nonprescribed buprenorphine/naloxone in the current study experienced up to five times the risk of overdose as nonusers. This finding suggests that, despite therapeutic intent, PWUO may be using NPB in ways that are ineffectual for addiction management, especially in the context of changing buprenorphine induction protocols in the context of fentanyl.
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Affiliation(s)
- Anna Kline
- Rutgers-Robert Wood Johnson Medical School, Department of Psychiatry, 317 George Street, New Brunswick, NJ 08901, United States.
| | - Jill M Williams
- Rutgers-Robert Wood Johnson Medical School, Department of Psychiatry, 317 George Street, New Brunswick, NJ 08901, United States.
| | - Marc L Steinberg
- Rutgers-Robert Wood Johnson Medical School, Department of Psychiatry, 317 George Street, New Brunswick, NJ 08901, United States.
| | - Dina Mattern
- Rutgers-Robert Wood Johnson Medical School, Department of Psychiatry, 317 George Street, New Brunswick, NJ 08901, United States.
| | - Megan Chesin
- William Paterson University, 300 Pompton Road, Wayne, NJ 07470, United States
| | - Suzanne Borys
- New Jersey Department of Human Services, Division of Mental Health and Addiction Services, 222 S. Warren St., PO Box 700, Trenton, NJ 08625-0700, United States.
| | - Vamsee Chaguturu
- Rutgers-Robert Wood Johnson Medical School, Department of Psychiatry, 317 George Street, New Brunswick, NJ 08901, United States.
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Sher L. Can buprenorphine reduce suicide mortality? Acta Psychiatr Scand 2023; 147:3-5. [PMID: 36529968 DOI: 10.1111/acps.13510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/09/2022] [Accepted: 10/10/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Leo Sher
- Inpatient Psychiatry, James J. Peters VA Medical Center, Bronx, New York, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York, USA
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Osibanjo O, Reinhardt R, Clemans S, Andoniadis S, Carson P, Benkstein K. Collaborative approach to harm reduction by managed care pharmacy team for populations with substance use disorder. J Am Pharm Assoc (2003) 2023; 63:396-402. [PMID: 36564331 DOI: 10.1016/j.japh.2022.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 10/28/2022] [Accepted: 10/31/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Oregon has one of the highest rates of substance use and substance use disorders (SUDs) in the nation. To improve access to SUD treatment in Oregon, CareOregon clinical pharmacists in collaboration with the behavioral health team have implemented these best practices to support members with SUD. OBJECTIVE The primary objective of this article is to describe the various harm reduction programs and interventions implemented by managed care clinical pharmacists at CareOregon to prevent overdose and ensure improved health outcomes for populations with SUD. PRACTICE DESCRIPTION The CareOregon team of managed care clinical pharmacists acts as a liaison with provider networks by providing pharmacy benefit knowledge and implementing several interventions and best practices to improve health outcomes for populations with SUD. PRACTICE INNOVATION The managed care clinical pharmacist team implemented a medication education (MEDS Ed) program to provide educational support to the CareOregon provider network on harm reduction, supported medication for opioid use disorder (MOUD) program initiatives to increase buprenorphine prescribing, and used programs to increase naloxone access for populations at high risk of overdose. EVALUATION METHODS A mixed-method approach was applied to evaluate the impact of the practice innovations implemented. A qualitative self-assessment questionnaire was used to evaluate the impact of the harm reduction MEDS Ed. Quantitative data accessed via CareOregon's claims data were used to evaluate the effect of initiatives to expand naloxone access and increase buprenorphine prescribing. RESULTS The CareOregon provider network reported an increase in knowledge about harm reduction by attending the MEDS Ed training. From the first quarter of 2019 to the second quarter of 2022, the number of naloxone prescriptions filled increased by 346%. From the third quarter of 2017 to the first quarter of 2022, the number of Drug Addiction Treatment Act-waivered providers prescribing buprenorphine increased by 331%. As a result, the number of prescriptions for MOUD doubled during this period. CONCLUSION The harm reduction interventions implemented by the managed care clinical pharmacist team at CareOregon were successful in improving knowledge on harm reduction and increasing naloxone access and buprenorphine prescribing for populations at risk of opioid use disorder.
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Livingston NA, Davenport M, Head M, Henke R, LeBeau LS, Gibson TB, Banducci AN, Sarpong A, Jayanthi S, Roth C, Camacho-Cook J, Meng F, Hyde J, Mulvaney-Day N, White M, Chen DC, Stein MD, Weisberg R. The impact of COVID-19 and rapid policy exemptions expanding on access to medication for opioid use disorder (MOUD): A nationwide Veterans Health Administration cohort study. Drug Alcohol Depend 2022; 241:109678. [PMID: 36368167 PMCID: PMC9624112 DOI: 10.1016/j.drugalcdep.2022.109678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/16/2022] [Accepted: 10/25/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND In March 2020, Veterans Health Administration (VHA) enacted policies to expand treatment for Veterans with opioid use disorder (OUD) during COVID-19. In this study, we evaluate whether COVID-19 and subsequent OUD treatment policies impacted receipt of therapy/counseling and medication for OUD (MOUD). METHODS Using VHA's nationwide electronic health record data, we compared outcomes between a comparison cohort derived using data from prior to COVID-19 (October 2017-December 2019) and a pandemic-exposed cohort (January 2019-March 2021). Primary outcomes included receipt of therapy/counseling or any MOUD (any/none); secondary outcomes included the number of therapy/counseling sessions attended, and the average percentage of days covered (PDC) by, and months prescribed, each MOUD in a year. RESULTS Veterans were less likely to receive therapy/counseling over time, especially post-pandemic onset, and despite substantial increases in teletherapy. The likelihood of receiving buprenorphine, methadone, and naltrexone was reduced post-pandemic onset. PDC on MOUD generally decreased over time, especially methadone PDC post-pandemic onset, whereas buprenorphine PDC was less impacted during COVID-19. The number of months prescribed methadone and buprenorphine represented relative improvements compared to prior years. We observed important disparities across Veteran demographics. CONCLUSION Receipt of treatment was negatively impacted during the pandemic. However, there was some evidence that coverage on methadone and buprenorphine may have improved among some veterans who received them. These medication effects are consistent with expected COVID-19 treatment disruptions, while improvements regarding access to therapy/counseling via telehealth, as well as coverage on MOUD during the pandemic, are consistent with the aims of MOUD policy exemptions.
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Affiliation(s)
- Nicholas A. Livingston
- National Center for PTSD, Behavioral Sciences Division, VA Boston Healthcare System, Boston, MA, USA,US Department of Veterans Affairs, VA Boston Healthcare System, Boston, MA, USA,Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA,Correspondence to: National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Ave, Boston, MA 02130, USA
| | - Michael Davenport
- Data Science Core, Boston CSPCC, VA Boston Healthcare System, Boston, MA, USA
| | | | | | | | | | - Anne N. Banducci
- US Department of Veterans Affairs, VA Boston Healthcare System, Boston, MA, USA,Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA,National Center for PTSD, Women’s Health Sciences Division, VA Boston Healthcare System, Boston, MA, USA
| | | | | | - Clara Roth
- Boston VA Research Institute, Boston, MA, USA
| | | | - Frank Meng
- Data Science Core, Boston CSPCC, VA Boston Healthcare System, Boston, MA, USA,Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Justeen Hyde
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, US Department of Veterans Affairs, Bedford, MA, USA,General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Norah Mulvaney-Day
- Department of Psychiatry, Cambridge Health Alliance, Harvard Medical School, Cambridge, MA, USA
| | | | - Daniel C. Chen
- Data Science Core, Boston CSPCC, VA Boston Healthcare System, Boston, MA, USA,General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Michael D. Stein
- Health Law, Policy & Management, Boston University School of Public Health, MA, USA
| | - Risa Weisberg
- US Department of Veterans Affairs, VA Boston Healthcare System, Boston, MA, USA,Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA,Department of Family Medicine, Alpert Medical School of Brown University, Providence, RI, USA,BehaVR, Inc, Elizabethtown, KY, USA
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12
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Jack HE, Denisiuk ED, Collins BA, Stephens D, Blalock KL, Klein JW, Bhatraju EP, Merrill JO, Hallgren KA, Tsui JI. Peer providers and linkage with buprenorphine care after hospitalization: A retrospective cohort study. Subst Abus 2022; 43:1308-1316. [PMID: 35896006 PMCID: PMC9586121 DOI: 10.1080/08897077.2022.2095078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Background: People with opioid use disorder (OUD) are increasingly started on buprenorphine in the hospital, yet many patients do not attend outpatient buprenorphine care after discharge. Peer providers, people in recovery themselves, are a growing part of addiction care. We examine whether patients who received a low-intensity, peer-delivered intervention during hospitalization had a greater rate of linking with outpatient buprenorphine care relative to those not seen by a peer. Methods: This was a retrospective cohort study of adults with OUD who were started on buprenorphine during hospitalization. The primary outcome was receipt of a buprenorphine prescription within 30 days of discharge. Secondary outcomes included attendance at a follow-up visit with a buprenorphine provider within 30 days and hospital readmission within 90 days. Modified Poisson regression analyses tested for differences in the rate ratios (RR) of each binary outcome for patients who were versus were not seen by a peer provider. Peer notes in the electronic health record were reviewed to characterize peer activities. Results: 111 patients met the study inclusion criteria, 31.5% of whom saw a peer provider. 55.0% received a buprenorphine prescription within 30 days of hospital discharge. Patients with versus without peer provider encounters did not significantly differ in the rates of receiving a buprenorphine prescription (RR = 1.06, 95% CI: 0.74-1.51), hospital readmission (RR = 1.45, 95% CI: 0.80-2.64), or attendance at a buprenorphine follow-up visit (RR = 1.03, 95% CI: 0.68-1.57). Peers most often listened to or shared experiences with patients (68.6% of encounters) and helped facilitate medical care (60.0% of encounters). Conclusions: There were no differences in multiple measures of buprenorphine follow-up between patients who received this low-intensity peer intervention and those who did not. There is need to investigate what elements of peer provider programs contribute to patient outcomes and what outcomes should be assessed when evaluating peer programs.
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Affiliation(s)
- Helen E. Jack
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Eric D. Denisiuk
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Brett A. Collins
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Dan Stephens
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Kendra L. Blalock
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Jared W. Klein
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Elenore P. Bhatraju
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Joseph O. Merrill
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Kevin A. Hallgren
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Judith I. Tsui
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
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13
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Leyrer-Jackson JM, Acuña AM, Olive MF. Current and emerging pharmacotherapies for opioid dependence treatments in adults: a comprehensive update. Expert Opin Pharmacother 2022; 23:1819-1830. [PMID: 36278879 PMCID: PMC9764962 DOI: 10.1080/14656566.2022.2140039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 10/21/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Opioid use disorder (OUD) is characterized by compulsive opioid seeking and taking, intense drug craving, and intake of opioids despite negative consequences. The prevalence of OUDs has now reached an all-time high, in parallel with peak rates of fatal opioid-related overdoses, where 15 million individuals worldwide meet the criteria for OUD. Further, in 2020, 120,000 opioid-related deaths were reported worldwide with over 75,000 of those deaths occurring within the United States. AREAS COVERED In this review, we highlight pharmacotherapies utilized in patients with OUDs, including opioid replacement therapies, and opioid antagonists utilized for opioid overdoses and deterrent of opioid use. We also highlight newer treatments, such as those targeting the neuroimmune system, which are potential new directions for research given the recently established role of opioids in activating neuroinflammatory pathways, as well as over the counter remedies, including kratom, that may mitigate withdrawal. EXPERT OPINION To effectively treat OUDs, a deeper understanding of the current therapeutics being utilized, their additive effects, and the added involvement of the neuroimmune system are essential. Additionally, a complete understanding of opioid-induced neuronal alterations and therapeutics that target these abnormalities - including the neuroimmune system - is required to develop effective treatments for OUDs.
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Affiliation(s)
- Jonna M. Leyrer-Jackson
- Department of Medical Education, School of Medicine, Creighton University, Phoenix, AZ, 85012, USA
| | - Amanda M. Acuña
- Department of Psychology, Arizona State University, Tempe, AZ, 85257, USA
- Interdepartmental Graduate Program in Neuroscience, Arizona State University, Tempe, AZ, 85257, USA
| | - M. Foster Olive
- Department of Psychology, Arizona State University, Tempe, AZ, 85257, USA
- Interdepartmental Graduate Program in Neuroscience, Arizona State University, Tempe, AZ, 85257, USA
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14
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Frost MC, Richards JE, Blosnich JR, Hawkins EJ, Tsui JI, Edelman EJ, Williams EC. Association between clinically recognized suicidality and subsequent initiation or continuation of medications for opioid use disorder. Drug Alcohol Depend 2022; 237:109521. [PMID: 35716644 PMCID: PMC9546132 DOI: 10.1016/j.drugalcdep.2022.109521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/09/2022] [Accepted: 05/28/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Among individuals with opioid use disorder (OUD), medications for OUD (MOUD) may lower suicide risk. Therefore, it is important that individuals with OUD and suicidality receive MOUD. This study examined associations between clinically recognized suicidality and subsequent initiation or continuation of MOUD among patients with OUD in the national Veterans Health Administration (VA). METHODS Electronic health record data were extracted for outpatients with OUD who received VA care 10/1/2016-7/31/2017. Suicidality was measured using diagnostic codes for suicidal ideation/attempt and patient record flags. Analyses were conducted separately among patients without prior-year MOUD receipt to examine MOUD initiation, and with prior-year MOUD receipt to examine MOUD continuation. Poisson regression models estimated likelihood of MOUD receipt in the following year for patients with prior-year suicidality relative to those without. Models were adjusted for sociodemographic and clinical characteristics. RESULTS Among 20,085 patients with no prior-year MOUD, 12% had suicidality and 12% received MOUD in the following year. Suicidality was positively associated with MOUD initiation (adjusted incidence rate ratio [aIRR]: 1.15, 95% confidence interval [CI]: 1.04-1.28). Among 10,162 patients with prior-year MOUD, 9% had suicidality and 84% received MOUD in the following year. Suicidality was negatively associated with MOUD continuation (aIRR: 0.95, 95% CI 0.91-0.98). CONCLUSIONS Among VA patients with OUD, clinically recognized suicidality may increase likelihood of MOUD initiation but decrease likelihood of continuation. Efforts to increase initiation overall and to support retention for patients with suicidality are needed.
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Affiliation(s)
- Madeline C Frost
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, USA; Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195, USA.
| | - Julie E Richards
- Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195, USA; Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA 98101, USA.
| | - John R Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 669W 34th St, Los Angeles, CA 90089, USA; Health Services Research & Development (HSR&D) Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA 15240, USA.
| | - Eric J Hawkins
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, USA; Center of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, USA; Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, USA.
| | - Judith I Tsui
- Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, USA.
| | - E Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, New Haven, CT 06510, USA.
| | - Emily C Williams
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, USA; Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195, USA.
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15
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Buprenorphine precipitated opioid withdrawal: Prevention and management in the ED setting. Am J Emerg Med 2022; 58:22-26. [DOI: 10.1016/j.ajem.2022.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/05/2022] [Accepted: 05/07/2022] [Indexed: 01/19/2023] Open
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Pals H, Bratberg J. Improving Access to Care via Psychiatric Clinical Pharmacist Practitioner Collaborative Management of Buprenorphine for Opioid Use Disorder. J Am Pharm Assoc (2003) 2022; 62:1422-1429. [DOI: 10.1016/j.japh.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/12/2022] [Accepted: 03/04/2022] [Indexed: 11/26/2022]
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Britton PC, Crasta D, Bohnert KM, Kane C, Klein J, Pigeon WR. Shorter and longer-term risk for non-fatal suicide attempts among male U.S. military veterans after discharge from psychiatric hospitalization. J Psychiatr Res 2021; 143:9-15. [PMID: 34438203 DOI: 10.1016/j.jpsychires.2021.08.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/30/2021] [Accepted: 08/18/2021] [Indexed: 11/24/2022]
Abstract
Although there are key differences in shorter-term (days 1-90) and longer-term (days 91-365) risk factors for suicide after discharge from inpatient psychiatry, there are no comparable data on non-fatal suicide attempts. Risk factors for non-fatal attempts in the first 90 days after discharge were compared with those over the remainder of the year to identify temporal changes in risk. Records were extracted from 208,554 male veterans discharged from Veterans Health Administration acute psychiatric inpatient units from 2008 through 2013. Proportional hazard regression models identified correlates of non-fatal attempts for 1-90 days and 91-365 days; adjusted piecewise proportional hazards regression compared risk between these time frames. 5010 (2.4%) veterans made a non-fatal attempt, 1261 (0.60%) on days 1-90 and 3749 (1.78%) on days 91-365. Risk across both time frames was highest among younger veterans ages 18-59, and those hospitalized with a suicide attempt or suicidal ideation. It was lowest among those with a dementia diagnosis. Risk estimates were generally stable over time but increased among those with substance use disorders and decreased among those with sleep disturbance and discharged against medical advice. Estimates of some risk factors for non-fatal attempts change over time in the year after discharge and differ from those that change for suicide. Different preventive approaches may be needed to reduce shorter and longer-term risk for non-fatal attempts and suicide in the year after discharge.
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Affiliation(s)
- Peter C Britton
- VISN 2 Center of Excellence for Suicide Prevention, Department of Veteran Affairs, Finger Lakes Healthcare System, Canandaigua, NY, USA; Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Dev Crasta
- VISN 2 Center of Excellence for Suicide Prevention, Department of Veteran Affairs, Finger Lakes Healthcare System, Canandaigua, NY, USA; Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Kipling M Bohnert
- Department of Public Health, Michigan State University, Lansing, MI, USA; Department of Veteran Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Cathleen Kane
- VISN 2 Center of Excellence for Suicide Prevention, Department of Veteran Affairs, Finger Lakes Healthcare System, Canandaigua, NY, USA
| | - John Klein
- VISN 2 Center of Excellence for Suicide Prevention, Department of Veteran Affairs, Finger Lakes Healthcare System, Canandaigua, NY, USA
| | - Wilfred R Pigeon
- VISN 2 Center of Excellence for Suicide Prevention, Department of Veteran Affairs, Finger Lakes Healthcare System, Canandaigua, NY, USA; Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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