Independent community pharmacists' attitudes and intentions toward dispensing buprenorphine/naloxone for opioid use disorder.

BACKGROUND: Buprenorphine/naloxone (BUP/NX) for opioid use disorder (OUD) is associated with positive health outcomes; however, challenges accessing prescribed BUP/NX at community pharmacies have been identified. OBJECTIVE: The theory of planned behavior was applied to determine whether independent community pharmacists' attitudes toward dispensing BUP/NX for OUD predict intentions to dispense. METHODS: A 40-item survey was administered to 185 Texas Community Pharmacy Enhanced Services Network pharmacists. The survey assessed intentions to dispense BUP/NX (3 items), attitudes toward BUP/NX (24 items), current barriers to dispensing BUP/NX (2 items), and demographics (10 items). Inferential statistics determined associations among pharmacists' attitudes, practice setting characteristics, and intentions to dispense BUP/NX. Regression analysis determined whether attitude predicted intention to dispense BUP/NX, controlling for practice setting and demographic characteristics. RESULTS: Responses were obtained from 82 community independent pharmacists (response rate = 44%). Respondents were predominantly non-Hispanic white (45.8%) and women (56.6%) and practiced in pharmacies with an average 1129.1 (± 1034.5) dispensed prescriptions/week. Pharmacists had positive intentions (6.2 ± 3.5) and attitudes (14.4 ± 24.9) toward dispensing BUP/NX and attitudes did not predict intentions to dispense (P = 0.330). Positive drivers of attitude were related to improving patient outcomes, fulfilling a community need, and absence of conflicts with pharmacists' personal and religious beliefs. A negative driver of attitude was financial reimbursement/loss. Pharmacists dispensing 2000 or more prescriptions/week had higher intentions (b = 3.22, P = 0.014) to dispense than those dispensing less than 500 prescriptions/week. The most common barrier to dispense BUP/NX was "refill was too soon" (54.8%). CONCLUSION: Community independent pharmacists had positive attitudes toward and intentions of dispensing BUP/NX for OUD. However, attitudes did not predict intentions to dispense. Negative drivers of attitudes were related to factors not within pharmacists' control, such as time to refill or financial reimbursement.Future studies focused on community pharmacy-based access to BUP/NX are warranted to elucidate issues that are impactful in improving pharmacists' dispensing intentions and behavior.

Shorter length of hospital stay for hip fracture in those with dementia and without a known diagnosis of osteoporosis in the USA.

BACKGROUND: About 50% of all hospitalized fragility fracture cases in older Americans are hip fractures. Approximately 3/4 of fracture-related costs in the USA are attributable to hip fractures, and these are mostly covered by Medicare. Hip fracture patients with dementia, including Alzheimer's disease, have worse health outcomes including longer hospital length of stay (LOS) and charges. LOS and hospital charges for dementia patients are usually higher than for those without dementia. Research describing LOS and acute care charges for hip fractures has mostly focused on these outcomes in trauma patients without a known pre-admission diagnosis of osteoporosis (OP). Lack of documented diagnosis put patients at risk of not having an appropriate treatment plan for OP. Whether having a diagnosis of OP would have an effect on hospital outcomes in dementia patients has not been explored. We aim to investigate whether having a diagnosis of OP, dementia, or both has an effect on LOS and hospital charges. In addition, we also report prevalence of common comorbidities in the study population and their effects on hospital outcomes. METHODS: We conducted a cross-sectional analysis of claims data (2012-2013) for 2175 Medicare beneficiaries (≥65 years) in the USA. RESULTS: Compared to those without OP or dementia, patients with demenia only had a shorter LOS (by 5%; P = .04). Median LOS was 6 days (interquartile range [IQR]: 5-7), and the median hospital charges were $45,100 (IQR: 31,500 - 65,600). In general, White patients had a shorter LOS (by 7%), and those with CHF and ischemic heart disease (IHD) had longer LOS (by 7 and 4%, respectively). Hospital charges were 6% lower for women, and 16% lower for White patients. CONCLUSION: This is the first study evaluating LOS in dementia in the context of hip fracture which also disagrees with previous reporting about longer LOS in dementia patients. Patients with CHF and IHD remains at high risk for longer LOS regardless of their diagnosis of dementia or OP.

Structural Basis for Interactions Between Contactin Family Members and Protein-tyrosine Phosphatase Receptor Type G in Neural Tissues.

Protein-tyrosine phosphatase receptor type G (RPTPγ/PTPRG) interacts in vitro with contactin-3-6 (CNTN3-6), a group of glycophosphatidylinositol-anchored cell adhesion molecules involved in the wiring of the nervous system. In addition to PTPRG, CNTNs associate with multiple transmembrane proteins and signal inside the cell via cis-binding partners to alleviate the absence of an intracellular region. Here, we use comprehensive biochemical and structural analyses to demonstrate that PTPRG·CNTN3-6 complexes share similar binding affinities and a conserved arrangement. Furthermore, as a first step to identifying PTPRG·CNTN complexes in vivo, we found that PTPRG and CNTN3 associate in the outer segments of mouse rod photoreceptor cells. In particular, PTPRG and CNTN3 form cis-complexes at the surface of photoreceptors yet interact in trans when expressed on the surfaces of apposing cells. Further structural analyses suggest that all CNTN ectodomains adopt a bent conformation and might lie parallel to the cell surface to accommodate these cis and trans binding modes. Taken together, these studies identify a PTPRG·CNTN complex in vivo and provide novel insights into PTPRG- and CNTN-mediated signaling.

Z-code documentation to identify social determinants of health among Medicaid beneficiaries.

INTRODUCTION: Social determinants of health (SDoH) are non-medical factors that impact individuals' health. SDoH can be documented in claims data using International Classification of Disease (ICD) 10th revision codes Z55 - Z65. The study objective was to describe the documentation of SDoH Z-codes among Medicaid beneficiaries in Texas. METHODS: Texas Medicaid medical and enrollment claims data were utilized. Beneficiaries with at least one claim associated with SDoH Z-codes between 2016 and 2019 were identified excluding those 65+ years of age and others dually eligible for Medicare. RESULTS: SDoH Z-code documentation was associated with approximately 1.2 million claims for 181,136 unique beneficiaries. Females (54.3%) and Hispanics (47.9%) comprised a majority of beneficiaries with Z-code documentation, and the average age was 14.2 ± 13.4 years. Nearly 40% had Z-code documentation of "problems related to upbringing" (Z62) (N = 68,478, 37.8%), followed by "problems related to primary support group including family circumstances" (Z63) (N = 42,378, 23.4%), and "problems related to education and literacy" (Z55) (N = 28,848, 15.9%). SDoH Z-code documentation increased slightly over the years from 1% of Medicaid beneficiaries in 2016 to 1.3% in 2019. CONCLUSION: A steady increase in SDoH Z-code documentation was observed among Medicaid beneficiaries but represented a relatively small proportion of the beneficiaries overall.

Assessing coprescription of opioids with central nervous system depressants for nonmalignant chronic musculoskeletal pain management in the outpatient setting.

OBJECTIVES: To determine annual prescribing trends of opioids and coprescription of central nervous system (CNS) depressants in nonmalignant chronic musculoskeletal pain from the National Ambulatory Medical Care Survey (NAMCS). To determine patient and provider characteristics associated with coprescription opioids and CNS depressants. DESIGN: The cross-sectional study analyzed NAMCS data from 2014 to 2016. Pain medications and CNS depressants were determined using Multum drug classification categories. All 30 medication entries were scanned in order to capture the maximum number of entries compared to previous studies. Multivariate logistic regressions were used to determine characteristics associated with opioid and CNS depressant coprescribing. PARTICIPANTS: Adults (18 years and older) with nonmalignant chronic musculoskeletal pain diagnosis based on ICD-9 codes were identified as the reason for visit. RESULTS: A total of 47,973,413 weighted visits with nonmalignant chronic musculoskeletal pain were reported in the US ambulatory setting from 2014 to 2016. Amongst these patients, 31 percent were on opioids, of which 26 percent were also prescribed benzodiazepines, 8 percent NBSH, and 22 percent gabapentinoids. The annual prescribing rate of opioids decreased significantly in 2016 compared to 2014 (OR: 0.63, 95 percent CI: 0.43-0.94). Polypharmacy and tobacco use were associated with higher odds of having opioids and concurrent opioid with CNS depressants. CONCLUSION: Our study results are in agreement with previous studies that found a steady decline in opioid prescribing even with the inclusion of all 30 medications in our study. Likewise, as previous studies have found, certain patient characteristics continue to be significant for receiving opioid and CNS depressant prescriptions.

Complex protein interactions mediate Drosophila Lar function in muscle tissue.

The type IIa family of receptor protein tyrosine phosphatases (RPTPs), including Lar, RPTPσ and RPTPδ, are well-studied in coordinating actin cytoskeletal rearrangements during axon guidance and synaptogenesis. To determine whether this regulation is conserved in other tissues, interdisciplinary approaches were utilized to study Lar-RPTPs in the Drosophila musculature. Here we find that the single fly ortholog, Drosophila Lar (Dlar), is localized to the muscle costamere and that a decrease in Dlar causes aberrant sarcomeric patterning, deficits in larval locomotion, and integrin mislocalization. Sequence analysis uncovered an evolutionarily conserved Lys-Gly-Asp (KGD) signature in the extracellular region of Dlar. Since this tripeptide sequence is similar to the integrin-binding Arg-Gly-Asp (RGD) motif, we tested the hypothesis that Dlar directly interacts with integrin proteins. However, structural analyses of the fibronectin type III domains of Dlar and two vertebrate orthologs that include this conserved motif indicate that this KGD tripeptide is not accessible and thus unlikely to mediate physical interactions with integrins. These results, together with the proteomics identification of basement membrane (BM) proteins as potential ligands for type IIa RPTPs, suggest a complex network of protein interactions in the extracellular space that may mediate Lar function and/or signaling in muscle tissue.

Polypharmacy and Cognition Function Among Rural Adults.

BACKGROUND: Polypharmacy (using≥5 medications) is associated with poor health outcomes. Mixed results from past studies surrounding chronic medication use, control of chronic conditions, and their effects on cognitive performance warrant further attention. OBJECTIVE: Investigate a link between polypharmacy and cognition function in rural-dwelling adults in Texas, USA. METHODS: Project FRONTIER (Facing Rural Obstacles to Healthcare Now Through Intervention, Education & Research) is a cross-sectional epidemiological study using community-based participatory research in three counties of Texas. Residents age > 40 were eligible for inclusion. The primary outcome is cognitive impairment, and exposures of interest are polypharmacy; comorbidities; and diabetes, hypertension, and depression medication. Logistic regression was used to assess association. RESULTS: Six hundred eighty-nine individuals participated; the mean age was 61, and the majority were female (68.7%).The median number of medications taken by participants was 3.3 (IQR: 0-5); the rate of polypharmacy was 29.6%. Anti-hypertensive agents were the most common medications (15%) used. Polypharmacy users were 2.84 times more likely to have cognitive impairment [OR: 2.84, 95%CI (1.32-6.09)] than those using < 5 medications. Participants on hypertensive medications had 1.85 times higher odds [OR: 1.85, 95%CI (1.14-3.01)] of having cognitive impairment than those who did not have cognitive impairment. CONCLUSION: Polypharmacy increases the odds of cognitive impairment. The odds of presenting with cognitive impairment increased as the number of medications increased. Additionally, we identified a large, concerning number of participants with pharmacotherapy and poor chronic disease management. A larger study should examine medication adherence among rural elders to manage chronic disease and any healthcare barriers to adherence.