1
|
Pytell JD, Binswanger IA. Addressing Opioid Use Disorder in Primary Care: Revisiting Core Primary Care Principles to Confidently Initiate Treatment. J Gen Intern Med 2024:10.1007/s11606-024-08727-5. [PMID: 38519747 DOI: 10.1007/s11606-024-08727-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 03/11/2024] [Indexed: 03/25/2024]
Affiliation(s)
- Jarratt D Pytell
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
- Department of Internal Medicine, Denver Health Medical Center, Denver, CO, USA.
- Institute of Health Research, Kaiser Permanente Colorado, Aurora, CO, USA.
| | - Ingrid A Binswanger
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Institute of Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Colorado Permanente Medical Group, Denver, CO, USA
| |
Collapse
|
2
|
Nguyen AP, Palzes VA, Binswanger IA, Ahmedani BK, Altschuler A, Andrade SE, Bailey SR, Clark RE, Haller IV, Hechter RC, Karmali R, Metz VE, Poulsen MN, Roblin DW, Rosa CL, Rubinstein AL, Sanchez K, Stephens KA, Yarborough BJH, Campbell CI. Association of initial opioid prescription duration and an opioid refill by pain diagnosis: Evidence from outpatient settings in ten US health systems. Prev Med 2024; 179:107828. [PMID: 38110159 PMCID: PMC11046737 DOI: 10.1016/j.ypmed.2023.107828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/06/2023] [Accepted: 12/15/2023] [Indexed: 12/20/2023]
Abstract
OBJECTIVE The Centers for Disease Control and Prevention's 2022 Clinical Practice Guideline for Prescribing Opioids for Pain cautioned that inflexible opioid prescription duration limits may harm patients. Information about the relationship between initial opioid prescription duration and a subsequent refill could inform prescribing policies and practices to optimize patient outcomes. We assessed the association between initial opioid duration and an opioid refill prescription. METHODS We conducted a retrospective cohort study of adults ≥19 years of age in 10 US health systems between 2013 and 2018 from outpatient care with a diagnosis for back pain without radiculopathy, back pain with radiculopathy, neck pain, joint pain, tendonitis/bursitis, mild musculoskeletal pain, severe musculoskeletal pain, urinary calculus, or headache. Generalized additive models were used to estimate the association between opioid days' supply and a refill prescription. RESULTS Overall, 220,797 patients were prescribed opioid analgesics upon an outpatient visit for pain. Nearly a quarter (23.5%) of the cohort received an opioid refill prescription during follow-up. The likelihood of a refill generally increased with initial duration for most pain diagnoses. About 1 to 3 fewer patients would receive a refill within 3 months for every 100 patients initially prescribed 3 vs. 7 days of opioids for most pain diagnoses. The lowest likelihood of refill was for a 1-day supply for all pain diagnoses, except for severe musculoskeletal pain (9 days' supply) and headache (3-4 days' supply). CONCLUSIONS Long-term prescription opioid use increased modestly with initial opioid prescription duration for most but not all pain diagnoses examined.
Collapse
Affiliation(s)
- Anh P Nguyen
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States of America.
| | - Vanessa A Palzes
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States of America
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States of America; Colorado Permanente Medical Group, Denver, CO, United States of America; Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, United States of America; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States of America
| | - Brian K Ahmedani
- Center for Health Policy & Health Services Research, Henry Ford Health, Detroit, MI, United States of America
| | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States of America
| | - Susan E Andrade
- Meyers Primary Care Health Institute/Fallon Health, Worcester, MA, United States of America
| | - Steffani R Bailey
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - Robin E Clark
- Department of Family Medicine and Community Health, University of Massachusetts Chan School of Medicine, Worcester, MA, United States of America
| | - Irina V Haller
- Essentia Institute of Rural Health, Duluth, MN, United States of America
| | - Rulin C Hechter
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States of America; Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States of America
| | | | - Verena E Metz
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States of America
| | - Melissa N Poulsen
- Department of Population Health Sciences, Geisinger, Danville, PA, United States of America
| | - Douglas W Roblin
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente, Rockville, MD, United States of America
| | - Carmen L Rosa
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD, United States of America
| | - Andrea L Rubinstein
- Department of Pain Medicine, The Permanente Medical Group, Santa Rosa, CA, United States of America
| | - Katherine Sanchez
- Baylor Scott & White Research Institute, Dallas, TX, United States of America; School of Social Work, University of Texas at Arlington, Arlington, TX, United States of America
| | - Kari A Stephens
- Department of Family Medicine, University of Washington, Seattle, WA, United States of America
| | - Bobbi Jo H Yarborough
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, United States of America
| | - Cynthia I Campbell
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States of America; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States of America; Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA, United States of America
| |
Collapse
|
3
|
Ford MA, Lapham GT, Matson TE, Luce C, Oliver MM, Binswanger IA. Comparing Cannabis Use for Pain to Use for Other Reasons in Primary Care Patients. J Am Board Fam Med 2024; 36:996-1007. [PMID: 37907351 DOI: 10.3122/jabfm.2023.230163r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/17/2023] [Accepted: 07/24/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Medical cannabis is commonly used for chronic pain, but little is known about differences in characteristics, cannabis use patterns, and perceived helpfulness among primary care patients who use cannabis for pain versus nonpain reasons. METHODS Among 1688 patients who completed a 2019 cannabis survey administered in a health system in Washington state, where recreational use is legal, participants who used cannabis for pain (n = 375) were compared with those who used cannabis for other reasons (n = 558) using survey and electronic health record data. We described group differences in participant characteristics, use patterns, and perceptions and applied adjusted multinomial logistic and modified Poisson regression. RESULTS Participants who used cannabis for pain were significantly more likely to report using applied (50.7% vs 10.6%) and beverage cannabis products (19.2% vs 11.6%), more frequent use (47.1% vs 33.1% for use ≥2 times per day; 81.6% vs 69.7% for use 4 to 7 days per week), and smoking tobacco cigarettes (19.2% vs 12.2%) than those who used cannabis for other reasons. They were also significantly more likely to perceive cannabis as very/extremely helpful (80.5% vs 72.7%), and significantly less likely to use cannabis for nonmedical reasons (4.8% vs 58.8%) or report cannabis use disorder symptoms (51.7% vs 61.1%). DISCUSSION Primary care patients who use cannabis for pain use it more frequently, often in applied and ingested forms, and have more co-use of tobacco, which may differentially impact safety and effectiveness. These findings suggest the need for different approaches to counseling in clinical care.
Collapse
Affiliation(s)
- Morgan A Ford
- From the Kaiser Permanente Colorado Institute for Health Research, Aurora, CO (MAF, IAB), Kaiser Permanente Washington Health Research Institute, Seattle, WA (GTL, TEM, CL, MMO), Department of Health Systems and Population Health, University of Washington, Seattle, WA (GTL), Colorado Permanente Medical Group, Aurora, CO (IAB), Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO (IAB), Department of Health Systems Sciences, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA (IAB)
| | - Gwen T Lapham
- From the Kaiser Permanente Colorado Institute for Health Research, Aurora, CO (MAF, IAB), Kaiser Permanente Washington Health Research Institute, Seattle, WA (GTL, TEM, CL, MMO), Department of Health Systems and Population Health, University of Washington, Seattle, WA (GTL), Colorado Permanente Medical Group, Aurora, CO (IAB), Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO (IAB), Department of Health Systems Sciences, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA (IAB)
| | - Theresa E Matson
- From the Kaiser Permanente Colorado Institute for Health Research, Aurora, CO (MAF, IAB), Kaiser Permanente Washington Health Research Institute, Seattle, WA (GTL, TEM, CL, MMO), Department of Health Systems and Population Health, University of Washington, Seattle, WA (GTL), Colorado Permanente Medical Group, Aurora, CO (IAB), Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO (IAB), Department of Health Systems Sciences, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA (IAB)
| | - Casey Luce
- From the Kaiser Permanente Colorado Institute for Health Research, Aurora, CO (MAF, IAB), Kaiser Permanente Washington Health Research Institute, Seattle, WA (GTL, TEM, CL, MMO), Department of Health Systems and Population Health, University of Washington, Seattle, WA (GTL), Colorado Permanente Medical Group, Aurora, CO (IAB), Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO (IAB), Department of Health Systems Sciences, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA (IAB)
| | - Malia M Oliver
- From the Kaiser Permanente Colorado Institute for Health Research, Aurora, CO (MAF, IAB), Kaiser Permanente Washington Health Research Institute, Seattle, WA (GTL, TEM, CL, MMO), Department of Health Systems and Population Health, University of Washington, Seattle, WA (GTL), Colorado Permanente Medical Group, Aurora, CO (IAB), Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO (IAB), Department of Health Systems Sciences, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA (IAB)
| | - Ingrid A Binswanger
- From the Kaiser Permanente Colorado Institute for Health Research, Aurora, CO (MAF, IAB), Kaiser Permanente Washington Health Research Institute, Seattle, WA (GTL, TEM, CL, MMO), Department of Health Systems and Population Health, University of Washington, Seattle, WA (GTL), Colorado Permanente Medical Group, Aurora, CO (IAB), Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO (IAB), Department of Health Systems Sciences, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA (IAB)
| |
Collapse
|
4
|
Xu S, Narwaney KJ, Nguyen AP, Binswanger IA, McClure DL, Glanz JM. An individual segmented trajectory approach for identifying opioid use patterns using longitudinal dispensing data. Pharmacoepidemiol Drug Saf 2024; 33:e5708. [PMID: 37814576 PMCID: PMC10841826 DOI: 10.1002/pds.5708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 10/11/2023]
Abstract
PURPOSE The aim of this study is to use electronic opioid dispensing data to develop an individual segmented trajectory approach for identifying opioid use patterns. The resulting opioid use patterns can be used for examining the association between opioid use and drug overdose. METHODS We retrospectively assembled a cohort of members on long-term opioid therapy (LTOT) between January 1, 2006 and June 30, 2019 who were 18 years and older and enrolled in one of three health care systems in the US. We have developed an individual segmented trajectory analysis for identifying various opioid use patterns by scanning over the follow-up and finding distinct opioid use patterns based on variability measured with coefficient of variation and trends of milligram morphine equivalents levels. RESULTS Among 31, 865 members who were on LTOT between January 1, 2006 and June 30, 2019, 58.3% were female, and the average age was 55.4 years (STD = 15.4). The study population had 152 557 person-years of follow-up, with an average follow-up of 4.4 years per enrollment per person (STD = 3.4). This novel approach identified up to 13 distinct patterns including 88 756 episodes of "stable" pattern (42.1%) with an average follow-up of 11.2 months, 29 140 episodes of "increasing" pattern (13.8%) with an average follow-up of 6.0 months, 13 201 episodes of ≤10% dose reduction (6.3%) with an average follow-up of 10.4 months, 7286 episodes of 11%-20% dose reduction (3.5%) with an average follow-up of 5.3 months, 4457 episodes of 21%-30% dose reduction (2.1%) with an average follow-up of 4.0 months, and 9903 episodes of >30% dose reduction (4.7%) with an average follow-up of 2.6 months. CONCLUSIONS A novel approach was developed to identify 13 distinct opioid use patterns using each individual's longitudinal dispensing data and these patterns can be used in examining overdose risk during the time that these patterns are ongoing.
Collapse
Affiliation(s)
- Stanley Xu
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Komal J Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Anh P Nguyen
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Ingrid A Binswanger
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Chemical Dependency Treatment Services, Colorado Permanente Medical Group, Aurora, Colorado, USA
| | - David L McClure
- Center for Clinical Epidemiology and Population Health, Marshfield Clinic Research Institute, Marshfield, Wisconsin, USA
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado, USA
| |
Collapse
|
5
|
Binswanger IA, Narwaney KJ, Barrow JC, Albers KB, Bechtel L, Steiner CA, Ann Shoup J, Glanz JM. Association between severe acute respiratory syndrome coronavirus 2 antibody status and reinfection: A case-control study nested in a Colorado-based prospective cohort study. Prev Med Rep 2024; 37:102530. [PMID: 38205171 PMCID: PMC10776776 DOI: 10.1016/j.pmedr.2023.102530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/09/2023] [Accepted: 11/30/2023] [Indexed: 01/12/2024] Open
Abstract
The association between the presence of detectable antibodies to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and SARS-CoV-2 reinfection is not well established. The objective of this study was to determine the association between antibody seronegativity and reinfection. METHODS Participants in Colorado, USA, were recruited between June 15, 2020, and March 28, 2021, and encouraged to complete SARS-CoV-2 molecular ribonucleic acid (RNA) and serology testing for antibodies every 28 days for 10 months. Participants with reinfections (positive SARS-CoV-2 RNA test ≥ 90 days after the first positive RNA test) were matched to controls without reinfections by age, sex, date of the first positive RNA test, date of the last serology test, and serology test type. Using conditional logistic regression, case patients were compared to control patients on the last serologic test result, with adjustment for demographic and clinical confounders. RESULTS The cohort (n = 4,235) included 2,033 participants with ≥ 1 positive RNA test, of whom 120 had reinfection. Among the 80 case patients who could be matched, the last serologic test was negative in 12 of the cases (15.0 %) whereas the last serologic test was negative in 77 of 1,034 (7.5 %) controls. Seronegativity (adjusted OR [aOR] 2.24; 95 % CI 1.07, 4.68), Hispanic ethnicity (aOR 1.87; 95 % 1.10, 3.18), and larger household size (aOR 1.15; 95 % 1.01, 1.30 for each additional household member) were associated with reinfection. CONCLUSIONS Seronegative status, Hispanic ethnicity, and increasing household size were associated with reinfection. Serologic testing could be considered to reduce vaccine hesitancy in higher risk populations.
Collapse
Affiliation(s)
- Ingrid A. Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, USA
- Colorado Permanente Medical Group, Denver, USA
- Department of Medicine, University of Colorado School of Medicine, Aurora, USA
- Department of Health Systems Science, Bernard J. Tyson Kaiser Permanente School of Medicine, Pasadena, USA
| | - Komal J. Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, USA
| | | | | | - Laura Bechtel
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, USA
- Siemens-Healthineers, USA
| | - Claudia A. Steiner
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, USA
- Colorado Permanente Medical Group, Denver, USA
- Department of Health Systems Science, Bernard J. Tyson Kaiser Permanente School of Medicine, Pasadena, USA
| | - Jo Ann Shoup
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, USA
| | - Jason M. Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, USA
| |
Collapse
|
6
|
Shoup JA, Welter J, Binswanger IA, Hess F, Dullenkopf A, Coker J, Berliner J. Spinal cord injury and prescribed opioids for pain: a scoping review. Pain Med 2023; 24:1138-1152. [PMID: 37280072 DOI: 10.1093/pm/pnad073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/05/2023] [Accepted: 06/01/2023] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Spinal cord injury (SCI) is a life-altering neurological condition affecting physical and psycho-social functioning and associated high rates of pain. Thus, individuals with SCI may be more likely to be exposed to prescription opioids. A scoping review was conducted to synthesize published research findings on post-acute SCI and prescription opioid use for pain, identify literature gaps, and propose recommendations for future research. METHODS We searched 6 electronic bibliographic databases (PubMed [MEDLINE], Ovid [MEDLINE], EMBASE, Cochrane Library, CINAHL, PsychNET) for articles published from 2014 through 2021. Terms for "spinal cord injury" and "prescription opioid use" were used. Included articles were in English and peer reviewed. Data were extracted using an electronic database by 2 independent reviewers. Opioid use risk factors for chronic SCI were identified and a gap analysis was performed. RESULTS Of the 16 articles included in the scoping review, a majority were conducted in the United States (n = 9). Most articles lacked information on income (87.5%), ethnicity (87.5%), and race (75%). Prescription opioid use ranged from 35% to 64% in articles reporting this information (n = 7 articles, n = 3675 participants). Identified risk factors for opioid use included middle age, lower income, osteoarthritis diagnosis, prior opioid use, and lower-level spinal injury. Limited reporting of diversity in study populations, absence of risk of polypharmacy, and limited high quality methodology were identified gaps. CONCLUSIONS Future research should report data on prescription opioid use in SCI populations, with additional demographics such as race, ethnicity, and income, given their importance to risk outcomes.
Collapse
Affiliation(s)
- Jo Ann Shoup
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO 80014, United States
- School of Public Affairs, University of Colorado Denver, Denver, CO 80204, United States
| | - JoEllen Welter
- Department of Orthopedic Surgery and Traumatology, Spital Thurgau, 8501 Frauenfeld, Switzerland
- Institute for Anesthesia and Intensive Care Medicine, Spital Thurgau, 8501 Frauenfeld, Switzerland
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO 80014, United States
- Colorado Permanente Medical Group, Denver, CO 80218, United States
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO 80045, United States
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA 91101, United States
| | - Florian Hess
- Department of Orthopedic Surgery and Traumatology, Spital Thurgau, 8501 Frauenfeld, Switzerland
| | - Alexander Dullenkopf
- Institute for Anesthesia and Intensive Care Medicine, Spital Thurgau, 8501 Frauenfeld, Switzerland
| | - Jennifer Coker
- Craig Hospital Research Department, Craig Hospital, Englewood, CO 80113, United States
| | - Jeffrey Berliner
- Craig Hospital Research Department, Craig Hospital, Englewood, CO 80113, United States
- CNS Medical Group, Craig Hospital, Englewood, CO 80113, United States
| |
Collapse
|
7
|
Nguyen AP, Glanz JM, Narwaney KJ, Zeng C, Wright L, Fairbairn LM, Binswanger IA. Update of a Multivariable Opioid Overdose Risk Prediction Model to Enhance Clinical Care for Long-term Opioid Therapy Patients. J Gen Intern Med 2023; 38:2678-2685. [PMID: 36944901 PMCID: PMC10506960 DOI: 10.1007/s11606-023-08149-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 03/09/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Clinical opioid overdose risk prediction models can be useful tools to reduce the risk of overdose in patients prescribed long-term opioid therapy (LTOT). However, evolving overdose risk environments and clinical practices in addition to potential harmful model misapplications require careful assessment prior to widespread implementation into clinical care. Models may need to be tailored to meet local clinical operational needs and intended applications in practice. OBJECTIVE To update and validate an existing opioid overdose risk model, the Kaiser Permanente Colorado Opioid Overdose (KPCOOR) Model, in patients prescribed LTOT for implementation in clinical care. DESIGN, SETTING, AND PARTICIPANTS The retrospective cohort study consisted of 33, 625 patients prescribed LTOT between January 2015 and June 2019 at Kaiser Permanente Colorado, with follow-up through June 2021. MAIN MEASURES The outcome consisted of fatal opioid overdoses identified from vital records and non-fatal opioid overdoses from emergency department and inpatient settings. Predictors included demographics, medication dispensings, substance use disorder history, mental health history, and medical diagnoses. Cox proportional hazards regressions were used to model 2-year overdose risk. KEY RESULTS During follow-up, 65 incident opioid overdoses were observed (111.4 overdoses per 100,000 person-years) in the study cohort, of which 11 were fatal. The optimal risk model needed to risk-stratify patients and to be easily interpreted by clinicians. The original 5-variable model re-validated on the new study cohort had a bootstrap-corrected C-statistic of 0.73 (95% CI, 0.64-0.85) compared to a C-statistic of 0.80 (95% CI, 0.70-0.88) in the updated model and 0.77 (95% CI, 0.66-0.87) in the final adapted 7-variable model, which was also well-calibrated. CONCLUSIONS Updating and adapting predictors for opioid overdose in the KPCOOR Model with input from clinical partners resulted in a parsimonious and clinically relevant model that was poised for integration in clinical care.
Collapse
Affiliation(s)
- Anh P Nguyen
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO, 80237-8066, USA.
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO, 80237-8066, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Komal J Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO, 80237-8066, USA
| | - Chan Zeng
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO, 80237-8066, USA
| | - Leslie Wright
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO, 80237-8066, USA
| | | | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO, 80237-8066, USA
- Colorado Permanente Medical Group, Denver, CO, USA
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Bernard J. Tyson Kaiser Permanente School of Medicine, Pasadena, CA, USA
| |
Collapse
|
8
|
Lyden JR, Xu S, Narwaney KJ, Glanz JM, Binswanger IA. Opioid Overdose Risk Following Hospital Discharge Among Individuals Prescribed Long-Term Opioid Therapy: a Risk Interval Analysis. J Gen Intern Med 2023; 38:2560-2567. [PMID: 36697930 PMCID: PMC9876414 DOI: 10.1007/s11606-022-08014-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/23/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Individuals prescribed long-term opioid therapy (LTOT) have increased risk of readmission and death after hospital discharge. The risk of opioid overdose during the immediate post-discharge time period is unknown. OBJECTIVE To examine the association between time since hospital discharge and opioid overdose among individuals prescribed LTOT. DESIGN Self-controlled risk interval analysis. PARTICIPANTS Adults prescribed LTOT with at least one hospital discharge at a safety-net health system and a non-profit healthcare organization in Colorado. MAIN MEASURES We identified individuals prescribed LTOT who were discharged from January 2006 through June 2019. The outcome was a composite of fatal and non-fatal opioid overdoses during a 90-day post-discharge observation period, identified using electronic health record (EHR) and vital statistics data. Risk intervals included days 0-6 after index and subsequent hospital discharges. Control intervals ranged from days 7 to 89 after index discharge and included all other time during the observation period that did not fall within a risk interval or time readmitted during a subsequent hospitalization, which was excluded. Poisson regression was used to estimate incidence rate ratios (IRR) and 95% confidence intervals (CI) for overdose events during risk in comparison to control intervals. KEY RESULTS We identified 7695 adults (63.3% over 55 years, 59.4% female, 20.3% Hispanic) who experienced 9499 total discharges during the study period. Twenty-one overdoses occurred during their observation periods (1174 per 100,000 person-years [9 in risk, 12 in control]). Overdose risk was significantly higher during the risk interval in comparison to the control interval (IRR 6.92; 95% CI 2.92-16.43). CONCLUSION During the first 7 days after hospital discharge, individuals prescribed LTOT appear to be at elevated risk for opioid overdose. Clarifying mechanisms of overdose risk may help inform in-hospital and post-discharge prevention strategies.
Collapse
Affiliation(s)
- Jennifer R Lyden
- Division of Hospital Medicine, Department of Medicine, Denver Health, 777 Bannock Street, Denver, CO, 80204, USA.
- Division of Hospital Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Stanley Xu
- Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Komal J Narwaney
- Institute of Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | - Jason M Glanz
- Institute of Health Research, Kaiser Permanente Colorado, Denver, CO, USA
- Department of Epidemiology, University of Colorado School of Public Health, Aurora, CO, USA
| | - Ingrid A Binswanger
- Institute of Health Research, Kaiser Permanente Colorado, Denver, CO, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Colorado Permanente Medical Group, Denver, CO, USA
- Bernard J. Tyson Kaiser Permanente School of Medicine, Pasadena, CA, USA
| |
Collapse
|
9
|
Glanz JM, Xu S, Narwaney KJ, McClure DL, Rinehart DJ, Ford MA, Nguyen AP, Binswanger IA. Association Between Opioid Dose Reduction Rates and Overdose Among Patients Prescribed Long-Term Opioid Therapy. Subst Abus 2023; 44:209-219. [PMID: 37702046 DOI: 10.1177/08897077231186216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
BACKGROUND Tapering long-term opioid therapy is an increasingly common practice, yet rapid opioid dose reductions may increase the risk of overdose. The objective of this study was to compare overdose risk following opioid dose reduction rates of ≤10%, 11% to 20%, 21% to 30%, and >30% per month to stable dosing. METHODS We conducted a retrospective cohort study in three health systems in Colorado and Wisconsin. Participants were patients ≥18 years of age prescribed long-term opioid therapy between January 1, 2006, and June 30, 2019. Five opioid dosing patterns and drug overdoses (fatal and nonfatal) were identified using electronic health records, pharmacy records, and the National Death Index. Cox proportional hazard regression was conducted on a propensity score-weighted cohort to estimate adjusted hazard ratios (aHRs) for follow-up periods of 1, 3, 6, 9, and 12 months after a dose reduction. RESULTS In a cohort of 17 540 patients receiving long-term opioid therapy, 42.7% of patients experienced a dose reduction. Relative to stable dosing, a dose reduction rate of >30% was associated with an increased risk of overdose and the aHR estimates decreased as the follow-up increased; the aHRs for the 1-, 6- and 12-month follow-ups were 5.33 (95% CI, 1.98-14.34), 1.81 (95% CI,1.08-3.03), and 1.49 (95% CI, 0.97-2.27), respectively. The slower tapering rates were not associated with overdose risk. CONCLUSIONS Patients receiving long-term opioid therapy exposed to dose reduction rates of >30% per month had increased overdose risk relative to patients exposed to stable dosing. Results support the use of slow dose reductions to minimize the risk of overdose.
Collapse
Affiliation(s)
- Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Stanley Xu
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Komal J Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - David L McClure
- Center for Clinical Epidemiology and Population Health, Marshfield Clinic Research Institute, Marshfield, WI, USA
| | - Deborah J Rinehart
- Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority, Denver, CO, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Morgan A Ford
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Anh P Nguyen
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Chemical Dependency Treatment Services, Colorado Permanente Medical Group, Aurora, CO, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| |
Collapse
|
10
|
Glanz JM, Binswanger IA, Clarke CL, Nguyen AP, Ford MA, Ray GT, Xu S, Hechter RC, Yarborough BJH, Roblin DW, Ahmedani B, Boscarino JA, Andrade SE, Rosa CL, Campbell CI. The association between buprenorphine treatment duration and mortality: a multi-site cohort study of people who discontinued treatment. Addiction 2023; 118:97-107. [PMID: 35815386 PMCID: PMC9722535 DOI: 10.1111/add.15998] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 06/22/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS Buprenorphine is an effective medication for opioid use disorder that reduces mortality; however, many patients are not retained in buprenorphine treatment, and an optimal length of treatment after which patients can safely discontinue treatment has not been identified. This study measured the association between buprenorphine treatment duration and all-cause mortality among patients who discontinued treatment. Secondary objectives were to measure the association between treatment duration and drug overdose and opioid-related overdoses. DESIGN Multi-site cohort study. SETTING Eight US health systems. PARTICIPANTS Patients who initiated and discontinued buprenorphine treatment between 1 January 2012 and 31 December 2018 (n = 6550). Outcomes occurring after patients discontinued buprenorphine treatment were compared between patients who initiated and discontinued treatment after 8-30, 31-90, 91-180, 181-365 and > 365 days. MEASUREMENTS Covariate data were obtained from electronic health records (EHRs). Mortality outcomes were derived from EHRs and state vital statistics. Non-fatal opioid and drug overdoses were obtained from diagnostic codes. Four sites provided cause-of-death data to identify fatal drug and opioid-related overdoses. Adjusted frailty regression was conducted on a propensity-weighted cohort to assess associations between duration of the final treatment episode and outcomes. FINDINGS The mortality rate after buprenorphine treatment was 1.82 per 100 person-years (n = 191 deaths). In regression analyses with > 365 days as the reference group, treatment duration was not associated with all-cause mortality and drug overdose (P > 0.05 for both). However, compared with > 365 days of treatment, 91-180 days of treatment was associated with increased opioid overdose risk (hazard ratio = 2.94, 95% confidence interval = 1.11-7.79). CONCLUSIONS Among patients who discontinue buprenorphine treatment, there appears to be no treatment duration period associated with a reduced risk for all-cause mortality. Patients who discontinue buprenorphine treatment after 91-180 days appear to be at heightened risk for opioid overdose compared with patients who discontinue after > 365 days of treatment.
Collapse
Affiliation(s)
- Jason M. Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO,Colorado School of Public Health, Aurora, CO
| | - Ingrid A. Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO,Colorado Permanente Medical Group, Aurora, CO,Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO,Department of Health System Sciences, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | | | - Anh P. Nguyen
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Morgan A. Ford
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - G. Thomas Ray
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Stanley Xu
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Rulin C. Hechter
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - Douglas W. Roblin
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD
| | - Brian Ahmedani
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI,Department of Behavioral Health Services, Henry Ford Health System, Detroit, MI
| | | | | | | | | |
Collapse
|
11
|
Braciszewski JM, Idu AE, Yarborough BJH, Stumbo SP, Bobb JF, Bradley KA, Rossom RC, Murphy MT, Binswanger IA, Campbell CI, Glass JE, Matson TE, Lapham GT, Loree AM, Barbosa-Leiker C, Hatch MA, Tsui JI, Arnsten JH, Stotts A, Horigian V, Hutcheson R, Bart G, Saxon AJ, Thakral M, Ling Grant D, Pflugeisen CM, Usaga I, Madziwa LT, Silva A, Boudreau DM. Sex Differences in Comorbid Mental and Substance Use Disorders Among Primary Care Patients With Opioid Use Disorder. Psychiatr Serv 2022; 73:1330-1337. [PMID: 35707859 PMCID: PMC9722542 DOI: 10.1176/appi.ps.202100665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The authors sought to characterize the 3-year prevalence of mental disorders and nonnicotine substance use disorders among male and female primary care patients with documented opioid use disorder across large U.S. health systems. METHODS This retrospective study used 2014-2016 data from patients ages ≥16 years in six health systems. Diagnoses were obtained from electronic health records or claims data; opioid use disorder treatment with buprenorphine or injectable extended-release naltrexone was determined through prescription and procedure data. Adjusted prevalence of comorbid conditions among patients with opioid use disorder (with or without treatment), stratified by sex, was estimated by fitting logistic regression models for each condition and applying marginal standardization. RESULTS Females (53.2%, N=7,431) and males (46.8%, N=6,548) had a similar prevalence of opioid use disorder. Comorbid mental disorders among those with opioid use disorder were more prevalent among females (86.4% vs. 74.3%, respectively), whereas comorbid other substance use disorders (excluding nicotine) were more common among males (51.9% vs. 60.9%, respectively). These differences held for those receiving medication treatment for opioid use disorder, with mental disorders being more common among treated females (83% vs. 71%) and other substance use disorders more common among treated males (68% vs. 63%). Among patients with a single mental health condition comorbid with opioid use disorder, females were less likely than males to receive medication treatment for opioid use disorder (15% vs. 20%, respectively). CONCLUSIONS The high rate of comorbid conditions among patients with opioid use disorder indicates a strong need to supply primary care providers with adequate resources for integrated opioid use disorder treatment.
Collapse
Affiliation(s)
- Jordan M Braciszewski
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Abisola E Idu
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Bobbi Jo H Yarborough
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Scott P Stumbo
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Jennifer F Bobb
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Katharine A Bradley
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Rebecca C Rossom
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Mark T Murphy
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Ingrid A Binswanger
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Cynthia I Campbell
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Joseph E Glass
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Theresa E Matson
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Gwen T Lapham
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Amy M Loree
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Celestina Barbosa-Leiker
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Mary A Hatch
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Judith I Tsui
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Julia H Arnsten
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Angela Stotts
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Viviana Horigian
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Rebecca Hutcheson
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Gavin Bart
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Andrew J Saxon
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Manu Thakral
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Deborah Ling Grant
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Chaya Mangel Pflugeisen
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Ingrid Usaga
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Lawrence T Madziwa
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Angela Silva
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| | - Denise M Boudreau
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit (Braciszewski, Loree); Kaiser Permanente Washington Health Research Institute (KPWHRI), Seattle (Idu, Bobb, Bradley, Glass, Matson, Lapham, Madziwa); Kaiser Permanente Northwest Center for Health Research, Portland, Oregon (Yarborough, Stumbo); HealthPartners Institute and Department of Research, University of Minnesota, Minneapolis (Rossom); MultiCare Institute for Research and Innovation, MultiCare Health System, Tacoma, Washington (Murphy, Pflugeisen, Silva); Kaiser Permanente Colorado Institute for Health Research, Colorado Permanente Medical Group, Department of Health System Science, Bernard J. Tyson Kaiser Permanente School of Medicine, University of Colorado School of Medicine, Aurora (Binswanger); Kaiser Permanente Northern California Division of Research, Oakland (Campbell); Department of Health Systems and Population Health, University of Washington, Seattle (Lapham, Hutcheson); Washington State University Health Sciences Spokane, Spokane (Barbosa-Leiker); Department of Psychiatry and Behavioral Sciences and Addictions, Drug and Alcohol Institute, University of Washington, Seattle (Hatch); Department of Medicine, University of Washington and Harborview Medical Center, Seattle (Tsui); Albert Einstein College of Medicine, Montefiore Medical Center, New York City (Arnsten); Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston (Stotts); Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami (Horigian, Usaga); Hennepin Healthcare and Department of Medicine, University of Minnesota Medical School, Minneapolis (Bart); Veterans Affairs Puget Sound Health Care System, Seattle (Saxon); Manning College of Nursing and Health Sciences, University of Massachusetts, Boston (Thakral); Kaiser Permanente Southern California Department of Research and Evaluation, Pasadena (Ling Grant); Genentech, Inc., San Francisco (Boudreau)
| |
Collapse
|
12
|
Binswanger IA, Shetterly SM, Xu S, Narwaney KJ, McClure DL, Rinehart DJ, Nguyen AP, Glanz JM. Opioid Dose Trajectories and Associations With Mortality, Opioid Use Disorder, Continued Opioid Therapy, and Health Plan Disenrollment. JAMA Netw Open 2022; 5:e2234671. [PMID: 36197665 PMCID: PMC9535531 DOI: 10.1001/jamanetworkopen.2022.34671] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Uncertainty remains about the longer-term benefits and harms of different opioid management strategies, such as tapering and dose escalation. For instance, opioid tapering could help patients reduce opioid exposure to prevent opioid use disorder, but patients may also seek care elsewhere and engage in nonprescribed opioid use. OBJECTIVE To evaluate the association between opioid dose trajectories observed in practice and patient outcomes. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted in 3 health systems in Colorado and Wisconsin. The study population included patients receiving long-term opioid therapy between 50 and 200 morphine milligram equivalents between August 1, 2014, and July 31, 2017. Follow-up ended on December 31, 2019. Data were analyzed from January 2020 to August 2022. EXPOSURES Group-based trajectory modeling identified 5 dosing trajectories over 1 year: 1 decreasing, 1 high-dose increasing, and 3 stable. MAIN OUTCOMES AND MEASURES Primary outcomes assessed after the trajectory period were 1-year all-cause mortality, incident opioid use disorder, continued opioid therapy at 1 year, and health plan disenrollment. Associations were tested using Cox proportional hazards regression and log-binomial models, adjusting for baseline covariates. RESULTS A total of 3913 patients (mean [SD] age, 59.2 [14.4] years; 2767 White non-Hispanic [70.7%]; 2237 female patients [57.2%]) were included in the study. Compared with stable trajectories, the decreasing dose trajectory was negatively associated with opioid use disorder (adjusted hazard ratio [aHR], 0.40; 95% CI, 0.29-0.55) and continued opioid therapy (site 1: adjusted relative risk [aRR], 0.39; 95% CI, 0.34-0.44), but was positively associated with health plan disenrollment (aHR, 1.66; 95% CI, 1.24-2.22). The decreasing trajectory was not associated with mortality (aHR, 1.28; 95% CI, 0.87-1.86). In contrast, the high-dose increasing trajectory was positively associated with mortality (aHR, 2.19; 95% CI, 1.44-3.32) and opioid use disorder (aHR, 1.81; 95% CI, 1.39-2.37) but was not associated with disenrollment (aHR, 0.90; 95% CI, 0.56-1.42) or continued opioid therapy (site 1: aRR, 0.98; 95% CI, 0.94-1.03). CONCLUSIONS AND RELEVANCE In this cohort study, decreasing opioid dose was associated with reduced risk of opioid use disorder and continued opioid therapy but increased risk of disenrollment compared with stable dosing, whereas the high-dose increasing trajectory was associated with an increased risk of mortality and opioid use disorder. These findings can inform opioid management decision-making.
Collapse
Affiliation(s)
- Ingrid A. Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
- Chemical Dependency Treatment Services, Colorado Permanente Medical Group, Aurora
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | | | - Stanley Xu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | | | - David L. McClure
- Center for Clinical Epidemiology and Population Health, Marshfield Clinic Research Institute, Marshfield, Wisconsin
| | - Deborah J. Rinehart
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
- Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority, Denver, Colorado
| | - Anh P. Nguyen
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Jason M. Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
- Department of Epidemiology, Colorado School of Public Health, Aurora
| |
Collapse
|
13
|
Binswanger IA, Rinehart D, Mueller SR, Narwaney KJ, Stowell M, Wagner N, Xu S, Hanratty R, Blum J, McVaney K, Glanz JM. Naloxone Co-Dispensing with Opioids: a Cluster Randomized Pragmatic Trial. J Gen Intern Med 2022; 37:2624-2633. [PMID: 35132556 PMCID: PMC9411391 DOI: 10.1007/s11606-021-07356-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/15/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Although naloxone prevents opioid overdose deaths, few patients prescribed opioids receive naloxone, limiting its effectiveness in real-world settings. Barriers to naloxone prescribing include concerns that naloxone could increase risk behavior and limited time to provide necessary patient education. OBJECTIVE To determine whether pharmacy-based naloxone co-dispensing affected opioid risk behavior. Secondary objectives were to assess if co-dispensing increased naloxone acquisition, increased patient knowledge about naloxone administration, and affected opioid dose and other substance use. DESIGN Cluster randomized pragmatic trial of naloxone co-dispensing. SETTING Safety-net health system in Denver, Colorado, between 2017 and 2020. PARTICIPANTS Seven pharmacies were randomized. Pharmacy patients (N=768) receiving opioids were followed using automated data for 10 months. Pharmacy patients were also invited to complete surveys at baseline, 4 months, and 8 months; 325 survey participants were enrolled from November 15, 2017, to January 8, 2019. INTERVENTION Intervention pharmacies implemented workflows to co-dispense naloxone while usual care pharmacies provided usual services. MAIN MEASURES Survey instruments assessed opioid risk behavior; hazardous drinking; tobacco, cannabis, and other drug use; and knowledge. Naloxone dispensings and opioid dose were evaluated using pharmacy data among pharmacy patients and survey participants. Intention-to-treat analyses were conducted using generalized linear mixed models accounting for clustering at the pharmacy level. KEY RESULTS Opioid risk behavior did not differ by trial group (P=0.52; 8-month vs. baseline adjusted risk ratio [ARR] 1.07; 95% CI 0.78, 1.47). Compared with usual care pharmacies, naloxone dispensings were higher in intervention pharmacies (ARR 3.38; 95% CI 2.21, 5.15) and participant knowledge increased (P=0.02; 8-month vs. baseline adjusted mean difference 1.05; 95% CI 0.06, 2.04). There was no difference in other substance use by the trial group. CONCLUSION Co-dispensing naloxone with opioids effectively increased naloxone receipt and knowledge but did not increase self-reported risk behavior. TRIAL REGISTRATION Registered at ClinicalTrials.gov ; Identifier: NCT03337100.
Collapse
Affiliation(s)
- Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA.
- Colorado Permanente Medical Group, Aurora, CO, USA.
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA.
| | - Deborah Rinehart
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Denver Health, Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority, Denver, CO, USA
| | - Shane R Mueller
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Komal J Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Melanie Stowell
- Denver Health, Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority, Denver, CO, USA
| | - Nicole Wagner
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Stan Xu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Rebecca Hanratty
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Medicine, Denver Health, Denver, CO, USA
| | - Josh Blum
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Medicine, Denver Health, Denver, CO, USA
| | - Kevin McVaney
- Department of Medicine, Denver Health, Denver, CO, USA
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Colorado School of Public Health, Aurora, CO, USA
| |
Collapse
|
14
|
Nguyen AP, Glanz JM, Shoup JA, Campbell CI, Clarke CL, Ford MA, Binswanger IA. Mortality Among Patients Prescribed Buprenorphine for Opioid Use Disorder After Disenrollment from an Insurance Plan and Healthcare System. J Gen Intern Med 2022; 37:2882-2884. [PMID: 35083649 PMCID: PMC9411360 DOI: 10.1007/s11606-021-07344-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 12/15/2021] [Indexed: 01/07/2023]
Affiliation(s)
- Anh P Nguyen
- Institute for Health Research, Kaiser Permanente Colorado, 2550 S. Parker Rd., Suite 200, Aurora, CO, 80014, USA.
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, 2550 S. Parker Rd., Suite 200, Aurora, CO, 80014, USA.,Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Jo Ann Shoup
- Institute for Health Research, Kaiser Permanente Colorado, 2550 S. Parker Rd., Suite 200, Aurora, CO, 80014, USA
| | - Cynthia I Campbell
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.,Bernard J. Tyson Kaiser Permanente School of Medicine, Pasadena, CA, USA.,Department of Psychiatry, University of California San Francisco, San Francisco, USA
| | - Christina L Clarke
- Institute for Health Research, Kaiser Permanente Colorado, 2550 S. Parker Rd., Suite 200, Aurora, CO, 80014, USA
| | - Morgan A Ford
- Institute for Health Research, Kaiser Permanente Colorado, 2550 S. Parker Rd., Suite 200, Aurora, CO, 80014, USA
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, 2550 S. Parker Rd., Suite 200, Aurora, CO, 80014, USA.,Bernard J. Tyson Kaiser Permanente School of Medicine, Pasadena, CA, USA.,Colorado Permanente Medical Group, Aurora, CO, USA.,Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|
15
|
Calcaterra SL, Lockhart S, Callister C, Hoover K, Binswanger IA. Opioid Use Disorder Treatment Initiation and Continuation: a Qualitative Study of Patients Who Received Addiction Consultation and Hospital-Based Providers. J Gen Intern Med 2022; 37:2786-2794. [PMID: 34981359 PMCID: PMC8722657 DOI: 10.1007/s11606-021-07305-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 11/23/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Hospitalizations related to opioid use disorder (OUD) are rising. Addiction consultation services (ACS) increasingly provide OUD treatment to hospitalized patients, but barriers to initiating and continuing medications for OUD remain. We examined facilitators and barriers to hospital-based OUD treatment initiation and continuation from the perspective of patients and healthcare workers in the context of an ACS. METHODS In this qualitative study, we sought input using key informant interviews and focus groups from patients who received care from an ACS during their hospitalization and from hospitalists, pharmacists, social workers, and nurses who work in the hospital setting. A multidisciplinary team coded and analyzed transcripts using a directed content analysis. FINDINGS We conducted 20 key informant interviews with patients, nine of whom were interviewed following hospital discharge and 12 of whom were interviewed during a rehospitalization. We completed six focus groups and eight key informant interviews with hospitalists and hospital-based medical staff (n = 62). Emergent themes related to hospital-based OUD treatment included the following: the benefit of an ACS to facilitate OUD treatment engagement; expanded use of methadone or buprenorphine to treat opioid withdrawal; the triad of hospitalization, self-efficacy, and easily accessible, patient-centered treatment motivates change in opioid use; adequate pain control and stabilization of mental health conditions among patients with OUD contributed to opioid agonist therapy (OAT) continuation; and stable housing and social support are prerequisites for OAT uptake and continuation. CONCLUSION Modifiable factors which facilitate hospital-based OUD treatment initiation and continuation include availability of in-hospital addiction expertise to offer easily accessible, patient-centered treatment and the use of methadone or buprenorphine to manage opioid withdrawal. Further research and public policy efforts are urgently needed to address reported barriers to hospital-based OUD treatment initiation and continuation which include unstable housing, poorly controlled chronic medical and mental illness, and lack of social support.
Collapse
Affiliation(s)
- Susan L Calcaterra
- Division of General Internal Medicine, University of Colorado, 8th Floor, Academic Office 1, Mailstop B180, 12631 E 17th Ave, Aurora, CO, 80045, USA.
- Division of Hospital Medicine, University of Colorado, Aurora, CO, USA.
| | - Steve Lockhart
- Adult and Child Consortium for Health Outcomes Research and Delivery Service, Univeristy of Colorado, School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | | | - Kaitlyn Hoover
- Clinical Science Graduate Program, University of Colorado, Aurora, CO, USA
| | - Ingrid A Binswanger
- Division of General Internal Medicine, University of Colorado, 8th Floor, Academic Office 1, Mailstop B180, 12631 E 17th Ave, Aurora, CO, 80045, USA
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Colorado Permanente Medical Group, Aurora, CO, USA
- Bernard J. Tyson School of Medicine, Pasadena, CA, USA
| |
Collapse
|
16
|
Lapham GT, Matson TE, Carrell DS, Bobb JF, Luce C, Oliver MM, Ghitza UE, Hsu C, Browne KC, Binswanger IA, Campbell CI, Saxon AJ, Vandrey R, Schauer GL, Pacula RL, Horberg MA, Bailey SR, McClure EA, Bradley KA. Comparison of Medical Cannabis Use Reported on a Confidential Survey vs Documented in the Electronic Health Record Among Primary Care Patients. JAMA Netw Open 2022; 5:e2211677. [PMID: 35604691 PMCID: PMC9127557 DOI: 10.1001/jamanetworkopen.2022.11677] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/23/2022] [Indexed: 12/18/2022] Open
Abstract
Importance Patients who use cannabis for medical reasons may benefit from discussions with clinicians about health risks of cannabis and evidence-based treatment alternatives. However, little is known about the prevalence of medical cannabis use in primary care and how often it is documented in patient electronic health records (EHR). Objective To estimate the primary care prevalence of medical cannabis use according to confidential patient survey and to compare the prevalence of medical cannabis use documented in the EHR with patient report. Design, Setting, and Participants This study is a cross-sectional survey performed in a large health system that conducts routine cannabis screening in Washington state where medical and nonmedical cannabis use are legal. Among 108 950 patients who completed routine cannabis screening (between March 28, 2019, and September 12, 2019), 5000 were randomly selected for a confidential survey about cannabis use, using stratified random sampling for frequency of past-year use and patient race and ethnicity. Data were analyzed from November 2020 to December 2021. Exposures Survey measures of patient-reported past-year cannabis use, medical cannabis use (ie, explicit medical use), and any health reason(s) for use (ie, implicit medical use). Main Outcomes and Measures Survey data were linked to EHR data in the year before screening. EHR measures included documentation of explicit and/or implicit medical cannabis use. Analyses estimated the primary care prevalence of cannabis use and compared EHR-documented with patient-reported medical cannabis use, accounting for stratified sampling and nonresponse. Results Overall, 1688 patients responded to the survey (34% response rate; mean [SD] age, 50.7 [17.5] years; 861 female [56%], 1184 White [74%], 1514 non-Hispanic [97%], and 1059 commercially insured [65%]). The primary care prevalence of any past-year patient-reported cannabis use on the survey was 38.8% (95% CI, 31.9%-46.1%), whereas the prevalence of explicit and implicit medical use were 26.5% (95% CI, 21.6%-31.3%) and 35.1% (95% CI, 29.3%-40.8%), respectively. The prevalence of EHR-documented medical cannabis use was 4.8% (95% CI, 3.45%-6.2%). Compared with patient-reported explicit medical use, the sensitivity and specificity of EHR-documented medical cannabis use were 10.0% (95% CI, 4.4%-15.6%) and 97.1% (95% CI, 94.4%-99.8%), respectively. Conclusions and Relevance These findings suggest that medical cannabis use is common among primary care patients in a state with legal use, and most use is not documented in the EHR. Patient report of health reasons for cannabis use identifies more medical use compared with explicit questions about medical use.
Collapse
Affiliation(s)
- Gwen T. Lapham
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Theresa E. Matson
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Health Systems and Population Health, University of Washington, Seattle
| | | | | | - Casey Luce
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Malia M. Oliver
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Udi E. Ghitza
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Clarissa Hsu
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Kendall C. Browne
- Center of Excellence in Substance Addiction Treatment and Education, Veteran Affairs Puget Sound Health Care System, Seattle, Washington
| | - Ingrid A. Binswanger
- Kaiser Permanente Colorado Institute for Health Research, Denver
- Colorado Permanente Medical Group, Denver
| | | | - Andrew J. Saxon
- Center of Excellence in Substance Addiction Treatment and Education, Veteran Affairs Puget Sound Health Care System, Seattle, Washington
| | - Ryan Vandrey
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Rosalie Liccardo Pacula
- Price School of Public Policy, University of Southern California, Los Angeles
- Leonard D Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles
| | - Michael A. Horberg
- Kaiser Permanente Mid-Atlantic Permanente Research Institute, North Bethesda, Maryland
| | - Steffani R. Bailey
- Department of Family Medicine, Oregon Health & Science University, Portland
| | - Erin A. McClure
- Medical University of South Carolina College of Medicine, Charleston
| | | |
Collapse
|
17
|
Carrell DS, Cronkite DJ, Shea M, Oliver M, Luce C, Matson TE, Bobb JF, Hsu C, Binswanger IA, Browne KC, Saxon AJ, McCormack J, Jelstrom E, Ghitza UE, Campbell CI, Bradley KA, Lapham GT. Clinical documentation of patient-reported medical cannabis use in primary care: Toward scalable extraction using natural language processing methods. Subst Abus 2022; 43:917-924. [PMID: 35254218 PMCID: PMC9134865 DOI: 10.1080/08897077.2021.1986767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background: Most states have legalized medical cannabis, yet little is known about how medical cannabis use is documented in patients' electronic health records (EHRs). We used natural language processing (NLP) to calculate the prevalence of clinician-documented medical cannabis use among adults in an integrated health system in Washington State where medical and recreational use are legal. Methods: We analyzed EHRs of patients ≥18 years old screened for past-year cannabis use (November 1, 2017-October 31, 2018), to identify clinician-documented medical cannabis use. We defined medical use as any documentation of cannabis that was recommended by a clinician or described by the clinician or patient as intended to manage health conditions or symptoms. We developed and applied an NLP system that included NLP-assisted manual review to identify such documentation in encounter notes. Results: Medical cannabis use was documented for 16,684 (5.6%) of 299,597 outpatient encounters with routine screening for cannabis use among 203,489 patients seeing 1,274 clinicians. The validated NLP system identified 54% of documentation and NLP-assisted manual review the remainder. Language documenting reasons for cannabis use included 125 terms indicating medical use, 28 terms indicating non-medical use and 41 ambiguous terms. Implicit documentation of medical use (e.g., "edible THC nightly for lumbar pain") was more common than explicit (e.g., "continues medical cannabis use"). Conclusions: Clinicians use diverse and often ambiguous language to document patients' reasons for cannabis use. Automating extraction of documentation about patients' cannabis use could facilitate clinical decision support and epidemiological investigation but will require large amounts of gold standard training data.
Collapse
Affiliation(s)
- David S Carrell
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - David J Cronkite
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Mary Shea
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Malia Oliver
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Casey Luce
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Theresa E Matson
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Jennifer F Bobb
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Clarissa Hsu
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Kendall C Browne
- Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Andrew J Saxon
- Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | | | | | - Udi E Ghitza
- National Institutes of Health, National Institutes on Drug Abuse, Rockville, MD, USA
| | - Cynthia I Campbell
- Kaiser Permanente Northern California Division of Research, Oakland, CA, USA
| | | | - Gwen T Lapham
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| |
Collapse
|
18
|
Taylor EN, Timko C, Binswanger IA, Harris AHS, Stimmel M, Smelson D, Finlay AK. A national survey of barriers and facilitators to medications for opioid use disorder among legal-involved veterans in the Veterans Health Administration. Subst Abus 2022; 43:556-563. [PMID: 34586978 PMCID: PMC9423124 DOI: 10.1080/08897077.2021.1975867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: Medications for opioid use disorder (MOUD) are clinically effective at treating OUD among legal-involved populations. However, research shows that legal-involved veterans who receive care through the VHA have lower rates of MOUD use compared to non-legal-involved veterans. Education may be a key factor in intervention strategies to improve MOUD access. This study was a national survey of VHA staff to identify barriers to and facilitators of MOUD, as well as MOUD-related education needs for VHA staff, community partners, criminal justice partners, and legal-involved veterans. Method: A 98-item online survey was conducted to examine VHA staff perspectives (N = 218) around needed education, barriers to, and facilitators of MOUD for legal-involved veterans. Descriptive statistics were conducted and linear regression analyses were used to evaluate differences in perceptions by respondents' current position at the VHA and their VHA facility's rate of provision of MOUD among legal-involved veterans. Results: Respondents endorsed a need for education in all areas of MOUD (e.g., existing medications for the treatment of OUD) for VHA staff and providers, community partners, criminal justice partners, and legal-involved veterans. VHA staff perceived barriers to MOUD for legal-involved veterans to include stigma and complicated guidelines around MOUD and OUD treatment. Facilities with low rates of MOUD use highlighted barriers including MOUD conflicting with the philosophy of the local VHA facility and provider stigma toward patients with OUD. Perceptions of efficacy of MOUD differed by respondents' current position at the VHA such that substance use disorder treatment providers perceived buprenorphine and methadone as more effective compared to Veterans Justice Specialists. Conclusion: The results of this study suggest a need for an educational intervention emphasizing the evidence supporting use of MOUD as a lack of knowledge about these medications was considered a barrier to access, whereas gaining education about MOUD was a facilitator to access. Education strategies specifically tailored to address VHA facility-level differences may help address barriers to MOUD experienced by legal-involved veterans.
Collapse
Affiliation(s)
- Emmeline N. Taylor
- U.S. Department of Veterans Affairs, VA Palo Alto Health Care System, Center for Innovation to Implementation, Palo Alto, CA, USA,Department of Psychology, University of Colorado Colorado Springs, Colorado Springs, CO, USA
| | - Christine Timko
- U.S. Department of Veterans Affairs, VA Palo Alto Health Care System, Center for Innovation to Implementation, Palo Alto, CA, USA,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Ingrid A. Binswanger
- Kaiser Permanente Colorado, Institute for Health Research, Denver, CO, USA,Colorado Permanente Medical Group, Denver, CO, USA,Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alex H. S. Harris
- U.S. Department of Veterans Affairs, VA Palo Alto Health Care System, Center for Innovation to Implementation, Palo Alto, CA, USA,Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Matthew Stimmel
- U.S. Department of Veterans Affairs, Veterans Justice Programs, Menlo Park, CA, USA
| | - David Smelson
- U.S. Department of Veterans Affairs, Edith Nourse Rodgers VA Medical Center, Center for Organization and Implementation Science, Bedford, MA, USA
| | - Andrea K. Finlay
- U.S. Department of Veterans Affairs, VA Palo Alto Health Care System, Center for Innovation to Implementation, Palo Alto, CA, USA,U.S. Department of Veterans Affairs, National Center on Homelessness Among Veterans, Menlo Park, CA, USA
| |
Collapse
|
19
|
Calcaterra SL, Binswanger IA, Edelman EJ, McNair BK, Wakeman SE, O’Connor PG. The impact of access to addiction specialist on attitudes, beliefs and hospital-based opioid use disorder related care: A survey of hospitalist physicians. Subst Abus 2022; 43:143-151. [PMID: 32267807 PMCID: PMC7541600 DOI: 10.1080/08897077.2020.1748169] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Hospitalizations for complications related to opioid use disorder (OUD) are increasing. Hospitalists care for most hospitalized patients in the United States, yet little is known about their attitudes, beliefs, and clinical practices regarding OUD-related care. Methods: We distributed an online survey to hospitalists in the United States to measure how access to addiction specialists affected attitudes and beliefs regarding hospital-based OUD care, OUD screening practices, naloxone prescribing, and buprenorphine initiation. Results: Among 262 respondents, 67.9% (n = 178) reported having access to addiction specialists. While 84.5% (n = 221) reported often or always caring for patients with OUD, 48.2% (n = 126) rarely or never screened for OUD, 57.1% (n = 149) rarely or never prescribed or recommended naloxone as harm reduction, and 88.9% (n = 233) rarely or never initiated buprenorphine. In multivariable analyses, compared to hospitalists without access to addiction specialists, hospitalist with access to addiction specialists were more likely to feel supported to screen and refer patients to treatment (aOR = 4.4, 95% CI 2.1 - 9.1; ρ < 0.001), to be aware of local treatment resources (aOR = 3.4, 95% CI 1.8 - 6.3; ρ < 0.001), and refer patients to treatment (aOR = 3.0, 95% CI 1.7 - 5.6; ρ < 0.001). Conclusions: Many hospitalists do not provide life-saving treatment to patients with OUD. Access to addiction specialists may increase provision of OUD-related care by hospitalists.
Collapse
Affiliation(s)
- Susan L Calcaterra
- Division of General Internal Medicine, University of Colorado, Aurora, CO, USA
| | - Ingrid A Binswanger
- Division of General Internal Medicine, University of Colorado, Aurora, CO, USA,Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA,Colorado Permanente Medical Group, Denver, CO, USA
| | - E. Jennifer Edelman
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA,Yale University School of Public Health, New Haven, CT, USA
| | - Bryan K McNair
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO, USA
| | - Sarah E. Wakeman
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Patrick G O’Connor
- Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
20
|
Metz TD, McMillin GA, Silver RM, Allshouse AA, Heard K, Jensen TL, Wymore EM, Stickrath E, Conageski C, Kinney GL, Binswanger IA. Quantification of prenatal marijuana use: evaluation of the correlation between self-report, serum, urine and umbilical cord assays among women delivering at two urban Colorado hospitals. Addiction 2022; 117:172-181. [PMID: 34142398 PMCID: PMC8664979 DOI: 10.1111/add.15606] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 02/01/2021] [Accepted: 06/02/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND AIMS To estimate during pregnancy correlations between frequency of self-reported use of marijuana and quantified marijuana metabolite in biospecimens including urine, sera and umbilical cord homogenate. DESIGN Prospective cohort. SETTING Two urban hospitals in Colorado with legal recreational and medicinal marijuana. PARTICIPANTS Pregnant women (<16 weeks gestation) self-reporting marijuana use. MEASUREMENTS Participants completed a written self-report survey and provided biospecimens at <16 weeks gestation (n = 46), 18 to 22 weeks gestation (n = 43), 32 to 36 weeks gestation (n = 39), and delivery (n = 37). Self-reported marijuana use frequency was calculated based on past-month days of use multiplied by number of daily uses. Maternal urine and sera were tested for presence (>5 ng/mL) of 11-nor-9-carboxy-delta-9-tetrahydrocannabinol (THC-COOH). Liquid chromatography tandem mass spectrometry quantified THC-COOH in umbilical cord homogenate (ng/g). Last marijuana use by any measure was recorded to evaluate the time frame over which THC-COOH remains detectable (>0.10 ng/g) in cord. FINDINGS From December 2017 through May 2019, 51 pregnant women enrolled, and 46 were included in analyses (2 withdrew and 3 had a spontaneous abortion). The majority were normal weight, White or Black race, and insured by Medicaid. At the time of enrollment between 7 to 15 weeks' gestation, 87% had ongoing use by self-report, or positive urine or serum. The majority (33 [66%]) stopped using before delivery. Sera and urine results were strongly correlated with self-reported use frequency (Spearman correlation coefficient [r] range 0.70-0.87 across visits, P < 0.001), and with each other. There was only one positive cord result when use stopped before 22 weeks. Frequency of self-reported marijuana use at delivery had strong correlation with quantified cord THC-COOH (r = 0.80, 95% CI = 0.62-0.89). CONCLUSIONS Quantified umbilical cord THC-COOH appears to strongly correlate with frequency of maternal marijuana use in the last month of pregnancy. Earlier use can be measured by either quantitative urine or serum assay.
Collapse
Affiliation(s)
- Torri D Metz
- University of Utah Health, Salt Lake City, UT, USA
| | - Gwendolyn A McMillin
- University of Utah Health, Salt Lake City, UT, USA
- ARUP Laboratories, Salt Lake City, UT, USA
| | | | | | - Kennon Heard
- University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | - Elaine Stickrath
- University of Colorado School of Medicine, Aurora, CO, USA
- Denver Health and Hospital Authority, Denver, CO, USA
| | | | | | - Ingrid A Binswanger
- University of Colorado School of Medicine, Aurora, CO, USA
- Kaiser Permanente Colorado, Institute for Health Research, Aurora, CO, USA
- Colorado Permanente Medical Group, Denver, CO, USA
| |
Collapse
|
21
|
Wagner NM, Binswanger IA, Shetterly SM, Rinehart DJ, Wain KF, Hopfer C, Glanz JM. Development and validation of a prediction model for opioid use disorder among youth. Drug Alcohol Depend 2021; 227:108980. [PMID: 34482048 PMCID: PMC8464513 DOI: 10.1016/j.drugalcdep.2021.108980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/15/2021] [Accepted: 07/16/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Youth are vulnerable to opioid use initiation and its complications. With growing rates of opioid overdose, strategies to identify youth at risk of opioid use disorder (OUD) to efficiently focus prevention interventions are needed. This study developed and validated a prediction model of OUD in youth aged 14-18 years. METHODS The model was developed in a Colorado healthcare system (derivation site) using Cox proportional hazards regression analysis. Model predictors and outcomes were identified using electronic health record data. The model was externally validated in a separate Denver safety net health system (validation site). Youth were followed for up to 3.5 years. We evaluated internal and external validity using discrimination and calibration. RESULTS The derivation cohort included 76,603 youth, of whom 108 developed an OUD diagnosis. The model contained 3 predictors (smoking status, mental health diagnosis, and non-opioid substance use or disorder) and demonstrated good calibration (p = 0.90) and discrimination (bootstrap-corrected C-statistic = 0.76: 95 % CI = 0.70, 0.82). Sensitivity and specificity were 57 % and 84 % respectively with a positive predictive value (PPV) of 0.49 %. The validation cohort included 45,790 youth of whom, 74 developed an OUD diagnoses. The model demonstrated poorer calibration (p < 0.001) but good discrimination (C-statistic = 0.89; 95 % CI = 0.84, 0.95), sensitivity of 87.8 % specificity of 68.6 %, and PPV of 0.45 %. CONCLUSIONS In two Colorado healthcare systems, the prediction model identified 57-88 % of subsequent OUD diagnoses in youth. However, PPV < 1% suggests universal prevention strategies for opioid use in youth may be the best health system approach.
Collapse
Affiliation(s)
- Nicole M Wagner
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, 13199 E Montview Blvd, Suite 300, Aurora, CO, 80045, USA; Institute for Health Research, Kaiser Permanente Colorado, 2550 S. Parker Road, Suite 200, Aurora, CO, 80014, USA.
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, 2550 S. Parker Road, Suite 200, Aurora, CO, 80014, USA; Colorado Permanente Medical Group, P.C., 10350 E. Dakota Ave., Denver, CO, 80247, USA; Division of General Internal Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, 12631 E 17thAve., Aurora, CO, 80045, USA.
| | - Susan M Shetterly
- Institute for Health Research, Kaiser Permanente Colorado, 2550 S. Parker Road, Suite 200, Aurora, CO, 80014, USA.
| | - Deborah J Rinehart
- Division of General Internal Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, 12631 E 17thAve., Aurora, CO, 80045, USA; Center for Health Systems Research, Denver Health Hospital and Authority, 777 Bannock St., M.C 6551, Denver, CO, 80204, USA.
| | - Kris F Wain
- Institute for Health Research, Kaiser Permanente Colorado, 2550 S. Parker Road, Suite 200, Aurora, CO, 80014, USA.
| | - Christian Hopfer
- Department of Psychiatry, School of Medicine, University of Colorado Anschutz, 13001 East 17thPlace, Q20-C2000, Aurora, CO, 80045, USA.
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, 2550 S. Parker Road, Suite 200, Aurora, CO, 80014, USA; Department of Epidemiology, University of Colorado School of Public Health, 13001 East 17thPlace, 3rd Floor, Aurora, CO, 80045, USA.
| |
Collapse
|
22
|
Boudreau DM, Lapham G, Johnson EA, Bobb JF, Matthews AG, McCormack J, Liu D, Campbell CI, Rossom RC, Binswanger IA, Yarborough BJ, Arnsten JH, Cunningham CO, Glass JE, Murphy MT, Zare M, Hechter RC, Ahmedani B, Braciszewski JM, Horigian VE, Szapocznik J, Samet JH, Saxon AJ, Schwartz RP, Bradley KA. Documented opioid use disorder and its treatment in primary care patients across six U.S. health systems. J Subst Abuse Treat 2021; 112S:41-48. [PMID: 32220410 DOI: 10.1016/j.jsat.2020.02.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 02/05/2020] [Accepted: 02/08/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND The United States is in the middle of an opioid overdose epidemic, and experts are calling for improved detection of opioid use disorders (OUDs) and treatment with buprenorphine or extended release (XR) injectable naltrexone, which can be prescribed in general medical settings. To better understand the magnitude of opportunities for treatment among primary care (PC) patients, we estimated the prevalence of documented OUD and medication treatment of OUD among PC patients. METHODS This cross-sectional study included patients with ≥2 visits to PC clinics across 6 healthcare delivery systems who were ≥16 years of age during the study period (fiscal years 2014-2016). Diagnoses, prescriptions, and healthcare utilization were ascertained from electronic health records and insurance claims (5 systems that also offer health insurance). Documented OUDs were defined as ≥1 International Classification of Diseases code for OUDs (active or remission), and OUD treatment was defined as ≥1 prescription(s) for buprenorphine formulations indicated for OUD or naltrexone XR, during the 3-year study period. The prevalence of documented OUD and treatment (95% confidence intervals) across health systems were estimated, and characteristics of patients by treatment status were compared. Prevalence of OUD and OUD treatment were adjusted for age, gender, and race/ethnicity. Combined results were also adjusted for site. RESULT Among 1,403,327 eligible PC patients, 54-62% were female and mean age ranged from 46 to 51 years across health systems. The 3-year prevalence of documented OUD ranged from 0.7-1.4% across the health systems. Among patients with documented OUD, the prevalence of medication treatment (primarily buprenorphine) varied across health systems: 3%, 12%, 16%, 20%, 22%, and 36%. CONCLUSION The prevalence of documented OUD and OUD treatment among PC patients varied widely across health systems. The majority of PC patients with OUD did not have evidence of treatment with buprenorphine or naltrexone XR, highlighting opportunities for improved identification and treatment in medical settings. These results can inform initiatives aimed at improving treatment of OUD in PC. Future research should focus on why there is such variation and how much of the variation can be addressed by improving access to medication treatment.
Collapse
Affiliation(s)
- Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute, United States of America.
| | - Gwen Lapham
- Kaiser Permanente Washington Health Research Institute, United States of America
| | - Eric A Johnson
- Kaiser Permanente Washington Health Research Institute, United States of America
| | - Jennifer F Bobb
- Kaiser Permanente Washington Health Research Institute, United States of America
| | | | | | - David Liu
- National Institute on Drug Abuse Center for Clinical Trials Network, United States of America
| | - Cynthia I Campbell
- Kaiser Permanente Northern California Division of Research, United States of America
| | | | - Ingrid A Binswanger
- Kaiser Permanente Colorado Institute for Health Research and Colorado Permanente Medical Group, United States of America
| | - Bobbi Jo Yarborough
- Kaiser Permanente Northwest Center for Health Research, United States of America
| | | | | | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, United States of America
| | | | - Mohammad Zare
- University of Texas at Houston, United States of America
| | - Rulin C Hechter
- Kaiser Permanente Southern California Department of Research and Evaluation, United States of America
| | | | | | | | | | - Jeffrey H Samet
- Boston Medical Center, Boston University School of Medicine, United States of America
| | - Andrew J Saxon
- Veteran Affairs Puget Sound Health Care System, United States of America
| | | | - Katharine A Bradley
- Kaiser Permanente Washington Health Research Institute, United States of America
| |
Collapse
|
23
|
Bagley SM, Chavez L, Braciszewski JM, Akolsile M, Boudreau DM, Lapham G, Campbell CI, Bart G, Yarborough BJH, Samet JH, Saxon AJ, Rossom RC, Binswanger IA, Murphy MT, Glass JE, Bradley KA. Receipt of medications for opioid use disorder among youth engaged in primary care: data from 6 health systems. Addict Sci Clin Pract 2021; 16:46. [PMID: 34233750 PMCID: PMC8262000 DOI: 10.1186/s13722-021-00249-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 06/09/2021] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Little is known about prevalence and treatment of OUD among youth engaged in primary care (PC). Medications are the recommended treatment of opioid use disorder (OUD) for adolescents and young adults (youth). This study describes the prevalence of OUD, the prevalence of medication treatment for OUD, and patient characteristics associated with OUD treatment among youth engaged in PC. METHODS This cross-sectional study includes youth aged 16-25 years engaged in PC. Eligible patients had ≥ 1 PC visit during fiscal years (FY) 2014-2016 in one of 6 health systems across 6 states. Data from electronic health records and insurance claims were used to identify OUD diagnoses, office-based OUD medication treatment, and patient demographic and clinical characteristics in the FY of the first PC visit during the study period. Descriptive analyses were conducted in all youth, and stratified by age (16-17, 18-21, 22-25 years). RESULTS Among 303,262 eligible youth, 2131 (0.7%) had a documented OUD diagnosis. The prevalence of OUD increased by ascending age groups. About half of youth with OUD had documented depression or anxiety and one third had co-occurring substance use disorders. Receipt of medication for OUD was lowest among youth 16-17 years old (14%) and highest among those aged 22-25 (39%). CONCLUSIONS In this study of youth engaged in 6 health systems across 6 states, there was low receipt of medication treatment, and high prevalence of other substance use disorders and mental health disorders. These findings indicate an urgent need to increase medication treatment for OUD and to integrate treatment for other substance use and mental health disorders.
Collapse
Affiliation(s)
| | - Laura Chavez
- Nationwide Children's Hospital, Abigail Wexner Research Institute, Columbus, USA
| | - Jordan M Braciszewski
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, USA
- Department of Psychiatry, Henry Ford Health System, Detroit, USA
| | - Mary Akolsile
- Kaiser Permanente Washington Health Research Institute, Seattle, USA
| | - Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute, Seattle, USA
| | - Gwen Lapham
- Nationwide Children's Hospital, Abigail Wexner Research Institute, Columbus, USA
| | - Cynthia I Campbell
- Division of Research, Kaiser Permanente Northern California, Oakland, USA
| | - Gavin Bart
- University of Minnesota Medical School/Hennepin Healthcare, Minneapolis, USA
| | | | | | - Andrew J Saxon
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System/University of Washington School of Medicine, Seattle, USA
| | - Rebecca C Rossom
- Health Partners Institute/University of Minnesota, Minneapolis, USA
| | - Ingrid A Binswanger
- Colorado Permanente Medical Group, Kaiser Permanente Colorado, The University of Colorado School of Medicine and The Kaiser Permanente Bernard J. Tyson School of Medicine, Aurora, USA
| | - Mark T Murphy
- MultiCare Institute for Research and Innovation, MultiCare Health System WA, Tacoma, USA
| | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, Seattle, USA
| | | |
Collapse
|
24
|
Shoup JA, Mueller SR, Binswanger IA, Williams AV, Strang J, Glanz JM. Modifying and Evaluating the Opioid Overdose Knowledge Scale for Prescription Opioids: A Pilot Study of the Rx-OOKS. Pain Med 2021; 21:2244-2252. [PMID: 32827044 DOI: 10.1093/pm/pnaa190] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To develop a validated instrument that measures knowledge about prescription opioid overdose. METHODS Within an integrated health care system, we adapted, piloted, and tested the reliability and predictive validity of a modified Opioid Overdose Knowledge Scale (OOKS) instrument specific to prescription opioids (Rx-OOKS) with a patient population prescribed long-term opioid therapy and potentially at risk of opioid overdose. We used an interdisciplinary team approach and patient interviews to adapt the instrument. We then piloted the survey on a patient sample and assessed it using Cronbach's alpha and logistic regression. RESULTS Rx-OOKS (N = 56) resulted in a three-construct, 25-item instrument. Internal consistency was acceptable for the following constructs: "signs of an overdose" (10 items) at α = 0.851, "action to take with opioid overdose" (seven items) at α = 0.692, and "naloxone use knowledge" (eight items) at α = 0.729. One construct, "risks of an overdose" (three items), had an α of 0.365 and was subsequently eliminated from analysis due to poor performance. We conducted logistic regression to determine if any of the constructs was strongly associated with future naloxone receipt. Higher scores on "actions to take in an overdose" had nine times the odds of receiving naloxone (odds ratio [OR] = 9.00, 95% confidence interval [CI] = 1.42-57.12); higher "naloxone use knowledge" scores were 15.8 times more likely to receive naloxone than those with lower scores (OR = 15.83, 95% CI = 1.68-149.17). CONCLUSIONS The Rx-OOKS survey instrument can reliably measure knowledge about prescription opioid overdose recognition and naloxone use. Further, knowledge about actions to take during an opioid overdose and naloxone use were associated with future receipt of naloxone.
Collapse
Affiliation(s)
- Jo Ann Shoup
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Shane R Mueller
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado.,Colorado Permanente Medical Group, Denver, Colorado.,Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Anna V Williams
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado.,Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado, USA
| |
Collapse
|
25
|
Matson TE, Carrell DS, Bobb JF, Cronkite DJ, Oliver MM, Luce C, Ghitza UE, Hsu CW, Campbell CI, Browne KC, Binswanger IA, Saxon AJ, Bradley KA, Lapham GT. Prevalence of Medical Cannabis Use and Associated Health Conditions Documented in Electronic Health Records Among Primary Care Patients in Washington State. JAMA Netw Open 2021; 4:e219375. [PMID: 33956129 PMCID: PMC8103224 DOI: 10.1001/jamanetworkopen.2021.9375] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/18/2021] [Indexed: 12/11/2022] Open
Abstract
Importance Many people use cannabis for medical reasons despite limited evidence of therapeutic benefit and potential risks. Little is known about medical practitioners' documentation of medical cannabis use or clinical characteristics of patients with documented medical cannabis use. Objectives To estimate the prevalence of past-year medical cannabis use documented in electronic health records (EHRs) and to describe patients with EHR-documented medical cannabis use, EHR-documented cannabis use without evidence of medical use (other cannabis use), and no EHR-documented cannabis use. Design, Setting, and Participants This cross-sectional study assessed adult primary care patients who completed a cannabis screen during a visit between November 1, 2017, and October 31, 2018, at a large health system that conducts routine cannabis screening in a US state with legal medical and recreational cannabis use. Exposures Three mutually exclusive categories of EHR-documented cannabis use (medical, other, and no use) based on practitioner documentation of medical cannabis use in the EHR and patient report of past-year cannabis use at screening. Main Outcomes and Measures Health conditions for which cannabis use has potential benefits or risks were defined based on National Academies of Sciences, Engineering, and Medicine's review. The adjusted prevalence of conditions diagnosed in the prior year were estimated across 3 categories of EHR-documented cannabis use with logistic regression. Results A total of 185 565 patients (mean [SD] age, 52.0 [18.1] years; 59% female, 73% White, 94% non-Hispanic, and 61% commercially insured) were screened for cannabis use in a primary care visit during the study period. Among these patients, 3551 (2%) had EHR-documented medical cannabis use, 36 599 (20%) had EHR-documented other cannabis use, and 145 415 (78%) had no documented cannabis use. Patients with medical cannabis use had a higher prevalence of health conditions for which cannabis has potential benefits (49.8%; 95% CI, 48.3%-51.3%) compared with patients with other cannabis use (39.9%; 95% CI, 39.4%-40.3%) or no cannabis use (40.0%; 95% CI, 39.8%-40.2%). In addition, patients with medical cannabis use had a higher prevalence of health conditions for which cannabis has potential risks (60.7%; 95% CI, 59.0%-62.3%) compared with patients with other cannabis use (50.5%; 95% CI, 50.0%-51.0%) or no cannabis use (42.7%; 95% CI, 42.4%-42.9%). Conclusions and Relevance In this cross-sectional study, primary care patients with documented medical cannabis use had a high prevalence of health conditions for which cannabis use has potential benefits, yet a higher prevalence of conditions with potential risks from cannabis use. These findings suggest that practitioners should be prepared to discuss potential risks and benefits of cannabis use with patients.
Collapse
Affiliation(s)
- Theresa E. Matson
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Health Services, University of Washington, Seattle
| | | | | | | | - Malia M. Oliver
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Casey Luce
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Udi E. Ghitza
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Clarissa W. Hsu
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Cynthia I. Campbell
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Kendall C. Browne
- Center of Excellence in Substance Addiction Treatment and Education, Veteran Affairs Puget Sound Health Care System, Seattle, Washington
| | - Ingrid A. Binswanger
- Kaiser Permanente Colorado Institute for Health Research and Colorado Permanente Medical Group, Denver
| | - Andrew J. Saxon
- Center of Excellence in Substance Addiction Treatment and Education, Veteran Affairs Puget Sound Health Care System, Seattle, Washington
| | - Katharine A. Bradley
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Health Services, University of Washington, Seattle
| | - Gwen T. Lapham
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Health Services, University of Washington, Seattle
| |
Collapse
|
26
|
Tsui JI, Akosile MA, Lapham GT, Boudreau DM, Johnson EA, Bobb JF, Binswanger IA, Yarborough BJH, Glass JE, Rossom RC, Murphy MT, Cunningham CO, Arnsten JH, Thakral M, Saxon AJ, Merrill JO, Samet JH, Bart GB, Campbell CI, Loree AM, Silva A, Stotts AL, Ahmedani B, Braciszewski JM, Hechter RC, Northrup TF, Horigian VE, Bradley KA. Prevalence and Medication Treatment of Opioid Use Disorder Among Primary Care Patients with Hepatitis C and HIV. J Gen Intern Med 2021; 36:930-937. [PMID: 33569735 PMCID: PMC8041979 DOI: 10.1007/s11606-020-06389-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 12/03/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Hepatitis C and HIV are associated with opioid use disorders (OUD) and injection drug use. Medications for OUD can prevent the spread of HCV and HIV. OBJECTIVE To describe the prevalence of documented OUD, as well as receipt of office-based medication treatment, among primary care patients with HCV or HIV. DESIGN Retrospective observational cohort study using electronic health record and insurance data. PARTICIPANTS Adults ≥ 18 years with ≥ 2 visits to primary care during the study (2014-2016) at 6 healthcare systems across five states (CO, CA, OR, WA, and MN). MAIN MEASURES The primary outcome was the diagnosis of OUD; the secondary outcome was OUD treatment with buprenorphine or oral/injectable naltrexone. Prevalence of OUD and OUD treatment was calculated across four groups: HCV only; HIV only; HCV and HIV; and neither HCV nor HIV. In addition, adjusted odds ratios (AOR) of OUD treatment associated with HCV and HIV (separately) were estimated, adjusting for age, gender, race/ethnicity, and site. KEY RESULTS The sample included 1,368,604 persons, of whom 10,042 had HCV, 5821 HIV, and 422 both. The prevalence of diagnosed OUD varied across groups: 11.9% (95% CI: 11.3%, 12.5%) for those with HCV; 1.6% (1.3%, 2.0%) for those with HIV; 8.8% (6.2%, 11.9%) for those with both; and 0.92% (0.91%, 0.94%) among those with neither. Among those with diagnosed OUD, the prevalence of OUD medication treatment was 20.9%, 16.0%, 10.8%, and 22.3%, for those with HCV, HIV, both, and neither, respectively. HCV was not associated with OUD treatment (AOR = 1.03; 0.88, 1.21), whereas patients with HIV had a lower probability of OUD treatment (AOR = 0.43; 0.26, 0.72). CONCLUSIONS Among patients receiving primary care, those diagnosed with HCV and HIV were more likely to have documented OUD than those without. Patients with HIV were less likely to have documented medication treatment for OUD.
Collapse
Affiliation(s)
- Judith I Tsui
- University of Washington/Harborview Medical Center, Seattle, USA
| | - Mary A Akosile
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Gwen T Lapham
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Eric A Johnson
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Jennifer F Bobb
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Ingrid A Binswanger
- Kaiser Permanente Colorado, Colorado Permanente Medical Group, and the University of Colorado School of Medicine, Aurora, USA
| | | | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Rebecca C Rossom
- HealthPartners Institute, University of Minnesota, Bloomington, USA
| | - Mark T Murphy
- MultiCare Institute for Research and Innovation, MultiCare Health System WA, Seattle, USA
| | - Chinazo O Cunningham
- Albert Einstein College of Medicine, Montefiore Medical Center, New York City, USA
| | - Julia H Arnsten
- Albert Einstein College of Medicine, Montefiore Medical Center, New York City, USA
| | - Manu Thakral
- College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, USA
| | - Andrew J Saxon
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System/University of Washington School of Medicine, Seattle, USA
| | - Joseph O Merrill
- University of Washington/Harborview Medical Center, Seattle, USA
| | | | - Gavin B Bart
- Hennepin Healthcare, University of Minnesota, Minneapolis, USA
| | - Cynthia I Campbell
- Division of Research, Kaiser Permanente Northern California, Oakland, USA
| | - Amy M Loree
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, USA
| | - Angela Silva
- MultiCare Institute for Research and Innovation, MultiCare Health System WA, Seattle, USA
| | - Angela L Stotts
- Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth), Houston, USA
| | - Brian Ahmedani
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, USA
| | - Jordan M Braciszewski
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, USA
- Department of Psychiatry, Henry Ford Health System, Detroit, USA
| | - Rulin C Hechter
- Department of Research and Evaluation, Kaiser Permanente Southern California, Oakland, USA
| | - Thomas F Northrup
- Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth), Houston, USA
| | - Viviana E Horigian
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Florida, USA
| | - Katharine A Bradley
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA.
| |
Collapse
|
27
|
Krsak M, Montague BT, Trowbridge P, Johnson SC, Binswanger IA. Opioid Use and Chronic Infections: The Value of Addressing the Syndemic in Correctional Settings Via Telemedicine Guidance and Broader Use of Long-Acting Medications. J Infect Dis 2021; 222:S486-S493. [PMID: 32877543 DOI: 10.1093/infdis/jiaa001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In the United States, we are experiencing linked epidemics (a syndemic) of substance use disorders (SUDs) and infections associated with drug use, including unsafe injecting and unsafe sex in exchange for drugs or money. Current drug laws, together with risk-taking behavior among persons with SUDs, contribute to disproportionately high prevalences of these conditions in correctional settings. Detection and treatment of diseases with a high impact on public health are best addressed in the settings where such conditions are most prevalent (ie, jails and prisons for SUDs and chronic infections). The effectiveness, safety, cost of care. and public health impact of these conditions can be improved by means of broader screening and expanded access to specialty consultations through telemedicine/telehealth, along with broader use of long-acting medications for the treatment of human immunodeficiency virus and SUDs. Expanding telemedicine/telehealth, first for specialties which do not require advanced technology (eg, infectious diseases, addictions), can eventually lead to further advancements in correctional healthcare.
Collapse
Affiliation(s)
- Martin Krsak
- Division of Infectious Diseases, University of Colorado School of Medicine, Colorado, USA
| | - Brian T Montague
- Division of Infectious Diseases, University of Colorado School of Medicine, Colorado, USA
| | - Paul Trowbridge
- Spectrum Health Center for Integrative Medicine, Grand Rapids, Michigan, USA
| | - Steven C Johnson
- Division of Infectious Diseases, University of Colorado School of Medicine, Colorado, USA
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA.,Colorado Permanente Medical Group, Denver, Colorado, USA.,Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| |
Collapse
|
28
|
Morse E, Binswanger IA, Taylor E, Gray C, Stimmel M, Timko C, Harris AHS, Smelson D, Finlay AK. Strategies to improve implementation of medications for opioid use disorder reported by veterans involved in the legal system: A qualitative study. J Subst Abuse Treat 2021; 129:108353. [PMID: 34080564 DOI: 10.1016/j.jsat.2021.108353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 12/07/2020] [Accepted: 02/28/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Veterans involved in the legal system have a high risk of overdose mortality but limited utilization of medications for opioid use disorder (MOUD). To increase the use of MOUD in Veterans Health Administration (VHA) facilities and reduce overdose mortality, the VHA should incorporate strategies identified by legal-involved veterans to improve quality of care and ensure that their patients' experiences are integrated into care delivery. This study aims to determine strategies to increase use of MOUD from the perspective of legal-involved veterans with a history of opioid use or opioid use disorder (OUD). METHODS Between February 2018 and March 2019, we conducted semistructured interviews with 18 veterans with a history of opioid use or OUD and legal involvement (15 men and 3 women; mean age 41, standard deviation 13, range 28-61). Veterans were from 9 geographically dispersed United States VHA facilities. The study analyzed verbatim transcripts using the framework method. The primary focus was themes that represented legal-involved veteran-identified strategies to improve the use of MOUD. RESULTS The 18 veterans interviewed had legal involvement directly related to their opioid use and most (n = 15; 83%) had previously used MOUD. Veteran-identified strategies to improve access to and use of MOUD included: (1) VHA should provide transportation or telehealth services; (2) legal agencies should increase access to MOUD during incarceration; (3) the VHA should reduce physician turnover; (4) the VHA should improve physician education to deliver compassionate, patient-centered treatment; (5) the VHA should improve veteran education about MOUD; and (6) the VHA should provide social support opportunities to veterans. CONCLUSIONS Legal-involved veterans provided strategies that can inform and expand MOUD to better meet their needs and the treatment needs of all patients with OUD. The VHA should consider incorporating these strategies into care, and should evaluate their impact on patients' experience, initiation of and retention on medications, and overdose rates.
Collapse
Affiliation(s)
- Erica Morse
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E Harvard Ave #300, Denver, CO 80231, USA.
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E Harvard Ave #300, Denver, CO 80231, USA; Colorado Permanente Medical Group, 1835 Franklin St, Denver, CO 80218, USA; Division of General Internal Medicine, University of Colorado School of Medicine, 12631 East 17th Avenue, Aurora, CO 80045, USA.
| | - Emmeline Taylor
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; Department of Clinical Psychology, University of Colorado, 1420 Austin Bluffs Pkwy, Colorado Springs, CO 80918, USA.
| | - Caroline Gray
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
| | - Matthew Stimmel
- Veterans Justice Programs, U.S. Department of Veterans Affairs (MS), 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
| | - Christine Timko
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 1199 Welch Road, Stanford, CA 94304, USA.
| | - Alex H S Harris
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; Department of Surgery, Stanford University School of Medicine, Always Building, Suite M121, 300 Pasteur Drive, Stanford, CA 94305-2200, USA.
| | - David Smelson
- Center for Organization and Implementation Science, Edith Nourse Rogers VA Medical Center, 200 Springs Road, Bedford, MA 01730, USA.
| | - Andrea K Finlay
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; National Center on Homelessness Among Veterans, Department of Veterans Affairs, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
| |
Collapse
|
29
|
Mueller SR, Glanz JM, Nguyen AP, Stowell M, Koester S, Rinehart DJ, Binswanger IA. Restrictive opioid prescribing policies and evolving risk environments: A qualitative study of the perspectives of patients who experienced an accidental opioid overdose. Int J Drug Policy 2021; 92:103077. [PMID: 33423916 DOI: 10.1016/j.drugpo.2020.103077] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/23/2020] [Accepted: 12/04/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Despite policy efforts to prevent overdose, accidental overdoses among individuals prescribed opioids continue to occur. Guided by Rhodes' Risk Environment Framework, we examined the unintended consequences of restrictive policies by identifying macro policy and micro-level contextual factors that patients prescribed opioids for pain identified as contributing to overdose events. METHODS Semi-structured interviews were conducted with 31 patients prescribed opioids who experienced an accidental opioid overdose between April 2017 and June 2019 in two health systems. RESULTS We identified three interrelated factors that emerged within an evolving risk environment and may have increased patients' vulnerability for an accidental opioid overdose: desperation from persistent pain and comorbidities; limited knowledge about opioid medication safety and effectiveness; and restrictive opioid prescribing policies that exacerbated stigma, fear and mistrust and prevented open patient-clinician communication. When experiencing persistent pain, patients took matters into their own hands by taking more medications or in different intervals than prescribed, mixing them with other substances, or using illicitly obtained opioids. CONCLUSION For some patients, macro-level policies and guidelines designed to reduce opioid overdoses by restricting opioid supply may have paradoxically created a micro-level risk environment that contributed to overdose events in a subset of patients.
Collapse
Affiliation(s)
- Shane R Mueller
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 80237, USA.
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 80237, USA; Department of Epidemiology, Colorado School of Public Health, 13001 E 17th Place, Mail Stop B-119, Aurora CO 80045, United States
| | - Anh P Nguyen
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 80237, USA
| | - Melanie Stowell
- Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority, 777 Bannock St, MC 6551 Denver, Colorado 80204, United States
| | - Stephen Koester
- Anthropology, Health & Behavioral Sciences, University of Colorado Denver, 777 Lawrence St, Denver, CO 80204, United States
| | - Deborah J Rinehart
- Center for Health Systems Research, Office of Research, Denver Health and Hospital Authority, 777 Bannock St, MC 6551 Denver, Colorado 80204, United States; Division of General Internal Medicine, University of Colorado School of Medicine, 13001 E 17th Place, Aurora CO 80045, United States
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, P.O. Box 378066, Denver, CO 80237, USA; Division of General Internal Medicine, University of Colorado School of Medicine, 13001 E 17th Place, Aurora CO 80045, United States; Colorado Permanente Medical Group, 10350 E. Dakota Ave, Denver CO 80247, United States
| |
Collapse
|
30
|
Derington CG, Mueller SR, Glanz JM, Binswanger IA. Identifying naloxone administrations in electronic health record data using a text-mining tool. Subst Abus 2020; 42:806-812. [PMID: 33320803 PMCID: PMC8203755 DOI: 10.1080/08897077.2020.1856288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: Effective and efficient methods are needed to identify naloxone administrations within electronic health record (EHR) data to conduct overdose surveillance and research. The objective of this study was to develop and validate a text-mining tool to identify naloxone administrations in EHR data. Methods: Clinical notes stored in databases between January 2017 and March 2018 were used to iteratively develop a text-mining tool to identify naloxone administrations. The first iteration of the tool used broad search terms. Then, after reviewing clinical notes of overdose encounters, we developed a list of phrases that described naloxone administrations to inform iteration two. While validating iteration two, additional phrases were found, which were then added to inform the final iteration. The comparator was an administrative code query extracted from the EHR. Medical record review was used to identify true positives. The primary outcome was the positive predictive values (PPV) of the second iteration, final iteration, and administrative code query. Results: Iteration two, the final iteration, and the administrative code had PPVs of 84.3% (95% confidence interval [CI] 78.6-89.0%), 83.8% (95% CI 78.6-88.2%), and 57.1% (95% CI 47.1-66.8%), respectively. Both iterations of the tool had a significantly higher PPV than the administrative code (p < 0.001). Conclusions: A text-mining tool improved the identification of naloxone administrations in EHR data from less than 60% with the administrative code to greater than 80% with both versions of the tool. Text-mining tools can inform the use of more sophisticated informatics methods, which often require significant time, resource, and expertise investment.
Collapse
Affiliation(s)
- Catherine G. Derington
- Department of Population Health Sciences, University of Utah, 295 Chipeta Way, Salt Lake City UT 84112
| | - Shane R. Mueller
- Institute for Health Research, Kaiser Permanente Colorado, 2550 S. Parker Road, Suite 200, Aurora CO 80014
| | - Jason M. Glanz
- Institute for Health Research, Kaiser Permanente Colorado, 2550 S. Parker Road, Suite 200, Aurora CO 80014
- Department of Epidemiology, Colorado School of Public Health, 13001 E 17 Place, Mail Stop B-119, Aurora CO 80045
| | - Ingrid A. Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, 2550 S. Parker Road, Suite 200, Aurora CO 80014
- Colorado Permanente Medical Group, 10350 E. Dakota Ave, Denver CO 80247
- Division of General Internal Medicine, University of Colorado School of Medicine, 13001 E 17 Place, Aurora CO 80045
| |
Collapse
|
31
|
Binswanger IA, Nguyen AP, Morenoff JD, Xu S, Harding DJ. The association of criminal justice supervision setting with overdose mortality: a longitudinal cohort study. Addiction 2020; 115:2329-2338. [PMID: 32267585 PMCID: PMC7541650 DOI: 10.1111/add.15077] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 11/11/2019] [Accepted: 03/27/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS Despite the high prevalence of substance use among people in the US criminal justice system, little is known about the incidence of overdose mortality by use patterns, drug convictions and supervision setting. We examined the associations between these characteristics and overdose mortality. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS Individuals sentenced to prison, jail, probation or jail plus probation for a felony conviction in Michigan, USA from 2003 to 2006. MEASUREMENTS Using the National Death Index, we assessed overdose mortality to December 2012. We calculated overdose mortality rates by pre-sentence opioid use, drug convictions and supervision setting. Multivariable analyses were conducted using competing risks regression with time-varying covariates. FINDINGS Among 140 266 individuals followed over a mean of 7.84 years [standard deviation (SD) = 1.52], 14.9% of the 1131 deaths were due to overdose (102.8 per 100 000 person-years). Over the follow-up, more than half of overdose deaths occurred in the community (57.7%), nearly a third (28.8%) on probation and 12.8% on parole. The adjusted risk of overdose death was lower on probation [hazard ratio (HR) = 0.71, 95% confidence interval (CI) = 0.60, 0.85] than in the community without probation or parole (HR = 1.00) but not significantly different on parole (HR = 1.13, 95% CI = 0.87, 1.47). Pre-sentence daily opioid use (HR = 3.54, 95% CI = 3.24, 3.87) was associated with an increased risk. Drug possession (HR = 1.11, 95% CI = 0.93, 1.31) and delivery convictions (HR = 0.92, 95% CI = 0.77, 1.09) were not significantly associated with overdose mortality. CONCLUSIONS Based on the absolute or relative risk, parole, probation and community settings are appropriate settings for enhanced overdose prevention interventions. Ensuring that individuals with pre-sentence opioid use have access to harm reduction and drug treatment services may help to prevent overdose among people involved with the criminal justice system.
Collapse
Affiliation(s)
- Ingrid A. Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado,Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado,Colorado Permanente Medical Group
| | - Anh P. Nguyen
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - Jeffrey D. Morenoff
- Sociology, University of Michigan, Ann Arbor, Michigan,Institute for Social Research-Populations Studies Center, University of Michigan, Ann Arbor, Michigan
| | - Stanley Xu
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado
| | - David J. Harding
- Sociology, University of California, Berkeley, California,Berkeley Population Center, University of California, Berkeley, California
| |
Collapse
|
32
|
Binswanger IA, Glanz JM, Faul M, Shoup JA, Quintana LM, Lyden J, Xu S, Narwaney KJ. The Association between Opioid Discontinuation and Heroin Use: A Nested Case-Control Study. Drug Alcohol Depend 2020; 217:108248. [PMID: 32927194 PMCID: PMC10959283 DOI: 10.1016/j.drugalcdep.2020.108248] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/12/2020] [Accepted: 08/15/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Opioid prescribing guidelines recommend reducing or discontinuing opioids for chronic pain if harms of opioid treatment outweigh benefits. As opioid discontinuation becomes more prevalent, it is important to understand whether opioid discontinuation is associated with heroin use. In this study, we sought to assess the association between opioid discontinuation and heroin use documented in the medical record. METHODS A matched nested case-control study was conducted in an integrated health plan and delivery system in Colorado. Patients receiving opioid therapy in the study period (January 2006-June 2018) were included. Opioid discontinuation was defined as ≥45 days with no opioids dispensed after initiating opioid therapy. The heroin use onset date represented the index date. Case patients were matched to up to 20 randomly selected patients without heroin use (control patients) by age, sex, calendar time, and time between initiating opioid therapy and the index date. Conditional logistic regression models estimated matched odds ratios (mOR) for the association between an opioid discontinuation prior to the index date and heroin use. RESULTS Among 22,962 patients prescribed opioid therapy, 125 patients (0.54%) used heroin after initiating opioid therapy, of which 74 met criteria for inclusion in the analysis. The odds of opioid discontinuation were approximately two times higher in case patients (n = 74) than control patients (n = 1045; mOR = 2.19; 95% CI 1.27-3.78). CONCLUSIONS Among patients prescribed chronic opioid therapy, the observed increased risk for heroin use associated with opioid discontinuation should be balanced with potential benefits.
Collapse
Affiliation(s)
- Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO; Colorado Permanente Medical Group, Aurora, CO; Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO.
| | - Jason M Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO; Colorado School of Public Health, Aurora, CO
| | - Mark Faul
- Centers for Disease Control and Prevention, Atlanta, GA
| | - Jo Ann Shoup
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - LeeAnn M Quintana
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Jennifer Lyden
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO; Denver Health, Department of Medicine, Denver, CO
| | - Stan Xu
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO; Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Komal J Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| |
Collapse
|
33
|
Finlay AK, Morse E, Stimmel M, Taylor E, Timko C, Harris AHS, Smelson D, Yu M, Blue-Howells J, Binswanger IA. Barriers to Medications for Opioid Use Disorder Among Veterans Involved in the Legal System: a Qualitative Study. J Gen Intern Med 2020; 35:2529-2536. [PMID: 32583337 PMCID: PMC7459011 DOI: 10.1007/s11606-020-05944-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 05/22/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Veterans involved in the legal system are at high risk for overdose but have lower receipt of medications for opioid use disorder than other veterans. OBJECTIVE The study aimed to understand barriers to medication access from the perspective of legally involved veterans with opioid use disorder and people who work with these veterans in the Veterans Health Administration (VHA) and the legal system. DESIGN This national qualitative study interviewed veterans and stakeholders from 14 geographically diverse VHA facilities to explore perceptions of barriers to medications for opioid use disorder. PARTICIPANTS Participants included veterans with a history of opioid use disorder and legal involvement (n = 18), VHA Veterans Justice Programs Specialists (n = 15), VHA and community substance use disorder treatment providers (n = 5), and criminal justice staff (n = 12). APPROACH We conducted interviews based on the Consolidated Framework for Implementation Research. Interview transcripts were analyzed using a team-based approach. KEY RESULTS Four key barriers, noted by group, were identified: (1) a preference for counseling along with or instead of medications (veterans, Specialists, treatment providers, criminal justice staff); (2) concerns about veterans using medications without a prescription, selling them, or providing them to others (veterans, Specialists, treatment providers, criminal justice staff); (3) concerns about perceived stigma towards medication use (veterans, Specialists, treatment providers, criminal justice staff); and (4) concerns about medication discontinuation after recurrent opioid use (veterans, criminal justice staff). A fifth theme, education, was noted by all stakeholders except providers as important to facilitating use of medications for opioid use disorder. All five themes mapped to the framework construct of knowledge and beliefs about the intervention. CONCLUSIONS Based on identified barriers, interventions focused on enhancing medication knowledge, reducing stigma towards use of medications, and increasing knowledge that opioid use may recur during treatment may help increase access to medication for veterans with legal involvement.
Collapse
Affiliation(s)
- Andrea K Finlay
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Road (MPD-152), Menlo Park, Willow, CA, 94025, USA. .,Department of Veterans Affairs, National Center on Homelessness Among Veterans, 795 Willow Road, Menlo Park, 94025, USA.
| | - Erica Morse
- Institute for Health Research, Kaiser Permanente Colorado, Denver, USA
| | - Matthew Stimmel
- Veterans Justice Programs, U.S. Department of Veterans Affairs, , Menlo Park, USA
| | - Emmeline Taylor
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Road (MPD-152), Menlo Park, Willow, CA, 94025, USA.,Department of Clinical Psychology, University of Colorado, Colorado Springs, Colorado Springs, USA
| | - Christine Timko
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Road (MPD-152), Menlo Park, Willow, CA, 94025, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, USA
| | - Alex H S Harris
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Road (MPD-152), Menlo Park, Willow, CA, 94025, USA.,Department of Surgery, Stanford University School of Medicine, Stanford, USA
| | - David Smelson
- Center for Organization and Implementation Science, Edith Nourse Rogers VA Medical Center, Bedford, USA
| | - Mengfei Yu
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Road (MPD-152), Menlo Park, Willow, CA, 94025, USA
| | - Jessica Blue-Howells
- Veterans Justice Programs, U.S. Department of Veterans Affairs, , Menlo Park, USA
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Denver, USA.,Colorado Permanente Medical Group, Denver, USA.,Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, USA
| |
Collapse
|
34
|
Golembeski CA, Sufrin CB, Williams B, Bedell PS, Glied SA, Binswanger IA, Hylton D, Winkelman TNA, Meyer JP. Improving Health Equity for Women Involved in the Criminal Legal System. Womens Health Issues 2020; 30:313-319. [PMID: 32739132 DOI: 10.1016/j.whi.2020.06.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 06/12/2020] [Accepted: 06/20/2020] [Indexed: 01/26/2023]
Affiliation(s)
- Cynthia A Golembeski
- Rutgers University School of Law and School of Public Affairs and Administration, Newark, New Jersey.
| | - Carolyn B Sufrin
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brie Williams
- University of California San Francisco, Division of Geriatrics and Amend at UCSF, Francisco, California
| | - Precious S Bedell
- University of Rochester College of Arts, Sciences, and Engineering, Turning Points Resource Center, Rochester, New York
| | - Sherry A Glied
- New York University Robert F. Wagner Graduate School of Public Service, New York, New York
| | - Ingrid A Binswanger
- Kaiser Permanente Institute for Health Research and Chemical Dependency Treatment Services, University of Colorado School of Medicine, Denver, Colorado
| | | | - Tyler N A Winkelman
- General Internal Medicine, Department of Medicine, Hennepin Healthcare; Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Jaimie P Meyer
- Yale University School of Medicine, New Haven, Connecticut
| |
Collapse
|
35
|
Frank JW, Binswanger IA. Commentary on Rhee & Rosenheck (2019): Buprenorphine prescribing for opioid use disorder in medical practice - can office-based out-patient care address the opiate crisis in the United States? Addiction 2020; 115:786-787. [PMID: 31762128 DOI: 10.1111/add.14907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/14/2019] [Accepted: 11/16/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Joseph W Frank
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA.,Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | - Ingrid A Binswanger
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA.,Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA.,Colorado Permanente Medical Group, Denver, CO, USA
| |
Collapse
|
36
|
Abstract
IMPORTANCE Family members are cited as a common source of prescription opioids used for nonmedical reasons. However, the overdose risk associated with exposure to opioids prescribed to family members among adolescents and young adults is not well established. OBJECTIVE To assess the association of opioids prescribed to family members with pharmaceutical opioid overdose among youth. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 45 145 family units with a total of 72 040 adolescents and young adults aged 11 to 26 years enrolled in a Kaiser Permanente Colorado health plan in 2006 and observed through June 2018. EXPOSURES Opioid prescriptions and dosage dispensed to family members and youth in the past month. MAIN OUTCOMES AND MEASURES Fatal pharmaceutical opioid overdoses identified in vital records and nonfatal pharmaceutical opioid overdoses identified in emergency department and inpatient settings. Time to first overdose was modeled using Cox regression. RESULTS The study population consisted of 72 040 adolescents and young adults (mean [SD] age across follow-up, 19.3 [3.7] years; 36 646 [50.9%] girls and women) nested in 45 145 family units. Youth were more commonly exposed to prescription opioids dispensed to a family member than through their own prescriptions. During follow-up, 26 284 youth (36.5%) filled at least 1 opioid prescription, and 47 461 youth (65.9%) had at least 1 family member with a prescription. Exposure to family members with opioid prescriptions in the past month was associated with increased risk of pharmaceutical opioid overdose (adjusted hazard ratio [aHR], 2.17; 95% CI, 1.24-3.79) independent of opioids prescribed to youth (aHR, 6.62; 95% CI, 3.39-12.91). Concurrent exposure to opioid prescriptions from youth and family members was associated with substantially increased overdose risk (aHR, 12.99; 95% CI, 5.08-33.25). High dosage of total morphine milligram equivalents (MME) prescribed to family members in the past month was associated with youth overdose (0 MME vs >0 to <200 MME: aHR, 1.39; 95% CI, 0.51-3.81; 0 MME vs 200 to <600 MME: aHR, 1.49; 95% CI, 0.59-3.77; 0 MME vs ≥600 MME: aHR, 2.93; 95% CI, 1.55-5.56). CONCLUSIONS AND RELEVANCE In this study of youth linked to family members, exposure to family members' prescribed opioids was associated with increased risk of pharmaceutical opioid overdose, independent of opioids prescribed to youth. Further interventions targeting youth and families are needed, including counseling patients about the risks of opioids to youth in their families.
Collapse
Affiliation(s)
- Anh P. Nguyen
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Jason M. Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO
| | - Komal J. Narwaney
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Ingrid A. Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
- Colorado Permanente Medical Group, Aurora, CO
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| |
Collapse
|
37
|
Lapham G, Boudreau DM, Johnson EA, Bobb JF, Matthews AG, McCormack J, Liu D, Samet JH, Saxon AJ, Campbell CI, Glass JE, Rossom RC, Murphy MT, Binswanger IA, Yarborough BJH, Bradley KA, Ahmedani B, Amoroso PJ, Arnsten JH, Bart G, Braciszewski JM, Cunningham CO, Hechter RC, Horigian VE, Liebschutz JM, Loree AM, Matson TE, McNeely J, Merrill JO, Northrup TF, Schwartz RP, Stotts AL, Szapocznik J, Thakral M, Tsui JI, Zare M. Prevalence and treatment of opioid use disorders among primary care patients in six health systems. Drug Alcohol Depend 2020; 207:107732. [PMID: 31835068 PMCID: PMC7158756 DOI: 10.1016/j.drugalcdep.2019.107732] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 10/25/2019] [Accepted: 11/11/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND The U.S. experienced nearly 48,000 opioid overdose deaths in 2017. Treatment of opioid use disorder (OUD) with buprenorphine is a recommended part of primary care, yet little is known about current U.S. practices in this setting. This observational study reports the prevalence of documented OUD and OUD treatment with buprenorphine among primary care patients in six large health systems. METHODS Adults with ≥2 primary care visits during a three-year period (10/1/2013-9/30/2016) in six health systems were included. Data were obtained from electronic health record and claims data, with measures, assessed over the three-year period, including indicators for documented OUD from ICD 9 and 10 codes and OUD treatment with buprenorphine. The prevalence of OUD treatment was adjusted for age, gender, race/ethnicity, and health system. RESULTS Among 1,368,604 primary care patients, 13,942 (1.0 %) had documented OUD, and among these, 21.0 % had OUD treatment with buprenorphine. For those with documented OUD, the adjusted prevalence of OUD treatment with buprenorphine varied across demographic and clinical subgroups. OUD treatment was lower among patients who were older, women, Black/African American and Hispanic (compared to white), non-commercially insured, and those with non-cancer pain, mental health disorders, greater comorbidity, and more opioid prescriptions, emergency department visits or hospitalizations. CONCLUSIONS Among primary care patients in six health systems, one in five with an OUD were treated with buprenorphine, with disparities across demographic and clinical characteristics. Less buprenorphine treatment among those with greater acute care utilization highlights an opportunity for systems-level changes to increase OUD treatment.
Collapse
Affiliation(s)
- Gwen Lapham
- Kaiser Permanente Washington Health Research Institute, United States; University of Washington, Department of Health Services, United States.
| | - Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute.,University of Washington Department of Pharmacy
| | | | | | | | | | - David Liu
- National Institute on Drug Abuse Center for Clinical Trials Network
| | - Jeffrey H Samet
- Boston University & Boston Medical Center Department of Medicine, Division of General Internal Medicine
| | - Andrew J Saxon
- Veteran Affairs Puget Sound Health Care System Center of Excellence in Substance Abuse Treatment and Education.,University of Washington Department of Psychiatry and Behavioral Sciences
| | | | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute.,University of Washington Department of Psychiatry and Behavioral Sciences
| | | | - Mark T Murphy
- Multicare Health System MultiCare Tacoma Central Family Medicine
| | - Ingrid A Binswanger
- Kaiser Permanente Colorado Institute for Health Research.,Colorado Permanente Medical Group, Denver, Colorado
| | | | - Katharine A Bradley
- Kaiser Permanente Washington Health Research Institute.,University of Washington Department of Health Services.,University of Washington Department of Medicine
| | - Brian Ahmedani
- Henry Ford Health System Center for Health Policy & Health Services Research
| | - Paul J Amoroso
- Multicare Health System MultiCare Institute for Research and Innovation
| | - Julia H Arnsten
- Montefiore Medical Center Department of Medicine.,Montefiore Medical Center Division of General Internal Medicine.,Albert Einstein College of Medicine Department of Medicine, Division of General Internal Medicine
| | | | | | - Chinazo O Cunningham
- Montefiore Medical Center Department of Medicine.,Albert Einstein College of Medicine Department of Medicine, Division of General Internal Medicine
| | - Rulin C Hechter
- Kaiser Permanente Southern California Department of Research and Evaluation
| | - Viviana E Horigian
- University of Miami Miller School of Medicine, Department of Public Health Sciences
| | - Jane M Liebschutz
- University of Pittsburgh School of Medicine Division of General Internal Medicine, Center for Research on Health Care
| | - Amy M Loree
- Henry Ford Health System Center for Health Policy & Health Services Research
| | | | - Jennifer McNeely
- New York University School of Medicine, Department of Population Health and Department of Medicine, Division of General Internal Medicine and Clinical Innovation
| | | | - Thomas F Northrup
- McGovern Medical School at The University of Texas Health Science Center at Houston
| | | | - Angela L Stotts
- McGovern Medical School at The University of Texas Health Science Center at Houston
| | - José Szapocznik
- University of Miami Miller School of Medicine, Department of Public Health Sciences
| | - Manu Thakral
- University of Massachusetts Boston College of Nursing and Health Sciences, Boston, MA, USA
| | - Judith I Tsui
- University of Washington Division of General Internal Medicine
| | - Mohammad Zare
- McGovern Medical School at The University of Texas Health Science Center at Houston
| |
Collapse
|
38
|
Borschmann R, Tibble H, Spittal MJ, Preen D, Pirkis J, Larney S, Rosen DL, Young JT, Love AD, Altice FL, Binswanger IA, Bukten A, Butler T, Chang Z, Chen CY, Clausen T, Christensen PB, Culbert GJ, Degenhardt L, Dirkzwager AJE, Dolan K, Fazel S, Fischbacher C, Giles M, Graham L, Harding D, Huang YF, Huber F, Karaminia A, Keen C, Kouyoumdjian FG, Lim S, Møller L, Moniruzzaman A, Morenoff J, O’Moore E, Pizzicato LN, Pratt D, Proescholdbell SK, Ranapurwala SI, Shanahan ME, Shaw J, Slaunwhite A, Somers JM, Spaulding AC, Stern MF, Viner KM, Wang N, Willoughby M, Zhao B, Kinner SA. The Mortality After Release from Incarceration Consortium (MARIC): Protocol for a multi-national, individual participant data meta-analysis. Int J Popul Data Sci 2020; 5:1145. [PMID: 32935053 PMCID: PMC7473255 DOI: 10.23889/ijpds.v5i1.1145] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION More than 30 million adults are released from incarceration globally each year. Many experience complex physical and mental health problems, and are at markedly increased risk of preventable mortality. Despite this, evidence regarding the global epidemiology of mortality following release from incarceration is insufficient to inform the development of targeted, evidence-based responses. Many previous studies have suffered from inadequate power and poor precision, and even large studies have limited capacity to disaggregate data by specific causes of death, sub-populations or time since release to answer questions of clinical and public health relevance. OBJECTIVES To comprehensively document the incidence, timing, causes and risk factors for mortality in adults released from prison. METHODS We created the Mortality After Release from Incarceration Consortium (MARIC), a multi-disciplinary collaboration representing 29 cohorts of adults who have experienced incarceration from 11 countries. Findings across cohorts will be analysed using a two-step, individual participant data meta-analysis methodology. RESULTS The combined sample includes 1,337,993 individuals (89% male), with 75,795 deaths recorded over 9,191,393 person-years of follow-up. CONCLUSIONS The consortium represents an important advancement in the field, bringing international attention to this problem. It will provide internationally relevant evidence to guide policymakers and clinicians in reducing preventable deaths in this marginalized population. KEY WORDS Mortality; incarceration; prison; release; individual participant data meta-analysis; consortium; cohort.
Collapse
Affiliation(s)
- R Borschmann
- Justice Health Unit, Centre for Health Equity, The University of Melbourne, 207 Bouverie street, Carlton 3010, Melbourne, Victoria, AUSTRALIA
| | - H Tibble
- Usher Institute of Population Health Sciences and Informatics, Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK
| | - MJ Spittal
- University of Melbourne, Melbourne School of Population and Global Health, Melbourne, AUSTRALIA
| | - D Preen
- The University of Western Australia, School of Population and Global Health, Nedlands, AUSTRALIA
| | - J Pirkis
- University of Melbourne, Melbourne School of Population and Global Health, Melbourne, AUSTRALIA
| | - S Larney
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, AUSTRALIA
| | - DL Rosen
- University of North Carolina at Chapel Hill, North Carolina, USA
| | - JT Young
- University of Melbourne, Melbourne School of Population and Global Health, Melbourne, AUSTRALIA
| | - AD Love
- University of Melbourne, Melbourne School of Population Health, Melbourne, AUSTRALIA
| | - FL Altice
- Yale University School of Medicine and Public Health, New Haven, Connecticut, USA
| | - IA Binswanger
- Kaiser Permanente Colorado, Colorado Permanente Medical Group, USA
| | - A Bukten
- Norwegian Centre for Addiction Research, Institute of Clinical Medicine, University of Oslo, Norway
| | - T Butler
- University of New South Wales, Kirby Institute, Sydney, AUSTRALIA
| | - Z Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, SWEDEN
| | - C-Y Chen
- National Yang-Ming University, Institute of Public Health, TAIWAN
| | - T Clausen
- Norwegian Centre for Addiction Research, Institute of Clinical Medicine, University of Oslo, Norway
| | - PB Christensen
- Department of Infectious Diseases, Odense University Hospital and Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, DENMARK
| | - GJ Culbert
- Department of Health Systems Science, University of Illinois at Chicago, Chicago, USA
| | - L Degenhardt
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, AUSTRALIA
| | - AJE Dirkzwager
- Netherlands Institute for the Study of Crime and Law Enforcement (NSCR), Amsterdam, NETHERLANDS
| | - K Dolan
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, AUSTRALIA
| | - S Fazel
- University of Oxford, Department of Psychiatry, Medical Sciences Division, Oxford, ENGLAND
| | - C Fischbacher
- NHS National Services, Information Services Division, Edinburgh, SCOTLAND
| | - M Giles
- Edith Cowan University, School of Arts and Humanities, Joondalup, AUSTRALIA
| | - L Graham
- NHS National Services, Information Services Division, Edinburgh, SCOTLAND
| | - D Harding
- University of California Berkeley, USA
| | - Y-F Huang
- Taiwan Centers for Disease Control, Taipei, TAIWAN
| | - F Huber
- Cayenne General Hospital, COREVIH Guyane, and Reseau Kikiwi, Cayenne, French Guiana, FRANCE
| | - A Karaminia
- University of New South Wales, Sydney, AUSTRALIA
| | - C Keen
- University of Melbourne, Melbourne School of Population and Global Health, Melbourne, AUSTRALIA
| | - FG Kouyoumdjian
- McMaster University, Department of Family Medicine, Hamilton, Ontario, CANADA
| | - S Lim
- New York City Department of Health and Mental Hygiene, Bureau of Epidemiology Services, Division of Epidemiology, New York, USA
| | - L Møller
- World Health Organization, Division of Noncommunicable Diseases and Promoting Health through the Life-course, Marmorvej, DENMARK
| | - A Moniruzzaman
- Somers Research Group, Simon Fraser University, Burnaby, British Columbia, CANADA
| | - J Morenoff
- University of Michigan, Department of Sociology, USA
| | - E O’Moore
- Public Health England, London, ENGLAND
| | - LN Pizzicato
- Philadelphia Department of Public Health, Philadelphia, PA, USA
| | - D Pratt
- University of Manchester, Division of Psychology and Mental Health, School of Health Sciences, Manchester, ENGLAND
| | - SK Proescholdbell
- North Carolina Department of Health and Human Services, North Carolina, USA
| | - SI Ranapurwala
- Department of Epidemiology, University of North Carolina at Chapel Hill, USA
| | - ME Shanahan
- Department of Maternal and Child Health, University of North Carolina at Chapel Hill, USA
| | - J Shaw
- Centre for Mental Health and Safety, Division of Psychology and Mental Health, University of Manchester, Manchester, ENGLAND
| | - A Slaunwhite
- BC Centre for Disease Control, Provincial Health Services Authority, Vancouver, British Columbia, CANADA
| | - JM Somers
- Somers Research Group, Simon Fraser University, Burnaby, British Columbia, CANADA
| | - AC Spaulding
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - MF Stern
- Department of Health Services, University of Washington, Seattle, Washington, USA
| | - KM Viner
- Philadelphia Department of Public Health, Philadelphia, PA, USA
| | - N Wang
- Institute of Public Health, National Yang-Ming University, TAIWAN
| | - M Willoughby
- University of Melbourne, Melbourne School of Population and Global Health, Melbourne, AUSTRALIA
| | - B Zhao
- BC Centre for Disease Control, Provincial Health Services Authority, Vancouver, British Columbia, CANADA
| | - SA Kinner
- Murdoch Children’s Research Institute, Centre for Adolescent Health, Melbourne, Victoria, AUSTRALIA
| |
Collapse
|
39
|
Metz TD, Binswanger IA, McMillin GA, Allshouse AA, Heard K, Jensen TL, Wymore E, Stickrath EH, Conageski C, Kinney GL, Silver RM. 1115: Measurement of prenatal marijuana use with bioassays and survey data. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.1127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
40
|
Binswanger IA, Maruschak LM, Mueller SR, Stern MF, Kinner SA. Principles to Guide National Data Collection on the Health of Persons in the Criminal Justice System. Public Health Rep 2019; 134:34S-45S. [PMID: 31059411 PMCID: PMC6505315 DOI: 10.1177/0033354919841593] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Ingrid A Binswanger
- 1 Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
- 2 Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Colorado, Aurora, CO, USA
- 3 Colorado Permanente Medical Group, Aurora, CO, USA
| | - Laura M Maruschak
- 4 Bureau of Justice Statistics, US Department of Justice, Washington, DC, USA
| | - Shane R Mueller
- 1 Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | - Marc F Stern
- 5 Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA
| | - Stuart A Kinner
- 6 Centre for Adolescent Health, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- 7 Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
- 8 Mater Research Institute-UQ, University of Queensland, Brisbane, Queensland, Australia
- 9 School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- 10 Griffith Criminology Institute, Griffith University, Brisbane, Queensland, Australia
| |
Collapse
|
41
|
Loeb DF, Monson SP, Lockhart S, Depue C, Ludman E, Nease DE, Binswanger IA, Kline DM, de Gruy FV, Good DG, Bayliss EA. Mixed method evaluation of Relational Team Development (RELATED) to improve team-based care for complex patients with mental illness in primary care. BMC Psychiatry 2019; 19:299. [PMID: 31615460 PMCID: PMC6792180 DOI: 10.1186/s12888-019-2294-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 09/16/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with mental illness are frequently treated in primary care, where Primary Care Providers (PCPs) report feeling ill-equipped to manage their care. Team-based models of care improve outcomes for patients with mental illness, but multiple barriers limit adoption. Barriers include practical issues and psychosocial factors associated with the reorganization of care. Practice facilitation can improve implementation, but does not directly address the psychosocial factors or gaps in PCP skills in managing mental illness. To address these gaps, we developed Relational Team Development (RELATED). METHODS RELATED is an implementation strategy combining practice facilitation and psychology clinical supervision methodologies to improve implementation of team-based care. It includes PCP-level clinical coaching and a team-level practice change activity. We performed a preliminary assessment of RELATED with a convergent parallel mixed method study in 2 primary care clinics in an urban Federally Qualified Health Center in Southwest, USA, 2017-2018. Study participants included PCPs, clinic staff, and patient representatives. Clinic staff and patients were recruited for the practice change activity only. Primary outcomes were feasibility and acceptability. Feasibility was assessed as ease of recruitment and implementation. Acceptability was measured in surveys of PCPs and staff and focus groups. We conducted semi-structured focus groups with 3 participant groups in each clinic: PCPs; staff and patients; and leadership. Secondary outcomes were change in pre- post- intervention PCP self-efficacy in mental illness management and team-based care. We conducted qualitative observations to better understand clinic climate. RESULTS We recruited 18 PCPs, 17 staff members, and 3 patient representatives. We ended recruitment early due to over recruitment. Both clinics developed and implemented practice change activities. The mean acceptability score was 3.7 (SD=0.3) on a 4-point Likert scale. PCPs had a statistically significant increase in their mental illness management self-efficacy [change = 0.9, p-value= <.01]. Focus group comments were largely positive, with PCPs requesting additional coaching. CONCLUSIONS RELATED was feasible and highly acceptable. It led to positive changes in PCP self-efficacy in Mental Illness Management. If confirmed as an effective implementation strategy, RELATED has the potential to significantly impact implementation of evidence-based interventions for patients with mental illness in primary care.
Collapse
Affiliation(s)
- Danielle F. Loeb
- 0000 0001 0703 675Xgrid.430503.1Division of General Internal Medicine, University of Colorado School of Medicine, Academic Office 1; Mailstop B180; 12631 East 17th Ave., Aurora, CO 80045 USA
| | | | - Steven Lockhart
- 0000 0001 0703 675Xgrid.430503.1Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), University of Colorado, Aurora, CO USA
| | - Cori Depue
- 0000 0001 0703 675Xgrid.430503.1Division of General Internal Medicine, University of Colorado School of Medicine, Academic Office 1; Mailstop B180; 12631 East 17th Ave., Aurora, CO 80045 USA
| | - Evette Ludman
- 0000 0004 0615 7519grid.488833.cKaiser Permanente Washington Health Research Institute, Seattle, WA USA
| | - Donald E. Nease
- 0000 0001 0703 675Xgrid.430503.1Department of Family Medicine, University of Colorado, Aurora, USA
| | - Ingrid A. Binswanger
- 0000 0000 9957 7758grid.280062.eKaiser Permanente Colorado Institute for Health Research, Aurora, CO USA
| | - Danielle M. Kline
- 0000 0001 0703 675Xgrid.430503.1Division of General Internal Medicine, University of Colorado School of Medicine, Academic Office 1; Mailstop B180; 12631 East 17th Ave., Aurora, CO 80045 USA
| | - Frank V. de Gruy
- 0000 0001 0703 675Xgrid.430503.1Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO USA
| | - Dixie G. Good
- 0000 0001 0703 675Xgrid.430503.1Division of General Internal Medicine, University of Colorado School of Medicine, Academic Office 1; Mailstop B180; 12631 East 17th Ave., Aurora, CO 80045 USA
| | - Elizabeth A. Bayliss
- 0000 0000 9957 7758grid.280062.eKaiser Permanente Colorado Institute for Health Research, Aurora, CO USA
| |
Collapse
|
42
|
Wenger LD, Showalter D, Lambdin B, Leiva D, Wheeler E, Davidson PJ, Coffin PO, Binswanger IA, Kral AH. Overdose Education and Naloxone Distribution in the San Francisco County Jail. Journal of Correctional Health Care 2019; 25:394-404. [DOI: 10.1177/1078345819882771] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - David Showalter
- Sociology Department, University of California, Berkeley, CA, USA
| | | | - David Leiva
- San Francisco Department of Public Health, Jail Health Services, CA, USA
| | | | | | - Phillip O. Coffin
- Population Health Division, San Francisco Department of Public Health, Community Health Equity & Promotion Branch, San Francisco, CA, USA
| | | | | |
Collapse
|
43
|
Loeb DF, Kline DM, Kroenke K, Boyd C, Bayliss EA, Ludman E, Dickinson LM, Binswanger IA, Monson SP. Designing the relational team development intervention to improve management of mental health in primary care using iterative stakeholder engagement. BMC Fam Pract 2019; 20:124. [PMID: 31492096 PMCID: PMC6728939 DOI: 10.1186/s12875-019-1010-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 08/19/2019] [Indexed: 12/21/2022]
Abstract
Background Team-based models of care are efficacious in improving outcomes for patients with mental and physical illnesses. However, primary care clinics have been slow to adopt these models. We used iterative stakeholder engagement to develop an intervention to improve the implementation of team-based care for this complex population. Methods We developed the initial framework for Relational Team Development (RELATED) from a qualitative study of Primary Care Providers’ (PCPs’) experiences treating mental illness and a literature review of practice facilitation and psychology clinical supervision. Subsequently, we surveyed 900 Colorado PCPs to identify factors associated with PCP self-efficacy in management of mental illness and team-based care. We then conducted two focus groups for feedback on RELATED. Lastly, we convened an expert panel to refine the intervention. Results We developed RELATED, a two-part intervention delivered by a practice facilitator with a background in clinical psychology. The facilitator observes PCPs during patient visits and provides individualized coaching. Next, the facilitator guides the primary care team through a practice change activity with a focus on relational team dynamics. Conclusion The iterative development of RELATED using stakeholder engagement offers a model for the development of interventions tailored to the needs of these stakeholders. Trial registration Not applicable. Electronic supplementary material The online version of this article (10.1186/s12875-019-1010-z) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Danielle F Loeb
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Academic Office 1; Mailstop B180; 12631 East 17th Ave, Aurora, CO, 80045, USA.
| | - Danielle M Kline
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Academic Office 1; Mailstop B180; 12631 East 17th Ave, Aurora, CO, 80045, USA
| | - Kurt Kroenke
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Cynthia Boyd
- John Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Evette Ludman
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - L Miriam Dickinson
- Department of Biostatistics & Informatics, Colorado School of Public Health; Department of Family Medicine, University of Colorado, Aurora, CO, USA
| | | | | |
Collapse
|
44
|
Kennedy LC, Binswanger IA, Mueller SR, Levy C, Matlock DD, Calcaterra SL, Koester S, Frank JW. "Those Conversations in My Experience Don't Go Well": A Qualitative Study of Primary Care Provider Experiences Tapering Long-term Opioid Medications. Pain Med 2019; 19:2201-2211. [PMID: 29126138 DOI: 10.1093/pm/pnx276] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective Given the risks of long-term opioid therapy, patients may benefit from tapering these medications. There is little evidence to guide providers' approach to this process. We explored primary care providers' experiences discussing and implementing opioid tapering with patients on long-term opioid therapy. Design Qualitative study using six semistructured, in-person focus groups. Subject Primary care providers (N = 40). Setting Six academically affiliated primary care clinics in university, urban safety net, and Veterans Health Administration medical centers in Colorado. Methods Focus groups were audio-recorded, transcribed, and analyzed using a mixed inductive-deductive approach in ATLAS.ti. Emergent themes were identified through an iterative, multidisciplinary team-based process. Results We identified 1) strategies for identifying candidates for opioid tapering, 2) barriers to opioid tapering, and 3) facilitators of opioid tapering. Strategies for identifying candidates for opioid tapering included evidence of high-risk behavior, serious adverse events, opioid-related side effects, and patient preference. Barriers included the providers' emotional burden, inadequate resources, and a lack of trust between patient and provider. Facilitators of opioid tapering included empathizing with the patient's experience, preparing patients for opioid tapering, individualizing implementation of opioid tapering, and supportive guidelines and policies. Conclusions While discussing and implementing opioid tapering present significant challenges, primary care providers described key facilitators. These findings suggest a need to develop and test the effectiveness of resources to support patient-centered opioid tapering and locally developed policies to support and standardize providers' approaches to opioid prescribing.
Collapse
Affiliation(s)
| | - Ingrid A Binswanger
- Divisions of General Internal Medicine.,Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
| | - Shane R Mueller
- Divisions of General Internal Medicine.,Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado.,Departments of Health and Behavioral Sciences
| | - Cari Levy
- Health Care Policy and Research.,VA Eastern Colorado Health Care System, Denver, Colorado
| | - Daniel D Matlock
- Geriatrics, University of Colorado School of Medicine, Aurora, Colorado.,Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado, Aurora, Colorado
| | - Susan L Calcaterra
- Divisions of General Internal Medicine.,Denver Health Medical Center, Denver, Colorado, USA
| | - Stephen Koester
- Departments of Health and Behavioral Sciences.,Anthropology, University of Colorado Denver, Denver, Colorado
| | - Joseph W Frank
- Divisions of General Internal Medicine.,VA Eastern Colorado Health Care System, Denver, Colorado
| |
Collapse
|
45
|
Moore A, Cox-Martin M, Dempsey AF, Berenbaum Szanton K, Binswanger IA. HPV Vaccination in Correctional Care: Knowledge, Attitudes, and Barriers Among Incarcerated Women. J Correct Health Care 2019; 25:219-230. [PMID: 31242811 DOI: 10.1177/1078345819853286] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Incarcerated women are at increased risk of developing cervical cancer and have high rates of human papillomavirus (HPV) infection, an important cause of cervical cancer. However, many correctional facilities do not offer HPV vaccination to female inmates. This pilot survey study, conducted with incarcerated women aged 18 to 26 at a facility that does not offer the vaccine, assessed attitudes and knowledge about HPV and the HPV vaccine, acceptability of and barriers to in-prison HPV vaccination, and self-reported HPV vaccination rates. Most participants reported that they had not received the HPV vaccine but had positive attitudes toward it and would be willing to get it in prison. Correctional facilities should consider offering this preventive service to this vulnerable population.
Collapse
Affiliation(s)
- Alia Moore
- 1 Los Angeles County Department of Health Services, Correctional Health Services, Los Angeles, CA, USA.,2 Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Matthew Cox-Martin
- 3 Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, USA
| | - Amanda F Dempsey
- 4 Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Ingrid A Binswanger
- 2 Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA.,6 Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| |
Collapse
|
46
|
Harding DJ, Morenoff JD, Nguyen AP, Bushway SD, Binswanger IA. A natural experiment study of the effects of imprisonment on violence in the community. Nat Hum Behav 2019; 3:671-677. [PMID: 31086334 DOI: 10.1038/s41562-019-0604-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 04/02/2019] [Indexed: 11/09/2022]
Abstract
One of the goals of imprisonment is to reduce violence1. Although imprisonment has risen dramatically since the 1970s, its effects on future violent crime are poorly understood2. This study's objective was to examine the effect of imprisonment on violent crime in the community among individuals on the policy margin between prison and probation sentences. Drawing on data from a population-based cohort of individuals convicted of a felony in Michigan between 2003 and 2006 (n = 111,110) and followed through June 2015, we compared the rates of commission of violent crime committed by individuals sentenced to prison with those of individuals sentenced to probation using a natural experiment based on the random assignment of judges to criminal cases. Being sentenced to prison had no significant effects on arrests or convictions for violent crimes after release from prison, but imprisonment modestly reduced the probability of violence if comparisons included the effects of incapacitation during imprisonment. These results suggest that for individuals on the current policy margin between prison and probation, imprisonment is an ineffective long-term intervention for violence prevention, as it has, on balance, no rehabilitative or deterrent effects after release.
Collapse
Affiliation(s)
- David J Harding
- Department of Sociology, University of California, Berkeley, Berkeley, CA, USA. .,Social Sciences D-Lab, University of California, Berkeley, Berkeley, CA, USA.
| | - Jeffrey D Morenoff
- Institute for Social Research, University of Michigan, Ann Arbor, MI, USA.,Department of Sociology, University of Michigan, Ann Arbor, MI, USA
| | - Anh P Nguyen
- Kaiser Permanente Colorado Institute for Health Research, Aurora, CO, USA
| | - Shawn D Bushway
- Department of Public Administration and Policy, Rockefeller College of Public Affairs and Policy, University at Albany, State University of New York, Albany, NY, USA
| | - Ingrid A Binswanger
- Kaiser Permanente Colorado Institute for Health Research, Aurora, CO, USA.,Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|
47
|
Abstract
IMPORTANCE Attempts to discontinue opioid therapy to reduce the risk of overdose and adhere to prescribing guidelines may lead patients to be exposed to variability in opioid dosing. Such dose variability may increase the risk of opioid overdose even if therapy discontinuation is associated with a reduction in risk. OBJECTIVE To examine the association between opioid dose variability and opioid overdose. DESIGN, SETTING, AND PARTICIPANTS A nested case-control study was conducted in a large Colorado integrated health plan and delivery system from January 1, 2006, through June 30, 2018. Cohort members were individuals prescribed long-term opioid therapy. EXPOSURES Dose variability was defined as the SD of the milligrams of morphine equivalents across each patient's follow-up and categorized based on the quintile distribution of the SD in the cohort (0-5.3, 5.4-9.1, 9.2-14.6, 14.7-27.2, and >27.2 mg of morphine equivalents). MAIN OUTCOMES AND MEASURES Opioid overdose cases were identified using International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. Each case patient with overdose was matched to up to 20 control patients using risk set sampling. Conditional logistic regression models were used to generate matched odds ratios and 95% CIs, adjusted for age, sex, race/ethnicity, drug or alcohol use disorder, tobacco use, benzodiazepine dispensings, medical comorbidities, mental health disorder, opioid dose, and opioid formulation. RESULTS In a cohort of 14 898 patients (mean [SD] age, 56.3 [16.0] years; 8988 [60.3%] female) prescribed long-term opioid therapy, 228 case patients with incident opioid overdose were matched to 3547 control patients. The mean (SD) duration of opioid therapy was 36.7 (33.7) months in case patients and 33.0 (30.9) months in control patients. High-dose variability (SD >27.2 mg of morphine equivalents) was associated with a significantly increased risk of overdose compared with low-dose variability (matched odds ratio, 3.32; 95% CI, 1.63-6.77) independent of opioid dose. CONCLUSIONS AND RELEVANCE Variability in opioid dose may be a risk factor for opioid overdose, suggesting that practitioners should seek to minimize dose variability when managing long-term opioid therapy.
Collapse
Affiliation(s)
- Jason M. Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
- Department of Epidemiology, Colorado School of Public Health, Aurora
| | - Ingrid A. Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
- Colorado Permanente Medical Group, Aurora
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
| | | | | | - Stan Xu
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora
| |
Collapse
|
48
|
Abstract
The United States opioid epidemic is a nationwide public health crisis. Initially driven by increased consumption and availability of pharmaceutical opioids, an increasing number of opioid overdoses are now related to heroin and illicitly manufactured fentanyl and fentanyl analogs. Addressing this epidemic requires addressing the stigma associated with opioid use disorders and its treatment, improving access to efficacious treatment options, specifically methadone and buprenorphine, and reducing opioid overdose fatalities with distribution of the opioid antagonist and overdose reversal agent naloxone.
Collapse
Affiliation(s)
- Jennifer Lyden
- Denver Health and Hospital Authority, Denver, CO, United States; Department of Medicine, University of Colorado School of Medicine, Denver, CO, United States.
| | - Ingrid A Binswanger
- Department of Medicine, University of Colorado School of Medicine, Denver, CO, United States; Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States; Colorado Permanente Medical Group, Aurora, CO, United States
| |
Collapse
|
49
|
Affiliation(s)
- Ingrid A Binswanger
- From the Institute for Health Research, Kaiser Permanente Colorado; the Colorado Permanente Medical Group; and the Division of General Internal Medicine, University of Colorado School of Medicine - all in Aurora
| |
Collapse
|
50
|
Hechter RC, Horberg MA, Weisner C, Campbell CI, Contreras R, Chen LH, Yarborough BJH, Lapham GT, Haller IV, Ahmedani BK, Binswanger IA, Kline-Simon AH, Satre DD. Healthcare Effectiveness Data and Information Set (HEDIS) measures of alcohol and drug treatment initiation and engagement among people living with the human immunodeficiency virus (HIV) and patients without an HIV diagnosis. Subst Abus 2019; 40:302-310. [PMID: 30908174 PMCID: PMC6761030 DOI: 10.1080/08897077.2019.1580239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background: Problematic use of alcohol and other drugs (AOD) is highly prevalent among people living with the human immunodeficiency virus (PLWH), and untreated AOD use disorders have particularly detrimental effects on human immunodeficiency virus (HIV) outcomes. The Healthcare Effectiveness Data and Information Set (HEDIS) measures of treatment initiation and engagement are important benchmarks for access to AOD use disorder treatment. To inform improved patient care, we compared HEDIS measures of AOD use disorder treatment initiation and engagement and health care utilization among PLWH and patients without an HIV diagnosis. Methods: Patients with a new AOD use disorder diagnosis documented between October 1, 2014, and August 15, 2015, were identified using electronic health records (EHR) and insurance claims data from 7 health care systems in the United States. Demographic characteristics, clinical diagnoses, and health care utilization data were also obtained. AOD use disorder treatment initiation and engagement rates were calculated using HEDIS measure criteria. Factors associated with treatment initiation and engagement were examined using multivariable logistic regression models. Results: There were 469 PLWH (93% male) and 86,096 patients without an HIV diagnosis (60% male) in the study cohort. AOD use disorder treatment initiation was similar in PLWH and patients without an HIV diagnosis (10% vs. 11%, respectively). Among those who initiated treatment, few engaged in treatment in both groups (9% PLWH vs. 12% patients without an HIV diagnosis). In multivariable analysis, HIV status was not significantly associated with either AOD use disorder treatment initiation or engagement. Conclusions: AOD use disorder treatment initiation and engagement rates were low in both PLWH and patients without an HIV diagnosis. Future studies need to focus on developing strategies to efficiently integrate AOD use disorder treatment with medical care for HIV.
Collapse
Affiliation(s)
- Rulin C Hechter
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Michael A Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, Maryland, USA
| | - Constance Weisner
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.,Department of Psychiatry, Weill Institute for Neurosciences, University of California, San Francisco, California, USA
| | - Cynthia I Campbell
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.,Department of Psychiatry, Weill Institute for Neurosciences, University of California, San Francisco, California, USA
| | - Richard Contreras
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Lie-Hong Chen
- Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena, California, USA
| | | | - Gwen T Lapham
- Health Research Institute, Kaiser Permanente Washington, Seattle, Washington, USA
| | - Irina V Haller
- Essentia Institute of Rural Health, Essentia Health, Duluth, Minnesota, USA
| | - Brian K Ahmedani
- Center for Health Policy and Health Services Research and Behavioral Health Services, Henry Ford Health System, Detroit, Michigan, USA
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, Colorado, USA
| | - Andrea H Kline-Simon
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Derek D Satre
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.,Department of Psychiatry, Weill Institute for Neurosciences, University of California, San Francisco, California, USA
| |
Collapse
|