Cannabis Use and Nonfatal Opioid Overdose among Patients Enrolled in Methadone Maintenance Treatment.

BACKGROUND: Some ecological studies found lower rates of opioid overdose in states with liberalized cannabis legislation, but results are mixed, and the association has not been analyzed in individuals. We quantified the association between cannabis use and nonfatal opioid overdose among individuals enrolled in methadone maintenance treatment (MMT) for opioid use disorder (OUD). METHODS: We recruited a convenience sample of individuals enrolled in four MMT clinics in Washington State and southern New England who completed a one-time survey.Descriptive statistics and multivariate logistic regression compared the prevalence and risk of nonfatal opioid overdose in the past 12 months between participants reporting frequent (at least weekly) or infrequent (once or none) cannabis use in the past month. RESULTS: Of 446 participants, 35% (n = 156) reported frequent cannabis use and 7% (n = 32) reported nonfatal opioid overdose in the past year. The prevalence of nonfatal opioid overdose was 3% among reporters of frequent cannabis use, and 9% among reporters of infrequent/no use (p = 0.02). After imputing missing data and controlling for demographic and clinical factors, the likelihood of self-reported nonfatal opioid overdose in the past year was 71% lower among reporters of frequent cannabis use in the past month (adjusted RR = 0.29, 95% CI 0.10-0.80, p = 0.02). CONCLUSIONS: Among individuals enrolled in MMT, frequent cannabis use in the past month was associated with fewer self-reported nonfatal opioid overdoses in the past year. Methodological limitations caution against causal interpretation of this relationship. Additional studies are needed to understand the prospective impact of co-occurring cannabis on opioid-related outcomes.

Gender Differences in Patterns and Correlates of Continued Substance Use among Patients in Methadone Maintenance Treatment.

BACKGROUND: Continued substance use is common during opioid use disorder (OUD) treatment. There are still inconsistencies in how continued substance use and concurrent patterns of substance use among patients with OUD varies by gender. There is still more to learn regarding how factors associated with continued and concurrent use might differ for men and women in methadone maintenance treatment (MMT). Methods: This cross-sectional study examined predictors of concurrent substance use subgroups among patients receiving MMT. The sample included 341 (n = 161 women) MMT patients aged 18 and older from opioid treatment programs in Southern New England and the Pacific Northwest. Patients completed a survey assessing sociodemographic and clinical characteristics including past-month substance use. Latent class analyses were conducted by gender to identify groups based on substance use and determine predictors of those classes. Results: Three-class solutions were the optimal fit for both men and women. For both genders, the first subgroup was characterized as Unlikely Users (59.8% women, 52.8% men). Classes 2 and 3 among women were Cannabis/Opioid Users (23.7%) and Stimulant/Opioid Users (13.0%). Among men, Classes 2 and 3 consisted of Alcohol/Cannabis Users (21.9%) and Cannabis/Stimulant/Opioid Users (25.3%). Ever using Suboxone (buprenorphine/naloxone) and depression/anxiety symptoms were significantly linked to substance use group among women, whereas homelessness and employment status were significantly associated with substance use group among men. Conclusions: This study furthers understanding of gender differences in factors associated with continued substance use and distinctive patterns of concurrent substance use that may guide tailored treatments among patients MMT.

Mindfulness as a protective factor against depressive symptoms in people with fibromyalgia.

Background: Depressive symptoms complicate pain management for people with FM, with adverse consequences such as a greater need for pain medications and limited pain coping strategies. Determining risks and protective factors associated with depressive symptoms in persons with FM could inform the development and implementation of mental health interventions.Aims: To formulate and test a behavioral activation model of depression with mindfulness as a protective factor for people with FM.Methods: We conducted an online cross-sectional survey with 117 adults with FM from community and clinic networks. Path analysis was used to assess the relationships of pain intensity, perceived stress, activity interference, pain catastrophizing and mindfulness with depressive symptoms.Results: Mindfulness has a negative direct association with depressive symptoms and a negative indirect association with depressive symptoms through perceived stress, activity interference and pain catastrophizing. Perceived stress, activity interference and pain catastrophizing had direct associations with depressive symptoms. Finally, perceived stress, activity interference and pain catastrophizing had indirect associations with depressive symptoms through pain intensity.Conclusions: Mindfulness seems to play an important role as a protective factor against the negative effects of stress and depression among people with FM and should be included in mental health interventions for chronic pain.

Self-Reported Pain Intensity and Depressive Symptoms Among Community-Dwelling Older Adults with Schizophrenia Spectrum Disorders.

Older adults with schizophrenia have some of the highest rates of both medical and psychiatric comorbidities. Despite this, little is known about comorbid pain and depressive symptoms in schizophrenia research. This study aimed to examine the associations between levels of pain intensity and depressive symptoms among community-dwelling adults aged 50 years and older with schizophrenia spectrum disorders. Recruited from U.S. community mental health centers, participants reported on pain and depressive symptoms at the onset of the Helping Older People Experience Success (HOPES) study. Unadjusted and adjusted regression analyses were conducted. Higher pain intensity was associated with elevated depressive symptoms in all analyses, which is consistent with other studies in the general population. Given the widespread efforts to manage pain and related mental health complications in older adults without serious mental illnesses, it is likewise important that community-based mental health professionals monitor and address intense pain and related depressive symptoms among older adults with schizophrenia.

Prevalence and Correlates of Loss of Control Eating among Adults Presenting for Methadone Maintenance Treatment.

BACKGROUND: Research suggests that substance use disorders and disordered eating are often comorbid. In light of the ongoing opioid epidemic, the purpose of the current study was to understand the prevalence and health-related correlates of loss of control (LOC) eating in adults seeking methadone maintenance treatment primarily for addiction to heroin and/or painkillers. METHODS: Participants were 447 adults surveyed at presentation for methadone maintenance treatment who responded to survey items on LOC eating. Descriptive statistics were used to investigate the prevalence of engaging in LOC eating in the past 2 weeks. Chi-square tests, t tests, and analyses of covariance were used to compare individuals with (LOC+; n = 164) and without (LOC-; n = 283) recent LOC eating on psychosocial, pain-related, and weight-related characteristics. RESULTS: Approximately one third of respondents endorsed LOC eating in the past 2 weeks. These participants reported greater affective symptoms, interpersonal dysfunction, pain intensity, and pain interference than the LOC- group (Cohen's d effect size range = .24-.94). LOC+ was also more likely to have engaged in recent illicit drug use and to report having concurrent overweight/obesity (φ effect size range = .09-.10). CONCLUSION: The prevalence of LOC eating in adults seeking methadone maintenance treatment was more than triple what has been reported in previous studies using community samples. Given its associations with other health-related variables, the presence of LOC eating may be a marker for more severe psychopathology in individuals seeking methadone maintenance treatment. Future research is needed to understand mechanisms explaining this comorbidity and to develop novel ways to prevent and treat their co-occurrence.

Hospitalization Risk and Potentially Inappropriate Medications among Medicare Home Health Nursing Patients.

BACKGROUND: Hospitalizations and potentially inappropriate medication (PIM) use are significant and costly issues among older home health patients, yet little is known about the prevalence of PIM use in home health or the relationship between PIM use and hospitalization risk in this population. OBJECTIVE: To describe the prevalence of PIM use and association with hospitalization among Medicare home health patients. DESIGN: Cross-sectional analysis using data from 132 home health agencies in the US. SUBJECTS: Medicare beneficiaries starting home health nursing services between 2013 and 2014 (n = 87,780). MAIN MEASURES: Prevalence of individual and aggregate PIM use at start of care, measured using the 2012 Beers criteria. Relative risk (RR) of 30-day hospitalization or re-hospitalization associated with individual and aggregate PIM use, compared to no PIM use. KEY RESULTS: In total, 30,168 (34.4%) patients were using at least one PIM, with 5969 (6.8%) taking at least two PIMs according to the Beers list. The most common types of PIMs were those affecting the brain or spinal cord, analgesics, and medications with anticholinergic properties. With the exception of nonsteroidal anti-inflammatory drugs (NSAIDs), PIM use across all classes was associated with elevated risk (10-33%) of hospitalization compared to non-use. Adjusting for demographic and clinical characteristics, patients using at least one PIM (excluding NSAIDs) had a 13% greater risk (RR = 1.13, 95% CI: 1.09, 1.17) of being hospitalized than patients using no PIMs, while patients using at least two PIMs had 21% greater risk (RR = 1.21, 95% CI: 1.12, 1.30). Similar associations were found between PIMs and re-hospitalization risk among patients referred to home health from a hospital. CONCLUSIONS: Given the high prevalence of PIM use and the association between PIMs and hospitalization risk, home health episodes represent opportunities to substantially reduce PIM use among older adults and prevent adverse outcomes. Efforts to address medication use during home health episodes, hospitalizations, and care transitions are justified.

Systematic Review of the Impact of Behavioral Health Homes on Cardiometabolic Risk Factors for Adults With Serious Mental Illness.

OBJECTIVE: This systematic review examined the impact of health homes on cardiometabolic risk among adults with serious mental illness. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses procedures were used to conduct the systematic review. Databases were searched for peer-reviewed articles published between 1946 and August 2018 that compared health homes with a control condition (e.g., usual care and secondary data analyses using matched samples). Participants, interventions, comparisons, outcomes, and study design criteria were used to assess study eligibility. Studies were assessed for methodological quality by using the Quality Assessment of Before and After Studies With No Control Group and the Quality Assessment of Controlled Intervention Studies. RESULTS: Eighteen studies (i.e., 11 observational studies, four quasi-experimental studies, and three randomized controlled trials) reported on 17 health homes. Most studies reported increases in receipt of screening for cardiometabolic risk factors and service use. There was a modest reduction in selected cardiometabolic risk factors among people with serious mental illness, but clinical outcomes varied widely among studies. CONCLUSIONS: Improvement in cardiometabolic risk factors varied across the studies, and the clinical significance of these reductions was not clear. Peer support and self-management training may represent strategies to improve cardiometabolic risk factors. Colocation of services may not be enough to significantly affect cardiometabolic risk factors. Health homes that include standardized screening, peer support and self-management training, and intervention components that target interdependent risk factors may have a greater impact on clinical outcomes.

Mental health treatment among older adults with mental illness on parole or probation.

BACKGROUND: The number of older adults on parole and probation is growing at an unprecedented rate, yet little is known about the mental health needs and treatment utilization patterns among this group. The objective of this study is to compare the prevalence of serious or moderate mental illness (SMMI), and the proportion of those with SMMI who receive mental health treatment, among community-dwelling older adults on correctional supervision (parole or probation) vs. not on correctional supervision. METHODS: Design: Cross-sectional analysis of data from the 2008-2014 National Surveys for Drug Use and Health (NSDUH). SETTING: Population-based national survey data. PARTICIPANTS: Older adults (age ≥ 50) who participated in the NSDUH between 2008 and 2014 (n = 44,624). Participants were categorized according to whether they were on parole or probation during the 12 months prior to survey completion (n = 379) vs. not (n = 44,245). MEASUREMENTS: Probable SMMI was defined using a validated measure in the NSDUH. Mental health treatment included any outpatient mental health services or prescriptions over the 12 months prior to survey completion. We compared the prevalence of SMMI, and the proportion of those with SMMI who received any treatment, by correctional status. RESULTS: Overall, 7% (N = 3266) of participants had SMMI; the prevalence was disproportionately higher among those on parole or probation (21% vs. 7%, p <  0.001). Sixty-two percent of those with SMMI received any mental health treatment, including 81% of those on parole or probation and 61% of those who were not (p <  0.001). This result remained statistically significant after logistic regression accounted for differences in sociodemographics and health. CONCLUSIONS: SMMI is disproportionally prevalent among older adults on parole or probation, and community correctional supervision programs may be facilitating linkages to needed community-based mental health treatment.

Methadone Maintenance Treatment for Older Adults: Cost and Logistical Considerations.

In a demographic shift, older adults now comprise an increasing proportion of those receiving methadone maintenance treatment (MMT) for opioid use disorder. A study of MMT recipients in New York City suggests that 13% of the population is over 60 years of age. Adults ages 50-59 are among the largest age demographic, evidence that the number of older adults receiving MMT will continue to increase. Because medical comorbidities, cognitive impairment, and neurobehavioral changes often accumulate with age, older adults on MMT become increasingly vulnerable. The cost of MMT and logistical considerations also pose challenges to continued care. Together, these issues warrant a reconsideration of emerging concerns and health policies related to use of MMT in this growing and understudied population. Given the changing health care system and the opioid epidemic, the need for evidence-based guidelines and supportive policies that consider the unique treatment needs of older populations is especially relevant.

Characteristics of Medicaid recipients in Methadone Maintenance Treatment: A comparison across the lifespan.

Methadone Maintenance Treatment (MMT) is utilized by an increasingly broad age-range of individuals with opioid use disorders. The present study aims to (1) describe health, behavioral, and psychosocial characteristics among adults aged 50 years and older compared with younger adults enrolled in MMT, (2) describe socioeconomic and clinical characteristics by age and time in MMT and (3) investigate whether age influences the associations between duration of MMT and health and psychosocial characteristics. Our sample consisted of 1364 recipients from four MMT programs (age ranged from 18 to 77 years; mean: 38 years: standard deviation: 11.1 years) in Southern New England Using descriptive analysis and logistic regression, we determined that one-third (33%) of adults 50 years of age and older had been admitted or readmitted into MMT within the previous 6 months, 27% had been in treatment for 7-47 months, while 40% had been in treatment for at least 4 years. Psychosocial problems and smoking were both common (>80%) at the time of MMT enrollment but declined with longer duration of MMT for all age groups. The prevalence of metabolic conditions was associated with increased duration of MMT for younger adults for both age (1.03; CI 1.02-1.05; p < 0.001) and time in treatment (1.29; 1.12-1.44; p < 0.001; interaction term 0.0996; CI 0.993-0.998). Tailored strategies to enhance engagement, retention, and prevention among MMT recipients should include considerations of age, health status upon enrollment, duration of treatment, and developmental context.

Perinatal substance use, residential instability, and negative behavioral outcomes among adolescents: Lessons from the maternal lifestyle study.

PROBLEM: Both housing instability and prenatal substance use are known risk factors for behavioral problems among adolescents. METHODS: The purpose of this study was to investigate the association between residential instability (residential mobility and homelessness) and delinquent behaviors among adolescents enrolled in the maternal lifestyle study (MLS), a 16-year research study that explored short-term and long-term effects of in-utero exposure to cocaine and/or opiates (N = 736). Logistic regression was used to measure the association between housing problems with youth crimes, school delinquency, and substance use at 11, 15, and 16 years of age. FINDINGS: Both high-frequency residential mobility and homelessness were associated with deviant behaviors across the entire sample of children born with in-utero cocaine/opiate exposure and those without. CONCLUSIONS: Psychiatric nursing care of youth should include a comprehensive assessment of residential instability to identify risk and target potential interventions.

Prevalence of and Factors Related to Prescription Opioids, Benzodiazepines, and Hypnotics Among Medicare Home Health Recipients.

High rates of controlled prescription drugs are associated with cognitive impairment, falls, and misuse and dependence. Little is known about the prevalence of these medications among older adults receiving home healthcare. The purpose of this study was to determine the frequency of, and the factors related to, opioid analgesics, benzodiazepines (BNZ), and nonbenzodiazepine (NBNZH) hypnotics among a large sample of older adults entering home healthcare services. The data came from administrative records of 133 Certified Home healthcare Agencies located across 32 states. Patients (age ≥ 65) receiving Medicare home healthcare services and who received a start-of-care Medicare OASIS assessment between January 1, 2013, and December 31, 2014, were included in the study (n = 87,780). Rates of controlled medication use were compared across patient-level sociodemographic, clinical, functional, and environmental variables. The prevalence of controlled medication was high, with 58% prescribed at least one class of controlled drug, 44% were prescribed an opioid, 19% were prescribed a BNZ, and almost 7% were prescribed a NBZDH. Factors independently associated with higher levels of controlled medication usage include younger-old age, white race, postsurgical status, injuries, referral from inpatient settings, and rural location. Home healthcare clinicians are well positioned to review and reconcile medication, oversee referrals and follow-up care, and provide ongoing assessment of risk regarding the use of opioids, BNZ, and hypnotics among home healthcare patients.