Addressing the Spectrum of Opioid Misuse Prevention, Treatment, and Recovery in Rural Washington State Communities: Provider Identified Barriers and Needs.

The opioid overdose epidemic has significantly impacted rural communities. Rural settings present unique challenges to addressing opioid misuse. The purpose of the current study was to understand the similarities and differences between rural and urban-based providers serving rural communities. Washington state-based opioid-related service providers who serve rural communities (N = 75) completed an online survey between July and September 2020. Chi-square tests of association were used to examine significant differences in proportions between rural providers and rural-serving urban providers across opioid prevention, treatment, and recovery training topics. Rural providers reported receiving significantly less opioid treatment and recovery training on the criminal legal system, workplace-based education on treatment and recovery, and co-occurring disorder treatment; and significantly higher prior opioid prevention training on the prevention programs for youth and accessing prevention funding. Differences between rural and rural-serving urban providers demonstrate ways in which rural-urban partnerships can be strengthened to enhance public health.

The urgent need for contingency management among Tribal communities in the United States: Considerations for implementation, policy, and sovereignty.

In two randomized controlled trials, culturally adapted contingency management (i.e., incentives provided for substance-negative urine samples) was associated with reduced alcohol and drug use among geographically diverse American Indian and Alaska Native (AI/AN) adults. In response to interest in contingency management from other Tribal and AI/AN communities, our research team in collaboration with AI/AN behavioral health experts, translated the research into practice with new AI/AN community partners. Tenets of community-based participatory research were applied to develop, pilot, and refine contingency management training and implementation tools, and identify implementation challenges. In partnership with the AI/AN communities, four members of the university team developed tools and identified implementation and policy strategies to increase the successful uptake of contingency management in each location. Through our collaborative work, we identified policy barriers including inadequate federal funding of contingency management incentives and a need for further clarity regarding federal anti-kickback regulations. Adoption of contingency management is feasible and can strengthen Tribal communities' capacity to deliver evidence-based substance use disorder treatments to AI/AN people. Unfortunately, non-evidence-based limits to the use of federal funding for contingency management incentives discriminate against AI/AN communities. We recommend specific federal policy reforms, as well as other practical solutions for Tribal communities interested in contingency management.

Youth risk profiles and their prediction of distal cannabis and tobacco co-use in the Population Assessment of Tobacco Health (PATH).

Background: Co-use of cannabis and tobacco is common and increases negative behavioral, physical and mental health consequences. This study aimed to describe latent profiles of youth internalizing and externalizing problems, sensation seeking, and family environment in the US and their relationships with substance co-use. Methods: Data come from the Population Assessment of Tobacco Health (PATH). Using latent profile analysis with a distal outcome, we conducted a secondary data analysis examining relationships between latent profiles and the distal outcome of cannabis/tobacco use and co-use one year later. Participants were a nationally representative sample of youth ages 12-17 (N = 13,651). Results: We identified five youth subgroups: (1;11%) Family Risk, (2;32%) Family Protection with Very Low Internalizing, (3;21%) Family Protection with High Youth Risk, (4;24%) Family Protection with Moderate Youth Risk, (5;12%) Family Risk with High Youth Risk. Relationships between group membership and tobacco/cannabis outcomes, one year later, indicated that the least likely tobacco/cannabis users were the Family Protection with Very Low Internalizing class (no lifetime use probability (PR)=0.86, standard error (SE)=0.007; no 30-day use PR = 0.96, SE = 0.004). In contrast, the Family Risk with High Youth Risk class had the highest probability of both co-use (lifetime co-use PR = 0.33; SE = 0.014; 30-day co-use PR = 0.10; SE = 0.010) and single substance use (probability of lifetime single substance use PR = 0.30; SE = 0.013; 30-day single substance use PR = 0.24; SE = 0.014). Conclusions: A "protective but reactive" risk buffering pattern effect of family factors on youth factors was observed in that the lowest rates of co-use were observed in the three classes with family protection. These findings highlight the need for interventions addressing multiple domains and focusing on youth and family risk factors.

Intraoperative Methadone Use in Cardiac Surgery: A Systematic Review.

OBJECTIVE: To investigate the effects of intraoperative methadone in comparison with those of standard-of-care intraoperative opioids, such as fentanyl and morphine, on pain scores, opioid consumption, and adverse effects in adults undergoing cardiothoracic surgery. METHODS: The literature was reviewed in PubMed, Embase, Cochrane Library, and Google Scholar, followed by a manual search of the reference lists of the identified articles. Search terms included a combination of "intraoperative methadone," "methadone," and "cardiac surgery." Our review includes four studies published between 2011 and 2020. Quality assessment of the studies was performed. RESULTS: The initial search identified 715 articles, from which 461 duplicates were removed and 236 were eliminated on the basis of inclusion and exclusion criteria. Eighteen articles underwent full-text review. Four studies evaluating a total of 435 patients with various cardiothoracic procedures were included in this review. We found that intraoperative methadone decreased acute postoperative pain and reduced postoperative opioid consumption in the first 24 postoperative hours in patients who received 0.1-0.3 mg/kg intraoperative methadone in comparison with morphine and fentanyl. No difference was found in adverse effects between the groups. Quality assessment of the studies showed a low risk of bias in three of the randomized controlled trials and a high risk of bias in the retrospective review because of the baseline confounding bias in the study design. CONCLUSIONS: Intraoperative methadone use reduces acute postoperative pain and lowers opioid consumption in comparison with morphine and fentanyl. Initial results suggest that methadone may be an equivalent opioid to be administered during cardiothoracic procedures to reduce acute postsurgical pain, though further research is warranted.

Crossover associations of alcohol and smoking, craving and biochemically verified alcohol and nicotine use in heavy drinking smokers.

This study examined associations between drinking and smoking prior to treatment (biochemically measured at baseline), alcohol and tobacco craving, and biochemical alcohol and tobacco use during the analog trial period. We conducted a secondary data analysis of a randomized clinical analog trial where participants with a Diagnostic and Statistical Manual, Fourth Edition Text Revision (DSM-IV-TR) diagnosis of alcohol dependence, abuse or reported heavy drinking, with a co-occurring DSM-IV-TR diagnosis of nicotine dependence, abuse or reported heavy use, who were not seeking treatment were recruited. A generalized estimation equation model for longitudinal binary outcomes was created (N = 34) to determine the predictive effects of baseline tobacco use, alcohol craving, and tobacco craving on alcohol use over the 4 weeks of the trial. Baseline smoking was significantly (*p < 0.05) associated with drinking over time [odds ratio (OR) = 3.09*], while baseline drinking was associated with smoking (OR = 4.17*). Baseline alcohol and tobacco craving were positively associated with smoking over time (OR = 3.21* and OR = 1.92*, respectively) but were negatively associated with alcohol use over time (OR = 0.79* and OR = 0.57*, respectively). Heavier use of either tobacco or alcohol preceding treatment may require more intensive interventions in order to reduce tobacco and alcohol use. Future trials designed to address mechanisms of behavior change in the context of novel treatments could promote a better understanding of the cross-rewarding effects related to the co-use of these substances and lead to the development of more integrated and appropriately intense treatments for individuals with concomitant tobacco and alcohol use disorders.

Spatial access to opioid treatment program and alcohol and cannabis outlets: analysis of missed doses of methadone during the first, second, and third 90 days of treatment.

Background: The burden of access to opioid treatment programs (OTPs) may change as clients become eligible for take-home privileges. Our previous study showed clients who lived more than 10-miles away from an OTP were more likely to miss methadone doses during the first 30 days of treatment. Proximity to alcohol and cannabis outlets may also negatively influence treatment adherence.Objective: To examine the association between access to this OTP, alcohol and cannabis outlets, and the number of missed methadone doses during the first, second, and third 90 days of treatment.Methods: The number of missed methadone doses was calculated for 752, 689, and 584 clients who remained in treatment, respectively, for at least 3, 6, and 9 months (50% female). Distance between client's home and the OTP, alcohol, and cannabis outlets was measured. Generalized linear models were employed.Results: Shorter distance from a client's residence to the OTP was associated with a decreased number of missed methadone doses during the first 90 days of treatment. Shorter distance to the closest cannabis retail outlet was associated with an increased number of missed methadone doses during the first and second 90 days of treatment. Shorter distance to the closest off-premise alcohol outlet was associated with an increased number of missed methadone doses during the third 90 days of treatment.Conclusions: Improving spatial accessibility of OTPs are essential to ensure treatment opportunities are available for individuals so affected. Exploring to what extent residing in areas that facilitate alcohol and cannabis availability can influence treatment adherence is warranted.

Decreases in smoking during treatment for methamphetamine-use disorders: preliminary evidence.

Despite high rates of smoking (70-90%) and the severely negative impact of smoking on physical and mental health, only 12% of individuals receiving stimulant-use disorder treatment also receive smoking-cessation treatment. The aim of this investigation was to examine the effect of a contingency management (CM) intervention targeting methamphetamine (MA) use on cigarette smoking. Sixty-one adults with MA-use disorders who were smokers were assigned to CM or standard psychosocial treatment. Rates of smoking-negative breath samples (carbon monoxide <3 ppm) were compared between the two groups while controlling for baseline carbon monoxide level, marijuana use, MA use, and time. This subgroup of mostly male (59%) participants included 44 participants in the CM group and 17 participants in the standard psychosocial treatment. Tobacco smoking participants who received CM targeting MA use were 140% (odds ratio: 2.395; 95% confidence interval: 1.073-5.346) more likely to submit a smoking-negative breath sample relative to standard psychosocial treatment during the treatment period, holding constant several other prespecified covariates. This study provides evidence that a behavioral treatment for MA use results in reductions in cigarette smoking in adults with MA-use disorder.

Pilot investigation: randomized-controlled analog trial for alcohol and tobacco smoking co-addiction using contingency management.

Contingency management (CM) is associated with decreases in off-target drug and alcohol use during primary target treatment. The primary hypothesis for this trial was that targeting alcohol use or tobacco smoking would yield increased abstinence in the opposite, nontargeted drug. We used a 2 [CM vs. noncontingent control (NC) for alcohol]×2 (CM vs. NC for smoking tobacco) factorial design, with alcohol intake (through urinary ethyl glucuronide) and tobacco smoking (through urinary cotinine) as the primary outcomes. Thirty-four heavy-drinking smokers were randomized into one of four groups, wherein they received CM, or equivalent NC reinforcement, for alcohol abstinence, smoking abstinence, both drugs, or neither drug. The CM for alcohol and tobacco group had only two participants and therefore was not included in analysis. Compared with the NC for alcohol and tobacco smoking group, both the CM for the tobacco smoking group [odds ratio (OR)=12.03; 95% confidence interval (CI): 1.50-96.31] and the CM for the alcohol group (OR=37.55; 95% CI: 4.86-290.17) submitted significantly more tobacco-abstinent urinalyses. Similarly, compared with the NC for the alcohol and tobacco group, both the CM for smoking (OR=2.57; 95% CI: 1.00-6.60) and the CM for alcohol groups (OR=3.96; 95% CI: 1.47-10.62) submitted significantly more alcohol-abstinent urinalyses. These data indicate cross-over effects of CM on indirect treatment targets. Although this is a pilot investigation, it could help to inform the design of novel treatments for alcohol and tobacco co-addiction.

Contingency management intervention targeting co-addiction of alcohol and drugs among American Indian adults: Design, methodology, and baseline data.

BACKGROUND/AIMS: American Indian adults have some of the highest alcohol abstinence rates compared to the overall US population. Despite this, many American Indian people are more likely to concurrently use alcohol and illicit drugs and are less likely to participate and remain in outpatient treatment for alcohol and other drug use compared to the general US population. There is limited knowledge about effective interventions targeting alcohol and drug co-addiction among American Indian adults. Contingency management is a behavioral intervention designed to increase drug abstinence by offering monetary incentives in exchange for drug and alcohol negative urine samples. We aim to evaluate and describe a culturally tailored contingency management intervention to increase alcohol and other drug abstinence among American Indian adults residing in a Northern Plains reservation. METHODS: This 2 × 2 factorial, randomized controlled trial currently includes 114 American Indian adults with alcohol and/or drug dependence who are seeking treatment. Participants were randomized into one of four groups that received (1) contingency management for alcohol, (2) contingency management for other drug, (3) contingency management for both substances, or (4) no contingency management for either substance. We present descriptive, baseline data to characterize the sample and describe the modified contingency management approach that is specific to the community wherein this trial was being conducted. RESULTS: The sample is 49.1% male, with an average age of 35.8 years (standard deviation = 10.4 years). At baseline, 43.0% of the sample tested positive for ethyl glucuronide, 50.9% of participants self-reported methamphetamine as their most used drug, 36.8% self-reported cannabis, and 12.3% self-reported prescription opiates as their most used drug. Among randomized participants, 47.4% tested positive for cannabis, 28.1% tested positive for methamphetamine, 16.7% tested positive for amphetamines, and 2.1% tested positive for opiates. CONCLUSION: This is the first study to examine a culturally tailored contingency management intervention targeting co-addiction of two substances among American Indian adults. By establishing a tribal-university partnership to adapt, implement, and evaluate contingency management, we will increase the literature on evidence-based addiction treatments and research, while improving trust for addiction interventions among American Indian communities through ongoing collaboration. Moreover, results have implications for the use of contingency management as an intervention for co-addiction in any population.

A randomized clinical trial to evaluate the efficacy of contingency management for treatment of waterpipe tobacco addiction.

BACKGROUND AND OBJECTIVES: Unlike cigarette smoking cessation, waterpipe tobacco smoking cessation is relatively understudied. The objective of this randomized clinical trial was to examine the efficacy of contingency management (CM) for promoting initial waterpipe smoking abstinence. METHODS: The study used a two-group, repeated measures design. Participants attended 10 visits (two visits per week, on Mondays and Thursdays) across 5 weeks. Thirty-nine adult waterpipe tobacco users who did not smoke cigarettes and were not planning on quitting waterpipe tobacco smoking were randomly assigned to either the contingent (n = 19) or non-contingent (n = 20) groups. Contingent group received monetary rewards based on negative salivary cotinine results. Earning rewards started at $14 and increased by $.50 with each subsequent negative sample for a maximum $192.50. Non-contingent group earned rewards independent of salivary cotinine results. Prolonged abstinence was defined as having negative salivary cotinine results for eight or more visits (two lapses were allowed); and 7-day point prevalence was defined as having negative salivary cotinine results at visit 9 and 10 (final week). RESULTS: The prolonged abstinence rate in the contingent and non-contingent groups were 42.1% and 5.0%, respectively, (p = .008). The 7-day point prevalence in the contingent and non-contingent were 47.4% and 5.0%, respectively, (p = .003). DISCUSSION AND CONCLUSIONS: Rewards contingent on biochemically verified abstinence promote initial waterpipe tobacco cessation. This is useful information for consideration in future cessation programs for waterpipe smokers. SCIENTIFIC SIGNIFICANCE: CM strategy may have potential benefit in addressing waterpipe tobacco smoking in non-treatment seeking adults. (Am J Addict 2018;27:202-209).

Seeking Chronic Pain Relief: A Hermeneutic Exploration.

BACKGROUND: In the United States, chronic pain is experienced by over 39.4 million adults, many of whom are treated with opioid pain medications. AIM: This research presents an interpretation of the experience of seeking pain relief for a group of people taking opioid pain medications whose pain is not adequately controlled. METHODS: A concurrent embedded mixed-methods design was used, including a Heideggerian hermeneutic qualitative approach that focuses on the participants' perceptions as a vehicle for understanding the phenomenon of seeking pain relief with descriptive quantitative data in a supporting role. Thirteen interviews and 15 surveys were analyzed, all of which met the following criteria: (1) self-reported chronic pain (persistent pain lasting a minimum of six months), (2) current use of prescription opioid medications, (3) pain not successfully controlled. RESULTS: The analysis revealed a paradox, which we describe as being lost/finding myself in the health care system. This paradox became the overarching pattern of experience that subsumed several dynamic, overlapping practices described in the patterns: (1) seeking relief as suffering; (2) being classified as an addict but not an addict; (3) living with pain as remembering; and (4) experiencing treatment modalities as fickle possibilities. CONCLUSION: Explication of and interpretive commentary on these patterns shift the focus from drug seeking to pain relief seeking behaviors in chronic pain sufferers. Such a shift could change the manner in which providers work with chronic pain sufferers to find appropriate treatment modalities.

Sex differences in opioid use and medical issues during buprenorphine/naloxone treatment.

BACKGROUND: There are sex differences in buprenorphine/naloxone clinical trials for opioid use. While women have fewer opioid-positive urine samples, relative to men, a significant decrease in opioid-positive samples was found during treatment for men, but not women. In order to inform sex-based approaches to improve treatment outcomes, research is needed to determine if opioid use, and predictors of opioid use, differs between men and women during treatment. OBJECTIVES: To test for sex differences in opioid use during a buprenorphine/naloxone clinical trial and determine if sex differences exist in the associations between addiction-related problem areas and opioid use over the course of the trial. METHOD: This secondary data analysis of the National Drug Abuse Treatment Clinical Trials Network (CTN) 0003 examined sex differences (men = 347, women = 169) in opioid-positive samples in a randomized clinical trial comparing 7-day vs. 28-day buprenorphine/naloxone tapering strategies. Addiction-related problem areas were defined by Addiction Severity-Lite (ASI-L) domain composite scores. RESULTS: Women were more likely than men to use opioids during the course of the buprenorphine/naloxone clinical trial (B = .33, p = .01) and medical issues were positively related to submitting an opioid-positive sample during treatment for women (B = 1.67, p = .01). No ASI-L domain composite score was associated with opioid-positive samples during treatment for men. CONCLUSION: Women were more likely than men to use opioids during the course of the buprenorphine/naloxone clinical trial, and medical issues predicted opioid use during treatment for women but not men. Complementary treatment for medical problems during opioid replacement therapy may benefit women.

Homelessness predicts attrition but not alcohol abstinence in outpatients experiencing co-occurring alcohol dependence and serious mental illness.

BACKGROUND: Adults experiencing homelessness and serious mental illnesses (SMI) are at an increased risk of poor mental health and treatment outcomes compared with stably housed adults with SMI. The additional issue of alcohol misuse further complicates the difficulties of those living with homelessness and SMI. In this secondary data analysis, the authors investigated the impact of homelessness on attrition and alcohol use in a contingency management (CM) intervention that rewarded alcohol abstinence in outpatients with SMI. METHODS: The associations between housing status and attrition and alcohol abstinence during treatment, as assessed by ethyl glucuronide (EtG) urine tests, were evaluated in 79 adults diagnosed with alcohol dependence and SMI. RESULTS: Thirty-nine percent (n = 31) of participants reported being homeless at baseline. Individuals who were homeless were more likely to drop out of CM (n = 10, 62.5%) than those who were housed (n = 4, 16.7%), χ2(1) = 8.86, P < .05. Homelessness was not associated with attrition in the noncontingent control group. Accounting for treatment group and prerandomization EtG levels, neither the effect of housing status nor the interaction of housing status and group were associated with EtG-assessed alcohol abstinence during treatment. CONCLUSIONS: Individuals experiencing homelessness and co-occurring alcohol dependence and SMI receiving CM had higher rates of attrition, relative to those who were housed. Homelessness was not associated with differences in biologically assessed alcohol abstinence.

Pretreatment ethyl glucuronide levels predict response to a contingency management intervention for alcohol use disorders among adults with serious mental illness.

BACKGROUND AND OBJECTIVES: This study investigated if pretreatment ethyl glucuronide (EtG) levels corresponding to light (100 ng/mL), heavy (500 ng/mL), and very heavy (1,000 ng/mL) drinking predicted longest duration of alcohol abstinence (LDA) and proportion of EtG-negative urine tests in outpatients receiving a 12-week EtG-based contingency management (CM) intervention for alcohol dependence. METHODS: Participants were 40 adults diagnosed with alcohol use disorders and serious mental illness who submitted up to 12 urine samples for EtG analysis during a 4-week observation period and were then randomized to 12-weeks of CM for alcohol abstinence and addiction treatment attendance. Alcohol use outcomes during CM as assessed by EtG and self-report were compared across those who did and did not attain a pre-treatment average EtG level of 500 ng/mL-a level that equates to frequent heavy drinking. RESULTS: Only the 500 ng/mL cutoff was associated with significant differences in LDA and proportion of EtG-negative samples during CM. Those with a pre-treatment EtG < 500 ng/mL attained a LDA 2.3 (alcohol) to 2.9 (drugs) weeks longer than pre-treatment heavy drinkers. DISCUSSION AND CONCLUSIONS: The EtG biomarker can be used to determine who will respond to a CM intervention for alcohol use disorders and could inform future trials that are designed to be tailored to individual patients. SCIENTIFIC SIGNIFICANCE: Results suggest pre-treatment EtG cutoffs equivalent to heavy and very heavy drinking predict outcomes in CM. (Am J Addict 2017;26:673-675).

A Randomized Controlled Trial of a Citywide Emergency Department Care-Coordination Program to Reduce Prescription Opioid-Related Visits: An Economic Evaluation.

BACKGROUND: Care provided in the emergency department (ED) can cost up to five times as much as care received for comparable diagnoses in alternative settings. Small groups of patients, many of whom suffer from an opioid use disorder, often account for a large proportion of total ED visits. We recently conducted, and demonstrated the effectiveness of, the first randomized controlled trial of a citywide ED care-coordination program intending to reduce prescription-opioid-related ED visits. All EDs in the metropolitan study area were connected to a Web-based information exchange system. OBJECTIVE: The objective of this article was to perform an economic evaluation of the 12-month trial from a third-party-payer perspective. METHODS: We modeled the person-period monthly for the 12-month observation period, and estimated total treatment costs and return on investment (ROI) with regard to cost offsets, over time, for all visits where the patient was admitted to and discharged from the ED. RESULTS: By the end of month 4, the mean cumulative cost differential was significantly lower for intervention relative to treatment-as-usual participants (-$1370; p = 0.03); this figure climbed to -$3200 (p = 0.02) by the end of month 12. The ROI trended upward throughout the observation period, but failed to reach statistical significance by the end of month 12 (ROI = 3.39, p = 0.07). CONCLUSION: The intervention produced significant cost offsets by the end of month 4, which continued to accumulate throughout the trial; however, ROI was not significant. Because the per-patient administrative costs of the program are incurred at the time of enrollment, our results highlight the importance of future studies that are able to follow participants for a period beyond 12 months to more accurately estimate the program's ROI.

Use of cell phones and computers for health promotion and tobacco cessation by American Indian college students in Montana.

INTRODUCTION: Cell phones and personal computers have become popular mechanisms for delivering and monitoring health information and education, including the delivery of tobacco cessation education and support. Tobacco smoking is prevalent among American Indians (AIs) and Alaska Natives (ANs), with 26% AI/AN adult men smoking compared to 19% of Caucasian adult males and 22% of African American adult males. Smoking is even more prevalent in Northern Plains AI populations, with 42% of men and women reporting current smoking. The literature on the availability and use of cell phones and computers, or the acceptability of use in health promotion among AIs and ANs, is scant. The authors report findings from a survey of AI students regarding their cell phone and computer access and use. The survey was conducted to inform the development and implementation of a text messaging smoking cessation intervention modeled on a program developed and used in Australia. METHODS: A 22-item paper and pencil survey was administered to students at tribal colleges in rural Montana. The survey questions included cell phone ownership and access to service, use of cell phones and computers for health information, demographics, tobacco use habits, and interest in an intervention study. The study was reviewed and determined exempt by the institutional review boards at the tribal colleges and the lead research university. The study was conducted by researchers at the tribal colleges. Survey respondents received $10 when the survey was completed and returned. Data analysis was performed with the Statistical Package for the Social Sciences. RESULTS: Among 153 AI respondents, the mean age was 29 years, range was 18-64 years. Overall, 40% reported smoking cigarettes with a mean age of 16 years at initiation. A total of 131 participants (86%) had cell phones and, of those, 122 (93%) had unlimited text messaging. A total of 104 (68%) had smart phones (with internet access), although 40% of those with smart phones reported that internet access on their phone was very slow or location limited. A total of 146 (95%) participants reported having access to a computer, although 32% of those did not have daily access. Students aged less than 23 years were more likely to have cell phones with internet access. Cell phone ownership differed by site (93% vs 77%, p=0.007). About 60% of the respondents who smoked indicated interest in participating in the intervention study. CONCLUSIONS: This study revealed that AI tribal college students in the rural communities surveyed had less cell phone, smart phone, and computer and internet access than that reported for undergraduate college students elsewhere in the USA. Research efforts and public health interventions must be culturally appropriate and technologically viable, therefore access to and acceptability of mobile technology must be evaluated when planning and implementing interventions for rural and other marginalized populations. The findings from this study contribute to the literature regarding the access to and acceptability of mobile technology for health promotion among AI/AN college students in rural and remote areas, and helped introduce the proposed study to the community and solicited useful data regarding tobacco prevalence and interest in tobacco research in the target population.

Self-reported smoking effects and comparative value between cigarettes and high dose e-cigarettes in nicotine-dependent cigarette smokers.

The objective of this experiment was to evaluate the comparative value of cigarettes versus high dose e-cigarettes among nicotine-dependent cigarette smokers when compared with money or use of their usual cigarette brand. The experiment used a within-subject design with four sessions. After baseline assessment, participants attended two 15-min unrestricted smoking sessions: one cigarette smoking session and one e-cigarette smoking session. Participants then attended two multiple-choice procedure (MCP) sessions: a session comparing cigarettes and money and a session comparing e-cigarettes and money. Participants (n=27) had used cigarettes regularly, had never used e-cigarettes, and were not currently attempting to quit smoking. The sample consisted primarily of males (72%), with a mean age of 34 years. When given the opportunity to choose between smoking a cigarette or an e-cigarette, participants chose the cigarette 73.9% of the time. Findings from the MCP demonstrated that after the first e-cigarette exposure sessions, the crossover value for cigarettes ($3.45) was significantly higher compared with the crossover value for e-cigarettes ($2.73). The higher participant preference, self-reported smoking effects, and higher MCP crossover points indicate that cigarettes have a higher comparative value than high dose e-cigarettes among e-cigarette naive smokers.

Association Between Prescription Opioid Use and Biomarkers of Kidney Disease in US Adults.

BACKGROUND/AIMS: Prescription opioid use is increasing despite concerns about drug safety. We examined relationships between use of analgesics with biomarkers of chronic kidney disease (CKD) in a representative sample of adults in the United States (US). METHODS: Participants (n=3980) were from the National Health and Nutrition Examination Survey (NHANES) 2009-2010. Use of any analgesic, prescription opioids, and NSAIDs were compared to referent groups with use of non-analgesic prescription medication or use of no prescription medication. CKD biomarkers including urine albumin-to-creatinine ratio (UACR) and serum-creatinine-based estimated glomerular filtration rate (eGFR; CKD Epidemiology Collaboration: CKD-EPI equation) were analyzed as continuous and binary variables (UACR ≥30 mg/g or eGFR <60 mL/min per 1.73m2; median splits). RESULTS: Frequencies of use were: any prescription analgesic 12.7% (507/3980); prescription opioids 5.1% (204/3980); NSAIDs 5.6% (224/3980); non-analgesic medication 38.7% (1540/3980); no medication 48.6% (1933/3980). Prescription analgesic use (ß=0.17, p=0.021) and opioid use (ß=0.19, p=0.002) were associated with higher UACR values, while NSAID use was not (ß=0.17, p=0.105). Prescription analgesic use was related to UACR ≥5.98 mg/g (median), (OR=1.34, 95%CI=1.01-7.79, p=0.045). No type of analgesic use was related to CKD-EPI eGFR. CONCLUSION: In a representative US population, prescription opioid use associated with higher albuminuria levels compared to non-opioid-users.

A Randomized Controlled Trial of a Citywide Emergency Department Care Coordination Program to Reduce Prescription Opioid Related Emergency Department Visits.

BACKGROUND: Increasing prescription overdose deaths have demonstrated the need for safer emergency department (ED) prescribing practices for patients who are frequent ED users. OBJECTIVES: We hypothesized that the care of frequent ED users would improve using a citywide care coordination program combined with an ED care coordination information system, as measured by fewer ED visits by and decreased controlled substance prescribing to these patients. METHODS: We conducted a multisite randomized controlled trial (RCT) across all EDs in a metropolitan area; 165 patients with the most ED visits for complaints of pain were randomized. For the treatment arm, drivers of ED use were identified by medical record review. Patients and their primary care providers were contacted by phone. Each patient was discussed at a community multidisciplinary meeting where recommendations for ED care were formed. The ED care recommendations were stored in an ED information exchange system that faxed them to the treating ED provider when the patient presented to the ED. The control arm was subjected to treatment as usual. RESULTS: The intervention arm experienced a 34% decrease (incident rate ratios = 0.66, p < 0.001; 95% confidence interval 0.57-0.78) in ED visits and an 80% decrease (odds ratio = 0.21, p = 0.001) in the odds of receiving an opioid prescription from the ED relative to the control group. Declines of 43.7%, 53.1%, 52.9%, and 53.1% were observed in the treatment group for morphine milligram equivalents, controlled substance pills, prescriptions, and prescribers, respectively. CONCLUSION: This RCT showed the effectiveness of a citywide ED care coordination program in reducing ED visits and controlled substance prescribing.

Determining ethyl glucuronide cutoffs when detecting self-reported alcohol use in addiction treatment patients.

BACKGROUND: Ethyl glucuronide (EtG) is an alcohol biomarker with potential utility as a clinical research and alcohol treatment outcome. Debate exists regarding the appropriate cutoff level for determining alcohol use, particularly with the EtG immunoassay. This study determined the EtG immunoassay cutoff levels that most closely correspond to self-reported drinking in alcohol-dependent outpatients. METHODS: Eighty adults with alcohol dependence and mental illness, taking part in an alcohol treatment study, provided urine samples 3 times per week for up to 16 weeks (1,589 samples). Self-reported drinking during 120 hours prior to each sample collection was assessed. Receiver operating characteristic analyses were conducted to assess the ability of the EtG immunoassay to detect self-reported alcohol use across 24- to 120-hour time periods. Sensitivity and specificity of EtG immunoassay cutoff levels was compared in 100 ng/ml increments (100 to 500 ng/ml) across 24 to 120 hours. RESULTS: Over half (57%) of the 1,589 samples indicated recent alcohol consumption. The EtG immunoassay closely corresponded to self-reported drinking from 24 (area under the curve [AUC] = 0.90, 95% confidence interval [CI]: 0.88, 0.92) to 120 hours (AUC = 0.88, 95% CI: 0.87, 0.90). When cutoff levels were compared across 24 to 120 hours, 100 ng/ml had the highest sensitivity (0.93 to 0.78) and lowest specificity (0.67 to 0.85). Relative to 100 ng/ml, the 200 ng/ml cutoff demonstrated a reduction in sensitivity (0.89 to 0.67), but improved specificity (0.78 to 0.94). The 300, 400, and 500 ng/ml cutoffs demonstrated the lowest sensitivity (0.86 to 0.33) and highest specificity (0.86 to 0.97) over 24 to 120 hours. CONCLUSIONS: For detecting alcohol use for >24 hours, the 200 ng/ml cutoff level is recommended for use as a research and clinical outcome.