Association of Disability Status and Type With Binge Drinking and Prescription Opioid Misuse Among Adults From a 3-State Sample.

BACKGROUND: Research examining at-risk substance use by disability status is limited, with little investigation into differences by disability type. We investigated binge drinking and prescription opioid misuse among adults with and without disabilities, and by type of disability, to inform need for assessment and intervention within these populations. METHODS: Secondary analyses of adults who completed the disability, alcohol, and prescription opioid misuse items in the 2018 Ohio, Florida, or Nebraska Behavioral Risk Factor Surveillance System surveys (n = 28 341), the only states that included prescription opioid misuse in 2018. Self-reported disability status (yes/no) relied on 6 standardized questions assessing difficulties with: vision, hearing, mobility, cognition, self-care, and independent living (dichotomous, nonmutually exclusive, for each disability). Logistic regression models estimated the association of disability status and type with (1) past 30-day binge drinking and (2) past-year prescription opioid misuse. Additional models were restricted to separate subsamples of adults who: (a) currently drink, (b) received a past-year prescription opioid, and (c) did not receive a past-year prescription opioid. RESULTS: One-third reported at least one disability, with mobility (19.5%), cognitive (11.5%), and hearing (10.2%) disability being the most common. Disability status was associated with lower odds of binge drinking (adjusted odds ratio [AOR] = 0.74, 95% confidence interval [CI] 0.68-0.80, P ≤ .01). However, among adults who currently drink, people with disabilities had higher odds of binge drinking (AOR = 1.11, 95% CI 1.01-1.22, P ≤ .05]. Disability was associated with higher odds of past-year prescription opioid misuse (AOR = 2.51, 95% CI 2.17-2.91, P ≤ .01). CONCLUSIONS: Adults with disabilities had higher odds of prescription opioid misuse, and among adults who currently drink, higher odds for binge drinking were observed. The magnitude of the association between disability status and prescription opioid misuse was particularly concerning. Providers should be trained to screen and treat for substance use problems for people with disabilities.

Healthcare utilization and readiness outcomes among soldiers with post-deployment at-risk drinking, by multimorbidity class.

Although alcohol use disorder (AUD) regularly co-occurs with other conditions, there has not been investigation of specific multimorbidity classes among military members with at-risk alcohol use. We used latent class analysis (LCA) to cluster 138,929 soldiers with post-deployment at-risk drinking based on their co-occurring psychological and physical health conditions and indicators of alcohol severity. We examined the association of these multimorbidity classes with healthcare utilization and military readiness outcomes. Latent class analysis was conducted on 31 dichotomous indicators capturing alcohol use severity, mental health screens, psychological and physical health diagnoses, and tobacco use. Longitudinal survival analysis was used to examine the relative hazards of class membership regarding healthcare utilization (e.g., emergency department visit, inpatient stay) and readiness outcomes (e.g., early separation for misconduct). Latent class analysis identified five classes: Class 1 -Relatively Healthy (51.6 %); Class 2 - Pain/Tobacco (17.3 %); Class 3 - Heavy Drinking/Pain/Tobacco (13.1 %); Class 4 - Mental Health/Pain/Tobacco (12.7 %); and Class 5 - Heavy Drinking/Mental Health/Pain/Tobacco (5.4 %). Musculoskeletal pain and tobacco use were prevalent in all classes, though highest in Classes 2, 4, and 5. Classes 4 and 5 had the highest hazards of all outcomes. Class 5 generally exhibited slightly higher hazards of all outcomes than Class 4, demonstrating the exacerbation of risk among those with heavy drinking/AUD in combination with mental health conditions and other multimorbidity. This study provides new information about the most common multimorbidity presentations of at-risk drinkers in the military so that targeted, individualized care may be employed. Future research is needed to determine whether tailored prevention and treatment approaches for soldiers in different multimorbidity classes is associated with improved outcomes.

The association between community social vulnerability and prescription opioid availability with individual opioid overdose.

BACKGROUND: This study aims to assess the association of community social vulnerability and community prescription opioid availability with individual non-fatal or fatal opioid overdose. METHODS: We identified patients 12 years of age or older from the Oregon All Payer Claims database (APCD) linked to other public health datasets. Community-level characteristics were captured in an exposure period (EP) (1/1/2018-12/31/2018) and included: census tract-level social vulnerability domains (socio-economic status, household composition, racial and ethnic minority status, and housing type and transportation), census tract-level prescriptions and community-level opioid use disorder (OUD) diagnoses per 100 capita binned into quartiles or quintiles. We employed Cox models to estimate the risk of fatal and non-fatal opioid overdoses events in the 12 months following the EP. MAIN FINDINGS: We identified 1,548,252 individuals. Patients were mostly female (54%), White (61%), commercially insured (54%), and lived in metropolitan areas (81%). Of the total sample, 2485 (0.2%) experienced a non-fatal opioid overdose and 297 died of opioid overdose. There was higher hazard for non-fatal overdose in communities with greater OUD per 100 capita. We also found higher non-fatal and fatal hazards for opioid overdose among patients in communities with higher housing type and transportation-related vulnerability compared to the lowest quintile. Conversely, patients were at less risk of opioid overdose when living in communities with greater prevalence of the young or the elderly, the disabled, single parent families or low English proficiency. CONCLUSION: These findings underscore the importance of the environmental context when considering public health policies to reduce opioid harms.

Association of Household Opioid Availability With Opioid Overdose.

Importance: Previous studies that examined the role of household opioid prescriptions in opioid overdose risk were limited to commercial claims, did not include fatal overdoses, and had limited inclusion of household prescription characteristics. Broader research is needed to expand understanding of the risk of overdose. Objective: To assess the role of household opioid availability and other household prescription factors associated with individuals' odds of fatal or nonfatal opioid overdose. Design, Setting, and Participants: A retrospective cohort study assessing patient outcomes from January 1, 2015, through December 31, 2018, was conducted on adults in the Oregon Comprehensive Opioid Risk Registry database in households of at least 2 members. Data analysis was performed between October 16, 2020, and January 26, 2023. Exposures: Household opioid prescription availability and household prescription characteristics. Main Outcomes and Measures: Opioid overdoses were captured from insurance claims, death records, and hospital discharge data. Household opioid prescription availability and prescription characteristics for individuals and households were modeled as 6-month cumulative time-dependent measures, updated monthly. To assess the association between household prescription availability, household prescription characteristics, and overdose, multilevel logistic regression models were developed, adjusting for demographic, clinical, household, and prescription characteristics. Results: The sample included 1 691 856 individuals in 1 187 140 households, of which most were women (53.2%), White race (70.7%), living in metropolitan areas (75.8%), and having commercial insurance (51.8%), no Elixhauser comorbidities (69.5%), and no opioid prescription fills in the study period (57.0%). A total of 28 747 opioid overdose events were observed during the study period (0.0526 per 100 person-months). Relative to individuals without personal or household opioid fills, the odds of opioid-related overdose increased by 60% when another household member had an opioid fill in the past 6 months (adjusted odds ratio [aOR], 1.60; 95% CI, 1.54-1.66) and were highest when both the individual and another household member had opioid fills in the preceding 6 months (aOR, 6.25; 95% CI, 6.09-6.40). Conclusions and Relevance: In this cohort study of adult Oregon residents in households of at least 2 members, the findings suggest that household prescription availability is associated with increased odds of opioid overdose for others in the household, even if they do not have their own opioid prescription. These findings underscore the importance of educating patients about proper opioid disposal and the risks of household opioids.

Opioid-related overdose and chronic use following an initial prescription of hydrocodone versus oxycodone.

BACKGROUND: Hydrocodone and oxycodone are prescribed commonly to treat pain. However, differences in risk of opioid-related adverse outcomes after an initial prescription are unknown. This study aims to determine the risk of opioid-related adverse events, defined as either chronic use or opioid overdose, following a first prescription of hydrocodone or oxycodone to opioid naïve patients. METHODS: A retrospective analysis of multiple linked public health datasets in the state of Oregon. Adult patients ages 18 and older who a) received an initial prescription for oxycodone or hydrocodone between 2015-2017 and b) had no opioid prescriptions or opioid-related hospitalizations or emergency department visits in the year preceding the prescription were followed through the end of 2018. First-year chronic opioid use was defined as ≥6 opioid prescriptions (including index) and average ≤30 days uncovered between prescriptions. Fatal or non-fatal opioid overdose was indicated from insurance claims, hospital discharge data or vital records. RESULTS: After index prescription, 2.8% (n = 14,458) of individuals developed chronic use and 0.3% (n = 1,480) experienced overdose. After adjustment for patient and index prescription characteristics, patients receiving oxycodone had lower odds of developing chronic use relative to patients receiving hydrocodone (adjusted odds ratio = 0.95, 95% confidence interval (CI) 0.91-1.00) but a higher risk of overdose (adjusted hazard ratio (aHR) = 1.65, 95% CI 1.45-1.87). Oxycodone monotherapy appears to greatly increase the hazard of opioid overdose (aHR 2.18, 95% CI 1.86-2.57) compared with hydrocodone with acetaminophen. Oxycodone combined with acetaminophen also shows a significant increase (aHR 1.26, 95% CI 1.06-1.50), but not to the same extent. CONCLUSIONS: Among previously opioid-naïve patients, the risk of developing chronic use was slightly higher with hydrocodone, whereas the risk of overdose was higher after oxycodone, in combination with acetaminophen or monotherapy. With a goal of reducing overdose-related deaths, hydrocodone may be the favorable agent.

Factors Associated With Opioid Overdose After an Initial Opioid Prescription.

Importance: The opioid epidemic continues to be a public health crisis in the US. Objective: To assess the patient factors and early time-varying prescription-related factors associated with opioid-related fatal or nonfatal overdose. Design, Setting, and Participants: This cohort study evaluated opioid-naive adult patients in Oregon using data from the Oregon Comprehensive Opioid Risk Registry, which links all payer claims data to other health data sets in the state of Oregon. The observational, population-based sample filled a first (index) opioid prescription in 2015 and was followed up until December 31, 2018. Data analyses were performed from March 1, 2020, to June 15, 2021. Exposures: Overdose after the index opioid prescription. Main Outcomes and Measures: The outcome was an overdose event. The sample was followed up to identify fatal or nonfatal opioid overdoses. Patient and prescription characteristics were identified. Prescription characteristics in the first 6 months after the index prescription were modeled as cumulative, time-dependent measures that were updated monthly through the sixth month of follow-up. A time-dependent Cox proportional hazards regression model was used to assess patient and prescription characteristics that were associated with an increased risk for overdose events. Results: The cohort comprised 236 921 patients (133 839 women [56.5%]), of whom 667 (0.3%) experienced opioid overdose. Risk of overdose was highest among individuals 75 years or older (adjusted hazard ratio [aHR], 3.22; 95% CI, 1.94-5.36) compared with those aged 35 to 44 years; men (aHR, 1.29; 95% CI, 1.10-1.51); those who were dually eligible for Medicaid and Medicare Advantage (aHR, 4.37; 95% CI, 3.09-6.18), had Medicaid (aHR, 3.77; 95% CI, 2.97-4.80), or had Medicare Advantage (aHR, 2.18; 95% CI, 1.44-3.31) compared with those with commercial insurance; those with comorbid substance use disorder (aHR, 2.74; 95% CI, 2.15-3.50), with depression (aHR, 1.26; 95% CI, 1.03-1.55), or with 1 to 2 comorbidities (aHR, 1.32; 95% CI, 1.08-1.62) or 3 or more comorbidities (aHR, 1.90; 95% CI, 1.42-2.53) compared with none. Patients were at an increased overdose risk if they filled oxycodone (aHR, 1.70; 95% CI, 1.04-2.77) or tramadol (aHR, 2.80; 95% CI, 1.34-5.84) compared with codeine; used benzodiazepines (aHR, 1.06; 95% CI, 1.01-1.11); used concurrent opioids and benzodiazepines (aHR, 2.11; 95% CI, 1.70-2.62); or filled opioids from 3 or more pharmacies over 6 months (aHR, 1.38; 95% CI, 1.09-1.75). Conclusions and Relevance: This cohort study used a comprehensive data set to identify patient and prescription-related risk factors that were associated with opioid overdose. These findings may guide opioid counseling and monitoring, the development of clinical decision-making tools, and opioid prevention and treatment resources for individuals who are at greatest risk for opioid overdose.

Association between medication adherence and non-drug healthcare utilisation and costs: a retrospective longitudinal cohort study among US women age 65 and older.

OBJECTIVES: To explore the association between hormone therapy (HT) adherence and non-drug healthcare utilisation and healthcare costs among patients with breast cancer. DESIGN: Retrospective longitudinal cohort study. SETTING: The US Medicare beneficiaries in the SEER-Medicare-linked database PARTICIPANTS: Women aged ≥ 65 with hormone-receptor positive breast cancer from 2007 through mid-2009 in the USA. INTERVENTIONS: We examined the relationship between HT and adherence and outcomes of our interests. PRIMARY AND SECONDARY OUTCOME MEASURES: Our study cohort's HT adherence, non-drug healthcare utilisation and healthcare costs for the first year of HT and each year, thereafter, for a total of 5 years. RESULTS: 6045 eligible Medicare beneficiaries that met our selection criteria were included. We found that patients who were adherent to HT were associated with lower healthcare utilisation of all kinds (inpatient (0.35 vs 0.43, p<0.001), length of study during hospitalisation (4.19 vs 4.89, p<0.01), physician office visits (25.16 vs 26.17, p<0.001)), and significant reductions in many types of medical costs and neutral total healthcare costs despite the increased pharmacy costs. Half of the total medical cost reduction came from savings in hospitalisation costs. CONCLUSIONS: Our study suggests that the added cost of HT adherence was all but offset by the reduced cost for other medical care. Our study provides evidence on the potential success of implementing value-based insurance design (VBID) plans among patients with breast cancer to improve their long-term oral medication adherence. Policymakers should consider adherence improvement strategies such as VBID plans, given that the costs likely will not surpass the total savings.

Association of Lifetime History of Traumatic Brain Injury With Prescription Opioid Use and Misuse Among Adults.

OBJECTIVE: To investigate associations of lifetime history of traumatic brain injury (TBI) with prescription opioid use and misuse among noninstitutionalized adults. PARTICIPANTS: Ohio Behavioral Risk Factor Surveillance System (BRFSS) participants in the 2018 cohort who completed the prescription opioid and lifetime history of TBI modules (n = 3448). DESIGN: Secondary analyses of a statewide population-based cross-sectional survey. MAIN MEASURES: Self-report of a lifetime history of TBI using an adaptation of the Ohio State University TBI-Identification Method. Self-report of past year: (1) prescription pain medication use (ie, prescription opioid use); and (2) prescription opioid misuse, defined as using opioids more frequently or in higher doses than prescribed and/or using a prescription opioid not prescribed to the respondent. RESULTS: In total, 22.8% of adults in the sample screened positive for a lifetime history of TBI. A quarter (25.5%) reported past year prescription opioid use, and 3.1% met criteria for prescription opioid misuse. A lifetime history of TBI was associated with increased odds of both past year prescription opioid use (adjusted odds ratio [AOR] = 1.52; 95% CI, 1.27-1.83; P < .01) and prescription opioid misuse (AOR = 1.65; 95% CI, 1.08-2.52; P < .05), controlling for sex, age, race/ethnicity, and marital status. CONCLUSION: Results from this study support the "perfect storm" hypothesis-that persons with a history of TBI are at an increased risk for exposure to prescription opioids and advancing to prescription opioid misuse compared with those without a history of TBI. Routine screening for a lifetime history of TBI may help target efforts to prevent opioid misuse among adults.

Examining differences in prescription opioid use behaviors among U.S. adults with and without disabilities.

We aimed to identify differences in prescription opioid-related behaviors between adults with and without disabilities in the U.S. We analyzed data from the 2015-2017 National Survey on Drug Use and Health (128,740 individuals; weighted N of 244,831,740) to examine disability-based differences in (1) reasons and sources of last prescription opioid misuse and, in multivariate models overall and stratified by disability, the likelihood of (2) prescription opioid use, and if used, (3) misuse and prescription opioid use disorder (OUD), overall and stratified by disability. Adults with disabilities were 11% more likely than adults without disabilities to report any past-year prescription opioid use, adjusted for sociodemographic, health, and behavioral health characteristics. However, among adults with any prescription opioid use, which is more common among people with disabilities, likelihood of prescription OUD did not vary by disability status. Pain relief as the reason for last misuse was associated with 18% increased likelihood of prescription OUD, if any use. To reduce risk of opioid misuse among people with disabilities, accessible and inclusive chronic pain management services are essential. Further, the substance use treatment field should provide accessible and inclusive services, and be aware of the need for pain management by many people with disabilities, which may include the use of prescription opioids. These findings highlight essential opportunities for public health and policies to improve access, accommodations, and quality of health and behavioral health care for people with disabilities, and to encourage a holistic perspective of people with disabilities and their needs.

Cost sharing for breast cancer hormone therapy: How do dual eligible patients' copayment impact adherence.

OBJECTIVE: To examine the different levels of copayment assistance and treatment adherence among Medicare and Medicaid dual eligible beneficiaries with breast cancer in the U.S. RESEARCH DESIGN: Propensity Score methodology was adopted to minimize potential selection bias from the nonrandom allocation of the treatment group (i.e., full Medicaid beneficiaries) and control group (i.e., Medicare Savings Programs [MSPs] beneficiaries). Longitudinal hierarchical model and Cox proportional-hazard model were adopted to examine patients' adherence over their full five-year course of adjuvant hormone therapy. RESULTS: Our study cohort consisted of 1,133 dual eligible beneficiaries diagnosed with hormone receptor-positive early stage breast cancer in years 2007 -mid 2009. About 80.5% of them received MSPs benefits, while the rest received full Medicaid benefits. On average for a standardized 30-day hormone therapy medication, full Medicaid beneficiaries spent $0.5-$2.0 and MSP beneficiaries spent $1.4-$4.8 in copayment. After adjusting for other factors, this copayment reduction wasn't associated with a significantly better adherence. However, when the catastrophic coverage threshold was reached (copayments reduced to zero), significant improvement in adherence was found in both groups. CONCLUSIONS: Our study found that small amount of cost-sharing reduction did not affect Medicare and Medicaid dual eligible patients' medication treatment adherence, however, the elimination of cost-sharing (even a minimal amount) was associated with improved adherence. Future legislative and advocacy efforts should be paid on eliminating cost sharing for dual eligibles, and possibly even a broader group of financially vulnerable patients.

Pregnancy and Neonatal Outcomes Among Deaf and Hard of Hearing Women: Results From Nationally Representative Data.

BACKGROUND: Although the literature suggests that women with disabilities are at increased risk for pregnancy complications and adverse birth outcomes, there are few population-based studies of pregnancy outcomes among deaf and hard of hearing (DHH) women in the United States. OBJECTIVE: To compare pregnancy complications and neonatal outcomes between deliveries to DHH and non-DHH women using national hospitalization discharge record data. STUDY DESIGN: We used the 2007-2016 Healthcare Cost and Utilization Project National Inpatient Sample to compare pregnancy complications and outcomes among deliveries to DHH women with deliveries to non-DHH women using bivariate and Poisson regressions, controlling for sociodemographic, hospital, and clinical characteristics. RESULTS: DHH women had an increased risk of adverse pregnancy outcomes and chronic medical conditions, including preexisting diabetes (relative risk [RR], 2.01; 95% confidence interval, 1.68-2.42; p < .001), gestational diabetes (RR, 1.31; 95% CI, 1.19-1.44; p < .001), chronic hypertension (RR, 1.51; 95% CI, 1.33-1.72; p < .001), preeclampsia and eclampsia (RR, 1.35; 95% CI, 1.21-1.51; p < .01), placenta previa (RR, 1.62; 95% CI, 1.22-2.16; p < .01), placental abruption (RR, 1.43; 95% confidence interval, 1.15-1.78; p < .01), labor induction (RR, 1.16; 95% CI, 1.05-1.27; p < .01), chorioamnionitis (RR, 1.43; 95% CI, 1.22-1.69; p < .001), cesarean delivery (RR, 1.09; 95% CI, 1.04-1.14; p < .001), premature rupture of membranes (RR, 1.34; 95% CI, 1.20-1.50; p < .001), antepartum hemorrhage (RR, 1.36; 95% CI, 1.13-1.64; p < .001), and postpartum hemorrhage (RR, 1.30; 95% CI, 1.13-1.49; p < .001). After adjustment for socioeconomic and hospital characteristics, the risk for gestational diabetes, preeclampsia and eclampsia, placenta previa, and chorioamnionitis remained unexplained. CONCLUSIONS: DHH women are at increased risk for adverse pregnancy, fetal, and neonatal outcomes, illuminating the need for awareness among obstetric and primary care providers as well as the need for systematic investigation of outcomes and evidence-based guidelines.

Use of Electronic Health Information Technology in a National Sample of Hospitals That Provide Specialty Substance Use Care.

OBJECTIVE: Most U.S. acute care hospitals have adopted basic electronic health record (EHR) functionality and health information exchange (HIE) (84% and 88%, respectively, in 2017). This study examined whether rates of EHR and HIE adoption by hospital-based substance use disorder programs are lower than rates by acute care hospitals. METHODS: Data from the 2017 National Survey on Substance Abuse Treatment Services were analyzed to examine adoption of basic EHR functionality (i.e., assessment, progress monitoring, discharge, labs, and prescription dispensing) and use of HIE by hospital-based programs. Analyses used weighted multivariable models of EHR and HIE outcomes, adjusted for nonresponse. RESULTS: Of 894 hospital-based substance use disorder programs with EHR information, two-thirds (N=606, 68%) reported use of basic EHR functionality. Psychiatric hospitals were less likely than acute care hospitals to have adopted EHR (odds ratio [OR]=0.49, 95% confidence interval [CI]=0.35-0.71). Compared with nonprofit hospitals, for-profit (OR=0.23, 95% CI=0.16-0.35) and government-owned (OR=0.52, 95% CI=0.33-0.83) hospitals were less likely to use basic EHR functionality. Hospital-based programs providing medications for alcohol or opioid use disorders were more likely than those not providing such medications to use basic EHR (OR=1.95, 95% CI=1.31-2.90). Of 839 hospitals with information on HIE use, 598 (71%) reported using electronic HIE. Adoption of basic EHR functionality was the strongest predictor of HIE use (OR=4.73, 95% CI=3.29-6.79). CONCLUSIONS: Hospital-based substance use disorder programs trail behind U.S. acute care hospitals in adoption of basic EHR and electronic HIE. Findings raise concerns about missed opportunities to improve hospital-based substance use disorder care quality and performance measurement.

The association of engagement in substance use treatment with negative separation from the military among soldiers with post-deployment alcohol use disorder.

BACKGROUND: Alcohol use disorder (AUD) reduces the health of soldiers and the readiness of the Armed Forces. It remains unknown if engagement in substance use treatment in the Military Health System improves retention in the military. METHODS: The sample consisted of active duty soldiers returning from an Afghanistan/Iraq deployment in fiscal years 2008-2010 who received an AUD diagnosis within 150 days of completing a post-deployment health re-assessment survey (n = 4,726). A Heckman probit procedure was used to examine predictors of substance use treatment initiation and engagement in accordance with Healthcare Effectiveness Data and Information Set (HEDIS) criteria. Cox proportional hazard modeling was used to examine the association between treatment engagement and retention, defined as a negative separation for a non-routine cause (e.g., separation due to misconduct, poor performance, disability) from the military in the two years following the index AUD diagnosis. RESULTS: 40 % of soldiers meeting HEDIS AUD criteria initiated and 24 % engaged in substance use treatment. Among soldiers diagnosed with AUD, meeting criteria for treatment engagement was associated with a significantly higher hazard of having a negative separation compared to soldiers who did not engage in treatment. CONCLUSIONS: Rates of initiation and engagement in substance use treatment for post-deployment AUD were relatively low. Soldiers with AUD who engaged in substance use treatment were more likely to have a negative separation from the military than soldiers with AUD who did not engage. Our findings imply that in the study cohort, treatment did not mitigate negative career consequences of AUD.

Effectiveness of value-based purchasing for substance use treatment engagement and retention.

INTRODUCTION: Many people drop out of substance use disorder (SUD) treatment within the first few sessions, which suggests the need for innovative strategies to address this. We examined the effectiveness of incentive-based contracting for Maine's publicly funded outpatient (OP) and intensive outpatient (IOP) SUD treatment, to determine its potential for improving treatment engagement and retention. METHODS: Maine's incentive-based contract with federally block grant-funded OP and IOP treatment agencies created a natural experiment, in which we could compare treatment engagement and retention with a group of state-licensed treatment agencies that were not part of the incentive-based contract. We used administrative data for OP (N = 18,375) and IOP (N = 5986) SUD treatment admissions from FY2005-FY2011 to capture trends prior to and after the FY2008 contract implementation date. We performed multivariable difference-in-difference logistic regression models following propensity score matching of clients. RESULTS: Two-thirds (66%) of OP admissions engaged in treatment, defined as 4+ treatment sessions, and 85% of IOP admissions satisfied the similar criteria of 4+ treatment days. About 40-45% of OP admissions reached the threshold for retention, defined as 90 days in treatment. IOP treatment completion was attained by 50-58% of admissions. For OP, the incentive and nonincentive groups had no significant differences in percentages with treatment engagement (AOR = 1.28, DID = 5.9%, p = .19), and 90-day retention was significant in the opposite direction of what we hypothesized (AOR = 0.80, DID = -4.6%, p = .0003). For IOP, the incentive group had a significant, but still small, increase in percentage with treatment engagement (AOR = 1.52, DID = 5.5%, p = .003), but the corresponding increase in treatment completion was not similarly significant (AOR = 1.12, DID = 2.7%, p = .53). In all models, individual-level variables were strong predictors of outcomes. CONCLUSION: We found little to no impact of the incentive-based contract on the treatment engagement, retention, and completion measures, adding to the body of evidence that shows few or null results for value-based purchasing in SUD treatment programs. The limited success of such efforts is likely to reflect the bandwidth that providers and programs have to focus on new endeavors, the importance of the incentive funding to their bottom line, and forces beyond their immediate control.

The impact of the introduction of generic aromatase inhibitors on adherence to hormonal therapy over the full course of 5-year treatment for breast cancer.

BACKGROUND: High out-of-pocket costs (OOPCs) often are found to be inversely associated with adherence to medical treatment. The introduction of generic aromatase inhibitors (GAIs) significantly reduced the OOPCs of patients. The objective of the current study was to explore the impact of the introduction of GAIs on adjuvant hormone therapy (AHT) adherence over the full course of breast cancer treatment. METHODS: Women aged ≥65 years who were diagnosed with hormone receptor-positive breast cancer from 2007 through mid-2009 were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. Multivariate logistic regression was used to estimate the likelihood of AHT initiation and an interrupted time series model was used to predict the association between the introduction of GAIs and AHT adherence. The model was stratified further using Medicare low-income subsidy (LIS) status. RESULTS: A total of 10,905 women were included, approximately 62.8% of whom initiated AHT within the first year of their breast cancer diagnosis. Adjusted adherence among LIS beneficiaries was 11.4% higher than among non-LIS beneficiaries (P < .001). Non-LIS beneficiaries had an overall decreasing trend of adherence (-0.035; P < .001) prior to the introduction of GAIs. They experienced a 3.4% increase in the slope 6 months after the first GAI, anastrozole, entered the market, and an additional 0.8% increase in the slope 6 months after letrozole and exemestane were introduced (P < .001). Adherence change among LIS patients was small and statistically insignificant. CONCLUSIONS: With the introduction of GAIs, the decrease trend of adherence to therapy atteunated over the course of treatment. Although the successful implementation of the Medicare LIS program minimized the OOPCs for financially vulnerable patients, policymakers should be cautious not to introduce disparities for those who may be of low income but ineligible for such a program.

Impact of recovery support navigators on continuity of care after detoxification.

Although evidence points to the benefits of continuity of care after detoxification (detox), especially when continuity of care occurs within a short time after discharge from a detox episode, the rate at which clients engage in continued treatment after detox remains low. The goal of the study was to develop and deploy a specially trained workforce, called recovery support navigators (RSNs), to increase the likelihood of clients continuing onto treatment after detox. Continuity of care is defined as receiving any substance use disorder (SUD) treatment service within 14 days of discharge from the index detox. We examined whether clients in the RSN Intervention group were more likely to meet the continuity of care after detox criteria than clients in the treatment-as-usual (TAU) group. A quasi-experimental intervention versus comparison group study was conducted. Data were from the Massachusetts Behavioral Health Partnership (MBHP), a Beacon Health Options company that manages behavioral health benefits for a subset of Medicaid beneficiaries in the state. Inclusion in the analytic sample (N = 4,236) required that the client's index admission to detox was between 3/29/13 and 3/31/15. RSN Intervention versus TAU status was assigned based on provider organization where the index detox occurred. Analyses were conducted on an intent-to-treat basis. Overall, the continuity of care rate across all study groups was 42%. The rate by study group was 38% for the TAU and 45% for the RSN group. Clients who were in the RSN group were significantly more likely to have continuity of care after discharge from detox than those in the TAU (OR = 1.233, p < .05, 95% CI = 1.044, 1.455). Clients who entered detox at a site that provided specialized training to RSN, which included motivational interviewing and educational sessions related to treatment issues, and allowing them to bill with a flexible daily case rate instead of the usual fee-for-service billing, were more likely to have continuity of care after discharge from detox compared to clients in the TAU group.

Nonpharmacological Treatment of Army Service Members with Chronic Pain Is Associated with Fewer Adverse Outcomes After Transition to the Veterans Health Administration.

BACKGROUND: Potential protective effects of nonpharmacological treatments (NPT) against long-term pain-related adverse outcomes have not been examined. OBJECTIVE: To compare active duty U.S. Army service members with chronic pain who did/did not receive NPT in the Military Health System (MHS) and describe the association between receiving NPT and adverse outcomes after transitioning to the Veterans Health Administration (VHA). DESIGN AND PARTICIPANTS: A longitudinal cohort study of active duty Army service members whose MHS healthcare records indicated presence of chronic pain after an index deployment to Iraq or Afghanistan in the years 2008-2014 (N = 142,539). Propensity score-weighted multivariable Cox proportional hazard models tested for differences in adverse outcomes between the NPT group and No-NPT group. EXPOSURES: NPT received in the MHS included acupuncture/dry needling, biofeedback, chiropractic care, massage, exercise therapy, cold laser therapy, osteopathic spinal manipulation, transcutaneous electrical nerve stimulation and other electrical manipulation, ultrasonography, superficial heat treatment, traction, and lumbar supports. MAIN MEASURES: Primary outcomes were propensity score-weighted proportional hazards for the following adverse outcomes: (a) diagnoses of alcohol and/or drug disorders; (b) poisoning with opioids, related narcotics, barbiturates, or sedatives; (c) suicide ideation; and (d) self-inflicted injuries including suicide attempts. Outcomes were determined based on ICD-9 and ICD-10 diagnoses recorded in VHA healthcare records from the start of utilization until fiscal year 2018. KEY RESULTS: The propensity score-weighted proportional hazards for the NPT group compared to the No-NPT group were 0.92 (95% CI 0.90-0.94, P < 0.001) for alcohol and/or drug use disorders; 0.65 (95% CI 0.51-0.83, P < 0.001) for accidental poisoning with opioids, related narcotics, barbiturates, or sedatives; 0.88 (95% CI 0.84-0.91, P < 0.001) for suicide ideation; and 0.83 (95% CI 0.77-0.90, P < 0.001) for self-inflicted injuries including suicide attempts. CONCLUSIONS: NPT provided in the MHS to service members with chronic pain may reduce risk of long-term adverse outcomes.

Exploration of the association of selected pain diagnoses with risky alcohol use among active duty soldiers.

BACKGROUND: Pain and its consequences remain of concern, particularly in high-risk occupations such as the military. Alcohol is a legal and accessible means of self-medication, and risky alcohol use is associated with potentially serious consequences. This exploratory analysis aimed to better understand the association of selected pain diagnoses with risky alcohol use among soldiers returning from deployment. Methods: Analysis of data from active duty soldiers returning from Afghanistan or Iraq deployments in fiscal years 2008-2011 who completed Department of Defense health questionnaires after deployment (n = 267,100). Each questionnaire included self-reported alcohol consumption and items yielding AUDIT-C screening scores. Military Health System data were used to identify diagnoses of pain-related conditions. Results: About 70% of soldiers had none of the selected pain diagnoses either pre- or post-deployment. 10% had incident pain diagnoses (only post-deployment), 7% had persistent pain diagnoses (both pre- and post-deployment), and 13% had remitted pain diagnoses (only pre-deployment). On the AUDIT-C, 39% screened positive for at-risk drinking and 6% were likely to have severe alcohol problems. Half of the respondents reported any binge drinking; 20% at least monthly binge drinking. Logistic regression analyses found reduced odds of risky alcohol use post-deployment in association with incident and persistent pain diagnoses, compared to no pain diagnoses pre- or post-deployment. Conclusions: Pain diagnoses, binge drinking, and risky alcohol use were prevalent among this sample of Army soldiers. An inverse relationship was found between pain diagnosis (incident, persistent) and risky alcohol use post-deployment. Attention should continue to be paid to risky alcohol use in this population, yet these exploratory findings do not suggest that soldiers with the pain diagnoses used in this study are at greater risk. Combat exposure, traumatic brain injury, and psychological health were more important predictors, and should continue to warrant enhanced alcohol screening.

Rural Clients' Continuity Into Follow-Up Substance Use Disorder Treatment: Impacts of Travel Time, Incentives, and Alerts.

PURPOSE: Treatment after discharge from detoxification or residential treatment is associated with improved outcomes. We examined the influence of travel time on continuity into follow-up treatment and whether financial incentives and weekly alerts have a modifying effect. METHODS: For a research intervention during October 2013 to December 2015, detoxification and residential substance use disorder treatment programs in Washington State were randomized into 4 groups: potential financial incentives for meeting performance goals, weekly alerts to providers, both interventions, and control. Travel time was used as both a main effect and interacted with other variables to explore its modifying impact on continuity of care in conjunction with incentives or alerts. Continuity was defined as follow-up care occurring within 14 days of discharge from detoxification or residential treatment programs. Travel time was estimated as driving time from clients' home ZIP Code to treatment agency ZIP Code. FINDINGS: Travel times to the original treatment agency were in some cases significant with longer travel times predicting lower likelihood of continuity. For detoxification clients, those with longer travel times (over 91 minutes from their residence) are more likely to have timely continuity. Conversely, residential clients with travel times of more than 1 hour are less likely to have timely continuity. Interventions such as alerts or incentives for performance had some mitigating effects on these results. Travel times to the closest agency for potential further treatment were not significant. CONCLUSIONS: Among rural clients discharged from detoxification and residential treatment, travel time can be an important factor in predicting timely continuity.

Cost Savings from a Navigator Intervention for Repeat Detoxification Clients.

BACKGROUND: Many clients with substance use disorders (SUD) have multiple admissions to a 24-hour level of care for detoxification without ever progressing to SUD treatment. In the US, health insurers have become concerned about the high costs and ineffective results of repeat detox admissions. For other diseases, health systems increasingly target high-risk, high-cost patients with individually tailored interventions delivered by `navigators' who help patients negotiate the complex health care system. Patient incentives are another increasingly common intervention. AIMS OF THE STUDY: (i) To examine how health care spending was affected by an intervention intended to improve entry to SUD treatment among clients who had multiple detox admissions. (ii) To see whether spending effects, overall and by type of service, differed by intervention arm. (iii) To assess whether the intervention resulted in net savings from the payer perspective, after subtracting implementation costs. METHODS: The intervention was implemented in a segment of the Massachusetts Medicaid population, and used Recovery Support Navigators (RSNs) who were trained to effectively engage and connect clients with SUD to follow-up care and community resources. Services were funded using a flat daily rate per client. Additionally, in one of the two intervention arms, clients were offered successive incentive payments for meeting pre-specified milestones to reinforce recovery-oriented behaviors. For this paper, multivariate analyses of claims and administrative data were used to measure the intervention's effect on health care spending, and to estimate net savings to the payer. RESULTS: Health care spending grew 1.6 percentage points more slowly for intervention-enrolled members than for others, implying gross savings of $68 per member per month. After subtracting intervention-related costs, net savings were estimated at $57 per member per month. The intervention was also associated with shifts in the health care service mix from more to less acute settings. DISCUSSION: While the results for total spending did not reach statistical significance, they suggest some potential for insurers to reduce the health care costs associated with repeat detox utilization by using a navigator-based intervention. Analyses reported elsewhere found that this intervention had favorable effects on rates of initiation of SUD treatment. Limitations of the study include the fact that neither subjects nor sites were randomized between study groups; lack of data on crime or productivity outcomes; low participant use of RSN services; and a policy change which altered the participant pool and truncated follow-up for some. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: These results suggest some potential for payers to reduce the health care costs associated with repeat detox by using a navigator-based intervention. To the extent that this results in shifting resources from repeat detox to actual treatment, the result should provide longer term benefit to the population coping with SUD. IMPLICATIONS FOR HEALTH POLICY: These results may encourage Medicaid and other payers to further experiment with similar interventions using navigators to decrease health care costs and improved the lives of SUD patients. IMPLICATIONS FOR FURTHER RESEARCH: It could be informative to test similar navigator interventions for detox patients in other settings where enrollment periods are longer.