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Schwab SD, Singh M. How power shapes behavior: Evidence from physicians. Science 2024; 384:802-808. [PMID: 38753782 DOI: 10.1126/science.adl3835] [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: 10/15/2023] [Accepted: 03/22/2024] [Indexed: 05/18/2024]
Abstract
Power-the asymmetric control of valued resources-affects most human interactions. Although power is challenging to study with real-world data, a distinctive dataset allowed us to do so within the critical context of doctor-patient relationships. Using 1.5 million quasi-random assignments in US military emergency departments, we examined how power differentials between doctor and patient (measured by using differences in military ranks) affect physician behavior. Our findings indicate that power confers nontrivial advantages: "High-power" patients (who outrank their physician) receive more resources and have better outcomes than equivalently ranked "low-power" patients. Patient promotions even increase physician effort. Furthermore, low-power patients suffer if their physician concurrently cares for a high-power patient. Doctor-patient concordance on race and sex also matters. Overall, power-driven variation in behavior can harm the most vulnerable populations in health care settings.
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Affiliation(s)
- Stephen D Schwab
- Department of Management, University of Texas at San Antonio, San Antonio, TX, USA
| | - Manasvini Singh
- Department of Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, PA, USA
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Kelber MS, Smolenski DJ, Belsher BE, O'Gallagher K, Issa F, Stewart LT, Evatt DP. The associations of opioid and benzodiazepine prescriptions with injuries among US military service members. Pain 2024:00006396-990000000-00586. [PMID: 38709494 DOI: 10.1097/j.pain.0000000000003264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/18/2024] [Indexed: 05/07/2024]
Abstract
ABSTRACT Given the high rates of physical trauma and pain among service members, opioid-prescribing practices and use patterns have significant implications for the well-being of service members and can affect military medicine and personnel readiness. This study measured the association between prescribed opioid and benzodiazepine medications and subsequently reported injuries (accidental, alcohol and drug related, self-inflicted, and violence related) among active duty military members. Participants were service members who entered the military between January 1, 2005, and June 30, 2010. In a nested case-control design, we compared individuals with injuries to individuals without injuries with respect to their opioid and benzodiazepine prescriptions in the 30 days before the injury of an index case. We used a multiintercept, logistic regression model to compare coefficient estimates by injury type. Overall, approximately 17% of individuals with an injury and 4% of individuals without an injury had a recorded opioid prescription. Individuals with an injury of any type had greater odds of prior exposure to opioid prescriptions than controls. Although a dose-response effect was observed for all injury types, it reached a plateau sooner for natural or environmental accidents and self-inflicted injuries relative to alcohol-related and drug-related injuries, violence-related injuries, vehicle accidents, accidental falls, and other accidents. Benzodiazepine prescriptions were found in 3.5% of individuals with an injury and 0.5% of individuals without an injury. The association between benzodiazepine prescriptions and injuries was strongest for natural and environmental accidents.
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Affiliation(s)
- Marija S Kelber
- Psychological Health Center of Excellence, Defense Health Agency
| | | | - Bradley E Belsher
- Psychological Health Center of Excellence, Defense Health Agency
- Carl T Hayden Veterans Medical Center, Phoenix VA Health Care System
| | | | - Fuad Issa
- Psychological Health Center of Excellence, Defense Health Agency
| | | | - Daniel P Evatt
- Psychological Health Center of Excellence, Defense Health Agency
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Leggett CG, Schmidt RO, Skinner J, Lurie JD, Luan WP. Public versus Private Care in the Military Health System: Evidence From Low Back Pain Patients. Mil Med 2024:usae074. [PMID: 38491995 DOI: 10.1093/milmed/usae074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/16/2024] [Accepted: 02/19/2024] [Indexed: 03/18/2024] Open
Abstract
INTRODUCTION There is a longstanding debate about whether health care is more efficiently provided by the public or private sector. The debate is particularly relevant to the Military Health System (MHS), which delivers care through a combination of publicly funded federal facilities and privately contracted providers. This study compares outcomes, treatments, and costs for MHS patients obtaining care for low back pain (LBP) from public versus private providers. MATERIALS AND METHODS A retrospective cohort study was completed using TRICARE Prime claims data from April 2015 to December 2018. The cohort was identified using International Classification of Diseases Ninth Revision and Tenth Revision diagnostic codes and then followed for 12 months after the index diagnosis to assess treatments, outcomes, and costs. Claims were classified as originating from either public or private providers. The primary outcome measure was resolution of LBP, defined as an absence of LBP diagnoses during the 6-to-12-month window following the index event. Instrumental variable models were used to assess the impact of care setting (i.e., private versus public), conditioning on the covariates. A regional measure of the fraction of private care was used as an instrument. RESULTS Resolution of LBP was achieved for 79.7% of 144,866 patients in the cohort. No significant association was found between resolution of LBP and fraction of privately provided care. Higher fraction of private care was associated with a greater likelihood of opioid treatments (odds ratio, 1.22; 95% CI, 1.02-1.46) and a lower likelihood of benzodiazepine (odds ratio, 0.56; 95% CI, 0.45-0.70) and physical therapy (odds ratio 0.55; 95% CI, 0.42-0.74) treatments; manual therapy was not significantly associated with the fraction of private care. There was a significant negative association between the fraction of private care and cost (coefficient -0.27; 95% CI, -0.44, -0.10). CONCLUSION This study found that privately provided care was associated with significantly higher opioid prescribing, less use of benzodiazepines and physical therapy, and lower costs. No systematic differences in outcomes (as measured by resolved cases) were identified. The findings suggest that publicly funded health care within the MHS context can attain quality comparable to privately provided care, although differences in treatment choices and costs point to possibilities for improved care within both systems.
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Affiliation(s)
- Christopher G Leggett
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
| | - Rachel O Schmidt
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
| | - Jonathan Skinner
- Department of Economics, Dartmouth College, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, and the National Bureau of Economic Research, Hanover, NH 03755, USA
| | - Jon D Lurie
- Geisel School of Medicine, Dartmouth Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA
| | - William Patrick Luan
- Cost Analysis and Research Division, Institute for Defense Analyses, Alexandria, VA 22305-3086, USA
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Dufour S, Banaag A, Schoenfeld AJ, Adams RS, Koehlmoos TP, Gray JC. Diagnostic profiles associated with long-term opioid therapy in active duty servicemembers. PM R 2024; 16:14-24. [PMID: 37162022 PMCID: PMC10786620 DOI: 10.1002/pmrj.12994] [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: 12/23/2022] [Revised: 03/20/2023] [Accepted: 04/26/2023] [Indexed: 05/11/2023]
Abstract
INTRODUCTION Over-prescription of opioids has diminished in recent years; however, certain populations remain at high risk. There is a dearth of research evaluating prescription rates using specific multimorbidity patterns. OBJECTIVE To identify distinct clinical profiles associated with opioid prescription and evaluate their relative odds of receiving long-term opioid therapy. DESIGN Retrospective analysis of the complete military electronic health record. We assessed demographics and 26 physiological, psychological, and pain conditions present during initial opioid prescription. Latent class analysis (LCA) identified unique clinical profiles using diagnostic data. Logistic regression measured the odds of these classes receiving long-term opioid therapy. SETTING All electronic health data under the TRICARE network. PARTICIPANTS All servicemembers on active duty during fiscal years 2016 through 2019 who filled at least one opioid prescription. MAIN OUTCOME MEASURES Number and qualitative characteristics of LCA classes; odds ratios (ORs) from logistic regression. We hypothesized that LCA classes characterized by high-risk contraindications would have significantly higher odds of long-term opioid therapy. RESULTS A total of N = 714,446 active duty servicemembers were prescribed an opioid during the study window, with 12,940 (1.8%) receiving long-term opioid therapy. LCA identified five classes: Relatively Healthy (82%); Musculoskeletal Acute Pain and Substance Use Disorders (6%); High Pain, Low Mental Health Burden (9%); Low Pain, High Mental Health Burden (2%), and Multisystem Multimorbid (1%). Logistic regression found that, compared to the Relatively Healthy reference, the Multisystem Multimorbid class, characterized by multiple opioid contraindications, had the highest odds of receiving long-term opioid therapy (OR = 9.24; p < .001; 95% confidence interval [CI]: 8.56, 9.98). CONCLUSION Analyses demonstrated that classes with greater multimorbidity at the time of prescription, particularly co-occurring psychiatric and pain disorders, had higher likelihood of long-term opioid therapy. Overall, this study helps identify patients most at risk for long-term opioid therapy and has implications for health care policy and patient care.
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Affiliation(s)
- Steven Dufour
- Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD
- Naval Medical Center Portsmouth, Portsmouth, VA
| | - Amanda Banaag
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD
| | - Andrew J. Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Rachel Sayko Adams
- Boston University School of Public Health, Department of Health Law, Policy and Management, Boston, MA
- Veterans Health Administration, Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, CO
| | - Tracey Perez Koehlmoos
- Center for Health Services Research, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Joshua C. Gray
- Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD
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Singh S, Sri Krishna V, Cherian Ambooken G, Peter DK. Nalbuphine: an underrecognized battlefield analgesic and its utilization in combat care and peripheral areas. Med J Armed Forces India 2024; 80:41-45. [PMID: 38239600 PMCID: PMC10793233 DOI: 10.1016/j.mjafi.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/04/2023] [Indexed: 01/22/2024] Open
Abstract
Battlefield injuries result in acute and severe uncontrolled pain, which can be reduced with the early use of analgesia. Apart from pain, battlefield injuries may also cause significant morbidity and a prolonged period of absence from active duty. Traditionally available opioids are known to cause various undesirable side effects such as respiratory depression that may worsen the condition of an already injured combatant. Nalbuphine is an opioid agonist-antagonist and has been increasingly used for postoperative analgesia over the last decade. In India, it is the only opioid analgesic that does not come under the Controlled Substances Act at the time of this publication. In today's world, where nalbuphine is being recommended for acute pain worldwide, its use in the Indian combat scenario needs to be conceptualized at the medical officer level (primary caregiver). This conceptualization will be discussed in detail in this review article.
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Affiliation(s)
- Shalendra Singh
- Senior Advisor (Anaesthesia & Neuro Anaesthesia), Command Hospital (Northern Command), Udhampur, India
| | | | | | - Deepu K. Peter
- Graded Specialist (Respiratory Medicine), Command Hospital (Northern Command), Udhampur, India
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Hurtado SL, Simon-Arndt CM, Belding JN, Sanchez SS, Spevak C, Osik A. Evaluation of Two Educational Modalities for the Clinical Practice Guideline for Opioid Therapy for Chronic Pain for US Military Physicians. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2023; 43:241-246. [PMID: 36728977 PMCID: PMC10664779 DOI: 10.1097/ceh.0000000000000476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/30/2022] [Indexed: 06/18/2023]
Abstract
INTRODUCTION The Department of Veterans Affairs and Department of Defense Clinical Practice Guideline (CPG) for the Management of Opioid Therapy for Chronic Pain was updated in 2017 with targeted guidance to provide safe opioid use while mitigating the increasing levels of prescription opioid misuse among military personnel. The objective of this study was to determine the effectiveness of two educational training modalities for the CPG (an online training [OLT] module and a mobile app) on provider's knowledge, practices, and comfort with the CPG. The OLT was a self-paced interactive slide-based module that emphasized practical application, and the app provided information on the revised CPG and provider and patient resources. METHODS Active duty providers (N = 56) were randomly assigned to one of four groups (OLT only, app only, OLT and app combined, or neither OLT nor the app), and they completed a pre-test and an 8-week post-test. RESULTS Compared with those who received neither intervention, providers who received OLT only or the app only showed significant increases in knowledge over time. The combination of both OLT and app did not seem to significantly increase knowledge above either the OLT or the app alone. Neither the OLT, the app, nor their combination significantly increased either practices or comfort over time. DISCUSSION These results show that use of these educational tools, individually, was associated with an increase in provider knowledge, suggesting that these tools constitute a valuable addition to the available resources to optimize CPG implementation.
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Affiliation(s)
- Suzanne L. Hurtado
- Hurtado: Research Behavioral Health Scientist, Naval Health Research Center, San Diego, CA. Simon-Arndt: Senior Behavioral Health Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Belding: Behavioral Health Researcher, Naval Health Research Center, Leidos, Inc, San Diego, CA. Sanchez: Research Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Spevak: Director Pain Management Fellowship, Director Opioid Safety Program, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD. Osik: Senior Program Manager, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD
| | - Cynthia M. Simon-Arndt
- Hurtado: Research Behavioral Health Scientist, Naval Health Research Center, San Diego, CA. Simon-Arndt: Senior Behavioral Health Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Belding: Behavioral Health Researcher, Naval Health Research Center, Leidos, Inc, San Diego, CA. Sanchez: Research Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Spevak: Director Pain Management Fellowship, Director Opioid Safety Program, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD. Osik: Senior Program Manager, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD
| | - Jennifer N. Belding
- Hurtado: Research Behavioral Health Scientist, Naval Health Research Center, San Diego, CA. Simon-Arndt: Senior Behavioral Health Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Belding: Behavioral Health Researcher, Naval Health Research Center, Leidos, Inc, San Diego, CA. Sanchez: Research Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Spevak: Director Pain Management Fellowship, Director Opioid Safety Program, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD. Osik: Senior Program Manager, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD
| | - Sandra S. Sanchez
- Hurtado: Research Behavioral Health Scientist, Naval Health Research Center, San Diego, CA. Simon-Arndt: Senior Behavioral Health Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Belding: Behavioral Health Researcher, Naval Health Research Center, Leidos, Inc, San Diego, CA. Sanchez: Research Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Spevak: Director Pain Management Fellowship, Director Opioid Safety Program, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD. Osik: Senior Program Manager, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD
| | - Christopher Spevak
- Hurtado: Research Behavioral Health Scientist, Naval Health Research Center, San Diego, CA. Simon-Arndt: Senior Behavioral Health Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Belding: Behavioral Health Researcher, Naval Health Research Center, Leidos, Inc, San Diego, CA. Sanchez: Research Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Spevak: Director Pain Management Fellowship, Director Opioid Safety Program, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD. Osik: Senior Program Manager, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD
| | - Amy Osik
- Hurtado: Research Behavioral Health Scientist, Naval Health Research Center, San Diego, CA. Simon-Arndt: Senior Behavioral Health Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Belding: Behavioral Health Researcher, Naval Health Research Center, Leidos, Inc, San Diego, CA. Sanchez: Research Scientist, Naval Health Research Center, Leidos, Inc, San Diego, CA. Dr. Spevak: Director Pain Management Fellowship, Director Opioid Safety Program, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD. Osik: Senior Program Manager, National Capital Region Pain Initiative, Walter Reed National Military Medical Center, Bethesda, MD
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Moore BA, Vincent SR, Schlenk MA, McNamara CL. Opioid use disorder in the active service: Implications for intervention. Am J Addict 2023; 32:415-418. [PMID: 36960793 DOI: 10.1111/ajad.13415] [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: 12/21/2022] [Revised: 02/22/2023] [Accepted: 03/22/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Military service members experience occupational-specific injuries that may result in chronic pain and comorbid behavioral health concerns. METHODS Data from the Defense Medical Epidemiology Database was used to examine opioid use disorder (OUD) diagnoses between 2016 and 2021. Statistical analysis calculated incidence rates and diagnostic variability by demographic density. RESULTS The average incidence rate of OUD was 6.1 (per 10,000) and declined by 34% between 2016 and 2021. Diagnoses were most frequently made in service members classified as male, married, white, aged 30-39, junior enlisted, and serving in the Army. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE To our knowledge, this is the first study to examine the incidence rates of OUD among active duty personnel.
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Affiliation(s)
- Brian A Moore
- Department of Psychological Science, Kennesaw State University, Kennesaw, Georgia, USA
- Center for the Advancement of Military and Emergency Services (AMES) Research, Kennesaw, Georgia, USA
| | - Sophie R Vincent
- Center for the Advancement of Military and Emergency Services (AMES) Research, Kennesaw, Georgia, USA
- Department of Molecular and Cellular Biology, Kennesaw State University, Kennesaw, Georgia, USA
| | - Michael A Schlenk
- Center for the Advancement of Military and Emergency Services (AMES) Research, Kennesaw, Georgia, USA
| | - Corinne L McNamara
- Department of Psychological Science, Kennesaw State University, Kennesaw, Georgia, USA
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Walk CT, Nowak R, Parikh PP, Crawford TN, Woods RJ. Perception versus Reality: A Review of Narcotic Prescribing Habits After Common Laparoscopic Surgeries. J Surg Res 2023; 283:188-193. [PMID: 36410235 DOI: 10.1016/j.jss.2022.10.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 10/10/2022] [Accepted: 10/18/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Data on how surgeons perceive their habits of prescribing narcotics compared to their actual practice are scarce. This study examines the perception and actual narcotic prescribing habits of surgeons and advanced practitioners. METHODS Surgical residents, attendings, and advanced practice providers (APPs) were surveyed to assess their perceived prescribing habits at discharge for laparoscopic appendectomy and laparoscopic cholecystectomy. Data on narcotics prescription for patients receiving either of the procedures from January 2017 to August 2020 were extracted from electronic health records. Prescribed narcotics were converted to morphine equivalent doses (MEQs) for comparison. RESULTS Of the 52 participants, the majority were residents (57.7%). Approximately 90% of residents, 72% of attendings, and 18% of APPs reported regularly prescribing narcotics at discharge. Approximately 67% (889/1332) of patients were discharged with narcotics. Of those, the majority of patients' narcotics were prescribed by surgery residents (71.2%). However, 72% of residents, 80% of attendings, and 72% of APPs were confident on prescribing the correct regimen of narcotics. There were no differences in average daily MEQs among the groups. However, the number of narcotics prescribed was higher among APPs compared to that in the other groups (P < 0.0001). CONCLUSIONS Most participants self-reported routinely prescribing narcotics at discharge. Although not the current recommendation, participants felt confident they were prescribing the correct regimen, but were observed to prescribe more than the recommended number of total narcotics which indicates a discrepancy between perception and actual habits of prescribing narcotics. Our findings suggest a need for education in the general surgery residency and continuing medical education setting.
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Affiliation(s)
- Casey T Walk
- Department of Surgery, Wright State University Boonshoft SOM, Dayton, Ohio.
| | - Rebecca Nowak
- Wright State University Boonshoft School of Medicine, Fairborn, Ohio
| | - Priti P Parikh
- Department of Surgery, Wright State University Boonshoft SOM, Dayton, Ohio
| | | | - Randy J Woods
- Department of Surgery, Wright State University Boonshoft SOM, Dayton, Ohio
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Alcover KC, Poltavskiy EA, Howard JT, Watrous JR, Janak JC, Walker LE, Stewart IJ. Post-Combat-Injury Opioid Prescription and Alcohol Use Disorder in the Military. Am J Prev Med 2022; 63:904-914. [PMID: 36127194 DOI: 10.1016/j.amepre.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/29/2022] [Accepted: 07/14/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Previous studies have identified combat exposure and combat traumatic experience as problematic drinking risk factors. Increasing evidence suggests that opioid use increases the risk of alcohol use disorder. This study investigated the association between opioid prescription use after injury and (1) alcohol use disorder and (2) severity of alcohol use disorder among deployed military servicemembers. METHODS Deidentified health records data of 9,029 deployed servicemembers from a retrospective cohort study were analyzed. Data were randomly selected from the Department of Defense Trauma Registry and included servicemembers with combat injuries during deployment in Iraq or Afghanistan (2002-2016). Pharmacy records and International Classification of Diseases, Ninth and Tenth Revision diagnosis codes were used. Three groups were identified (no opioid prescription use, nonpersistent opioid prescription use, and persistent opioid prescription use) and were compared on the basis of alcohol use disorder risk using Cox proportional hazard models. Data analyses were performed in 2021. RESULTS Of the 9,029 servicemembers with combat injury, 2,262 developed alcohol use disorder (1,322 developed severe alcohol use disorder). Compared with no opioid prescription use, increased alcohol use disorder risk was associated with persistent opioid prescription use, with a hazard ratio of 1.13 (95% CI=1.02, 1.26). After covariate adjustment, increased risk remained statistically significant (hazards ratio=1.24; 95% CI=1.10, 1.39). There was no significant difference in alcohol use disorder risk between no opioid prescription use and nonpersistent opioid prescription use. The risk of severe alcohol use disorder did not vary by opioid use among servicemembers with alcohol use disorder diagnosis. CONCLUSIONS The findings of the study suggest that the incidence of alcohol use disorder was higher among injured servicemembers with persistent opioid prescription use than among those without opioid use. If replicated in prospective studies, the findings highlight the need for clinicians to consider the current and history of alcohol use of patients in initiating treatment involving opioids.
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Affiliation(s)
- Karl C Alcover
- Department of Medicine, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences (USUHS), Bethesda, Maryland.
| | - Eduard A Poltavskiy
- Clinical Investigation Facility, David Grant U.S. Air Force Medical Center, Travis AFB, Fairfield, California
| | - Jeffrey T Howard
- Department of Public Health, The University of Texas San Antonio, San Antonio, Texas
| | - Jessica R Watrous
- Department of Medicine, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences (USUHS), Bethesda, Maryland
| | | | - Lauren E Walker
- Department of Medicine, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences (USUHS), Bethesda, Maryland; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - Ian J Stewart
- Department of Medicine, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences (USUHS), Bethesda, Maryland
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Atkins D, Bohnert ASB. The Work-Opioid Connection: What Do Construction Workers and Military Veterans Have in Common? Am J Public Health 2022; 112:S33-S35. [PMID: 35143275 PMCID: PMC8842203 DOI: 10.2105/ajph.2021.306663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2021] [Indexed: 02/03/2023]
Affiliation(s)
- David Atkins
- David Atkins is with the Office of Research and Development, Department of Veterans Affairs, Washington, DC. Amy S. B. Bohnert is with the VA Center for Clinical Management Research, Ann Arbor, MI, and the Departments of Anesthesiology, Psychiatry, and Epidemiology, University of Michigan, Ann Arbor. Note. The opinions expressed in this editorial are those of the authors alone and do not reflect official policy of the Department of Veterans Affairs or any federal agency
| | - Amy S B Bohnert
- David Atkins is with the Office of Research and Development, Department of Veterans Affairs, Washington, DC. Amy S. B. Bohnert is with the VA Center for Clinical Management Research, Ann Arbor, MI, and the Departments of Anesthesiology, Psychiatry, and Epidemiology, University of Michigan, Ann Arbor. Note. The opinions expressed in this editorial are those of the authors alone and do not reflect official policy of the Department of Veterans Affairs or any federal agency
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Kim SY, Buckenmaier CC, Howe EG, Choi KH. The Newest Battlefield Opioid, Sublingual Sufentanil: A Proposal to Refine Opioid Usage in the U.S. Military. Mil Med 2021; 187:77-83. [PMID: 34586416 DOI: 10.1093/milmed/usab395] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/02/2021] [Accepted: 09/13/2021] [Indexed: 12/20/2022] Open
Abstract
There is an ongoing opioid epidemic in the USA, and the U.S. military is not immune to the health threat. To combat the epidemic, the Department of Defense (DoD) and Department of Veterans' Affairs (DVA) issued new clinical practice guidelines and launched the Opioid Safety Initiative aimed at reducing opioid prescriptions. Furthermore, the DoD continually refined opioid protocols for acute pain on the battlefield, evolving from intramuscular morphine to intravenous morphine administration to oral transmucosal fentanyl citrate lollipops (Actiq) to finally sublingual sufentanil tablets (SSTs, Dsuvia). Interestingly, the newest introduction of SSTs into the military sparked great controversy, as there are concerns over the drug's potential for misuse. However, although the opioid crisis may understandably foster an aversion to new candidate opioids, the therapeutic benefits of effective opioids in acute trauma settings should not be overlooked. SSTs may offer an improved analgesic option to meet the battlefield's unmet needs with its non-invasive, sublingual delivery system and favorable pharmacologic properties that mitigate the risk for side effects, addiction, and adverse outcomes. Accordingly, this commentary aims to (1) review the evolution of opioid use on the battlefield and discuss the medical benefits and limitations of SSTs in acute trauma settings, (2) highlight the importance of chronic pain management post-deployment through evidence-based non-opioid modalities, and (3) explore avenues of future research. Ultimately, we propose that SSTs are an important improvement from existing battlefield opioids and that refining, not abandoning, opioid usage will be key to effectively managing pain in the military.
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Affiliation(s)
- Sharon Y Kim
- School of Medicine, Uniformed Services University, Bethesda, MD 20814, USA.,Program in Neuroscience, Uniformed Services University, Bethesda, MA 20814, USA
| | - Chester C Buckenmaier
- School of Medicine, Uniformed Services University, Bethesda, MD 20814, USA.,Department of Anesthesiology, Uniformed Services University, Bethesda, MA 20814, USA
| | - Edmund G Howe
- School of Medicine, Uniformed Services University, Bethesda, MD 20814, USA.,Department of Psychiatry, Uniformed Services University, Bethesda, MA 20814, USA.,Center for the Study of Traumatic Stress, Uniformed Services University, Bethesda, MA 20814, USA
| | - Kwang H Choi
- School of Medicine, Uniformed Services University, Bethesda, MD 20814, USA.,Program in Neuroscience, Uniformed Services University, Bethesda, MA 20814, USA.,Department of Psychiatry, Uniformed Services University, Bethesda, MA 20814, USA.,Center for the Study of Traumatic Stress, Uniformed Services University, Bethesda, MA 20814, USA
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Teyhen DS, Capaldi VF, Drummond SPA, Rhon DI, Barrett AS, Silvernail JL, Boland DM. How sleep can help maximize human potential: The role of leaders. J Sci Med Sport 2021; 24:988-994. [PMID: 34481741 DOI: 10.1016/j.jsams.2021.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 03/23/2021] [Accepted: 08/11/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE During multi-domain operations (MDO), soldiers need the physical supremacy, cognitive dominance, and emotional resilience to help defend and win our nation's wars. Optimal sleep has been shown to boost physical performance and cognitive processing. This manuscript will discuss how recent advances in sleep science strongly argue for the integration of sleep planning into military operations. DESIGN Review article. METHODS We reviewed the current understanding of how sleep affects Soldier readiness, how sleep and pain are interrelated, and unique challenges to obtaining adequate sleep in military training environments. We then address solutions that can be implemented by leaders and individuals to manage warfighter fatigue and optimize unit performance. RESULTS Since sleep is foundational to soldier health and readiness, improving warfighter fatigue management is a priority for leaders. CONCLUSION To succeed in MDO, military personnel require physical supremacy, cognitive dominance, and emotional resilience to fight and win. Sleep science is a rapidly emerging field, and the clear implications for maximizing human performance argue strongly for more deliberate integration into military training and operations. Leaders that incorporate sleep and fatigue management into the planning and execution phases of operations will help facilitate mission priorities and prove a powerful force multiplier.
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Affiliation(s)
| | | | - Sean P A Drummond
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Australia
| | | | - Amelia S Barrett
- Consortium for Health and Military Performance, Department of Military and Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, USA
| | | | - David M Boland
- Army-Baylor University Doctoral Program in Physical Therapy, USA
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13
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Albright DL, McDaniel JT, Suntai Z, Laha-Walsh MK, Frick K, Weatherly T, McIntosh S. Medication-assisted treatment and self-help group participation among military veterans with opioid or alcohol use disorder. BMJ Mil Health 2021; 169:256-262. [PMID: 34253642 DOI: 10.1136/bmjmilitary-2021-001845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/29/2021] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Medication-assisted treatment (MAT) is a combination of behavioural therapy and medications to assist with recovery and has been administered to individuals with alcohol and opioid withdrawal symptoms. Military veterans seeking MAT could have barriers preventing them from receiving the care they desire. The present study sought to compare outcomes in individuals who received MAT or those who participated in self-help groups for opioid or alcohol use disorder. In addition, the present study sought to compare outcomes between veterans and non-military-connected individuals. METHODS We used the 2015-2017 United States Treatment Episode Data Set Discharges data from the Substance Abuse and Mental Health Services Administration. The data set included 138 594 unique discharges. A multinomial logistic regression model was used to examine differences in substance use outcomes for veterans/non-veterans in MAT and a self-help group. RESULTS Fewer veterans (2.58%) than non-veterans (4.28%) reported usage of MAT. Fewer veterans (38.94%) than non-veterans (40.17%) reported signing up for a self-help group. Finally, those who participated in MAT and a self-help group had a better outcome (66.64%)-defined as no substance use at discharge-than those who only received MAT (43.02%) and those who did not participate in MAT or self-help groups (34.84%). CONCLUSIONS Recommendations for future research on MAT and implementation for the veteran population would benefit the literature base.
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Affiliation(s)
- David L Albright
- School of Social Work, The University of Alabama, Tuscaloosa, Alabama, USA
| | - J T McDaniel
- School of Human Sciences, Southern Illinois University Carbondale, Carbondale, Illinois, USA
| | - Z Suntai
- School of Social Work, The University of Alabama, Tuscaloosa, Alabama, USA
| | - M K Laha-Walsh
- School of Social Work, The University of Alabama, Tuscaloosa, Alabama, USA
| | - K Frick
- Southern Illinois University System, Carbondale, Illinois, USA
| | - T Weatherly
- Southern Illinois University System, Carbondale, Illinois, USA
| | - S McIntosh
- School of Social Work, The University of Alabama, Tuscaloosa, Alabama, USA
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14
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Jaskiewicz JL, Garry CB, Ernst AJ, Cole JH, Allen ML, Fox CC, Gendron RT, Gentry SL, Hughey SB, Stedje-Larsen ET. Impact of a Multidisciplinary Long-Term Opioid Therapy Safety Program at a Military Tertiary Academic Medical Center. Mil Med 2021; 187:22-27. [PMID: 34179995 DOI: 10.1093/milmed/usab255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/04/2021] [Accepted: 06/16/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE In light of the ongoing opioid crisis, Naval Medical Center Portsmouth (NMCP) created the Long-Term Opioid Therapy Safety (LOTS) program to reduce risks and improve long-term opioid therapy outcomes. Our primary outcome was change in compliance with the recommended safety metrics. DESIGN This is a retrospective cohort study performed at NMCP, a large military academic medical center providing comprehensive medical care to DoD beneficiaries. The NMCP LOTS program provides both patient and provider narcotic education as well as medical record auditing. The NMCP LOTS program promotes adherence to published CDC, the DVA, and DoD guidelines. METHODS Anonymized data were compiled each fiscal quarter and were analyzed retrospectively. Adult patients prescribed opioids for at least 90 days without a gap of 30 days between prescriptions were included in this study. The investigators recorded and reported provider compliance with LOTS metrics over the same period. RESULTS Compliance with the recommended safety metrics improved. We noted a decrease in the number of long-term opioid patients, concurrent benzodiazepine prescriptions, and patients prescribed greater than 90 morphine equivalents per day during the observation period. The number of naloxone prescriptions for LOTS patients also increased, reflecting improved guideline adherence. CONCLUSION Systematic education and feedback to providers are effective in creating a system and culture of opioid reduction, safe opioid prescribing, and system accountability. This article presents a comprehensive approach to modifying prescribing patterns of long-term opioids in a large healthcare system.
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Affiliation(s)
| | - Conor B Garry
- Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Andrew J Ernst
- Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Jacob H Cole
- Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA.,Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | | | | | | | - Shari L Gentry
- Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Scott B Hughey
- Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA.,Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Eric T Stedje-Larsen
- Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA.,Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
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15
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Barrientos RC, Whalen C, Torres OB, Sulima A, Bow EW, Komla E, Beck Z, Jacobson AE, Rice KC, Matyas GR. Bivalent Conjugate Vaccine Induces Dual Immunogenic Response That Attenuates Heroin and Fentanyl Effects in Mice. Bioconjug Chem 2021; 32:2295-2306. [PMID: 34076427 PMCID: PMC8603354 DOI: 10.1021/acs.bioconjchem.1c00179] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Opioid use disorders and fatal overdose due to consumption of fentanyl-laced heroin remain a major public health menace in the United States. Vaccination may serve as a promising potential remedy to combat accidental overdose and to mitigate the abuse potential of opioids. We previously reported the heroin and fentanyl monovalent vaccines carrying, respectively, a heroin hapten, 6-AmHap, and a fentanyl hapten, para-AmFenHap, conjugated to tetanus toxoid (TT). Herein, we describe the mixing of these antigens to formulate a bivalent vaccine adjuvanted with liposomes containing monophosphoryl lipid A (MPLA) adsorbed on aluminum hydroxide. Immunization of mice with the bivalent vaccine resulted in IgG titers of >105 against both haptens. The polyclonal sera bound heroin, 6-acetylmorphine, morphine, and fentanyl with dissociation constants (Kd) of 0.25 to 0.50 nM. Mice were protected from the anti-nociceptive effects of heroin, fentanyl, and heroin +9% (w/w) fentanyl. No cross-reactivity to methadone and buprenorphine was observed in vivo. Naloxone remained efficacious in immunized mice. These results highlighted the potential of combining TT-6-AmHap and TT-para-AmFenHap to yield an efficacious bivalent vaccine that could ablate heroin and fentanyl effects. This vaccine warrants further testing to establish its potential translatability to humans.
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Affiliation(s)
- Rodell C Barrientos
- Laboratory of Adjuvant and Antigen Research, U.S. Military HIV Research Program, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, Maryland 20910, United States.,Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, Maryland 20817, United States
| | - Connor Whalen
- Laboratory of Adjuvant and Antigen Research, U.S. Military HIV Research Program, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, Maryland 20910, United States
| | - Oscar B Torres
- Laboratory of Adjuvant and Antigen Research, U.S. Military HIV Research Program, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, Maryland 20910, United States.,Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, Maryland 20817, United States
| | - Agnieszka Sulima
- Drug Design and Synthesis Section, Molecular Targets and Medications Discovery Branch, Intramural Research Program, National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Department of Health and Human Services, 9800 Medical Center Drive, Bethesda, Maryland 20892, United States
| | - Eric W Bow
- Drug Design and Synthesis Section, Molecular Targets and Medications Discovery Branch, Intramural Research Program, National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Department of Health and Human Services, 9800 Medical Center Drive, Bethesda, Maryland 20892, United States
| | - Essie Komla
- Laboratory of Adjuvant and Antigen Research, U.S. Military HIV Research Program, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, Maryland 20910, United States.,Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, Maryland 20817, United States
| | - Zoltan Beck
- Laboratory of Adjuvant and Antigen Research, U.S. Military HIV Research Program, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, Maryland 20910, United States.,Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, Maryland 20817, United States
| | - Arthur E Jacobson
- Drug Design and Synthesis Section, Molecular Targets and Medications Discovery Branch, Intramural Research Program, National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Department of Health and Human Services, 9800 Medical Center Drive, Bethesda, Maryland 20892, United States
| | - Kenner C Rice
- Drug Design and Synthesis Section, Molecular Targets and Medications Discovery Branch, Intramural Research Program, National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Department of Health and Human Services, 9800 Medical Center Drive, Bethesda, Maryland 20892, United States
| | - Gary R Matyas
- Laboratory of Adjuvant and Antigen Research, U.S. Military HIV Research Program, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, Maryland 20910, United States
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16
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Winters JR, Hill CJ, Frasier SD, Riddick JD, Schlocker CM. Postoperative Opioid Pain Medication Usage Following Adult Tonsillectomy. Mil Med 2021; 187:e1143-e1147. [PMID: 33825889 DOI: 10.1093/milmed/usab127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/18/2021] [Accepted: 03/26/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The purpose of this study was to determine if short-term, high-quantity opioid use following adult tonsillectomy in active duty military members results in opioid misuse, using a proxy measure of referrals to substance abuse rehabilitation programs. MATERIALS AND METHODS An Institutional Review Board-approved retrospective chart review was performed of 741 active duty patients who underwent tonsillectomy between 2012 and 2017. Data collection included preoperative medications within 60 days of surgery, all postoperative opioid prescriptions up to 12 months following surgery, and referrals to substance abuse rehabilitation within a year of surgery. RESULTS Out of 741 patients, 658 met inclusion criteria. Fifty-one percent were women and the average age was 26 years. Fifty-nine percent of patients received 5 mg/325 mg oxycodone/acetaminophen as their initial postoperative pain medication. The average number of opioid tablets prescribed was 70 ± 18. Ninety three percent of patients received at least 60 tabs. The refill rate within 30 days of tonsillectomy was 38.6%. In the year following surgery, 25.4% of patients received additional doses of outpatient opioids for other indications. Nineteen patients (2.9%) were referred for substance abuse treatment within 1 year of tonsillectomy: seventeen for alcohol abuse, one for marijuana, and one for alcohol/marijuana. There were no referrals for opiate misuse or abuse. CONCLUSION Short-term, high-quantity opioid treatment of post-tonsillectomy pain in active duty adults does not result in long-term opioid misuse, as measured by substance abuse treatment program referrals within a year after surgery. This finding supports the appropriateness of adequate short-term narcotic medication treatment. The long-term readiness of these patients appears unaffected by long-term opioid misuse or abuse. Even with this finding, there is an institutional shift to multi-modality pain management and appropriate opioid reduction to further mitigate the risk of opioid misuse. Extrapolation of these findings to all adult tonsillectomy patients should be done with caution, as there are several protective factors in the active duty population such as stable full-time employment with mandatory random drug screening.
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Affiliation(s)
- Jessica R Winters
- Department of Otolaryngology-Head and Neck Surgery, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Christopher J Hill
- Department of Otolaryngology-Head and Neck Surgery, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Samuel D Frasier
- Department of Otolaryngology-Head and Neck Surgery, Naval Hospital Jacksonville, Jacksonville, FL 32214, USA
| | - Jeanelle D Riddick
- Department of Otolaryngology-Head and Neck Surgery, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Caroline M Schlocker
- Department of Otolaryngology-Head and Neck Surgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
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17
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Katzman J, Tomedi L, Swift R, Castillo E, Morrow C, Lutz L, Galloway KT, McCoy-Stafford K, Klein Z, Turner G, Beckman DJ, Terrell J, Forde S, Martin C, Morgan S. Extension for Community Healthcare Outcomes (ECHO) Telementoring in the Military: Where We Are Now, Opportunities and Challenges. Mil Med 2021; 186:236-241. [PMID: 33585892 PMCID: PMC8399216 DOI: 10.1093/milmed/usab010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/20/2020] [Accepted: 01/13/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction In collaboration with the ECHO (Extension for Community Healthcare Outcomes) Institute since 2012, the Army, Navy, and Air Force have developed medical teleECHO programs to address various health and safety issues affecting military personnel. This article describes and compares the current state of military teleECHOs as well as the growth and change over time. Materials and Methods This study evaluated continuing education units (CEUs) offered, average session attendance, and number of spoke sites for current military teleECHO programs across the service branches. Results Between 2012 and 2019, the military teleECHO initiative grew from one program to seven different teleECHO programs, covering topics from pain to diabetes to amputee care. Military ECHOs now provide training to 10 countries and 27 states in the United States. Between October 2018 and September 2019, the military ECHO programs provided a total of 51,769 continuing medical education (CME) hours to a total of 3,575 attendees from 223 spoke sites. Conclusions The military has successfully used the ECHO model to improve the health and safety of active-duty military, retirees, and dependents.
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Affiliation(s)
- Joanna Katzman
- ECHO Institute, University of New Mexico, Albuquerque, NM 87102, USA
| | - Laura Tomedi
- ECHO Institute, University of New Mexico, Albuquerque, NM 87102, USA
| | - Robin Swift
- ECHO Institute, University of New Mexico, Albuquerque, NM 87102, USA
| | - Erick Castillo
- Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Connie Morrow
- Air Force Diabetes Center of Excellence, JBSA-Lackland, AFB, TX 78236, USA
| | - Laurie Lutz
- Defense Health Headquarters, Falls Church, VA 22040, USA
| | - Kevin T Galloway
- Strategic Communications and Policy, Defense & Veterans Center for Integrative Pain Management, Rockville, MD 20852, USA
| | | | | | | | - Darrick J Beckman
- Air Force Diabetes Center of Excellence, JBSA-Lackland, AFB, TX 78236, USA
| | | | - Shannon Forde
- Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Chamron Martin
- ECHO Institute, University of New Mexico, Albuquerque, NM 87102, USA
| | - Sharon Morgan
- Connected Health Branch Clinical Support Division, Medical Affairs, Defense Health Agency, Falls Church, VA 22041, USA
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18
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Bell A, Andrews C, Highland KB, Senese Forbes A. Opioid-Free Anesthesia in the Perioperative Setting-A Preliminary Retrospective Matched Cohort Study. Mil Med 2020; 187:e290-e296. [PMID: 33369677 DOI: 10.1093/milmed/usaa570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/09/2020] [Accepted: 12/19/2020] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Anesthesiologists have long used multimodal analgesia for effective pain control. Opioid-sparing anesthetics are gaining popularity among practitioners in light of increasing concerns for both immediate opioid side effects and the long-term opioid misuse among susceptible patients. Currently, there is a critical gap in knowledge regarding outcomes after an opioid-free anesthetic (OFA) during general anesthesia. We hypothesized that an opioid-free general anesthetic will not be inferior to a traditional opioid anesthetic (OA) as measured by the perioperative outcomes of postanesthesia care unit (PACU) duration, 12-hour postoperative summed pain intensity (SPI12) scores, total morphine equivalent doses (MEDs) utilized in the 12-hour postoperative inpatient (MED12) and total MEDs utilized in the 90-day outpatient periods (MED90). MATERIALS AND METHODS Patients were included if they were ≥18 years old, met criteria for American Society of Anesthesiologists classification I-IV, received general endotracheal anesthesia from a single anesthesia provider for a surgical operation in 2016, did not receive intraoperative administration of opioids, and were recovered in the PACU. A total of 25 patients were included in the OFA group and 29 control patients in the OA group (n = 54). A retrospective chart review of intraoperative records, perioperative pain scores, and medication utilization (inpatient and outpatient) was performed to obtain the data for the analysis of the primary outcomes. RESULTS In both OFA and OA groups, the continuous outcomes were not normally distributed. Subsequent bivariate tests of the indicated OA versus OFA age (d = 0.58), surgery duration (d = 0.24), and preoperative pain score (d = 0.51) warranted inclusion in the multinomial regression. Surgical duration was not significantly associated with the primary outcomes. However, the continuous variables of age and preoperative Defense and Veterans Pain Rating Scale score were associated with differences in primary outcomes. Every 1-year increase in the age was associated with a 5.06 increase in SPI12 and 5.73 mg increase in MED12. Every 1-point increase in the preoperative Defense and Veterans Pain Rating Scale score was associated with an 8.45 minutes increase in PACU duration, 11.25 increase in SPI12, 17.85 mg increase in MED12, and 20.83 mg increase in MED90. In regard to the primary outcomes, there was a lack of significant differences between the OFA and OA groups in all outcomes (PACU duration, mean SPI12, MED12, and MED90). CONCLUSIONS To our knowledge, this is the first matched cohort study directly comparing an OFA with a traditional anesthetic for general anesthesia in a wide range of surgical and clinical scenarios. There was no significant difference in SPI12 between the OFA group and OA group, suggesting that patients' subjective pain was similar immediately after surgery whether or not they received intraoperative opioids. Concurrently, no "catch-up" effect was observed as the PACU duration; MED12 and MED90 were not different between the OFA and OA groups. However, there were many covariates identified in this study because of the small sample size or each group. Additional research is needed to explore if these findings can be extrapolated to a larger more heterogeneous population. Our preliminary work suggests that eliminating patient exposure to opioids in the intraoperative period does not have a deleterious effect on perioperative patient outcomes.
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Affiliation(s)
- Austin Bell
- Anesthesiology Department, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Christopher Andrews
- Anesthesiology Department, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Krista B Highland
- Defense and Veterans Center for Integrative Pain Management, Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, MD 20814, USA.,Henry M. Jackson Foundation, Rockville, MD 20852, USA
| | - Angela Senese Forbes
- Anesthesiology Department, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
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19
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Tam CC, Zeng C, Li X. Prescription opioid misuse and its correlates among veterans and military in the United States: A systematic literature review. Drug Alcohol Depend 2020; 216:108311. [PMID: 33010713 DOI: 10.1016/j.drugalcdep.2020.108311] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 08/20/2020] [Accepted: 09/15/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Prescription opioid misuse (POM) has become a critical public health issue in the United States (US), with veteran and military population being especially vulnerable to POM. However, limited behavioral interventions have been developed for veterans and military to reduce POM risk due to the lack of an adequate understanding of POM andrelated factors among veterans and military. The current study aims to review and synthesize empirical findings regarding POM and its correlates among US veterans and military. METHODS We conducted a systematic review of 17 empirical studies (16 quantitative studies and one qualitative study) from 1980 to 2019 that reported POM statistics (e.g., prevalence) and examined correlates of POM in veterans and military. RESULTS The prevalence of POM in veterans and military ranged from 6.9%-77.9% varying by study samples, individual POM behaviors, and recalled time periods. Several factors were identified to be associated with POM in veterans and military. These factors included socio-demographic factors (age, race/ethnicity, education, relationship status, and military status), pain-related factors (pain symptoms, severity, interference, and cognitions), other physical factors (e.g., common illness), opioid-medication-related factors (receipt of opioid medications and quantity of opioid medications), behavioral factors (substance use disorder, alcohol use, cigarette use, and other prescription drug use), and psychological factors (psychiatric symptoms and cognitive factors). CONCLUSIONS POM was prevalent in veterans and military and could be potentially influenced by multiple psycho-behavioral factors. Future research guided by a theoretical framework is warranted to examine psycho-behavioral influences on POM and their mechanisms and to inform effective psychosocial POM interventions in veterans and military.
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Affiliation(s)
- Cheuk Chi Tam
- South Carolina SmartState Center for Healthcare Quality, Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Discovery I, 915 Greene Street, Columbia, SC, 29208, USA.
| | - Chengbo Zeng
- South Carolina SmartState Center for Healthcare Quality, Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Discovery I, 915 Greene Street, Columbia, SC, 29208, USA
| | - Xiaoming Li
- South Carolina SmartState Center for Healthcare Quality, Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Discovery I, 915 Greene Street, Columbia, SC, 29208, USA
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20
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Barrientos RC, Bow EW, Whalen C, Torres OB, Sulima A, Beck Z, Jacobson AE, Rice KC, Matyas GR. Novel Vaccine That Blunts Fentanyl Effects and Sequesters Ultrapotent Fentanyl Analogues. Mol Pharm 2020; 17:3447-3460. [PMID: 32787282 PMCID: PMC7482402 DOI: 10.1021/acs.molpharmaceut.0c00497] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
![]()
Active
immunization is an emerging potential modality to combat
fatal overdose amid the opioid epidemic. In this study, we described
the design, synthesis, formulation, and animal testing of an efficacious
vaccine against fentanyl. The vaccine formulation is composed of a
novel fentanyl hapten conjugated to tetanus toxoid (TT) and adjuvanted
with liposomes containing monophosphoryl lipid A adsorbed on aluminum
hydroxide. The linker and hapten N-phenyl-N-(1-(4-(3-(tritylthio)propanamido)phenethyl)piperidin-4-yl)propionamide
were conjugated sequentially to TT using amine-N-hydroxysuccinimide-ester
and thiol–maleimide reaction chemistries, respectively. Conjugation
was facile, efficient, and reproducible with a protein recovery of
>98% and a hapten density of 30–35 per carrier protein molecule.
In mice, immunization induced high and robust antibody endpoint titers
in the order of >106 against the hapten. The antisera
bound
fentanyl, carfentanil, cyclopropyl fentanyl, para-fluorofentanyl, and furanyl fentanyl in vitro with
antibody-drug dissociation constants in the range of 0.36–4.66
nM. No cross-reactivity to naloxone, naltrexone, methadone, or buprenorphine
was observed. In vivo, immunization shifted the antinociceptive
dose–response curve of fentanyl to higher doses. Collectively,
these preclinical results showcased the desired traits of a potential
vaccine against fentanyl and demonstrated the feasibility of immunization
to combat fentanyl-induced effects.
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Affiliation(s)
- Rodell C Barrientos
- Laboratory of Adjuvant and Antigen Research, U.S. Military HIV Research Program, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, Maryland 20910, United States.,U.S. Military HIV Research Program, Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, Maryland 20817, United States
| | - Eric W Bow
- Drug Design and Synthesis Section, Molecular Targets and Medications Discovery Branch, Intramural Research Program, National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism, Department of Health and Human Services, National Institutes of Health, 9800 Medical Center Drive, Bethesda, Maryland 20892-3373, United States
| | - Connor Whalen
- Laboratory of Adjuvant and Antigen Research, U.S. Military HIV Research Program, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, Maryland 20910, United States
| | - Oscar B Torres
- Laboratory of Adjuvant and Antigen Research, U.S. Military HIV Research Program, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, Maryland 20910, United States.,U.S. Military HIV Research Program, Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, Maryland 20817, United States
| | - Agnieszka Sulima
- Drug Design and Synthesis Section, Molecular Targets and Medications Discovery Branch, Intramural Research Program, National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism, Department of Health and Human Services, National Institutes of Health, 9800 Medical Center Drive, Bethesda, Maryland 20892-3373, United States
| | - Zoltan Beck
- Laboratory of Adjuvant and Antigen Research, U.S. Military HIV Research Program, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, Maryland 20910, United States.,U.S. Military HIV Research Program, Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, Maryland 20817, United States
| | - Arthur E Jacobson
- Drug Design and Synthesis Section, Molecular Targets and Medications Discovery Branch, Intramural Research Program, National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism, Department of Health and Human Services, National Institutes of Health, 9800 Medical Center Drive, Bethesda, Maryland 20892-3373, United States
| | - Kenner C Rice
- Drug Design and Synthesis Section, Molecular Targets and Medications Discovery Branch, Intramural Research Program, National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism, Department of Health and Human Services, National Institutes of Health, 9800 Medical Center Drive, Bethesda, Maryland 20892-3373, United States
| | - Gary R Matyas
- Laboratory of Adjuvant and Antigen Research, U.S. Military HIV Research Program, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, Maryland 20910, United States
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