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Conti JL, Bosco-Ruggiero SA, Hochheimer M, Doub TW, Salsberg J, Daniels-Sommers S. Improving the effectiveness of SUD treatment through a national registry. J Opioid Manag 2023; 19:61-71. [PMID: 37879661 DOI: 10.5055/jom.2023.0800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
CONTEXT Recent research into the effectiveness of abstinence-based substance use disorder (SUD) treatment indicates that there has not been a substantial improvement since the Drug Abuse Treatment Outcome Study research in 1993. Research into medication-supported treatments for SUD are hindered by a dearth of real-world longitudinal outcome studies. Patient registries have dramatically improved survival rates in many diseases by providing researchers with longitudinal data on a broad spectrum of patients undergoing a variety of treatments. Policy prescription: We recommend the creation of a national registry for patients receiving treatment for SUD akin to the Surveillance, Epidemiology, and End Results Program established in 1971 to track cancer patient outcomes. One option would be to expand the data currently being collected in the Treatment Episode Data Set (TEDS) to include all nonpublicly funded treatment and to allow for longitudinal tracking of deidentified individuals. Information on medication use and deaths could be kept up to date through integrations with state-wide death registries and Prescription Drug Monitoring Programs. The TEDS dataset already undergoes extensive data deidentification to make sure individuals cannot be identified prior to releasing the admissions and discharge datasets to researchers. Once longitudinal tracking is available, even more stringent deidentification will be necessary, and access to the dataset would be restricted to public health researchers. CONCLUSION The development of a registry of individuals undergoing treatment for SUD can be expected to enhance our understanding of the progression of the disease and the relative effectiveness of different treatment modalities for patients with different drug use histories and characteristics.
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Affiliation(s)
- Joanna L Conti
- Conquer Addiction, Inc., Port St. Lucie, Florida. ORCID: https://orcid.org/0000-0002-3489-8141
| | | | - Martin Hochheimer
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Balti-more, Maryland
| | - Thomas W Doub
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jamie Salsberg
- Onward Counseling Group and Consulting, Lake Worth, Florida
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Bilazarian A, McHugh J, Schlak AE, Liu J, Poghosyan L. Primary Care Practice Structural Capabilities and Emergency Department Utilization Among High-Need High-Cost Patients. J Gen Intern Med 2023; 38:74-80. [PMID: 35941491 PMCID: PMC9849605 DOI: 10.1007/s11606-022-07706-y] [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: 11/29/2021] [Accepted: 06/16/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND US primary care practices are actively identifying strategies to improve outcomes and reduce costs among high-need high-cost (HNHC) patients. HNHC patients are adults with high health care utilization who suffer from multiple chronic medical and behavioral health conditions such as depression or substance abuse. HNHC patients with behavioral health conditions face heightened challenges accessing timely primary care and managing their conditions, which is reflected by their high rates of emergency department (ED) utilization and preventable spending. Structural capabilities (i.e., care coordination, chronic disease registries, shared communication systems, and after-hours care) are key attributes of primary care practices which can enhance access and quality of chronic care delivery. OBJECTIVE The purpose of this study was to analyze the association between structural capabilities and ED utilization among HNHC patients with behavioral health conditions. DESIGN AND MEASURES We merged cross-sectional survey data on structural capabilities from 240 primary care practices in Arizona and Washington linked with Medicare claims data on 70,182 HNHC patients from 2019. KEY RESULTS Using multivariable Poisson models, we found shared communication systems were associated with lower rates of all-cause and preventable ED utilization among HNHC patients with alcohol use (all-cause: aRR 0.72, 95% CI: 0.62, 0.84; preventable: aRR 0.5, 95% CI: 0.40, 0.64) and HNHC patients with substance use disorders (all-cause: aRR 0.76, 95% CI: 0.68, 0.85; preventable: aRR 0.61, 95% CI: 0.52, 0.71). Care coordination was also associated with decreased rates of ED utilization among the overall HNHC population and those with alcohol use, but not among HNHC patients with depression or substance use disorders. CONCLUSION Shared communication systems and care coordination have the potential to increase the effectiveness of primary care delivery for specific HNHC patients.
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Affiliation(s)
- Ani Bilazarian
- School of Nursing, Columbia University, New York, NY, USA.
| | - John McHugh
- School of Nursing, Columbia University, New York, NY, USA
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | | | - Jianfang Liu
- School of Nursing, Columbia University, New York, NY, USA
| | - Lusine Poghosyan
- School of Nursing, Columbia University, New York, NY, USA
- Mailman School of Public Health, Columbia University, New York, NY, USA
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Abstract
The U.S. is in the midst of an opioid epidemic. At the same time, tobacco use remains the leading cause of preventable death and disability. While the shared biological underpinnings of nicotine and opioid addiction are well established, clinical implications for co-treatment of these two substance use disorders has not been emphasized in the literature, nor have researchers, clinicians, and policy makers adequately outlined pathways for incorporating co-treatment into existing clinical workflows. The current brief review characterizes the metabolic and neural mechanisms which mediate co-use of nicotine and opioids, and then outlines clinical and policy implications for concurrently addressing these two deadly epidemics. Screening, assessment, medication-assisted treatment (MAT), and tobacco-free policy are discussed. The evidence suggests that clinical care and policies that facilitate co-treatment are an expedient means of delivering healthcare to individuals that result in better health for the population while also meeting patients' substance abuse disorder recovery goals.
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Affiliation(s)
- Chad D Morris
- University of Colorado, Anschutz Medical Campus, 1784 Racine Street, Campus Box F478, Building 401, Aurora, CO, 80045, USA.
| | - Christine E Garver-Apgar
- University of Colorado, Anschutz Medical Campus, 1784 Racine Street, Campus Box F478, Building 401, Aurora, CO, 80045, USA
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Feller DJ, Lor M, Zucker J, Yin MT, Olender S, Ferris DC, Elhadad N, Mamykina L. An investigation of the information technology needs associated with delivering chronic disease care to large clinical populations. Int J Med Inform 2020; 137:104099. [PMID: 32088558 DOI: 10.1016/j.ijmedinf.2020.104099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/08/2020] [Accepted: 02/12/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND The growing number of individuals with complex medical and social needs has motivated the adoption of care management (CM) - programs wherein multidisciplinary teams coordinate and monitor the clinical and non-clinical aspects of care for patients with chronic disease. Despite claims that health information technology (IT) is essential to CM, there has been limited research focused on the IT needs of clinicians providing care management to large groups of patients with chronic disease. OBJECTIVE To assess clinicians' needs pertaining to CM and to identify inefficiencies and bottlenecks associated with the delivery of CM to large groups of patients with chronic disease. METHODS A qualitative study of two HIV care programs. Methods included observations of multidisciplinary care team meetings and semi-structured interviews with physicians, care managers, and social workers. Thematic analysis was conducted to analyze the data. RESULTS CM was perceived by staff as requiring the development of novel strategies including patient prioritization and patient monitoring, which was supported by patient registries but also required the creation of additional homegrown tools. Common challenges included: limited ability to identify pertinent patient information, specifically in regards to social and behavioral determinants of health, limited assistance in matching patients to appropriate interventions, and limited support for communication within multidisciplinary care teams. CONCLUSION Clinicians delivering care management to chronic disease patients are not adequately supported by electronic health records and patient registries. Tools that better enable population monitoring, facilitate communication between providers, and help address psychosocial barriers to treatment could enable more effective care.
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Affiliation(s)
- Daniel J Feller
- Department of Biomedical Informatics, Columbia University, New York, NY, United States.
| | - Maichou Lor
- School of Nursing, Columbia University, New York, NY, United States
| | - Jason Zucker
- Division of Infectious Disease, Department of Medicine, Columbia University, New York, NY, United States
| | - Michael T Yin
- Division of Infectious Disease, Department of Medicine, Columbia University, New York, NY, United States
| | - Susan Olender
- Division of Infectious Disease, Department of Medicine, Columbia University, New York, NY, United States
| | - David C Ferris
- Department of Population Health, BronxCare Health System, Bronx, NY, United States
| | - Noémie Elhadad
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
| | - Lena Mamykina
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
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Saxon AJ, Akerman SC, Liu CC, Sullivan MA, Silverman BL, Vocci FJ. Extended-release naltrexone (XR-NTX) for opioid use disorder in clinical practice: Vivitrol's Cost and Treatment Outcomes Registry. Addiction 2018; 113:1477-1487. [PMID: 29493836 DOI: 10.1111/add.14199] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 07/11/2017] [Accepted: 02/12/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS Extended-release naltrexone (XR-NTX), a μ-opioid receptor antagonist for prevention of relapse to opioid dependence, has demonstrated efficacy compared with placebo and comparative effectiveness with buprenorphine-naloxone. We report outcomes for XR-NTX in Vivitrol's Cost and Treatment Outcomes Registry. DESIGN Observational, open-label, single-arm, multi-center registry assessing baseline characteristics and clinical and health-related quality-of-life outcomes associated with XR-NTX treatment in clinical practice. SETTING 32 US treatment centers from 2011 to 2013. PARTICIPANTS Patients with opioid dependence who were prescribed XR-NTX treatment and then enrolled into the registry. MEASUREMENTS Monthly visits were evaluated for the full population and for patient ubgroups retrospectively, defined by injection number, focusing on the period between baseline and month 6 (1-, 2/3- or 6-XR-NTX). FINDINGS Of 403 enrolled patients, 395 were analyzed. Most patients (n = 349) received out-patient care. On average, patients received five injections (median = 3; range = 1-25). The median number of injections administered within 6 months was higher in patients who at baseline were employed (three versus two unemployed, P = 0.02) or had private insurance (five versus two self-payment, P = 0.005; versus two state-funded, P < 0.001). The 1-, 2/3- and 6-XR-NTX groups had 132, 152 and 111 patients, respectively. At baseline, the 6-XR-NTX patients were more likely to meet normal/minimal mental illness criteria and attend school and less likely to report recent drug use. Within 6 months, the 6-XR-NTX group demonstrated improvements in employment, mental health and psychosocial functioning, and decreases in opioid craving, drug use and drug-related behavior. CONCLUSIONS Among opioid-dependent people receiving XR-NTX treatment, better mental health, higher education and lower recent drug use at baseline are associated with greater treatment duration; in turn, longer treatment duration is associated with lower relapse rates and improved outcomes generally.
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Affiliation(s)
- Andrew J Saxon
- Center of Excellence in Substance Abuse Treatment and Education, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | | | | | - Maria A Sullivan
- Alkermes, Inc., Waltham, MA, USA.,Columbia University, New York, NY, USA
| | | | - Frank J Vocci
- Friends Research Institute, Inc., Baltimore, MD, USA
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Hoffman KA, Terashima JP, McCarty D, Muench J. Toward a Patient Registry for Cannabis Use: An Exploratory Study of Patient Use in an Outpatient Health-Care Clinic in Oregon. WORLD MEDICAL & HEALTH POLICY 2017; 9:307-317. [PMID: 29034118 PMCID: PMC5636179 DOI: 10.1002/wmh3.237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Movement toward legalization of cannabis grows in the United States yet little is known about long‐term use effects. This study was an initial step in the instrument development of a patient registry questionnaire of cannabis users who will be followed over time. Cannabis‐using patients (12 females, 10 males) aged 20–64, were sampled from a Portland, Oregon primary care health center. Respondents completed semistructured qualitative interviews describing methods of cannabis use, motivations for use, and perceptions of risks and benefits. Qualitative analysis used a content analysis approach to assess and extract salient themes. Patients smoked, inhaled, ingested, and applied a wide variety of cannabis products. All participants but one reported using cannabis for perceived physiological or psychological pain and several used cannabis to alleviate cravings for opioid medications. Other motivations included relief from suicidal thoughts and depression, anxiety, migraines, and neuropathic pain. Relatively few perceived risks as compared to benefits were reported. This study provides relevant insight into how and why these primary care patients use cannabis. Results will be used to construct a quantitative questionnaire for a patient registry that can provide critical information about long‐term use effects.
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Affiliation(s)
- Kim A Hoffman
- School of Public Health, Oregon Health and Science University. International Center for Advanced Research and Applied Science
| | - Javier Ponce Terashima
- University Hospitals Cleveland Medical Center/Case Western Reserve University. International Center for Advanced Research and Applied Science
| | - Dennis McCarty
- School of Public Health, Oregon Health and Science University
| | - John Muench
- Department of Family Medicine, Oregon Health and Science University
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Hser YI, Mooney LJ, Saxon AJ, Miotto K, Bell DS, Huang D. Chronic pain among patients with opioid use disorder: Results from electronic health records data. J Subst Abuse Treat 2017; 77:26-30. [PMID: 28476267 DOI: 10.1016/j.jsat.2017.03.006] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 03/08/2017] [Accepted: 03/08/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE To examine the prevalence of comorbid chronic pain among patients with opioid use disorder (OUD) and to compare other comorbidities (substance use disorder (SUD), mental health disorders, health/disease conditions) among patients in four categories: no chronic pain (No Pain), OUD prior to pain (OUD First), OUD and pain at the same time (Same Time), or pain condition prior to OUD (Pain First). METHODS Using an electronic health record (EHR) database from 2006-2015, the study assessed 5307 adult patients with OUD in a large healthcare system; 35.6% were No Pain, 9.7% were OUD First, 14.9% were Same Time, and 39.8% were Pain First. RESULTS Most OUD patients (64.4%) had chronic pain conditions, and among them 61.8% had chronic pain before their first OUD diagnosis. Other SUDs occurred more frequently among OUD First patients than among other groups in terms of alcohol (33.4% vs. 25.4% for No Pain, 20.7% for Same Time, and 20.3% for Pain First), cocaine (19.0%, vs. 13.8%, 9.4%, 7.1%), and alcohol or drug-induced disorders. OUD First patients also had the highest rates of HIV (4.7%) and hepatitis C virus (HCV; 28.2%) among the four groups. Pain First patients had the highest rates of mental disorder (81.7%), heart disease (72.0%), respiratory disease (68.4%), sleep disorder (41.8%), cancer (23.4%), and diabetes (19.3%). CONCLUSIONS The alarming high rates of chronic pain conditions occurring before OUD and the associated severe mental health and physical health conditions require better models of assessment and coordinated care plans to address these complex medical conditions.
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Affiliation(s)
- Yih-Ing Hser
- University of California, Los Angeles, United States.
| | | | - Andrew J Saxon
- Veterans Affairs Puget Sound Health Care System, United States
| | - Karen Miotto
- University of California, Los Angeles, United States
| | | | - David Huang
- University of California, Los Angeles, United States
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