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Liu O, Leon D, Gough E, Hanna M, Jaremko K. A retrospective analysis of perioperative medications for opioid-use disorder and tapering additional postsurgical opioids via a transitional pain service. Br J Clin Pharmacol 2024. [PMID: 38817150 DOI: 10.1111/bcp.16118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/19/2024] [Accepted: 04/27/2024] [Indexed: 06/01/2024] Open
Abstract
AIMS To investigate perioperative opioid requirements in patients on methadone or buprenorphine as medication for opioid-use disorder (MOUD) who attended a transitional pain clinic (Personalized Pain Program, PPP). METHODS This retrospective cohort study assessed adults on MOUD with surgery and attendance at the Johns Hopkins PPP between 2017 and 2022. Daily non-MOUD opioid use over 6 time-points was evaluated with regression models controlling for days since surgery. The time to complete non-MOUD opioid taper was analysed by accelerated failure time and Kaplan-Meier models. RESULTS Fifty patients (28 on methadone, 22 on buprenorphine) were included with a median age of 44.3 years, 54% male, 62% Caucasian and 54% unemployed. MOUD inpatient administration occurred in 92.8% of patients on preoperative methadone but only in 36.3% of patients on preoperative buprenorphine. Non-MOUD opioid use decreased over time postoperatively (β = -0.54, P < .001) with a median decrease of 90 mg morphine equivalents (MME) between the first and last PPP visit, resulting in 46% tapered off by PPP completion. Older age and duration in PPP were associated with lower MME, while mental health conditions, longer hospital stays and higher discharge opioid prescriptions were associated with higher MME. The average time to non-MOUD opioid taper was 1.79× longer in patients on buprenorphine (P = .026), 2.75× in males (P = .023), 4.66× with mental health conditions (P < .001), 2.37× with chronic pain (P = .031) and 3.51× if on preoperative non-MOUD opioids; however, higher initial MOUD level decreased time to taper (P = .001). CONCLUSIONS Postoperative opioid tapering utilizing a transitional pain service is possible in patients on MOUD.
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Affiliation(s)
- Olivia Liu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David Leon
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ethan Gough
- Department of Biostatistics, Epidemiology and Data Management Core, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Marie Hanna
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kellie Jaremko
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Petrakis IL, Meshberg-Cohen S, Nich C, Kelly MM, Claudio T, Jane JS, Pisani E, Ralevski E. Cognitive processing therapy (CPT) versus individual drug counseling (IDC) for PTSD for veterans with opioid use disorder maintained on buprenorphine. Am J Addict 2024. [PMID: 38624259 DOI: 10.1111/ajad.13557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 03/28/2024] [Accepted: 04/02/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND AND OBJECTIVES There are high rates of comorbidity between posttraumatic stress disorder (PTSD) and opioid use disorder (OUD). Evidence-based trauma-focused psychotherapies such as Cognitive Processing Therapy (CPT) are a first-line treatment for PTSD. Veterans with OUD are treated primarily in substance use disorder (SUD) clinics where the standard of care is drug counseling; they often do not have access to first-line PTSD treatments. This study tested whether CPT can be conducted safely and effectively in veterans with comorbid OUD treated with buprenorphine. METHODS This 12-week, 2-site, randomized clinical trial (RCT) included open-label randomization to two groups: (a) CPT versus (b) Individual Drug Counselling (IDC) in veterans with PTSD and comorbid OUD who were maintained on buprenorphine (N = 38). RESULTS Veterans randomized to either IDC (n = 18) or CPT (n = 20) showed a significant reduction in self-reported PTSD symptoms over time as measured by the PTSD checklist (PCL-5) but there were no treatment group differences; there was some indication that reduction in PTSD symptoms in the CPT group were sustained in contrast to the IDC group. Recruitment was significantly impacted by COVID-19 pandemic, so this study serves as a proof-of-concept pilot study. DISCUSSION AND CONCLUSIONS Veterans with OUD and PTSD can safely and effectively participate in evidence-based therapy for PTSD; further work should confirm that trauma-focused treatment may be more effective in leading to sustained remission of PTSD symptoms than drug counseling. SCIENTIFIC SIGNIFICANCE This is the first study to evaluate CPT for PTSD in the context of buprenorphine treatment for OUD.
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Affiliation(s)
- Ismene L Petrakis
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Psychiatry, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Sarah Meshberg-Cohen
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Psychiatry, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Charla Nich
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Megan M Kelly
- Department of Psychiatry, VA Bedford Healthcare System, Bedford, Massachusetts, USA
- Department of Psychiatry, UMass Chan Medical School, North Worcester, Massachusetts, USA
| | - Tracy Claudio
- Department of Psychiatry, VA Bedford Healthcare System, Bedford, Massachusetts, USA
| | - Jane Serrita Jane
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Psychiatry, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Emily Pisani
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Psychiatry, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Elizabeth Ralevski
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Psychiatry, VA Connecticut Healthcare System, West Haven, Connecticut, USA
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3
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Lepley J. President's message. J Addict Dis 2024; 42:1-4. [PMID: 37971783 DOI: 10.1080/10550887.2023.2282960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Affiliation(s)
- Jon Lepley
- Medical Director of Addiction Medicine, Penn Medicine Lancaster General Health, Lancaster, PA, USA
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Nowels MA, Duberstein PR, Crystal S, Treitler P, Miles J, Olfson M, Samples H. Suicide within 1 year of non-fatal overdose: Risk factors and risk reduction with medications for opioid use disorder. Gen Hosp Psychiatry 2024; 86:24-32. [PMID: 38061284 PMCID: PMC10880030 DOI: 10.1016/j.genhosppsych.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/15/2023] [Accepted: 11/03/2023] [Indexed: 01/27/2024]
Abstract
OBJECTIVE Individuals with substance use disorders and overdoses have high risk of suicide death, but evidence is limited on the relationship between interventions following the initial overdose and subsequent suicide death. METHODS National Medicare data were used to identify Medicare disability beneficiaries (MDBs) with inpatient or emergency care for non-fatal opioid overdoses from 2008 to 2016. Data were linked with National Death Index (NDI) to obtain dates and causes of death for the sample. Cox proportional hazards models estimated the associations between exposure to interventions (mechanical ventilation, MOUD) and suicide death. RESULTS The sample (n = 81,654) had a suicide rate in the year following a non-fatal overdose of 566 per 100,000 person-years. Post-overdose MOUD was associated with an adjusted hazard ratio of 0.20 (95%CI: 0.05,0.85). Risk of suicide was elevated for those whose initial overdoses required mechanical ventilation as part of the treatment (aHR: 1.86, 95%CI:[1.48,2.34]). CONCLUSIONS The year following a non-fatal opioid overdose is a very high-risk period for suicide among MDBs. Those receiving MOUD had an 80% reduction in the hazards of suicide, while those whose overdose treatment involved mechanical ventilation had 86% higher hazards of death by suicide. Our findings highlight the importance of psychiatric intervention in this high-risk population. Efforts are needed to initiate and retain more patients in MOUD.
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Affiliation(s)
- Molly A Nowels
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, 683 Hoes Lane West, Piscataway, NJ 08854, USA; Institute for Health, Health Care Policy, and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ 08901, USA.
| | - Paul R Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, 683 Hoes Lane West, Piscataway, NJ 08854, USA
| | - Stephen Crystal
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ 08901, USA
| | - Peter Treitler
- School of Social Work, Boston University, 264 Bay State Road, Boston, MA 02215, USA
| | - Jennifer Miles
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ 08901, USA
| | - Mark Olfson
- New York Psychiatric Institute, Columbia University, 1051 Riverside Drive, New York, NY 10032, USA
| | - Hillary Samples
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, 683 Hoes Lane West, Piscataway, NJ 08854, USA; Institute for Health, Health Care Policy, and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ 08901, USA
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5
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Vekaria V, Patra BG, Xi W, Murphy SM, Avery J, Olfson M, Pathak J. Association of opioid or other substance use disorders with health care use among patients with suicidal symptoms. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 156:209177. [PMID: 37820869 PMCID: PMC10841388 DOI: 10.1016/j.josat.2023.209177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 06/23/2023] [Accepted: 09/30/2023] [Indexed: 10/13/2023]
Abstract
INTRODUCTION Prior literature establishes noteworthy relationships between suicidal symptoms and substance use disorders (SUDs), particularly opioid use disorder (OUD). However, engagement with health care services among this vulnerable population remains underinvestigated. This study sought to examine patterns of health care use, identify risk factors in seeking treatment, and assess associations between outpatient service use and emergency department (ED) visits. METHODS Using electronic health records (EHRs) derived from five health systems across New York City, the study selected 7881 adults with suicidal symptoms (including suicidal ideation, suicide attempt, or self-harm) and SUDs between 2010 and 2019. To examine the association between SUDs (including OUD) and all-cause service use (outpatient, inpatient, and ED), we performed quasi-Poisson regressions adjusted for age, gender, and chronic disease burden, and we estimated the relative risks (RR) of associated factors. Next, the study evaluated cause-specific utilization within each resource category (SUD-related, suicide-related, and other-psychiatric) and compared them using Mann-Whitney U tests. Finally, we used adjusted quasi-Poisson regression models to analyze the association between outpatient and ED utilization among different risk groups. RESULTS Among patients with suicidal symptoms and SUD diagnoses, relative to other SUDs, a diagnosis of OUD was associated with higher all-cause outpatient visits (RR: 1.22), ED visits (RR: 1.54), and inpatient hospitalizations (RR: 1.67) (ps < 0.001). Men had a lower risk of having outpatient visits (RR: 0.80) and inpatient hospitalizations (RR: 0.90), and older age protected against ED visits (RR range: 0.59-0.69) (ps < 0.001). OUD was associated with increased SUD-related encounters across all settings, and increased suicide-related ED visits and inpatient hospitalizations (p < 0.001). Individuals with more mental health outpatient visits were less likely to have suicide-related ED visits (RR: 0.86, p < 0.01), however this association was not found among younger and male patients with OUD. Although few OUD patients received medications for OUD (MOUD) treatment (9.9 %), methadone composed the majority of MOUD prescriptions (77.7 %), of which over 70 % were prescribed during an ED encounter. CONCLUSIONS This study reinforces the importance of tailoring SUD and suicide risk interventions to different age groups and types of SUDs, and highlights missed opportunities for deploying screening and prevention resources among the male and OUD populations. Redressing underutilization of MOUD remains a priority to reduce acute health outcomes among younger patients with OUD.
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Affiliation(s)
- Veer Vekaria
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, United States of America
| | - Braja G Patra
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, United States of America
| | - Wenna Xi
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, United States of America
| | - Sean M Murphy
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, United States of America
| | - Jonathan Avery
- Department of Psychiatry, Weill Cornell Medicine, New York, NY, United States of America
| | - Mark Olfson
- Department of Psychiatry, Columbia University, New York, NY, United States of America
| | - Jyotishman Pathak
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, United States of America; Department of Psychiatry, Weill Cornell Medicine, New York, NY, United States of America.
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Peltzman T, Park J, Shiner B. Development and validation of a prognostic index for mental health and substance use disorder burden. Gen Hosp Psychiatry 2023; 85:213-219. [PMID: 37988871 DOI: 10.1016/j.genhosppsych.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/12/2023] [Accepted: 10/17/2023] [Indexed: 11/23/2023]
Abstract
OBJECTIVE To develop an accessible index which quantifies MHSUD burden among patients of Veterans Affairs hospitals. METHOD We used 21 disorder categories provided by the diagnostic and statistical manual (DSM) to characterize diagnoses among primary care (PC) patients. For each patient, we generated counts of unique disorder categories present during the PC encounter or in the year prior. We used these counts to generate multiple indexes, which we compared in a 60% training sample of our population. Using model fit statistics generated from ordered multinomial logistic regressions, we identified the subset of DSM categories which, structured as index, were most predictive of MHSUD hospitalization and death. We validated and fine-tuned the form of the selected index in the full population using measures of calibration and discrimination. RESULTS In model development, the index (I-6) which best fit the data (R2 = 0.191) included the following six disorder categories: substance use, depressive, psychotic, bipolar, trauma, and personality. When applied in the full population and weighted by disorder severity, this index demonstrated good predictive discrimination for MHSUD death (C = 0.66) and hospitalization (C = 0.88) and was well calibrated in comparisons of observed versus predicted outcomes. CONCLUSIONS We recommend the I-6 as a parsimonious and effective tool for MHSUD burden risk adjustment.
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Affiliation(s)
- Talya Peltzman
- Veterans Affairs Medical Center, White River Junction, VT, USA.
| | - Jenna Park
- Veterans Affairs Medical Center, White River Junction, VT, USA; Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | - Brian Shiner
- Veterans Affairs Medical Center, White River Junction, VT, USA; Geisel School of Medicine at Dartmouth College, Hanover, NH, USA; National Center for Posttraumatic Stress Disorder, White River, Junction, VT, USA
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Mutter R, Spencer D, McPheeters J. Outcomes Associated with Treatment with and Without Medications for Opioid Use Disorder. J Behav Health Serv Res 2023; 50:524-539. [PMID: 37311970 DOI: 10.1007/s11414-023-09841-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 06/15/2023]
Abstract
There is limited research on outcomes for patients who start treatment for opioid use disorder (OUD) with only psychosocial treatment compared to those who initiate treatment with either medications for OUD (MOUD) or the combination of psychosocial treatment and MOUD. Cox proportional hazards regression was used on a database of individuals with commercial health insurance or Medicare Advantage to estimate the associations of treatment type with opioid overdose and self-harm (separately). Logistic regression was used to estimate the association of treatment type with prescription opioid fill following treatment initiation. Relative to patients who initiated treatment with only psychosocial treatment, patients who also initiated treatment with MOUD had lower risk of having an overdose inpatient or emergency department (ED) encounter, a self-harm inpatient or ED encounter, and a prescription opioid filled following treatment initiation. Starting treatment with MOUD was associated with better patient outcomes than initiating treatment with only psychosocial treatment.
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Affiliation(s)
- Ryan Mutter
- Health Analysis Division, Congressional Budget Office, 441 D St SW, Washington, DC, 20515, USA
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8
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Felthous AR, Kulkarni N, Belean C. DSM-5-TR diagnosis as a guide to suicide risk assessment. BEHAVIORAL SCIENCES & THE LAW 2023; 41:373-396. [PMID: 37076959 DOI: 10.1002/bsl.2617] [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: 10/18/2022] [Revised: 02/27/2023] [Accepted: 03/01/2023] [Indexed: 05/03/2023]
Abstract
A specific mental disorder can itself constitute a risk factor for a completed suicide. Even more important, the disorder is typically a modifiable risk factor which informs its own treatment. Recent editions of the DSM have included "suicide subsections" for specific mental disorders and conditions in which the risks of suicidal thoughts and behaviors for the disorder are noted in the literature. The DSM-5-TR can therefore serve as a compendium to be referred to for initial guidance as to whether a specific disorder could contribute to the risk. Adding completed suicides and suicide attempts, also addressed in these subsections, the sections were examined individually for the four parameters of suicidality. Accordingly, the four parameters of suicidality examined here are: suicide, suicidal thoughts, suicidal behavior, and suicide attempts. After providing interpretive comments for each, the parameters for all disorders with a suicide subsection were tabulated for ease of reference. Because specific medical disorders are also associated with elevated rates of suicide, these disorders and the supporting research are tabulated and briefly acknowledged. Allowing for the limitations of the suicide subsections and their analysis, this exegesis is proposed to contribute to training in risk assessment for forensic psychiatry and psychology fellows and to highlight the potential referential value of the DSM-5-TR's suicide subsections for clinical practitioners and those who pursue research on suicide.
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Affiliation(s)
- Alan R Felthous
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, Saint Louis, Missouri, USA
| | - Neha Kulkarni
- Saint Louis University School of Medicine, Saint Louis, Missouri, USA
| | - Catalina Belean
- Department of Psychiatry and Behavioral Neuroscience, Saint Louis University School of Medicine, Saint Louis, Missouri, USA
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Lent MR, Dugosh KL, Hurstak E, Callahan HR, Mazur K. Prevalence and predictors of suicidality among adults initiating office-based buprenorphine. Addict Sci Clin Pract 2023; 18:37. [PMID: 37264472 DOI: 10.1186/s13722-023-00393-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 05/26/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND Individuals who have substance use disorders may have an elevated risk of suicidality. This study sought to examine the prevalence of, and identify factors associated with, suicidality in adults with opioid use disorder (OUD) initiating office-based buprenorphine treatment. METHODS Individuals were eligible to participate if they had OUD and had initiated treatment in the past month. Participants (n = 244) completed a semi-structured interview using the Addiction Severity Index-Lite. RESULTS At baseline, 37.70% of participants reported significant thoughts of suicide over their lifetime and 27.46% reported suicidal attempts over their lifetime. Logistic regression analyses were used to identify predictors of lifetime suicidal thoughts and attempts. A history of physical abuse (OR = 4.31, p < .001), having chronic pain-related conditions (OR = 3.28, p < .001), a history of depression (OR = 3.30, p = .001) or anxiety (OR = 7.47, p = .001), and Latino/a/x ethnicity (OR = 2.66, p = .01) were associated with an increased risk of lifetime suicidal thoughts. A history of sexual abuse (OR = 2.89, p = .01), Latino/a/x ethnicity (OR = 4.01, p < .001), a history of depression (OR = 4.03, p = .001) or anxiety (OR = 15.65, p = .007) and having a chronic pain-related condition (OR = 2.43, p = .01), were associated with an increased risk of lifetime suicide attempts. CONCLUSIONS Results demonstrate the high prevalence of suicidal thoughts and attempts among patients initiating buprenorphine. Findings may help to better identify at-risk patients and to inform screening, prevention, and mental health treatment efforts. TRIAL REGISTRATION ClinicalTrials.gov, NCT04650386 (registered 12 December 2020, https://clinicaltrials.gov/ct2/show/NCT04650386 ) and NCT04257214 (registered 5 February 2020, https://clinicaltrials.gov/ct2/show/NCT04257214 ).
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Affiliation(s)
- Michelle R Lent
- School of Professional and Applied Psychology, Philadelphia College of Osteopathic Medicine, 4190 City Avenue, Rowland Hall, Philadelphia, PA, 19131, USA.
| | - Karen L Dugosh
- Research and Evaluation Group, Public Health Management Corporation, 1500 Market Street, Philadelphia, PA, 19102, USA
| | - Emily Hurstak
- Boston University School of Medicine, 801 Massachusetts Avenue, 2nd floor, Boston, MA, 02118, USA
| | - Hannah R Callahan
- School of Professional and Applied Psychology, Philadelphia College of Osteopathic Medicine, 4190 City Avenue, Rowland Hall, Philadelphia, PA, 19131, USA
| | - Kimberly Mazur
- AtlantiCare HealthPlex, 1401 Atlantic Avenue, Atlantic City, NJ, 08401, USA
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Silwal A, Talbert J, Bohler RM, Kelsch J, Cook C, Blevins D, Gallivan M, Hunt T, Hatcher SM, Thomas CP, Williams S, Fanucchi L, Lofwall MR. State alignment with federal regulations in 2022 to relax buprenorphine 30-patient waiver requirements. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 7:100164. [PMID: 37234704 PMCID: PMC10206439 DOI: 10.1016/j.dadr.2023.100164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 04/28/2023] [Accepted: 05/01/2023] [Indexed: 05/28/2023]
Abstract
Background In 2021, the Department of Health and Human Services released guidelines allowing waiver-eligible providers seeking to treat up to 30 patients to be exempt from waiver training (WT) and the counseling and other ancillary services (CAS) attestation. This study evaluates if states and the District of Columbia had more restrictive policies preventing adoption of the 2021 federal guidelines. Methods First, the Westlaw database was searched for buprenorphine regulations. Second, state medical, osteopathic, physician assistant, nursing boards, and single state agencies (SSA) were surveyed to assess for the WT and CAS requirements and if they were discussing the 2021 guidelines. Results were recorded and compared by state and waiver-eligible provider types. Results The Westlaw search revealed seven states with regulations requiring the WT and ten states requiring CAS. Survey results showed ten state boards/SSAs required WT for at least one waiver-eligible practitioner type and eleven state boards/SSAs required CAS. In some states, the WT and CAS requirements only applied in special circumstances. Eleven states had discrepancies between the Westlaw and survey results among three waiver-eligible provider types. Conclusions Despite the 2021 federal change intended to increase access to buprenorphine, several states had regulations and/or provider boards and SSAs that were not supportive. Now, the Mainstreaming Addiction Treatment (MAT) Act of 2022 eliminated the federal x-waiver requirement to prescribe buprenorphine. However, these states may continue to have barriers to treatment access despite the MAT Act. Strategies to engage states with these restrictive policies are needed to improve buprenorphine treatment capacity.
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Affiliation(s)
- Anita Silwal
- Substance Use Priority Research Area (SUPRA), University of Kentucky, Lexington KY, USA
- Department of Communication, College of Communication and Information, University of Kentucky, Lexington, KY, USA
| | - Jeffery Talbert
- Division of Biomedical Informatics, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Robert M. Bohler
- Heller School for Social Policy and Management at Brandeis University, Waltham, MA, USA
| | - Jordan Kelsch
- Substance Use Priority Research Area (SUPRA), University of Kentucky, Lexington KY, USA
| | - Christopher Cook
- Substance Use Priority Research Area (SUPRA), University of Kentucky, Lexington KY, USA
| | - Derek Blevins
- Division of Substance Use Disorders, New York State Psychiatric Institute / Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
| | - Molly Gallivan
- Substance Use Priority Research Area (SUPRA), University of Kentucky, Lexington KY, USA
| | - Timothy Hunt
- Social Intervention Group, School of Social Work, Columbia University, New York, NY, USA
| | | | - Cindy Parks Thomas
- Heller School for Social Policy and Management at Brandeis University, Waltham, MA, USA
| | - Soncere Williams
- Social Intervention Group, School of Social Work, Columbia University, New York, NY, USA
| | - Laura Fanucchi
- Center on Drug and Alcohol Research, University of Kentucky, 845 Angliana Avenue, Lexington, KY 40508, USA
- Division of Infectious Diseases, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Michelle R. Lofwall
- Center on Drug and Alcohol Research, University of Kentucky, 845 Angliana Avenue, Lexington, KY 40508, USA
- Departments of Behavioral Science and Psychiatry, College of Medicine, University of Kentucky, Lexington, KY, USA
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11
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Riblet NB, Young-Xu Y, Shiner B, Schnurr PP, Watts BV. The efficacy and safety of buprenorphine for the treatment of depression: A systematic review and meta-analysis. J Psychiatr Res 2023; 161:393-401. [PMID: 37019069 PMCID: PMC10149594 DOI: 10.1016/j.jpsychires.2023.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/01/2023] [Accepted: 03/27/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND Depressive disorders are common. Many patients with major depression do not achieve remission with available treatments. Buprenorphine has been raised as a potential treatment for depression as well as suicidal behavior but may pose certain risks. METHODS A meta-analysis comparing the efficacy, tolerability, and safety of buprenorphine (or combinations such as buprenorphine/samidorphan) versus control in improving symptoms in patients with depression. Medline, Cochrane Database, PsycINFO, Excerpta Medica Database and The Cumulative Index to Nursing and Allied Health Literature were searched from inception through January 2, 2022. Depressive symptoms were pooled using Hedge's g with 95% Confidence Intervals (CI). Tolerability, safety, suicide outcomes were summarized qualitatively. RESULTS 11 studies (N = 1699) met inclusion criteria. Buprenorphine had a small effect on depressive symptoms (Hedges' g 0.17, 95%CI: 0.05-0.29). Results were driven by six trials of buprenorphine/samidorphan (N = 1,343, Hedges's g 0.17, 95%CI: 0.04-0.29). One study reported significant improvement in suicidal thoughts (Least Squares Mean Change: -7.1, 95%CI: -12.0 - 2.3). Most studies found buprenorphine was well-tolerated with no evidence of abuse behavior or dependency. CONCLUSIONS Buprenorphine may have a small benefit for depressive symptoms. Future research should clarify the dose response relationship between buprenorphine and depression.
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Affiliation(s)
- Natalie B Riblet
- Veterans Affairs Medical Center, Mental Health Service, 215 North Main Street, White River Junction, VT, 05009, USA; Geisel School of Medicine at Dartmouth, Department of Psychiatry and Dartmouth Institute, 1 Rope Ferry Road, Hanover, NH, 03755, USA.
| | - Yinong Young-Xu
- Veterans Affairs Medical Center, Mental Health Service, 215 North Main Street, White River Junction, VT, 05009, USA; Geisel School of Medicine at Dartmouth, Department of Psychiatry, 1 Rope Ferry Road, Hanover, NH, 03755, USA
| | - Brian Shiner
- Veterans Affairs Medical Center, Mental Health Service, 215 North Main Street, White River Junction, VT, 05009, USA; Geisel School of Medicine at Dartmouth, Department of Psychiatry and Dartmouth Institute, 1 Rope Ferry Road, Hanover, NH, 03755, USA; National Center for PTSD, 215 North Main Street, White River Junction, VT, 05009, USA
| | - Paula P Schnurr
- Geisel School of Medicine at Dartmouth, Department of Psychiatry, 1 Rope Ferry Road, Hanover, NH, 03755, USA; National Center for PTSD, 215 North Main Street, White River Junction, VT, 05009, USA
| | - Bradley V Watts
- Veterans Affairs Medical Center, Mental Health Service, 215 North Main Street, White River Junction, VT, 05009, USA; Geisel School of Medicine at Dartmouth, Department of Psychiatry, 1 Rope Ferry Road, Hanover, NH, 03755, USA; Veterans Rural Health Resource Center, White River Junction VA Medical Center, White River Junction, VT, 05009, USA
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12
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Mark TL, Parish WJ, Weber EM, Steinberg DG, Henretty K. The cost of opioid use disorder-related conditions in Medicare. Drug Alcohol Depend 2023; 244:109778. [PMID: 36701935 DOI: 10.1016/j.drugalcdep.2023.109778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/06/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023]
Abstract
BACKGROUND Medicare coverage excludes some levels of substance use disorder (SUD) care, such as intensive outpatient and residential treatment. Expanding access to SUD treatment could increase Medicare spending. However, these costs could be offset if SUD treatment resulted in cost savings from reducing SUD-related medical events and SUD-related medical comorbidities. METHODS This study estimated cost savings from expanding access to SUD treatment for persons with opioid use disorders (OUD) using three methods. First, we compared total Medicare fee-for-service spending on individuals with OUD and no treatment with OUD medications (MOUD) to Medicare spending on individuals without OUD after matching on age/sex/Medicare-Medicaid eligibility status. Second, we compared Medicare spending on individuals with OUD who received MOUD to spending individuals with OUD who did not receive MOUD. Third, we determined OUD-attributable Medicare spending for comorbid physical and mental conditions with a strong association with OUD. RESULTS Beneficiaries with OUD but no MOUD totaled $15.8 billion more than beneficiaries without OUD. Beneficiaries with OUD but no MOUD totaled $12.1 billion more than individuals with OUD and MOUD. Lastly, Medicare spending on OUD-attributable comorbidities was $4.7 billion if all medical and mental health comorbidities were included and $3.0 billion with only medical comorbidities. The totals could be 1.7 times higher if Medicare Advantage enrollees were included. CONCLUSION Expanding Medicare coverage of appropriate levels of care could improve access to effective treatment and reduce the costs associated with untreated OUD. This will likely result in substantial Medicare cost savings.
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Affiliation(s)
- Tami L Mark
- RTI International, 701 13th Street NW, Suite 750, Washington, DC 20005, USA.
| | - William J Parish
- RTI International, 3040 East Cornwallis Rd, P.O. Box 12194, Research Triangle Park, NC 27709, USA.
| | - Ellen M Weber
- Legal Action Center, 810 1st Street, NE, Suite 200, Washington DC 20002, USA.
| | - Deborah G Steinberg
- Legal Action Center, 810 1st Street, NE, Suite 200, Washington DC 20002, USA.
| | - Kristen Henretty
- RTI International, 3040 East Cornwallis Rd, P.O. Box 12194, Research Triangle Park, NC 27709, USA.
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13
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Sher L. Can buprenorphine reduce suicide mortality? Acta Psychiatr Scand 2023; 147:3-5. [PMID: 36529968 DOI: 10.1111/acps.13510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/09/2022] [Accepted: 10/10/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Leo Sher
- Inpatient Psychiatry, James J. Peters VA Medical Center, Bronx, New York, USA.,Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, New York, USA
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Gottlieb DJ, Shiner B, Hoyt JE, Riblet NB, Peltzman T, Teja N, Watts BV. A comparison of mortality rates for buprenorphine versus methadone treatments for opioid use disorder. Acta Psychiatr Scand 2023; 147:6-15. [PMID: 35837885 DOI: 10.1111/acps.13477] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/24/2022] [Accepted: 07/12/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Mortality from opioid use disorder (OUD) can be reduced for patients who receive opioid agonist treatment (OAT). In the United States (US), OATs have different requirements including nearly daily visits to a dispensing facility for methadone but weekly to monthly prescriptions for buprenorphine. Our objective was to compare mortality rates for buprenorphine and methadone treatments among a large sample of US patients with OUD. METHODS We measured all-cause mortality, overdose mortality, and suicide mortality among US Department of Veterans Affairs patients with a diagnosis of OUD who received OAT from 2010 through 2019. We leveraged substantial and sustained regional variation in prescribing buprenorphine versus methadone as an instrumental variable (IV) and used inverse propensity of treatment weighting to balance relevant covariates across treatment groups. We compared mortality with true two-stage IV using both probit and linear probability models, as well as a reduced form IV model, adjusting for demographics and health status. RESULTS Our cohort consisted of 61,997 patients with OUD who received OAT, of whom 92.7% were male with a mean age of 47.9 (SD = 14.1) years. Patients were followed for a median of 2 (IQR = 1,4) calendar years. Across regional terciles, mean methadone prescribing was 4.8%, 19.5%, and 75.1% of OAT patients. All models identified significant reductions in all-cause and suicide mortality for buprenorphine relative to methadone. For example, predicted all-cause mortality from the probit model was 169.7 per 10,000 person years (95% CI, 157.8, 179.6) in the lowest tercile of methadone prescribing compared with 206.1 (95% CI, 196.0, 216.3) in the highest tercile. No difference was identified for overdose mortality. CONCLUSION We found significantly lower all-cause mortality and suicide mortality rates for buprenorphine compared with methadone. Our results support the less restrictive prescribing practices for buprenorphine as OAT in the US.
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Affiliation(s)
- Daniel J Gottlieb
- Mental Health and Behavioral Science Service, White River Junction VA Medical Center, White River Junction, Vermont, USA
| | - Brian Shiner
- Mental Health and Behavioral Science Service, White River Junction VA Medical Center, White River Junction, Vermont, USA.,Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
| | - Jessica E Hoyt
- Mental Health and Behavioral Science Service, White River Junction VA Medical Center, White River Junction, Vermont, USA
| | - Natalie B Riblet
- Mental Health and Behavioral Science Service, White River Junction VA Medical Center, White River Junction, Vermont, USA.,Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
| | - Talya Peltzman
- Mental Health and Behavioral Science Service, White River Junction VA Medical Center, White River Junction, Vermont, USA
| | - Nikhil Teja
- Mental Health and Behavioral Science Service, White River Junction VA Medical Center, White River Junction, Vermont, USA.,Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
| | - Bradley V Watts
- Mental Health and Behavioral Science Service, White River Junction VA Medical Center, White River Junction, Vermont, USA.,Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
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15
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Masum M, Sparks J. Labor force status as a buffer against mortality risks associated with alcohol consumption: A study of adult U.S. women, 2001-2015. Prev Med 2022; 161:107139. [PMID: 35809823 PMCID: PMC9507174 DOI: 10.1016/j.ypmed.2022.107139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 05/05/2022] [Accepted: 07/02/2022] [Indexed: 11/25/2022]
Abstract
The association between women's labor force participation, their alcohol consumption patterns, and mortality risk is unclear. This study assessed all-cause mortality risk among women in the United States, considering their labor force status and alcohol drinking. This study used discrete-time hazard models to examine this association using 2001-2015 National Health Interview Survey-Linked Mortality Files (NHIS-LMF) data (n = 147,714) for women aged 25 to 65 with 5725 deaths in this sample. Complex survey-weighted adjustments and E-values calculations were used to limit quantitative and observational biases. Alcohol consumption and labor force status together lead to substantial mortality risks. There is a statistically significant mortality risk among unemployed women (HR 2.15, 95% CI 1.18-3.91) and women not in labor force (HR 2.38, 95% CI 1.87-3.01). In the stratified models, non-Hispanic blacks (HR 1.48, 95% CI 1.30-1.67) and Asians (HR 1.93, 95% CI 1.54-2.44) have heightened mortality risks borne out of employment. Women with higher psychological distress have a 26% higher risk of all-cause mortality when not in labor force. With the help of cross-sectional data, this study demonstrates that women not in labor force and unemployed women are more likely to be affected by their drinking habits, and their employment status is associated with lower mortality risk. Further research should be focused on cause-specific mortality, gender roles and norms, reasons for unemployment, and comorbidities using more recent data, causal modeling techniques, and an extended mortality follow-up period.
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Affiliation(s)
- Muntasir Masum
- Prevention Research Center, The Pennsylvania State University, 314 Biobehavioral Health Building, University Park, PA 16802, United States.
| | - Johnelle Sparks
- Department of Demography, The University of Texas at San Antonio, One UTSA Circle, San Antonio, TX 78249, United States
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16
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Frost MC, Richards JE, Blosnich JR, Hawkins EJ, Tsui JI, Edelman EJ, Williams EC. Association between clinically recognized suicidality and subsequent initiation or continuation of medications for opioid use disorder. Drug Alcohol Depend 2022; 237:109521. [PMID: 35716644 PMCID: PMC9546132 DOI: 10.1016/j.drugalcdep.2022.109521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/09/2022] [Accepted: 05/28/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Among individuals with opioid use disorder (OUD), medications for OUD (MOUD) may lower suicide risk. Therefore, it is important that individuals with OUD and suicidality receive MOUD. This study examined associations between clinically recognized suicidality and subsequent initiation or continuation of MOUD among patients with OUD in the national Veterans Health Administration (VA). METHODS Electronic health record data were extracted for outpatients with OUD who received VA care 10/1/2016-7/31/2017. Suicidality was measured using diagnostic codes for suicidal ideation/attempt and patient record flags. Analyses were conducted separately among patients without prior-year MOUD receipt to examine MOUD initiation, and with prior-year MOUD receipt to examine MOUD continuation. Poisson regression models estimated likelihood of MOUD receipt in the following year for patients with prior-year suicidality relative to those without. Models were adjusted for sociodemographic and clinical characteristics. RESULTS Among 20,085 patients with no prior-year MOUD, 12% had suicidality and 12% received MOUD in the following year. Suicidality was positively associated with MOUD initiation (adjusted incidence rate ratio [aIRR]: 1.15, 95% confidence interval [CI]: 1.04-1.28). Among 10,162 patients with prior-year MOUD, 9% had suicidality and 84% received MOUD in the following year. Suicidality was negatively associated with MOUD continuation (aIRR: 0.95, 95% CI 0.91-0.98). CONCLUSIONS Among VA patients with OUD, clinically recognized suicidality may increase likelihood of MOUD initiation but decrease likelihood of continuation. Efforts to increase initiation overall and to support retention for patients with suicidality are needed.
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Affiliation(s)
- Madeline C Frost
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, USA; Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195, USA.
| | - Julie E Richards
- Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195, USA; Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA 98101, USA.
| | - John R Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 669W 34th St, Los Angeles, CA 90089, USA; Health Services Research & Development (HSR&D) Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA 15240, USA.
| | - Eric J Hawkins
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, USA; Center of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, USA; Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, USA.
| | - Judith I Tsui
- Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, USA.
| | - E Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, New Haven, CT 06510, USA.
| | - Emily C Williams
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, USA; Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195, USA.
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17
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Kalin NH. Integrating Clinical and Basic Research: Opioid Use Disorder, Psychotic Illnesses, and Prefrontal Microcircuits Relevant to Schizophrenia. Am J Psychiatry 2022; 179:255-258. [PMID: 35360918 DOI: 10.1176/appi.ajp.20220151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Ned H Kalin
- Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, Madison
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Affiliation(s)
- Larissa J Mooney
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, and VA Greater Los Angeles Healthcare System, Los Angeles
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