Surgical prescription opioid trajectories among state Medicaid enrollees.

OBJECTIVE: The objective of this study was to evaluate opioid use trajectories among a sample of 10,138 Medicaid patients receiving one of six index surgeries: lumbar spine, total knee arthroplasty, cholecystectomy, appendectomy, colon resection, and tonsillectomy. DESIGN: Retrospective cohort. SETTING: Administrative claims data. PATIENTS AND PARTICIPANTS: Patients, aged 13 years and older, with 15-month continuous Medicaid eligibility surrounding index surgery, were selected from single-state Medicaid medical and pharmacy claims data for surgeries performed between 2014 and 2017. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Baseline comorbidities and presurgery opioid use were assessed in the 6 months prior to admission, and patients' opioid use was followed for 9 months post-discharge. Generalized linear model with log link and Poisson distribution was used to determine risk of chronic opioid use for all risk factors. Group-based trajectory models identified groups of patients with similar opioid use trajectories over the 15-month study period. RESULTS: More than one in three (37.7 percent) patients were post-surgery chronic opioid users, defined as the dichotomous outcome of filling an opioid prescription 90 or more days after surgery. Key variables associated with chronic post-surgery opioid use include presurgery opioid use, 30-day post-surgery opioid use, and comorbidities. Latent trajectory modeling grouped patients into six distinct opioid use trajectories. Associates of trajectory group membership are reported. CONCLUSIONS: Findings support the importance of surgeons setting realistic patient expectations for post-surgical opioid use, as well as the importance of coordination of post-surgical care among patients failing to fully taper off opioids within 1-3 months of surgery.

New chronic opioid use in Medicaid patients following cholecystectomy.

Background: Commercial insurance data show that chronic opioid use in opioid-naive patients occurs in 1.5% to 8% of patients undergoing surgical procedures, but little is known about patients with Medicaid. Methods: Opioid prescription data and medical coding data from 4,788 Medicaid patients who underwent cholecystectomy were analyzed to determine opioid use patterns. Results: A total of 54.4% of patients received opioids prior to surgery, and 38.8% continued to fill opioid prescriptions chronically; 27.1% of opioid-naive patients continued to get opioids chronically. Patients who received ≥ 50 MME/d had nearly 8 times the odds of chronic opioid use. Each additional opioid prescription filled within 30 days was associated with increased odds of chronic use (odds ratio: 1.71). Conclusion: Opioid prescriptions are common prior to cholecystectomy in Medicaid patients, and 38.8% of patients continue to receive opioid prescriptions well after surgical recovery. Even 27.1% of opioid-naive patients continued to receive opioid prescriptions chronically.

Incidence and patterns of persistent opioid use in children following appendectomy.

BACKGROUND: The past 5 years have witnessed a concerted national effort to assuage the rising tide of the opioid misuse in our country. Surgical procedures often serve as the initial exposure of children to opioids, however the trajectory of use following these exposures remains unclear. We hypothesized that opioid exposure following appendectomy would increase the risk of persistent opioid use among publicly insured children. STUDY DESIGN: A retrospective longitudinal cohort study was conducted on South Carolina Medicaid enrollees who underwent appendectomy between January 2014 and December 2017 using administrative claims data. The primary outcome was chronic opioid use. Generalized linear models and finite mixture models were employed in analysis. RESULTS: 1789 Medicaid pediatric patients underwent appendectomy and met inclusion criteria. The mean age was 11.1 years and 40.6% were female. Most patients (94.6%) did not receive opioids prior to surgery. Opioid prescribing ≥90 days after surgery (chronic opioid use) occurred in 127 (7.1%) patients, of which 102 (80.3%) had no opioid use in the preexposure period. Risk factors for chronic opioid use included non-naïve opioid status, re-hospitalization more than 30 days following surgery, multiple opioid prescribers, age, and multiple antidepressants/antipsychotic prescriptions. Group-based trajectory analysis demonstrated four distinct post-surgical opioid use patterns: no opioid use (91.3%), later use (6.7%), slow wean (1.9%), and higher use throughout (0.4%). CONCLUSION: Opioid exposure after appendectomy may serve as a priming event for persistent opioid use in some children. Eighty percent of children who developed post-surgical persistent opioid use had not received opioids in the 90 days leading up to surgery. Several mutable and immutable factors were identified to target future efforts toward opioid minimization in this at-risk patient population. LEVEL OF EVIDENCE: III.

Patterns of dispensed opioids after tonsillectomy in children and adolescents in South Carolina, United States, 2010-2017.

OBJECTIVES: Tonsillectomy (with or without adenoidectomy) is a common pediatric surgical procedure requiring post-operative analgesia. Because of the respiratory depression effects of opioids, clinicians strive to limit the use of these drugs for analgesia post-tonsillectomy. The objective of this study was to identify demographic and medication use patterns predictive of persistent opioid dispensing (as a proxy for opioid use) to pediatric patients post-tonsillectomy. PATIENTS AND METHODS: Retrospective cohort of South Carolina (USA) Medicaid-insured children and adolescents 0-18 years old without malignancy who had tonsillectomy in 2014-2017. We evaluated opioid dispensing pre-surgery and in the 30 days exposure period after hospital discharge. The main outcome, persistent opioid dispensing, was defined as any subject dispensed ≥1 opioid prescription 90-270 days after discharge. Group-based trajectory analyses described post-procedure opioid dispensing trajectories. RESULTS: There were 11,578 subjects representing 12,063 tonsillectomy procedures. Few (3.5%) procedures were followed by persistent opioid dispensing. Any opioid dispensing during the exposure period was associated with an increased odds of persistent opioid dispensing status during the follow up period (OR 1.51 for 1-6 days of exposure and OR 1.65 for 7-30 days of opioid exposure), as was pre-procedure opioid dispensing, having >1 tonsillectomy procedure, and having complex chronic medical conditions. Group-based trajectory analyses identified 4 distinct patterns of post-discharge opioid dispensing. CONCLUSIONS: Any opioid dispensing during the 30 days after tonsillectomy increased the odds of persistent opioid dispensing by > 50%. Multivariable and group-based trajectory analyses identified patient and procedure variables that correlate with persistent opioid dispensing, primarily driven by groups receiving pre-tonsillectomy opioids and a second group who experienced multiple episodes of tonsillectomy.

Substance Use Prevention Programming for Adolescents and Young Adults: A Mixed-Method Examination of Substance Use Perceptions and Use of Prevention Services.

BACKGROUND: Although substance use problems are highly prevalent among adolescents and emerging adults, this population does not regularly receive substance use prevention programming in their communities. Low perceived risk of substance use, which is linked to actual behavior, may contribute to low rates of engagement in community prevention efforts for substance use. To examine this, the current study used a mixed methods approach to: (1) examine the relationship between engagement in prevention education and substance use; and, (2) analyze qualitative data on education programs offered in the community to help identify strengths and gaps in prevention resources. Method: Quantitative and qualitative data were collected from adolescents (age 13-18) and young adults (age 19-25) living in the Southeast, recruited from local schools and community events to participate in a preventive intervention focused on prevention of HIV, substance use, and other risky behaviors. Prior to engagement in this intervention, self-report questionnaires were completed by adolescents assessing: substance use, perceived risk, and engagement in substance use education classes. Focus groups were also conducted with adolescents recruited from a local high school and young adults recruited from local colleges to obtain additional information about engagement in education programs. Results: Regarding perceived risk, 71.8% of adolescents reported moderate to great risk in having five or more drinks once or twice a week and 43% of adolescents reported moderate to great risk in smoking cannabis once or twice a week. Forty-four percent of adolescents had talked to one of their parents about the dangers of tobacco, alcohol, or drug use in the past year. Further, 18% of adolescents had been to a class or program on prevention of alcohol and other drug abuse in the past month and 50.7% had heard, read, or watched an advertisement about prevention of substance use in the past year. Qualitative results Eight overarching themes, each with its own sub-themes, emerged from the participant's responses during the focus groups. Each is described below with representative quotes provided throughout for illustrative purposes. Conclusions: Findings revealed several gaps in resources identified by adolescents and young adults that are needed to adequately address substance use, which provide important next steps for substance use prevention among youth.

Gender differences in subjective stress and neuroendocrine response to a stress task among individuals with opioid dependence: A pilot study.

BACKGROUND: Opioid dependence is a significant public health problem in the United States and the number of opioid overdose deaths among women has increased dramatically in comparison to men in the last few years. In this context, understanding the biological mechanisms underlying gender differences in vulnerability to opioid dependence is essential. METHODS: The current pilot study examined gender differences in subjective stress, heart rate (HR), and cortisol/dephydroepiandrosterone (DHEA) response to a laboratory stressor (Trier Social Stress Test; TSST) or a no-stress condition, and drug cue paradigm among men (n = 21) and women (n = 18) with opioid dependence. RESULTS: Significant group (TSST vs. no stress) differences emerged in self-reported stress [F(1,35) = 23.8, p < .001], HR [F(1,31) = 12.3; p = .001] and cortisol (F1,34 = 5.0; p = .032) response, such that the TSST group was more reactive than the no-stress group. Women reported greater subjective stress [F(1,35) = 6.5, p <= .015] in response to the TSST compared to men. However, men evidenced marginally greater cortisol and DHEA responses to the TSST compared to women [F(1,34) = 2.7; p = .113 and F(1,31) = 3.4; p = .073, respectively]. CONCLUSIONS: Although women with opioid dependence reported greater subjective stress when exposed to a laboratory stress paradigm as compared to men, the neuroendocrine response was more robust in men. This pattern was similar to gender findings in men and women with cocaine and tobacco use disorders. The blunted cortisol combined with an increased subjective response among women may be a sign of HPA axis dysregulation which could increase vulnerability to relapse in women.

Adolescent Substance Use Following a Deadly U.S. Tornado Outbreak: A Population-Based Study of 2,000 Families.

Despite conceptual links between disaster exposure and substance use, few studies have examined prevalence and risk factors for adolescent substance use and abuse in large, population-based samples affected by a recent natural disaster. We addressed this gap using a novel address-based sampling methodology to interview adolescents and parents who were affected by the 4th deadliest tornado outbreak in U.S. HISTORY: Postdisaster interviews were conducted with 2,000 adolescent-parent dyads living within a 5-mile radius of the spring 2011 U.S. tornadoes. In addition to descriptive analyses to estimate prevalence, hierarchical linear and logistic regression analyses were used to examine a range of protective and risk factors for substance use and abuse. Approximately 3% reported substance abuse since the tornado. Greater number of prior traumatic events and older age emerged as consistent risk factors across tobacco and alcohol use and substance abuse since the tornado. Tornado incident characteristics, namely, greater loss of services and resources after the tornado and posttraumatic stress disorder since the tornado, were associated with greater alcohol consumption. Service loss increased risk for binge drinking, whereas, for substance abuse, posttraumatic stress disorder increased risk and parent presence during the tornado decreased risk. Greater family tornado exposure was associated with a greater number of cigarettes smoked in female but not male teen participants. Both trauma and non-trauma-related factors are relevant to postdisaster substance abuse among adolescents. Future research should examine the role of broader ecological systems in heightening or curtailing substance use risk for adolescents following disaster exposure.

A Double-Blind, Randomized, Controlled Pilot Trial of N-Acetylcysteine in Veterans With Posttraumatic Stress Disorder and Substance Use Disorders.

OBJECTIVE: The antioxidant N-acetylcysteine is being increasingly investigated as a therapeutic agent in the treatment of substance use disorders (SUDs). This study explored the efficacy of N-acetylcysteine in the treatment of posttraumatic stress disorder (PTSD), which frequently co-occurs with SUD and shares impaired prefrontal cortex regulation of basal ganglia circuitry, in particular at glutamate synapses in the nucleus accumbens. METHODS: Veterans with PTSD and SUD per DSM-IV criteria (N = 35) were randomly assigned to receive a double-blind, 8-week course of N-acetylcysteine (2,400 mg/d) or placebo plus cognitive-behavioral therapy for SUD (between March 2013 and April 2014). Primary outcome measures included PTSD symptoms (Clinician-Administered PTSD Scale, PTSD Checklist-Military) and craving (Visual Analog Scale). Substance use and depression were also assessed. RESULTS: Participants treated with N-acetylcysteine compared to placebo evidenced significant improvements in PTSD symptoms, craving, and depression (ß values < -0.33; P values < .05). Substance use was low for both groups, and no significant between-group differences were observed. N-acetylcysteine was well tolerated, and retention was high. CONCLUSIONS: This is the first randomized controlled trial to investigate N-acetylcysteine as a pharmacologic treatment for PTSD and SUD. Although preliminary, the findings provide initial support for the use of N-acetylcysteine in combination with psychotherapy among individuals with co-occurring PTSD and SUD. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02499029.

Forty days after the Great East Japan Earthquake: field research investigating community engagement and traumatic stress screening in a post-disaster community mental health training.

The current article describes the results of posttraumatic stress educational outreach and screening offered to 141 citizens of Japan who attended a public-service mental health training regarding post-disaster coping 40 days after a 6.8 Richter Scale earthquake, local and regional deaths, and an ongoing nuclear radiation threat. Attendees were given access to anonymous questionnaires that were integrated into the training as a tool to help enhance mental health literacy and bridge communication gaps. Questionnaires were turned in by a third of those in attendance. Among respondents, multiple exposures to potentially-traumatic events were common. More than a quarter of respondents met criteria for probable PTSD. Physical health and loss of sense of community were related to PTSD symptoms. Associations and diagnosis rates represented in these data are not generalizable to the population as a whole or intended for epidemiological purposes; rather, they are evidence of a potentially useful approach to post-disaster clinical screening, education, and engagement. Results are presented in the context of previous findings in Japan and ecologically-supportive post-disaster field research is discussed.

Substance use among women receiving post-rape medical care, associated post-assault concerns and current substance abuse: results from a national telephone household probability sample.

OBJECTIVE: To examine post-rape substance use, associated post rape medical and social concern variables, and past year substance abuse among women reporting having received medical care following a most recent or only lifetime incident of rape. METHOD: Using a subsample of women who received post-rape medical care following a most recent or only rape incident (n=104) drawn from a national household probability sample of U.S. women, the current study described the extent of peritraumatic substance use, past year substance misuse behaviors, post-rape HIV and pregnancy concerns, and lifetime mental health service utilization as a function of substance use at time of incident. RESULTS: One-third (33%) of women seeking post-rape medical attention reported consuming alcohol or drugs at the time of their rape incident. Nearly one in four (24.7%) and one in seven (15%) women seeking medical attention following their most recent rape incident endorsed drug (marijuana, illicit, non-medical use of prescription drugs, or club drug) use or met substance abuse criteria, respectively, in the past year. One in twelve (8.4%) women reported at least monthly binge drinking in the past year. Approximately two-thirds of women reported seeking services for mental health needs in their lifetime. Post-rape concerns among women reporting peritraumatic substance use were not significantly different from those of women not reporting such use. CONCLUSIONS: Substance use was reported by approximately one-third of women and past year substance abuse was common among those seeking post-rape medical care. Implications for service delivery, intervention implementation, and future research are discussed.

National prevalence of posttraumatic stress disorder among sexually revictimized adolescent, college, and adult household-residing women.

CONTEXT: Despite empirical links between sexual revictimization (ie, experiencing 2 or more sexual assaults) and posttraumatic stress disorder (PTSD), to our knowledge, no epidemiological studies document the prevalence of sexual revictimization and PTSD. Establishing estimates is essential to determine the scope, public health impact, and psychiatric sequelae of sexual revictimization. OBJECTIVE: To estimate the prevalence of sexual revictimization and PTSD among 3 national female samples (adolescent, college, and adult household probability). DESIGN: Surveys were used to collect data from the National Women's Study-Replication (2006; college) as well as household probability samples from the National Survey of Adolescents-Replication (2005) and the National Women's Study-Replication (2006; household probability). SETTING: Households and college campuses across the United States. PARTICIPANTS: One thousand seven hundred sixty-three adolescent girls, 2000 college women, and 3001 household-residing adult women. MAIN OUTCOME MEASURES: Behaviorally specific questions assessed unwanted sexual acts occurring over the life span owing to the use of force, threat of force, or incapacitation via drug or alcohol use. Posttraumatic stress disorder was assessed with a module validated against the criterion standard Structured Clinical Interview for DSM-IV. RESULTS: About 53% of victimized adolescents, 50% of victimized college women, and 58.8% of victimized household-residing women reported sexual revictimization. Current PTSD was reported by 20% of revictimized adolescents, 40% of revictimized college women, and 27.2% of revictimized household-residing women. Compared with nonvictims, odds of meeting past 6-month PTSD were 4.3 to 8.2 times higher for revictimized respondents and 2.4 to 3.5 times higher for single victims. CONCLUSIONS: Population prevalence estimates suggest that 769 000 adolescent girls, 625 000 college women, and 13.4 million women in US households reported sexual revictimization. Further, 154 000 sexually revictimized adolescents, 250 000 sexually revictimized college women, and 3.6 million sexually revictimized household women met criteria for past 6-month PTSD. Findings highlight the importance of screening for sexual revictimization and PTSD in pediatric, college, and primary care settings.