Medical complications associated with substance use disorders in patients with type 2 diabetes and hypertension: electronic health record findings

Comparing Rates of Undiagnosed Hypertension and Diabetes in Patients With and Without Substance Use Disorders

BACKGROUND

Individuals with substance use disorders (SUDs) have increased risk for developing chronic conditions, though few studies assess rates of diagnosis of these conditions among patients with SUDs.

OBJECTIVE

To compare rates of undiagnosed hypertension and diabetes among patients with and without an SUD.

DESIGN

Cross-sectional analysis using electronic health record (EHR) data from 58 primary care clinics at a large, urban, healthcare system in New York.

PARTICIPANTS

Patients who had at least two primary care visits from 2019-2022 were included in our patient sample. Patients without an ICD-10 hypertension diagnosis or prescribed hypertension medications and with at least two blood pressure (BP) readings ≥ 140/90 mm were labeled 'undiagnosed hypertension,' and patients without a diabetes diagnosis or prescribed diabetes medications and with A1C/hemoglobin ≥ 6.5% were labeled 'undiagnosed diabetes.'

MAIN MEASURES

We calculated the mean number of patients with and without an ICD-10 SUD diagnosis who were diagnosed and undiagnosed for each condition. We used multivariate logistic regression to assess the association between being undiagnosed for each condition, and having an SUD diagnosis, patient demographic characteristics, clinical characteristics (body mass index, Elixhauser comorbidity count, diagnosed HIV and psychosis), the percentage of visits without a BP screening, and the total number of visits during the time period.

KEY RESULTS

The percentage of patients with undiagnosed hypertension (2.74%) and diabetes (22.98%) was higher amongst patients with SUD than patients without SUD. In multivariate models, controlling for other factors, patients with SUD had significantly higher odds of having undiagnosed hypertension (OR: 1.81; 95% CI: 1.48, 2.20) and undiagnosed diabetes (OR: 1.93; 1.72, 2.16). Being younger, female, and having an HIV diagnosis was also associated with significantly higher odds for being undiagnosed.

CONCLUSIONS

We found significant disparities in rates of undiagnosed chronic diseases among patients with SUDs, compared with patients without SUDs.

Comorbidity Burden and Health Care Utilization by Substance use Disorder Patterns among People with HIV in Florida

Substance use disorder (SUD), a common comorbidity among people with HIV (PWH), adversely affects HIV clinical outcomes and HIV-related comorbidities. However, less is known about the incidence of different chronic conditions, changes in overall comorbidity burden, and health care utilization by SUD status and patterns among PWH in Florida, an area disproportionately affected by the HIV epidemic. We used electronic health records (EHR) from a large southeastern US consortium, the OneFlorida + clinical research data network. We identified a cohort of PWH with 3 + years of EHRs after the first visit with HIV diagnosis. International Classification of Diseases (ICD) codes were used to identify SUD and comorbidity conditions listed in the Charlson comorbidity index (CCI). A total of 42,271 PWH were included (mean age 44.5, 52% Black, 45% female). The prevalence SUD among PWH was 45.1%. Having a SUD diagnosis among PWH was associated with a higher incidence for most of the conditions listed on the CCI and faster increase in CCI score overtime (rate ratio = 1.45, 95%CI 1.42, 1.49). SUD in PWH was associated with a higher mean number of any care visits (21.7 vs. 14.8) and more frequent emergency department (ED, 3.5 vs. 2.0) and inpatient (8.5 vs. 24.5) visits compared to those without SUD. SUD among PWH was associated with a higher comorbidity burden and more frequent ED and inpatient visits than PWH without a diagnosis of SUD. The high SUD prevalence and comorbidity burden call for improved SUD screening, treatment, and integrated care among PWH.

When the Going Gets Tough: Multimorbidity and Heavy and Binge Drinking Among Adults

INTRODUCTION

Multimorbidity, the presence of two or more long-term health conditions in the same individual, is an emerging epidemic associated with increased morbidity and mortality. Continued drinking concurrent with alcohol-related chronic conditions, particularly with multimorbidity, is likely to further elevate health risk. This study aimed to examine the associations of multimorbidity among diabetes, hypertension, heart disease, and cancer with drinking, and moderation of these associations by age.

METHODS

Logistic regression modeling was performed in 2023 using a nationally representative sample of U.S. adults from the 2015-19 National Survey on Drug Use and Health. Multimorbidity was assessed using (1) a count of these conditions and (2) disease-specific categories. The outcomes were past month heavy drinking (7+/14+ drinks weekly) and binge drinking (4+/5+ drinks per occasion) for women and men.

RESULTS

A pattern of reduced odds for drinking outcomes associated with a greater degree of multimorbidity was found. This pattern was more apparent in models using the continuous measure of multimorbidity than in those using the categorical measure, and more consistent for binge drinking than for heavy drinking and for women than for men. Significant age interactions were found: the log odds of heavy drinking and binge drinking for both men and women decreased as the number of conditions increased, and more steeply for those ages 50+ than the younger. The log odds of heavy drinking varied little among men under age 50 regardless of multimorbidity.

CONCLUSIONS

Alcohol interventions to reduce drinking with multimorbidity, particularly among heavy-drinking men under age 50, are warranted.

At-Risk Drinking in US Adults with Health Conditions: Differences by Gender, Race, and Ethnicity in the National Survey of Drug Use and Health, 2015-2019

Few studies in the US address alcohol consumption patterns in adults with chronic health conditions, and little is known about race and ethnicity differences. This study examined at-risk drinking prevalence rates among US adults with hypertension, diabetes, heart condition or cancer and assessed differences by gender and, among adults aged 50 and older, by race and ethnicity. We used data from the 2015-2019 National Survey on Drug Use and Health (N = 209,183) to estimate (1) prevalence rates and (2) multivariable logistic regression models predicting odds of at-risk drinking among adults with hypertension, diabetes, heart condition, or cancer, compared to adults with none of these conditions. To examine subgroup differences, analyses were stratified by gender (ages 18-49 and ages 50 +) and by gender and race and ethnicity for adults ages 50 + . Results showed that all adults with diabetes and women ages 50 + with heart conditions in the full sample had lower odds of at-risk drinking relative to their counterparts without any of the four conditions. Men ages 50 + with hypertension had greater odds. In race and ethnicity assessments among adults ages 50 + , only non-Hispanic White (NHW) men and women with diabetes and heart conditions had lower odds, and NHW men and women and Hispanic men with hypertension had greater odds of at-risk drinking. There were differential associations of at-risk drinking with demographic and lifestyle indicators across race and ethnicity groups. These findings underscore tailored efforts in community and clinical settings to reduce at-risk drinking in subgroups with health condition diagnoses.

Exploring Health Informatics in the Battle against Drug Addiction: Digital Solutions for the Rising Concern

Drug addiction is a rising concern globally that has deeply attracted the attention of the healthcare sector. The United States is not an exception, and the drug addiction crisis there is even more serious, with 10% of adults having faced substance use disorder, while around 75% of this number has been reported as not having received any treatment. Surprisingly, there are annually over 70,000 deaths reported as being due to drug overdose. Researchers are continually searching for solutions, as the current strategies have been ineffective. Health informatics platforms like electronic health records, telemedicine, and the clinical decision support system have great potential in tracking the healthcare data of patients on an individual basis and provide precise medical support in a private space. Such technologies have been found to be useful in identifying the risk factors of drug addiction among people and mitigating them. Moreover, the platforms can be used to check prescriptions of addictive drugs such as opioids and caution healthcare providers. Programs such as the Prescription Drug Monitoring Program (PDMP) and the Drug and Alcohol Services Information Systems (DASIS) are already in action in the US, but the situation demands more in-depth studies in order to mitigate substance use disorders. Artificial intelligence (AI), when combined with health informatics, can aid in the analysis of large amounts of patient data and aid in classifying nature of addiction to assist in the provision of personalized care.

Nativity and the risk of opioid use disorder among Hispanic/Latinx women in primary care in Los Angeles, CA

BACKGROUND

While rates of opioid use disorder (OUD) are lower among women compared to men, nativity may have disproportionate impacts on OUD risk among Hispanic/Latinx women but remain understudied.

OBJECTIVE

To assess the association between country of birth and reported OUD risk among low-income Hispanic/Latinx women in primary care in Los Angeles, CA.

METHODS

This was a cross-sectional study of 1189 non-pregnant, Hispanic/Latinx women attending two federally qualified health centers in Los Angeles between March and July 2013. OUD risk was assessed using the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), and moderate-to-high risk was defined as ASSIST score ≥ 4.

RESULTS

Overall, 4.2% of women (n = 49) were at moderate-to-high risk for OUD. Risk for OUD was higher among US-born women compared to foreign-born women (6.7 vs. 1.7%; p < .01), those who reported 2+ chronic medical conditions (p < .01), and those who were at moderate-to-high risk for other substance use disorders (p < .01). In multivariable logistic regression analyses, being U.S.-born was independently associated with being at moderate-to-high risk for OUD among Hispanic/Latinx women as compared to those who were foreign-born (AOR = 2.8; 95% CI 1.2-6.8).

CONCLUSION

Among low-income Hispanic/Latinx women presenting to primary care, one in twenty patients is at-risk for OUD. The odds of moderate-high risk of OUD were three times as high in US-born compared to foreign-born women, and higher among those with chronic medical conditions and those at risk of other substance use disorders. Gender-specific and culturally-tailored screening for OUD may inform overdose prevention interventions for US-born Hispanic/Latinx women.

Effectiveness of pharmacotherapies for diabetes on nicotine, food, and water intake in insulin-resistant rats

The intersectionality between diabetes medications and nicotine consumption was assessed in female and male rats. Briefly, the rats were fed a high-fat diet (HFD) or regular diet (RD) for 4 weeks. Then separate groups received vehicle or a low dose of streptozotocin (STZ; 25 mg/kg). Three days later, insulin resistance was assessed by measuring plasma glucose levels for 180 min following an injection of insulin (0.75 U/kg). The rats were then prepared with jugular catheters, and they were given 23 h access to nicotine intravenous self-administration (IVSA) in 4 days cycles with 3 days of forced abstinence in their home cages where they consumed their respective diet. During the IVSA sessions, operant responses for food and water and changes in body weight were recorded. Prior to administration of the pharmacotherapies, the rats were given access to two doses of nicotine (0.015 then 0.03 mg/kg for the remainder of the study). Then, daily injections of the pharmacotherapies were given at the onset of dark cycle (6 p.m.) in the following order: 1) dapagliflozin (3.0 then 10.0 mg/kg), 2) insulin (0.75 U/kg twice), and 3) bromocriptine (3.0 then 10.0 mg/kg). The results suggest that our HFD+STZ regiment induced insulin resistance in female and male rats. Also, the HFD-fed rats displayed higher nicotine intake than RD controls, regardless of sex. Administration of insulin, but not dapagliflozin or bromocriptine, normalized nicotine intake in HFD-fed rats to control levels. These results have clinical implications regarding the potential efficacy of insulin to control excessive nicotine intake in persons with diabetes.

Context of substance initiation among urban Native Americans: an exploratory retrospective case-control study

Background

Addiction is a significant problem among many Native American groups but has rarely been examined in urban populations. In particular, little is known about the context in which urban Native Americans first use substances. This study compares cases (people with a history of addiction) to controls (people without a history of addiction) on demographics, substance use history, context of first substance use, and polysubstance use. In addition, this appears to be the first study to overcome the lack of Native American professionals by employing and training lay community members to identify criteria of substance use disorders in survey participants. Employing community members helped foster trust that enabled the revelation of sensitive and often illegal activity. As a result, the investigators were able to recruit participants who likely would not have engaged with traditional researchers.

Methods

The trained Native American lay research assistants recruited community members and administered surveys. They first asked questions regarding the criteria for substance use disorders. Individuals who were determined to have met criteria for a substance use disorder in the past were classified as cases (n = 38) and those who never met such criteria were classified as controls (n = 42). They then asked demographic, substance use, and polysubstance use questions. Lastly, eight cases and eight controls were randomly selected for a second interview by a licensed drug and alcohol counselor (LDAC) who conducted a blinded assessment regarding the presence or absence of a history of a substance use disorder.

Results

Both groups reported a relatively young age of first substance use (age 16 years for cases and age 15 years for controls). Alcohol was the first substance most commonly used in both groups. Controls reported first benzodiazepine use at a younger age than cases but no other significant differences were found. Both groups reported first obtaining their first drug from family, friends, or at home (rather than a party, bar, or store). Most commonly, the location of their first use of drugs occurred at a friend's home, a party, a bar, or school rather than at their own home. Cases were marginally more likely to report that their first drug use occurred with a friend rather than with a family member when compared with controls. The majority of both groups reported that their first drug use occurred with other Native Americans rather than with non-Native Americans. Polysubstance use was common in both groups (43-45%). There were no significant differences between the groups regarding polysubstance use. The LDAC arrived at the same determination as the trained research assistants on all eight cases and eight controls.

Hazardous drinking by older adults with chronic conditions during the COVID-19 pandemic: Evidence from a Chicago-based cohort

BACKGROUND

It is unclear how older adults with chronic conditions, who have greater risk of alcohol-related adverse outcomes, used alcohol throughout the COVID-19 pandemic. We assess changes in hazardous drinking prevalence May 2020-December 2021 and factors associated with hazardous drinking.

METHODS

Data are from structured phone interviews of older adults (age 60+) with chronic conditions (e.g., hypertension, diabetes, pulmonary disease, heart disease) in a Chicago-based longitudinal cohort (Chicago COVID-19 Comorbidities survey, Waves 3-7, n = 247). We tested differences in the prevalence of hazardous drinking (defined as AUDIT-C score of 3+ for women and 4+ for men) across waves for the full sample, by demographic group (sex, race, and ethnicity), and by chronic condition burden (<3 conditions, 3+ conditions). Generalized estimating equations investigated associations of hazardous drinking with sociodemographic and pandemic coping-related factors (stress, loneliness, outside contacts, depression, anxiety).

RESULTS

Participants were 66.8% female; 27.9% non-Hispanic Black, 14.2% Hispanic, 4.9% other race. Hazardous drinking was reported by 44.9% of participants in May 2020, but declined to 23.1% by July-August 2020 and continued to slowly decline to 19.4% by September-December 2021. Differences from May 2020 were significant at the 0.05 level. Subgroups followed similar trajectories. Hazardous drinking prevalence was initially higher but declined more among men than women, consistently higher among non-Hispanic White respondents than among Hispanic and non-Hispanic Black respondents, and declined more rapidly among adults with 3+ chronic conditions. In adjusted models, race and ethnicity were associated with lower prevalence of hazardous drinking (non-Hispanic Black: adjusted prevalence ratio [aPR] = 0.50, 95% confidence interval [CI] = 0.33, 0.74; other race: aPR = 0.26, 95% CI = 0.09, 0.81, compared with non-Hispanic White). No coping-related factors were significantly associated with hazardous drinking.

CONCLUSION

Among a cohort of older adults with chronic conditions, almost half engaged in hazardous drinking in early summer of the COVID-19 pandemic. While prevalence fell, these rates reinforce the need for alcohol screening and intervention in clinical settings among this population.

Factors associated with higher alcohol concentrations in emergency department presentations: PACE study

INTRODUCTION

The health impact from alcohol is of recognised concern, from acute intoxication as well as increased risk of chronic health issues over time. Identifying factors associated with higher alcohol consumption when presenting to the emergency department (ED) will inform public health policy and enable more targeted health care and appropriate referrals.

METHODS

Secondary testing of blood samples collected during routine clinical care of 1160 ED patients presenting to the Royal Brisbane and Women's Hospital in Queensland, Australia, for 10 days between 22 January and 1 February 2021. Alcohol was measured by blood ethanol (intake in recent hours) and phosphatidylethanol (PEth; intake over 2-4 weeks). Zero-inflated negative binomial regression was used to identify demographic and clinical factors associated with higher alcohol concentrations.

RESULTS

Males were found to have 83% higher blood ethanol and 32% higher PEth concentrations than females (adjusted rate ratio [ARR] 1.83, 95% confidence interval [CI] 1.37-2.45 and ARR 1.32, 95% CI 1.04-1.68, respectively). Blood ethanol concentrations were 3.4 times higher for those 18-44 years, compared to those aged 65+ (ARR 3.40, 95% CI 2.40-4.82) whereas PEth concentrations were found to be the highest in those aged 45-64 years, being 70% higher than those aged 65+ (ARR 1.70, 95% CI 1.19-2.44). Patients brought in involuntarily had eight-times higher blood ethanol concentrations than those who self-attended.

DISCUSSION AND CONCLUSIONS

This study used two alcohol markers to identify factors associated with higher alcohol concentrations in emergency presentations. The findings demonstrate how these biomarkers can provide informative data for public health responses and monitoring of alcohol use trends.

Potential effect of antidepressants on remission from cocaine use disorder - A nationwide matched retrospective cohort study

BACKGROUND

Cocaine use disorder (CUD) is a significant public health issue for which there is no Food and Drug Administration-approved pharmacotherapy. Depressive disorders are common psychiatric comorbidity amongst individuals with CUD.

METHODS

A retrospective cohort study was conducted among 161,544 patients diagnosed with CUD and depression to evaluate the effectiveness of 13 antidepressants on CUD remission. For any antidepressant found to be associated with CUD remission that had an additional indication, we conducted an additional analysis to evaluate the effectiveness of the candidate drug in patients with CUD with that indication. We then analyzed publicly genomic and functional databases to identify potential explanatory mechanisms of action of the candidate drug in the treatment of CUD.

RESULTS

Among these antidepressants, bupropion was associated with higher rates of CUD remission compared to propensity-score matched patients prescribed other antidepressants: hazard ratio (HR) and 95% confidence interval (CI) 1.57 (95% CI: 1.27-1.94). Bupropion is also approved for smoking cessation. We identified CUD patients with co-occurring nicotine dependence and observed that patients prescribed bupropion displayed a higher rate of CUD remission compared to matched individuals prescribed other drugs for nicotine dependence: 1.38 (95% CI: 1.11-1.71). Genetic and functional analyses revealed that bupropion interacts with four protein-encoding genes (COMT, DRD2, SLC6A3, and SLC6A4) which are also associated with CUD and targets CUD-associated pathways including serotonergic synapses, cocaine addiction, and dopaminergic synapses.

CONCLUSIONS

Our findings suggest that bupropion might be considered a treatment for improving CUD remission in patients with CUD and co-occurring depression or nicotine dependence.

Repurposing ketamine to treat cocaine use disorder: integration of artificial intelligence-based prediction, expert evaluation, clinical corroboration and mechanism of action analyses

BACKGROUND AND AIMS

Cocaine use disorder (CUD) is a significant public health issue for which there is no Food and Drug Administration (FDA) approved medication. Drug repurposing looks for new cost-effective uses of approved drugs. This study presents an integrated strategy to identify repurposed FDA-approved drugs for CUD treatment.

DESIGN

Our drug repurposing strategy combines artificial intelligence (AI)-based drug prediction, expert panel review, clinical corroboration and mechanisms of action analysis being implemented in the National Drug Abuse Treatment Clinical Trials Network (CTN). Based on AI-based prediction and expert knowledge, ketamine was ranked as the top candidate for clinical corroboration via electronic health record (EHR) evaluation of CUD patient cohorts prescribed ketamine for anesthesia or depression compared with matched controls who received non-ketamine anesthesia or antidepressants/midazolam. Genetic and pathway enrichment analyses were performed to understand ketamine's potential mechanisms of action in the context of CUD.

SETTING

The study utilized TriNetX to access EHRs from more than 90 million patients world-wide. Genetic- and functional-level analyses used DisGeNet, Search Tool for Interactions of Chemicals and Kyoto Encyclopedia of Genes and Genomes databases.

PARTICIPANTS

A total of 7742 CUD patients who received anesthesia (3871 ketamine-exposed and 3871 anesthetic-controlled) and 7910 CUD patients with depression (3955 ketamine-exposed and 3955 antidepressant-controlled) were identified after propensity score-matching.

MEASUREMENTS

EHR analysis outcome was a CUD remission diagnosis within 1 year of drug prescription.

FINDINGS

Patients with CUD prescribed ketamine for anesthesia displayed a significantly higher rate of CUD remission compared with matched individuals prescribed other anesthetics [hazard ratio (HR) = 1.98, 95% confidence interval (CI) = 1.42-2.78]. Similarly, CUD patients prescribed ketamine for depression evidenced a significantly higher CUD remission ratio compared with matched patients prescribed antidepressants or midazolam (HR = 4.39, 95% CI = 2.89-6.68). The mechanism of action analysis revealed that ketamine directly targets multiple CUD-associated genes (BDNF, CNR1, DRD2, GABRA2, GABRB3, GAD1, OPRK1, OPRM1, SLC6A3, SLC6A4) and pathways implicated in neuroactive ligand-receptor interaction, cAMP signaling and cocaine abuse/dependence.

CONCLUSIONS

Ketamine appears to be a potential repurposed drug for treatment of cocaine use disorder.

Detecting Problematic Opioid Use in the Electronic Health Record: Automation of the Addiction Behaviors Checklist in a Chronic Pain Population

Importance

Individuals whose chronic pain is managed with opioids are at high risk of developing an opioid use disorder. Large data sets, such as electronic health records, are required for conducting studies that assist with identification and management of problematic opioid use.

Objective

Determine whether regular expressions, a highly interpretable natural language processing technique, could automate a validated clinical tool (Addiction Behaviors Checklist1) to expedite the identification of problematic opioid use in the electronic health record.

Design

This cross-sectional study reports on a retrospective cohort with data analyzed from 2021 through 2023. The approach was evaluated against a blinded, manually reviewed holdout test set of 100 patients.

Setting

The study used data from Vanderbilt University Medical Center's Synthetic Derivative, a de-identified version of the electronic health record for research purposes.

Participants

This cohort comprised 8,063 individuals with chronic pain. Chronic pain was defined by International Classification of Disease codes occurring on at least two different days.18 We collected demographic, billing code, and free-text notes from patients' electronic health records.

Main Outcomes and Measures

The primary outcome was the evaluation of the automated method in identifying patients demonstrating problematic opioid use and its comparison to opioid use disorder diagnostic codes. We evaluated the methods with F1 scores and areas under the curve - indicators of sensitivity, specificity, and positive and negative predictive value.

Results

The cohort comprised 8,063 individuals with chronic pain (mean [SD] age at earliest chronic pain diagnosis, 56.2 [16.3] years; 5081 [63.0%] females; 2982 [37.0%] male patients; 76 [1.0%] Asian, 1336 [16.6%] Black, 56 [1.0%] other, 30 [0.4%] unknown race patients, and 6499 [80.6%] White; 135 [1.7%] Hispanic/Latino, 7898 [98.0%] Non-Hispanic/Latino, and 30 [0.4%] unknown ethnicity patients). The automated approach identified individuals with problematic opioid use that were missed by diagnostic codes and outperformed diagnostic codes in F1 scores (0.74 vs. 0.08) and areas under the curve (0.82 vs 0.52).

Conclusions and Relevance

This automated data extraction technique can facilitate earlier identification of people at-risk for, and suffering from, problematic opioid use, and create new opportunities for studying long-term sequelae of opioid pain management.

Relationship between criminal legal system exposure and health care utilization in US adults with diabetes: A cross-sectional study

BACKGROUND

Black Americans have a higher prevalence of diabetes compared to White Americans and have higher rates of complications and death. Exposure to the criminal legal system (CLS) is a social risk factor for chronic disease morbidity and mortality with significant overlap with populations most likely to experience poor diabetes outcomes. However, little is known about the association between CLS exposure and healthcare utilization patterns among U.S. adults with diabetes.

METHODS

Using data from the National Survey of Drug Use and Health (2015-2018) a cross-sectional, nationally representative sample of U.S. adults with diabetes was created. Negative binomial regression was used to test the association between lifetime CLS exposure and three utilization types (emergency department (ED), inpatient, and outpatient) controlling for relevant socio-demographic and clinical covariates.

RESULTS

Of 11,562 (weighted to represent 25,742,034 individuals) adults with diabetes, 17.1% reported lifetime CLS exposure. In unadjusted analyses, exposure was associated with increased ED (IRR 1.30 95% CI 1.17-1.46) and inpatient utilization (IRR 1.23, 95% CI 1.01-1.50), but not outpatient visits (IRR 0.99 95% CI 0.94-1.04). The association between CLS exposure and ED (IRR 1.02, p=0.70) and inpatient utilization (IRR 1.18, p=0.12) was attenuated in adjusted analyses. Low socioeconomic status, comorbid substance use disorder, and comorbid mental illness were independently associated with health care utilization in this population.

CONCLUSIONS

Among those with diabetes, lifetime CLS exposure is associated with higher ED and inpatient visits in unadjusted analyses. Adjusting for socioeconomic status and clinical confounders attenuated these relationships, thus more research is needed to understand how CLS exposure interacts with poverty, structural racism, addiction and mental illness to influence health care utilization for adults with diabetes.

Untreated substance use disorder affects glycemic control: Results in patients with type 2 diabetes served within a network of community-based healthcare centers in Florida

Introduction

Patients with diabetes and comorbid substance use disorders (SUD) experience poor diabetes management, increased medical complications and mortality. However, research has documented that patients engaged in substance abuse treatment have better management of their comorbid conditions. The current study examines diabetes management among patients with type 2 diabetes, with and without comorbid SUD, receiving care at Florida-based Federally Qualified Health Centers (FQHC) of Health Choice Network (HCN).

Methods

A retrospective analysis was conducted using deidentified electronic health records of 37,452 patients with type 2 diabetes who received care at a HCN site in Florida between 2016 and 2019. A longitudinal logistic regression analysis examined the impact of SUD diagnosis on achievement of diabetes management [HbA1c < 7.0% (53 mmol/mol)] over time. A secondary analysis evaluated, within those with an SUD diagnosis, the likelihood of HbA1c control between those with and without SUD treatment.

Results

The longitudinal assessment of the relationship between SUD status and HbA1c control revealed that those with SUD (N = 6,878, 18.4%) were less likely to control HbA1c over time (OR = 0.56; 95% CI = 0.49-0.63). Among those with SUD, patients engaged in SUD treatment were more likely to control HbA1c (OR = 5.91; 95% CI = 5.05-6.91).

Discussion

Findings highlight that untreated SUD could adversely affect diabetes control and sheds light on the opportunity to enhance care delivery for patients with diabetes and co-occurring SUD.

Health outcomes associated with patterns of substance use disorders among patients with type 2 diabetes and hypertension: Electronic health record findings

AIMS

To identify substance use disorder (SUD) patterns and their association with T2DM health outcomes among patients with type 2 diabetes and hypertension.

METHODS

We used latent class analysis on electronic health records from the MetroHealth System (Cleveland, Ohio) to obtain the target SUD groups: i) only tobacco (TUD), ii) tobacco and alcohol (TAUD), and iii) tobacco, alcohol, and at least one more substance (PSUD). A matching program with Mahalanobis distance within propensity score calipers created the matched control groups: no SUD (NSUD) for TUD and TUD for the other two SUD groups. The numbers of participants for the target-control groups were 8009 (TUD), 1672 (TAUD), and 642 (PSUD).

RESULTS

TUD was significantly associated with T2DM complications. Compared to TUD, the TAUD group showed a significantly higher likelihood for all-cause mortality (adjusted odds ratio (aOR) = 1.46) but not for any of the T2DM complications. Compared to TUD, the PSUD group experienced a significantly higher risk for cerebrovascular accident (CVA) (aOR = 2.19), diabetic neuropathy (aOR = 1.76), myocardial infarction (MI) (aOR = 1.76), and all-cause mortality (aOR = 1.66).

CONCLUSIONS

The findings of increased risk associated with PSUDs may provide insights for better management of patients with T2DM and hypertension co-occurrence.

The Critical Role of Pharmacists in Treating Older People in the Opioid Crisis

Pharmacy-based Opioid Use Disorder (OUD) treatment has been identified as a central pillar in curbing the spiraling opioid epidemic that claimed more than 100,000 lives in the United States in a one year period for the first time. This epidemic is also partially responsible for the plummeting US life expectancy that began prior to the COVID-19 pandemic and has now claimed more than 500,000 lives since 1999 with more than 70% of the 70,630 overdose deaths in 2019 involved with an opioid. Older people are at increased risk of both OUD and OUD-related complications. Recent studies have demonstrated that people older than 65 years of age were more likely to die of OUD-related complications, and - because of an increased likelihood of polypharmacy - are more likely to experience a drug interaction that magnifies the risk of an opioid-related misadventure.

Mortality and its association with chronic alcohol-related diseases in patients admitted to the emergency department for acute alcoholic intoxication: retrospective cohort study

We assessed long-term mortality and its association with chronic alcohol-related diseases in patients admitted to the emergency department (ED) because of acute alcoholic intoxication (AAI). A retrospective cohort study was performed at the ED of Sant'Orsola-Malpighi Hospital, Bologna, Italy. 3304 patients, corresponding to 6415 admissions for AAI, who accessed the ED from January 1, 2005, to December 31, 2017, were studied. The ED electronic registry system was used to assess living status on 08 May 2020 and to obtain the prespecified potential predictors, i.e., age at first admission, sex, alcohol use disorder (AUD), substance use disorder (SUD), more than 1 admission to ED for trauma, mental and behavioral disorders, neurological disorders, and cardiovascular disease. The median follow-up time was 9.3 years and the time on risk was 30,053 person years (PY) with a death rate corresponding to 4.42 (95% CI 3.74-5.26) per 1000 PY (n = 133 deaths). The death rate was higher in patients with AUD (17.30) than in those without AUD (1.98) and in those with SUD (13.58) than in those without SUD (3.80). Lastly, there was a clearly higher death rate among AUD+ SUD+ (20.89) compared to AUD-SUD-patients (1.74). At multivariable Cox regression, AUD, SUD, and liver cirrhosis were strong and independent predictors of time-to-death. Using standardized mortality ratios, a clear excess of mortality was evident for all the age bands from (40-45] to (60-65] years. Mortality is higher in AAI than in the general population and chronic alcohol-related diseases are strongly associated with it.

COVID-19 broken access: implications for individuals with substance use disorders

The impact of the COVID-19 (coronavirus) pandemic created a paradigm shift in the delivery of substance abuse treatment services. Still, it also provided an opportunity for healthcare workers and professionals, and treatment providers to adjust, problem-solve, and meet these challenges head-on. The pandemic led practitioners and healthcare professionals to change how they deliver treatment options but still ensuring that their clients received access to adequate and effective clinical services. It is suggested that during the ongoing COVID-19 pandemic, healthcare professionals should make every effort to ensure accessibility and availability of substance abuse treatment services through critical actions. This paper will address the physical health implications, as well as the trauma-stress related effects of COVID-19 on individuals with substance use disorders (SUD). In all, this article will identify barriers to treatment access, accentuate treatment strategies, and provide measures and recommendations for maintaining and improving services for substance-dependent patients.

Five-year incidence of substance use and mental health diagnoses following exposure to opioids or opioids with benzodiazepines during an emergency department encounter for traumatic injury

BACKGROUND

Benzodiazepines and opioids are used alone or in conjunction in certain care settings, but each have the potential for misuse.

OBJECTIVE

This longitudinal observational study evaluated substance use and mental health outcomes associated with providing opioids with or without benzodiazepine to treat traumatic injury in the emergency department (ED) setting.

METHODS

We analyzed a limited dataset obtained through the IBM Watson Health Explorys. Matched cohorts were defined for: 1) patients treated with opioids during the ED encounter (ED-Opioid) vs. neither opioid or benzodiazepine treatment (No medication) (n = 5372); 2) patients treated with opioids and benzodiazepines during the ED encounter (ED-Opioid+Benzodiazepines) vs. No Medication (n = 2454); and 3) ED-Opioid+Benzodiazepines vs. ED-Opioid (n = 2454). Patients consisted of adults with an emergency department encounter in the MetroHealth System (Cleveland, Ohio) with a chief complaint of traumatic injury and medical records for five years following the encounter. Control patients for each cohort were matched to the exposure patients on demographics, body mass index, and residential zip code median income. Outcomes were five-year incidence rates for alcohol, substance use, depression, and anxiety-related diagnoses.

RESULTS

Our results indicate that, although receiving opioids during the ED visit predicted a relatively lower likelihood of subsequent substance use and mental health diagnoses, the brief co-use of benzodiazepines was strongly associated with poorer outcomes.

CONCLUSIONS

Even brief exposure to co-prescribed opioids and benzodiazepines during emergency traumatic injury care may be associated with negative substance use and mental health consequences in the years following the event.

Early versus late Catheter Ablation of Atrial Fibrillation and Risk of Permanent Pacemaker Implantation in patients with underlying Sinus Node Dysfunction

Background

Atrial fibrillation (AF) is associated with anatomical and electrical remodeling. Some patients with AF have concomitant sick sinus syndrome and may need permanent pacemaker (PPM) implantation. Association between catheter ablation of AF timing and need for PPM in sick sinus syndrome has not been assessed.

Methods and Results

We used pooled electronic health data to perform retrospective cross‐sectional analysis of 66,  595 patients with AF and sick sinus syndrome to assess the need of PPM implantation temporally, with AF performed divided into earlier within 5 years (group 1), 5 to 10 years (group 2), or beyond 10 years (group 3) of diagnosis. PPM implantation was lowest among those who had catheter ablation within 5 years of sick sinus syndrome diagnosis: group 1 versus group 2 (18.15% versus 27.21%) and group 1 versus group 3 (18.15% versus 27.22%). Interestingly, there was no difference in risk of PPM between group 2 and group 3 (27.21% versus 27.22%; odds ratio [OR], 1.00 [95% CI, 0.85–1.20]).

Conclusions

Even after controlling known risk factors that increase the need for pacemaker implantation, timing of AF ablation was the strongest predictor for need for PPM. Patients adjusted OR of PPM was lower if patients had catheter ablation within 5 years of diagnosis compared with later than 5 years (adjusted OR, 0.64 [95% CI, 0.59–0.70]).

Individual and Combined Effect of Diabetes and Lifetime Criminal Justice Involvement on Healthcare Utilization in US Adults, 2015-2019

BACKGROUND

Diabetes and criminal justice involvement (CJI) are both associated with poor health outcomes and increased healthcare utilization. However, little is known about the additive effects of these risk factors when combined. This study examined the individual and combined effects of diabetes and CJI on healthcare utilization.

METHODS

Data from the National Survey of Drug Use and Health (2015-2019) was used to create a cross-sectional, nationally representative sample of US adults with diabetes, CJI, combination of both, or neither. Negative binomial regression was used to test the association between those with CJI and diabetes (compared to diabetes alone) and three utilization types (outpatient, ED, and inpatient) controlling for relevant sociodemographic and clinical covariates.

RESULTS

Of 212,079 respondents, representing 268,893,642 US adults, 8.8% report having diabetes alone, 15.2% report having CJI alone, and 1.8 % report both diabetes and lifetime CJI. After adjustment, those with diabetes and CJI had increased acute care utilization compared to those with diabetes alone (ED visits: IRR 1.13; 95% CI 1.00-1.28; nights hospitalized: IRR 1.34; 95% CI 1.08-1.67). There was no difference in outpatient utilization between those with both diabetes and CJI compared to those with diabetes alone (IRR 1.04, 95% CI 0.99-1.10).

CONCLUSION

Individuals with complex social and health risks such as diabetes and lifetime CJI experience increased acute healthcare utilization but no difference in outpatient utilization. Tailored interventions that target both diabetes and CJI are needed to reduce unnecessary utilization in this population.

Proposing a “Brain Health Checkup (BHC)” as a Global Potential “Standard of Care” to Overcome Reward Dysregulation in Primary Care Medicine: Coupling Genetic Risk Testing and Induction of “Dopamine Homeostasis”

In 2021, over 100,000 people died prematurely from opioid overdoses. Neuropsychiatric and cognitive impairments are underreported comorbidities of reward dysregulation due to genetic antecedents and epigenetic insults. Recent genome-wide association studies involving millions of subjects revealed frequent comorbidity with substance use disorder (SUD) in a sizeable meta-analysis of depression. It found significant associations with the expression of NEGR1 in the hypothalamus and DRD2 in the nucleus accumbens, among others. However, despite the rise in SUD and neuropsychiatric illness, there are currently no standard objective brain assessments being performed on a routine basis. The rationale for encouraging a standard objective Brain Health Check (BHC) is to have extensive data available to treat clinical syndromes in psychiatric patients. The BHC would consist of a group of reliable, accurate, cost-effective, objective assessments involving the following domains: Memory, Attention, Neuropsychiatry, and Neurological Imaging. Utilizing primarily PUBMED, over 36 years of virtually all the computerized and written-based assessments of Memory, Attention, Psychiatric, and Neurological imaging were reviewed, and the following assessments are recommended for use in the BHC: Central Nervous System Vital Signs (Memory), Test of Variables of Attention (Attention), Millon Clinical Multiaxial Inventory III (Neuropsychiatric), and Quantitative Electroencephalogram/P300/Evoked Potential (Neurological Imaging). Finally, we suggest continuing research into incorporating a new standard BHC coupled with qEEG/P300/Evoked Potentials and genetically guided precision induction of “dopamine homeostasis” to diagnose and treat reward dysregulation to prevent the consequences of dopamine dysregulation from being epigenetically passed on to generations of our children.

Dynamics and correlations in multiplex immune profiling reveal persistent immune inflammation in male drug users after withdrawal

Drug withdrawal elicits immune responses that contribute to the development of withdrawal symptoms and relapse. The understanding of the immunologic dynamics after drug withdrawal is limited, precluding the finding of promising immune intervention measures. Here, we performed cytokine and multiplex immune profiling in heroin, methamphetamine (METH) and ephedrine users after withdrawal and identified the correlation between cytokines and other immune parameters. We showed that broad and strong inflammatory responses occurred at the early stage after drug withdrawal, and the inflammatory responses showed a downtrend with the extension of withdrawal time. Notably, immune dysregulation remained through and may last longer than 12 months after withdrawal in heroin and METH users. Our findings suggest that cytokines, immune cells, complement and immunoglobulin form a complex immune network that regulates immune responses after withdrawal. These data provide a reference for future scientific research and drug research and development.

The emergence of insulin resistance following a chronic high-fat diet regimen coincides with an increase in the reinforcing effects of nicotine in a sex-dependent manner

The present study assessed the sex-dependent effects of insulin resistance on the reinforcing effects of nicotine. Female and male rats received a chronic high-fat diet (HFD) or regular diet (RD) for 8 weeks. A subset of rats then received vehicle or a dose of streptozotocin (STZ; 25 mg/kg) that induces insulin resistance. To assess insulin resistance, glucose levels were measured 15, 30, 60, 120, and 180 min after an insulin injection (0.75 U/kg). Nine days later, the rats were given extended access to intravenous self-administration (IVSA) of nicotine (0.015, 0.03, 0.06 mg/kg) in an operant box where they consumed their respective diet ad libitum and performed responses for water deliveries. Each nicotine dose was delivered for 4 days with 3 intermittent days of abstinence in their home cage. The day after the last IVSA session, physical signs were compared following administration of mecamylamine (3.0 mg/kg) to precipitate nicotine withdrawal. The results revealed that there were no changes in insulin resistance or nicotine intake in HFD alone rats regardless of sex. Insulin resistance was observed in HFD-fed rats that received STZ, and the magnitude of this effect was greater in males versus females. Our major finding was that nicotine intake was greater among HFD + STZ female rats as compared to males. Lastly, the physical signs of withdrawal were similar across all groups. Our results suggest that females diagnosed with disorders that disrupt insulin signaling, such as diabetes may be at risk of greater vulnerability to nicotine use due to enhanced reinforcing effects of this drug.

Substance Use Disorders and Diabetes Care: Lessons From New York Health Homes

BACKGROUND

Individuals that have both diabetes and substance use disorder (SUD) are more likely to have adverse health outcomes and are less likely to receive high quality diabetes care, compared with patients without coexisting SUD. Care management programs for patients with chronic diseases, such as diabetes and SUD, have been associated with improvements in the process and outcomes of care.

OBJECTIVE

The aim was to assess the impact of having coexisting SUD on diabetes process of care metrics.

RESEARCH DESIGN

Preintervention/postintervention triple difference analysis.

SUBJECTS

Participants in the New York State Medicaid Health Home (NYS-HH) care management program who have diabetes and a propensity-matched comparison group of nonparticipants (N=37,260).

MEASURES

Process of care metrics for patients with diabetes: an eye (retinal) exam, HbA1c test, medical attention (screening laboratory measurements) for nephropathy, and receiving all 3 in the past year.

RESULTS

Before enrollment in NYS-HH, individuals with comorbid SUD had fewer claims for eye exams and HbA1c tests compared with those without comorbid SUD. Diabetes process of care improvements associated with NYS-HH enrollment were larger among those with comorbid SUD [eye exam: adjusted odds ratio (AOR)=1.08; 95% confidence interval (CI): 1.01-1.15]; HbA1c test: AOR=1.20 (95% CI: 1.11-1.29); medical attention for nephropathy: AOR=1.21 (95% CI: 1.12-1.31); all 3: AOR=1.09 (95% CI: 1.02-1.16).

CONCLUSIONS

Individuals with both diabetes and SUD may benefit moderately more from care management than those without comorbid SUD. Individuals with both SUD and diabetes who are not enrolled in care management may be missing out on crucial diabetes care.

Service utilization and chronic condition outcomes among primary care patients with substance use disorders and co-occurring chronic conditions

BACKGROUND

Patients with a substance use disorder (SUD) often present with co-occurring chronic conditions in primary care. Despite the high co-occurrence of chronic medical conditions and SUD, little is known about whether chronic condition outcomes or related service utilization in primary care varies between patients with versus without documented SUDs. This study examined whether having a SUD influenced the use of primary care services and common chronic condition outcomes for patients with diabetes, hypertension, and obesity.

METHODS

A longitudinal cohort observational study examined electronic health record data from 21 primary care clinics in Washington and Idaho to examine differences in service utilization and clinical outcomes for diabetes, hypertension, and obesity in patients with and without a documented SUD diagnosis. Differences between patients with and without documented SUD diagnoses were compared over a three-year window for clinical outcome measures, including hemoglobin A1c, systolic and diastolic blood pressure, and body mass index, as well as service outcome measures, including number of encounters with primary care and co-located behavioral health providers, and orders for prescription opioids. Adult patients (N = 10,175) diagnosed with diabetes, hypertension, or obesity before the end of 2014, and who had ≥2 visits across a three-year window including at least one visit in 2014 (baseline) and at least one visit occurring 12 months or longer after the 2014 visit (follow-up) were examined.

RESULTS

Patients with SUD diagnoses and co-occurring chronic conditions were seen by providers more frequently than patients without SUD diagnoses (p's < 0.05), and patients with SUD diagnoses were more likely to be prescribed opioid medications. Chronic condition outcomes were no different for patients with versus without SUD diagnoses.

DISCUSSION

Despite the higher visit rates to providers in primary care, a majority of patients with SUD diagnoses and chronic medical conditions in primary care did not get seen by co-located behavioral health providers, who can potentially provide and support evidence informed care for both SUD and chronic conditions. Patients with chronic medical conditions also were more likely to get prescribed opioids if they had an SUD diagnosis. Care pathway innovations for SUDs that include greater utilization of evidence-informed co-treatment of SUDs and chronic conditions within primary care settings may be necessary for improving care overall for patients with comorbid SUDs and chronic conditions.

The effects of substance use on severe acute respiratory syndrome coronavirus infection risks and outcomes

PURPOSE OF REVIEW

Severe acute respiratory syndrome coronavirus (SARS-CoV2) infection rates are currently occurring at alarmingly accelerated rates. There is also a long-standing and concurrent rise in the prevalence and severity of substance use disorders (SUD). Therefore, the intersection between these two conditions needs to be carefully considered to ensure a more effective delivery of healthcare.

RECENT FINDINGS

Generally, those with SUDs are more likely to have higher risk social determinants of health factors. Therefore, these patients are more likely to have barriers that can create difficulties in following appropriate infection control measures which in turn increases the risk of exposure to SARS-CoV2. In addition, these individuals have higher rates of medical comorbidities which increases the risk of all adverse outcomes, including mortality, from SARS-CoV2 infection.

SUMMARY

Individuals with SUDs are at increased risk of both contracting SARS-CoV2 infection and suffering from worse outcomes afterwards. Though these risks of adverse outcomes are specific of SARS-CoV2 infection, the risk of exposure to other infectious diseases is increased in this population too. Healthcare providers and policymakers should then consider how to better protect this at-risk population and alleviate this increased disease burden.

COVID-19 risk and outcomes in patients with substance use disorders: analyses from electronic health records in the United States

The global pandemic of COVID-19 is colliding with the epidemic of opioid use disorders (OUD) and other substance use disorders (SUD) in the United States (US). Currently, there is limited data on risks, disparity, and outcomes for COVID-19 in individuals suffering from SUD. This is a retrospective case-control study of electronic health records (EHRs) data of 73,099,850 unique patients, of whom 12,030 had a diagnosis of COVID-19. Patients with a recent diagnosis of SUD (within past year) were at significantly increased risk for COVID-19 (adjusted odds ratio or AOR = 8.699 [8.411-8.997], P < 10^-30), an effect that was strongest for individuals with OUD (AOR = 10.244 [9.107-11.524], P < 10^-30), followed by individuals with tobacco use disorder (TUD) (AOR = 8.222 ([7.925-8.530], P < 10^-30). Compared to patients without SUD, patients with SUD had significantly higher prevalence of chronic kidney, liver, lung diseases, cardiovascular diseases, type 2 diabetes, obesity and cancer. Among patients with recent diagnosis of SUD, African Americans had significantly higher risk of COVID-19 than Caucasians (AOR = 2.173 [2.01-2.349], P < 10^-30), with strongest effect for OUD (AOR = 4.162 [3.13-5.533], P < 10^-25). COVID-19 patients with SUD had significantly worse outcomes (death: 9.6%, hospitalization: 41.0%) than general COVID-19 patients (death: 6.6%, hospitalization: 30.1%) and African Americans with COVID-19 and SUD had worse outcomes (death: 13.0%, hospitalization: 50.7%) than Caucasians (death: 8.6%, hospitalization: 35.2%). These findings identify individuals with SUD, especially individuals with OUD and African Americans, as having increased risk for COVID-19 and its adverse outcomes, highlighting the need to screen and treat individuals with SUD as part of the strategy to control the pandemic while ensuring no disparities in access to healthcare support.

Insulin restores the neurochemical effects of nicotine in the mesolimbic pathway of diabetic rats

This study examined whether insulin modulates the neurochemical effects of nicotine in the mesolimbic pathway of diabetic rats. The rats received vehicle or streptozotocin (STZ) to induce hypoinsulinemia. A subset of STZ-treated rats was implanted with insulin pellets that rapidly normalized glucose levels. Two-weeks later, dialysis probes were implanted into the nucleus accumbens (NAc) and ipsilateral ventral tegmental area (VTA). The next day, dialysate samples were collected during baseline and then following systemic administration of nicotine. Samples were also collected following intra-VTA administration of the gamma-aminobutyric acid (GABA)A receptor antagonist, bicuculline. Dopamine, GABA, glutamate, and acetylcholine (ACh) levels were assessed using liquid chromatography/mass spectrometry (LC/MS). The results revealed that vehicle-treated rats displayed a nicotine-induced increase in NAc dopamine levels. In contrast, STZ-treated rats did not display any changes in NAc dopamine following nicotine administration, an effect that was likely related to a concomitant increase in GABA and decrease in glutamate levels in both the NAc and VTA. Intra-VTA administration of bicuculline increased NAc dopamine in vehicle-treated rats, and this effect was absent in STZ-treated rats. Vehicle-treated rats displayed a nicotine-induced increase in ACh levels in the NAc (but not VTA), an effect that was lower in the NAc of STZ-treated rats. Insulin supplementation normalized the neurochemical effects of nicotine in the NAc and VTA of STZ-treated rats, suggesting that insulin modulates the neurochemical effects of nicotine in the mesolimbic pathway of diabetic rats.

Assessment of metformin, nicotine, caffeine, and methamphetamine use during Chinese public holidays

Metformin, nicotine, caffeine, and methamphetamine are widely used in China. However, the consumption pattern of these substances among the general population during Chinese public holidays may be different. Influent wastewater samples were collected from a municipal wastewater treatment plant in Yingkou, China on public holidays (n = 6) and working days (n = 20) to examine the changes in metformin, nicotine, caffeine, and methamphetamine consumption. The consumption of metformin in the city ranged from 1.94 to 14.4 g d^-1 1000 people^-1, while that of nicotine, caffeine, and methamphetamine ranged from 0.46 to 2.18 g d^-1 1000 people^-1, 31.8-89.8 g d^-1 1000 people^-1, and 87.0-657 mg d^-1 1000 people^-1, respectively. The highest consumption of metformin, caffeine, and methamphetamine was observed during the Spring Festival. The results indicated that the consumption of these substances showed almost the same trend and was higher during the Spring Festival, which may be influenced by personal habits and traditional festival reunions. There is a correlation between the consumption of nicotine and caffeine. Moreover, there are correlations between the consumption of metformin and nicotine, caffeine, as well as methamphetamine. The information based on wastewater epidemiology and consumption behavior, suggests that drug use in the region requires more attention or monitoring during holidays.

The association between regular cocaine use, with and without tobacco co-use, and adverse cardiovascular and respiratory outcomes

BACKGROUND

Understanding the potential impact of cocaine use on health is increasingly important as cocaine use rises in the U.S.

OBJECTIVES

This study evaluated the associations of regular cocaine use, with and without tobacco co-use, with cardiovascular and respiratory outcomes.

METHODS

Analysis of a limited dataset obtained through IBM Watson Health Explorys, a platform integrating electronic health record data. Matched controls were defined for: 1) cocaine-using patients (n = 8244; 44 % female); and subgroups of cocaine-using patients: 2) with an encounter diagnosis for tobacco use disorder (TUD; n = 4706); and 3) without a TUD diagnosis (non-TUD; n = 3538). Patients had at least one documented medical evaluation in the MetroHealth System (Cleveland, Ohio). Cocaine-using patients had an encounter diagnosis of cocaine abuse/dependence and/or ≥2 cocaine-positive drug screens. Control patients, with no documented cocaine-use, were matched to the cocaine-using patients on demographics, residential zip code median income, body mass index, and, for the total sample, TUD-status. Outcomes were encounter diagnosis (yes/no) of cerebrovascular accident, heart arrhythmia, myocardial infarction, subarachnoid hemorrhage, asthma, chronic obstructive pulmonary disease (COPD), pneumonia, and all-cause mortality.

RESULTS

TUD-patients had the greatest prevalence of cardiovascular and respiratory disease, regardless of cocaine-use indication. In the total sample, TUD, and non-TUD subgroups, regular cocaine use was significantly associated with greater risk for cerebrovascular accident, arrhythmia, myocardial infarction, asthma, COPD, pneumonia and mortality.

CONCLUSIONS

Cocaine use is associated with significantly greater risk of adverse cardiovascular and respiratory diagnoses and all-cause mortality.

Does the Encounter Type Matter When Defining Diabetes Complications in Electronic Health Records?

BACKGROUND

Electronic health records (EHRs) and claims records are widely used in defining type 2 diabetes mellitus (T2DM) complications across different types of health care encounters.

OBJECTIVE

This study investigates whether using different EHR encounter types to define diabetes complications may lead to different results when examining associations between diabetes complications and their risk factors in patients with T2DM.

RESEARCH DESIGN

The study cohort of 64,855 adult patients with T2DM was created from EHR data from the Research Action for Health Network (REACHnet), using the Surveillance Prevention, and Management of Diabetes Mellitus (SUPREME-DM) definitions. Incidence of coronary heart disease (CHD) and stroke events were identified using International Classification of Diseases (ICD)-9/10 codes and grouped by encounter types: (1) inpatient (IP) or emergency department (ED) type, or (2) any health care encounter type. Cox proportional hazards regression was used to estimate associations between diabetes complications (ie, CHD and stroke) and risk factors (ie, low-density lipoprotein cholesterol and hemoglobin A1c).

RESULTS

The incidence rates of CHD and stroke in all health care settings were more than twice the incidence rates of CHD and stroke in IP/ED settings. The age-adjusted and multivariable-adjusted hazard ratios for incident CHD and stroke across different levels of low-density lipoprotein cholesterol and hemoglobin A1c were similar between IP/ED and all settings.

CONCLUSION

While there are large variations in incidence rates of CHD and stroke as absolute risks, the associations between both CHD and stroke and their respective risk factors measured by hazard ratios as relative risks are similar, regardless of alternative definitions.

The association between regular cannabis use, with and without tobacco co-use, and adverse cardiovascular outcomes: cannabis may have a greater impact in non-tobacco smokers

BACKGROUND

Understanding the potential impact of cannabis use on cardiovascular health is increasingly important as cannabis use rises in the U.S. Objectives: This study evaluated the associations between regular cannabis use, with and without tobacco co-use, and cardiovascular outcomes.

METHODS

Analysis of a limited dataset obtained through IBM Watson Health Explorys, a platform integrating electronic health record data. Matched controls using Mahalanobis distance within propensity score calipers were defined for: 1) cannabis-using patients (n = 8,944; 43% female); and subgroups of cannabis-using patients: 2) with an encounter diagnosis for tobacco use disorder (TUD; n = 4,682); and 3) without a TUD diagnosis (non-TUD; n = 4,262). Patients had ≥1 blood pressure measurement and blood chemistry lab result in the MetroHealth System (Cleveland, Ohio). Cannabis-using patients had an encounter diagnosis of cannabis abuse/dependence and/or ≥2 cannabis-positive urine drug screens. Control patients, with no cannabis-use-documentation, were matched to the cannabis-using patients on demographics, residential zip code median income, body mass index, and, for the total sample, TUD-status. Outcomes were encounter diagnosis (yes/no) of cerebrovascular accident (CVA), heart arrhythmia, myocardial infarction, subarachnoid hemorrhage (SAH), and all-cause mortality.

RESULTS

TUD-patients had the greatest prevalence of cardiovascular disease, regardless of cannabis-use indication. In the total sample and non-TUD subgroup, regular cannabis use was significantly associated with greater risk for CVA, arrhythmia, SAH, and mortality. In the TUD subgroup, regular cannabis use was significantly associated with greater risk for arrhythmia and SAH.

CONCLUSIONS

Cannabis use is associated with significantly greater risk of adverse cardiovascular diagnoses and overall death, particularly in non-tobacco users.

Tumor Necrosis Factor (TNF) blocking agents are associated with lower risk for Alzheimer's disease in patients with rheumatoid arthritis and psoriasis

This large, retrospective case-control study of electronic health records from 56 million unique adult patients examined whether or not treatment with a Tumor Necrosis Factor (TNF) blocking agent is associated with lower risk for Alzheimer’s disease (AD) in patients with rheumatoid arthritis (RA), psoriasis, and other inflammatory diseases which are mediated in part by TNF and for which a TNF blocker is an approved treatment. The analysis compared the diagnosis of AD as an outcome measure in patients receiving at least one prescription for a TNF blocking agent (etanercept, adalimumab, and infliximab) or for methotrexate. Adjusted odds ratios (AORs) were estimated using the Cochran-Mantel-Haenszel (CMH) method and presented with 95% confidence intervals (CIs) and p-values. RA was associated with a higher risk for AD (Adjusted Odds Ratio (AOR) = 2.06, 95% Confidence Interval: (2.02–2.10), P-value <0.0001) as did psoriasis (AOR = 1.37 (1.31–1.42), P <0.0001), ankylosing spondylitis (AOR = 1.57 (1.39–1.77), P <0.0001), inflammatory bowel disease (AOR = 2.46 (2.33–2.59), P < 0.0001), ulcerative colitis (AOR = 1.82 (1.74–1.91), P <0.0001), and Crohn’s disease (AOR = 2.33 (2.22–2.43), P <0.0001). The risk for AD in patients with RA was lower among patients treated with etanercept (AOR = 0.34 (0.25–0.47), P <0.0001), adalimumab (AOR = 0.28 (0.19–0.39), P < 0.0001), or infliximab (AOR = 0.52 (0.39–0.69), P <0.0001). Methotrexate was also associated with a lower risk for AD (AOR = 0.64 (0.61–0.68), P <0.0001), while lower risk was found in patients with a prescription history for both a TNF blocker and methotrexate. Etanercept and adalimumab also were associated with lower risk for AD in patients with psoriasis: AOR = 0.47 (0.30–0.73 and 0.41 (0.20–0.76), respectively. There was no effect of gender or race, while younger patients showed greater benefit from a TNF blocker than did older patients. This study identifies a subset of patients in whom systemic inflammation contributes to risk for AD through a pathological mechanism involving TNF and who therefore may benefit from treatment with a TNF blocking agent.

Alcohol and illicit drug use in people with diabetes

As the prevalence of type 1 and type 2 diabetes increases and population-level patterns of alcohol and illicit drug use evolve, clinicians will continue to encounter people with diabetes whose substance use is affecting health outcomes. Substance use contributes substantially to the population-level prevalence of cardiovascular events, cerebrovascular events, cancers, mental health conditions, road trauma, and domestic violence. Alcohol and drug use also have a measurable effect on diabetes incidence and the development of both acute and chronic diabetes-related complications. In this Review, we examine the effect of alcohol and illicit drug use on people with type 1 or type 2 diabetes. We describe evidence for substance use as a risk factor for new-onset diabetes, prevalence of use in people with diabetes, evidence linking substance use with diabetes-related health outcomes, and evidence on the management of these co-occurring conditions.

Regular cannabis use, with and without tobacco co-use, is associated with respiratory disease

BACKGROUND

Cannabis use is a potential risk factor for respiratory disease but its role apart from tobacco use is unclear. We evaluated the association between regular cannabis use, with and without tobacco co-use, and onset of asthma, chronic obstructive pulmonary disease (COPD), and pneumonia.

METHODS

Analysis of a limited data set obtained through IBM Watson Health Explorys, an electronic-health-record-integration platform. Matched controls using Mahalanobis distance within propensity score calipers were defined for: 1) cannabis-using patients (n = 8932); and subgroups of cannabis-using patients: 2) with an encounter diagnosis for tobacco use disorder (TUD; n = 4678); and 3) without a TUD diagnosis (non-TUD; n = 4254). Patients had at least: one recorded blood pressure measurement and one blood chemistry lab result in the MetroHealth System (Cleveland, Ohio). Cannabis-using patients had an encounter diagnosis of cannabis abuse/dependence and/or ≥2 cannabis-positive urine drug screens (UDSs). Control patients, not having cannabis-related diagnoses or cannabis-positive UDSs, were matched to the cannabis-using patients on demographics, residential zip code median income, body mass index, and, for the total sample, TUD-status.

RESULTS

Regular cannabis use was significantly associated with greater risk for asthma (odds ratio (OR) = 1.44; adjusted odds ratio (aOR) = 1.50; OR = 1.32), COPD (OR = 1.56; aOR = 1.44; OR = 2.17), and pneumonia (OR = 1.80; OR = 1.84; OR = 2.13) in the total sample and TUD and non-TUD subgroups, respectively. TUD-patients had the greatest prevalence of respiratory disease, regardless of cannabis-use indication.

CONCLUSIONS

Regular cannabis use is associated with significantly greater risk of respiratory disease regardless of TUD status. Future research to understand the impact of cannabis use on respiratory health is warranted.

Commentary on Winhusen et al. (2019): Substance use disorders, chronic diseases, and electronic health records-a paradigm for screening and intervention

The use of the electronic health record to study the relationship between substance use disorders, diabetes and hypertension has identified high-severity, high-cost conditions. Improving data quality and validation will enhance our ability to perform medical record-based screening of substance use disorders and treatment of their complications among patients with multiple chronic illnesses.