Colorectal Cancer Screening Among Individuals With a Substance Use Disorder: A Retrospective Cohort Study.

Introduction: There is limited evidence on colorectal cancer screening among individuals with a substance use disorder. This study aims to investigate the association between personal history of a substance use disorder and colorectal cancer colonoscopy screening completion rates. Methods: This retrospective cohort study analyzed 176,300 patients, of whom 171,973 had no substance use disorder and 4,327 had a substance use disorder diagnosis from electronic health record data (January 1, 2008-December 31, 2022) in a Midwestern healthcare system. Baseline was January 1, 2013, and a 10-year follow-up period ran through December 31, 2022. The outcome was receipt of colonoscopy in the 10-year follow-up period. Patients were aged 50-65 years at baseline, meaning that they were eligible for a colonoscopy through the entirety of the 10-year follow-up period. Covariates included demographics (age, race, and neighborhood SES), health services utilization, psychiatric and physical comorbidities, and prior colonoscopy or fecal occult blood testing. Entropy balancing was used to control for confounding in weighted log-binomial models calculating RR and 95% CIs. Results: Patients were on average aged 57.1 (±4.5) years, 58.2% were female, 81.0% were White, and 16.9% were of Black race. The most prevalent comorbidities were obesity (29.6%) and hypertension (29.4%), followed by smoking/nicotine dependence (21.0%). The most prevalent psychiatric comorbidity was depression (6.4%), followed by anxiety disorder (4.5%). During the 10-year follow-up period, 40.3% of eligible patients completed a colorectal cancer colonoscopy screening test, and individuals with a substance use disorder diagnosis were significantly less likely to receive a colorectal cancer colonoscopy screening test both prior to and after controlling for confounding (RR=0.73; 95% CI=0.70, 0.77 and RR=0.81; 95% CI=0.74, 0.89, respectively). Results were not modified by sex, race, psychiatric comorbidity, or neighborhood SES. Conclusions: Personal history of substance use disorder was independently associated with lower screening completion rates. Healthcare professionals should recognize unique barriers among individuals with substance use disorder and then address them individually as a multidisciplinary team in the outpatient setting to reduce this health disparity.

Characteristics of patients with non-cancer pain and long-term prescription opioid use who have used medical versus recreational marijuana.

OBJECTIVE: Marijuana use is increasingly common among patients with chronic non-cancer pain (CNCP) and long-term opioid therapy (LTOT). We determined if lifetime recreational and medical marijuana use were associated with more frequent and higher dose prescription opioid use. DESIGN: Cross-sectional SUBJECTS: Eligible patients (n=1,037), who had a new period of prescription opioid use lasting 30-90 days, were recruited from two midwestern health care systems to a study of long-term prescription opioid use and mental health outcomes. The present cross-sectional analyses uses baseline data from this on-going cohort study. METHODS: Primary exposures were participant reported lifetime recreational and medical marijuana use versus no lifetime marijuana use. Prescription opioid characteristics included daily versus non-daily opioid use and ≥50 morphine milligram equivalent (MME) dose per day vs. <50 MME. Multivariate, logistic regression models estimated the association between lifetime recreational and medical marijuana use vs. no use and odds of daily and higher dose prescription opioid use, before and after adjusting for confounding. RESULTS: The sample was an average of 54.9 (SD±11.3) years of age, 57.3% identified as female gender, 75.2% identified as White, and 22.5% identified as Black race. Among all participants, 44.4% were never marijuana users, 21.3% were recreational only, 7.7% medical only and 26.6% were both recreational and medical marijuana users. After controlling for all confounders, lifetime recreational marijuana use, as compared to no use, was significantly associated with increased odds of daily prescription opioid use (OR=1.61; 95%CI:1.02-2.54). There was no association between lifetime recreational or medical marijuana use and daily opioid dose. CONCLUSION: Lifetime medical marijuana use is not linked to current opioid dose, but lifetime recreational use is associated with more than a 60% odds of being a daily prescription opioid user. Screening for lifetime recreational marijuana use may identify patients with chronic pain who are vulnerable to daily opioid use which increases risk for adverse opioid outcomes. Prospective data is needed to determine how marijuana use influences the course of LTOT and vice versa.

Baseline Characteristics From a New Longitudinal Cohort of Patients With Noncancer Pain and Chronic Opioid Use in the United States.

Retrospective cohort studies have consistently observed that long-term prescription opioid use is a risk factor for new major depressive episodes. However, prospective studies are needed to confirm these findings and establish evidence for causation. The Prescription Opioids and Depression Pathways cohort study is designed for this purpose. The present report describes the baseline sample and associations between participant characteristics and odds of daily versus nondaily opioid use. Second, we report associations between participant characteristics and odds of depression, dysthymia, anhedonia, and vital exhaustion. Patients with noncancer pain were eligible if they started a new period of prescription opioid use lasting 30 to 90 days. Participants were 54.8 (standard deviation ± 11.3) years of age, 57.3% female and 73% White race. Less than college education was more common among daily versus nondaily opioid users (32.4% vs 27.3%; P = .0008), as was back pain (64.2% vs 51.3%; P < .0001), any nonopioid substance use disorder (12.8% vs 4.8%; P < .0001), and current smoking (30.7% vs 18.4% P < .0001). High pain interference (50.9% vs 28.4%; P < .0001) was significantly associated with depression, as was having more pain sites (6.9 ± 3.6 vs 5.7 ± 3.6; P < .0001), and benzodiazepine comedication (38.2% vs 23.4%; P < .0001). High pain interference was significantly more common among those with anhedonia (46.8% vs 27.4%; P < .0001), and more pain sites (7.0 ± 3.7 vs 5.6 ± 3.6; P < .0001) were associated with anhedonia. Having more pain sites (7.9 ± 3.6 vs 5.5 ± 3.50; P < .0001) was associated with vital exhaustion, as was back pain (71.9% vs 56.8%; P = .0001) and benzodiazepine comedication (42.8% vs 22.8%; P < .0001). Patients using prescription opioids for noncancer pain have complex pain, psychiatric, and substance use disorder comorbidities. Longitudinal data will reveal whether long-term opioid therapy leads to depression or other mood disturbances such as anhedonia and vital exhaustion. PERSPECTIVE: This study reports baseline characteristics of a new prospective, noncancer pain cohort study. Risk factors for adverse opioid outcomes were most common in those with depression and vital exhaustion and less common in dysthymia and anhedonia. Baseline data highlight the complexity of patients receiving long-term opioid therapy for noncancer pain.

Factors Associated With Interest in Engaging in Psychological Interventions for Pain Management.

OBJECTIVE: Engagement in evidence-based psychological interventions for pain management is low. Identifying characteristics associated with interest in interventions can inform approaches to increase uptake and engagement. The purpose of this study was to examine factors associated with interest in psychological interventions among persons with chronic noncancer pain receiving prescription opioids. METHODS: Participants with chronic noncancer pain and a new 30 to 90 day opioid prescription were recruited from 2 health systems. Participants (N=845) completed measures regarding pain, opioid use, psychiatric symptoms, emotional support, and interest in psychological interventions for pain management. RESULTS: There were 245 (29.0%) participants who reported a high interest in psychological interventions for pain management. In bivariate analyses, variables associated with interest included younger age, female sex, greater pain severity, greater pain interference, greater number of pain sites, lower emotional support, depression, anxiety, and post-traumatic stress disorder ( P <0.05). In a multivariate model, greater pain severity (odds ratio [OR]=1.17; CI: 1.04-1.32), depression (OR=2.10; CI: 1.39-3.16), post-traumatic stress disorder (OR=1.85; CI: 1.19-2.95), and lower emotional support (OR=0.69; CI: 0.5-0.97) remained statistically significant. DISCUSSION: The rate of interest in psychological interventions for pain management was low, which may indicate that patients initiating opioid treatment of chronic noncancer pain have low interest in psychological interventions. Greater pain severity and psychiatric distress were related to interest, and patients with these characteristics may especially benefit from psychological interventions. Providers may want to refer to psychological interventions before or when opioids are initiated. Additional work is needed to determine whether this would reduce long-term opioid use.

The Affordable Care Act and suicide incidence among adults with cancer.

BACKGROUND: Patients with cancer are at an increased suicide risk, and socioeconomic deprivation may further exacerbate that risk. The Affordable Care Act (ACA) expanded insurance coverage options for low-income individuals and mandated coverage of mental health care. Our objective was to quantify associations of the ACA with suicide incidence among patients with cancer. METHODS: We identified US patients with cancer aged 18-74 years diagnosed with cancer from 2011 to 2016 from the Surveillance, Epidemiology, and End Results database. The primary outcome was the 1-year incidence of suicide based on cumulative incidence analyses. Difference-in-differences (DID) analyses compared changes in suicide incidence from 2011-2013 (pre-ACA) to 2014-2016 (post-ACA) in Medicaid expansion relative to non-expansion states. We conducted falsification tests with 65-74-year-old patients with cancer, who are Medicare-eligible and not expected to benefit from ACA provisions. RESULTS: We identified 1,263,717 patients with cancer, 812 of whom died by suicide. In DID analyses, there was no change in suicide incidence after 2014 in Medicaid expansion vs. non-expansion states for nonelderly (18-64 years) patients with cancer (p = .41), but there was a decrease in suicide incidence among young adults (18-39 years) (- 64.36 per 100,000, 95% CI = - 125.96 to - 2.76, p = .041). There were no ACA-associated changes in suicide incidence among 65-74-year-old patients with cancer. CONCLUSIONS: We found an ACA-associated decrease in the incidence of suicide for some nonelderly patients with cancer, particularly young adults in Medicaid expansion vs. non-expansion states. Expanding access to health care may decrease the risk of suicide among cancer survivors.

A Preliminary Study of Stress, Mental Health, and Pain Related to the COVID-19 Pandemic and Odds of Persistent Prescription Opioid Use.

BACKGROUND: The COVID-19 pandemic has been associated with increased opioid prescribing. It is not known if perceived COVID-19 related stress is associated with increased odds of long-term opioid use. OBJECTIVE: To determine if greater COVID-19-related stress and worsening pain attributed to the pandemic was associated with LTOT over a 6-month observation period. DESIGN: Longitudinal cohort. PARTICIPANTS: Patients (n=477) from two midwestern health care systems, with any acute or chronic non-cancer pain, starting a new period of 30-90-day prescription opioid use, were invited to participate in the Prescription Opioids and Depression Pathways Cohort Study, a longitudinal survey study of pain, opioid use, and mental health outcomes. MAIN MEASURES: Baseline and 6-month follow-up assessments were used to measure the association between perceived COVID-19 stressors, the perception that pain was made worse by the pandemic and the odds of persistent opioid use, i.e., remaining a prescription opioid user at 6-month follow-up. Multivariate models controlled for demographics, opioid dose, and change in pain characteristics, mental health measures, and social support. KEY RESULTS: Participants were, on average, 53.9 (±11.4) years of age, 67.1% White race, and 70.9% female. The most frequently endorsed COVID-19 stressor was "worry about health of self/others" (85.7% endorsed) and the least endorsed was "worsened pain due to pandemic" (26.2%). After adjusting for all covariates, "worsened pain due to pandemic" (OR=2.88; 95%CI: 1.33-6.22), change in pain interference (OR=1.20; 95%CI: 1.04-1.38), and change in vital exhaustion (OR=0.90; 95%CI: 0.82-0.99) remained significantly associated with persistent opioid use. CONCLUSIONS: Patients who attribute worsening pain to the COVID-19 pandemic are more likely to be persistent opioid users. Further research is warranted to identify mechanisms underlying this association. Clinicians may consider discussing pain in the context of the pandemic to identify patients at high risk for persistent opioid use.

Demographic factors, psychiatric and physical comorbidities associated with starting preexposure prophylaxis in a nationally distributed cohort.

Due to a large number of small studies and limited control for confounding, existing evidence regarding patient characteristics associated with PrEP initiation is inconsistent. We used a large electronic health record cohort to determine which demographic, physical morbidity and psychiatric conditions are associated with PrEP initiation. Eligible adult (≥18 years) patients were selected from the Optum® de-identified Electronic Health Record dataset (2010-2018). Non-HIV sexually transmitted diseases and high risk sexual behavior was used to identify patients eligible for PrEP. A fully adjusted Poisson regression model estimated the association between age, gender, race, insurance status, comorbidity index, depression, anxiety, dysthymia, severe mental illness, substance use disorder and nicotine dependence/smoking and rate of PrEP initiation. The cohort (n = 30,909) was mostly under 40 years of age (64.3%), 67.6% were female and 58.2% were White. The cumulative incidence of PrEP initiation was 1.3% (n = 408). Patients ≥60 years of age, compared to 18-29 year olds and Black compared to White patients had significantly lower rates of PrEP initiation. Anxiety disorder was significantly associated with higher rate of PrEP initiation (RR = 1.67; 95%CI:1.20-2.33) and nicotine dependence/smoking with a lower rate (RR = 0.73; 95%CI:0.54-0.97). PrEP is underutilized, and a race disparity exists in PrEP initiation. In the context of existing research, nicotine dependence/smoking is the patient characteristic most consistently associated lower rates of starting PrEP. Given the high prevalence of smoking in PrEP eligible patients, physicians may want to integrate discussions of smoking cessation in patient-provider decisions to start PrEP.

Characteristics of Patients with Non-Cancer Pain and Perceived Severity of COVID-19 Related Stress.

Synopsis Patients with non-cancer pain reported increased pain and pain interference during the first months of the COVID-19 pandemic. We determined if pain, prescription opioid use, and comorbidities were associated with perceived COVID-19-related stress as the pandemic peaked. Analysis of survey data revealed that depression/anxiety, pain severity, and pain interference were most strongly and consistently associated with greater stress due to COVID-19 related changes in lifestyle, worsening of emotional/mental health and worsening pain. Identifying specific stressful experiences that most impacted patients with non-cancer pain may help target public health and treatment interventions. Background: During the first months of the COVID-19 pandemic, patients with chronic pain reported increased pain severity and interference. This study measured the association between pain, prescription opioid use, and comorbidities with perceived COVID-19-related stress as the pandemic peaked in the United States. Methods: From 9/2020 to 3/2021, the first 149 subjects from a prospective cohort study of non-cancer pain, completed a survey which contained the Complementary and Integrative Research (CAIR) Pandemic Impact Questionnaire (C-PIQ). Respondents also reported whether the pandemic has contributed to their pain or opioid use. Bivariate comparisons explored patient characteristics with each CAIR domain. Results: Respondents mean age was 54.6 (±11.3) years, 69.8% were female, 64.6% were White. Respondent characteristics were not associated with reading/watching/thinking about the pandemic or with worry about health. Depression/anxiety (p=0.003), using any prescription opioid in the prior three months (p=0.009), higher morphine milligram equivalent used (p=0.005), higher pain severity (p=0.011), and higher pain interference (p=0.0004) were all positively and significantly associated with moderate to severe stress due to COVID-19 related lifestyle changes. Depression/anxiety, pain severity, and pain interference were positively associated with COVID-19-related worsening emotional/mental health. Depression/anxiety were significantly (p<0.0001) associated with reporting that the pandemic made their pain worse. Conclusion: Depression, anxiety, pain severity, and pain interference were most strongly and consistently associated with COVID-19 changes in way of life, worsening of emotional/mental health, and worsening pain. Identifying specific stressful experiences that most impacted patients with noncancer pain may inform public health and treatment interventions.

Depression and Long-Term Prescription Opioid Use and Opioid Use Disorder: Implications for Pain Management in Cancer.

OPINION STATEMENT: Preventing depression in cancer patients on long-term opioid therapy should begin with depression screening before opioid initiation and repeated screening during treatment. In weighing the high morbidity of depression and opioid use disorder in patients with chronic cancer pain against a dearth of evidence-based therapies studied in this population, patients and clinicians are left to choose among imperfect but necessary treatment options. When possible, we advise engaging psychiatric and pain/palliative specialists through collaborative care models and recommending mindfulness and psychotherapy to all patients with significant depression alongside cancer pain. Medications for depression should be reserved for moderate to severe symptoms. We recommend escitalopram/citalopram or sertraline among selective serotonin reuptake inhibitors (SSRIs), or the serotonin and norepinephrine reuptake inhibitors (SNRIs) duloxetine, venlafaxine, or desvenlafaxine if patients have a significant component of neuropathic pain or fibromyalgia. Tricyclic antidepressants (TCAs) (consider nortriptyline or desipramine, which have better anticholinergic profiles) should be considered for patients who do not respond to or tolerate SSRI/SNRIs. Existing evidence is inadequate to definitively recommend methylphenidate or novel agents, such as ketamine or psilocybin, as adjunctive treatments for cancer-related depression and pain. Physicians who treat patients with cancer pain should utilize universal precautions to limit the risk of non-medical opioid use (non-medical opioid use). Patients should be screened for non-medical opioid use behaviors at initial consultation and at regular intervals during treatment using a non-judgmental approach that reduces stigma. Co-management with an addiction specialist may be indicated for patients at high risk of non-medical opioid use and opioid use disorder. Buprenorphine and methadone are indicated for the treatment of opioid use disorder, and while they have not been systematically studied for treatment of opioid use disorder in patients with cancer pain, they do provide analgesia for cancer pain. While an interdisciplinary team approach to manage psychological stress may be beneficial, this may not be possible for patients treated outside of comprehensive cancer centers.

Increased Smoking Cessation Among Veterans With Large Decreases in Posttraumatic Stress Disorder Severity.

INTRODUCTION: Improvement in posttraumatic stress disorder (PTSD) is associated with better health behavior such as better medication adherence and greater use of nutrition and weight loss programs. However, it is not known if reducing PTSD severity is associated with smoking cessation, a poor health behavior common in patients with PTSD. AIMS AND METHODS: Veterans Health Affairs (VHA) medical record data (2008-2015) were used to identify patients with PTSD diagnosed in specialty care. Clinically meaningful PTSD improvement was defined as ≥20 point PTSD Checklist (PCL) decrease from the first PCL ≥50 and the last available PCL within 12 months and at least 8 weeks later. The association between clinically meaningful PTSD improvement and smoking cessation within 2 years after baseline among 449 smokers was estimated in Cox proportional hazard models. Entropy balancing controlled for confounding. RESULTS: On average, patients were 39.4 (SD = 12.9) years of age, 86.6% were male and 71.5% were white. We observed clinically meaningful PTSD improvement in 19.8% of participants. Overall, 19.4% quit smoking in year 1 and 16.6% in year 2. More patients with versus without clinically meaningful PTSD improvement stopped smoking (n = 36, cumulative incidence = 40.5% vs. 111, cumulative incidence = 30.8%, respectively). After controlling for confounding, patients with versus without clinically meaningful PTSD improvement were more likely to stop smoking within 2 years (hazard ratio = 1.57; 95% confidence interval: 1.04-2.36). CONCLUSIONS: Patients with clinically meaningful PTSD improvement were significantly more likely to stop smoking. Further research should determine if targeted interventions are needed or whether improvement in PTSD symptoms is sufficient to enable smoking cessation. IMPLICATIONS: Patients with PTSD are more likely to develop chronic health conditions such as heart disease and diabetes. Poor health behaviors, including smoking, partly explain the risk for chronic disease in this patient population. Our results demonstrate that clinically meaningful PTSD improvement is followed by greater likelihood of smoking cessation. Thus, PTSD treatment may enable healthier behaviors and reduce risk for smoking-related disease.

Provider specialty and odds of a new codeine, hydrocodone, oxycodone and tramadol prescription before and after the CDC opioid prescribing guideline publication.

The CDC Guideline for Prescribing Opioids for Chronic Pain cautioned against high dose prescribing but did not provide guidance on type of opioid for new pain episodes. We determined if new prescriptions for Schedule II opioids vs. tramadol decreased in the 18 months after vs. before the CDC guideline and if this decrease was associated with physician specialty. New opioid prescriptions, provider type and covariates were measured using a nationally distributed, Optum® de-identified Electronic Health Record (EHR) data base. Eligible patients were free of cancer and HIV and started a new prescription for Schedule II opioids (i.e. codeine, hydrocodone, oxycodone) or Schedule IV (tramadol) in the 18 months before (n = 141,219) or 18 months after (n = 138,216) guideline publication. Fully adjusted multilevel multinomial models estimated the association between provider type (anesthesiology/pain medicine, surgical specialty, emergency, hospital, primary care, other specialty and unknown) before and after adjusting for covariates. New oxycodone prescriptions were most common among surgical and anesthesia/pain management, and new tramadol prescriptions were most common in primary care. The greatest decreases in odds of a Schedule II opioid vs. tramadol were observed in emergency care (oxycodone vs. tramadol OR = 0.82; 95%CI:0.76-0.88) and primary care (hydrocodone vs. tramadol OR = 0.85; 95%CI:0.81-0.89). Surgical specialists were least likely to start opioid therapy with tramadol. In the 18 months after vs. before the CDC guideline, emergency care and primary care providers increased tramadol prescribing. Guidelines tailored to specialists that frequently begin opioid therapy with oxycodone may enhance safe opioid prescribing.

Depression and Buprenorphine Treatment in Patients with Non-cancer Pain and Prescription Opioid Dependence without Comorbid Substance Use Disorders.

BACKGROUND: Depression occurs in 40% of patients with prescription opioid dependence (POD). Existing studies of the association between depression and buprenorphine (BUP) treatment for POD are inconsistent and often include patients with comorbid substance use disorders (SUD). We estimated the association between depression and BUP use in patients with pain and POD and free of comorbid SUD. METHODS: Optum® de-identified Electronic Health Record dataset from 2010 to 2018 was used to identify 5,529 patients with chronic pain, with and without depression, receiving prescription opioids and free of substance use disorder diagnoses for one year before POD diagnoses. Unadjusted and adjusted Cox proportional hazard models and negative binomial regression models were computed to estimate the association between depression and time to BUP start, number of BUP prescriptions in the year after BUP start and time to >30 day BUP gap. RESULTS: Patients' mean age was 52.4 (SD±15.3) years, 62% were female and 84% were white and 4.9% (n=270) started BUP. Depression was not associated with BUP initiation.. Among BUP starters, depression vs. no depression, was significantly associated with receiving 29% fewer BUP prescriptions (RR=0.71; 95%CI: 0.51-0.98) and an increased risk for > 30 day gap (HR=1.76; 95%CI:1.01-3.09). LIMITATIONS: Missing data prevented measuring BUP dose. CONCLUSIONS: Depression is likely associated with earlier BUP treatment dropout. Depression related medication non-adherence or possible worsening of depression following BUP taper could explain results. Research is needed to determine if depression severity is associated with BUP dose trajectories and multi-year BUP retention..

Comparison of Opioids Prescribed for Patients at Risk for Opioid Misuse Before and After Publication of the Centers for Disease Control and Prevention's Opioid Prescribing Guidelines.

Importance: It is not known whether decreases in Schedule II (high abuse potential) vs Schedule IV (lower abuse potential) opioid prescriptions overall and among high-risk patients followed publication of the Centers for Disease Control and Prevention (CDC) opioid prescribing guideline on March 15, 2016. Objectives: To compare the odds of new Schedule II opioid (codeine, hydrocodone, oxycodone) prescriptions vs Schedule IV opioid (tramadol) prescriptions in the 18-month periods before and after the CDC guideline release to determine whether new prescriptions for Schedule II opioids decreased relative to new prescriptions for tramadol and to assess whether patients with benzodiazepine prescriptions or those with depression, anxiety, or substance use disorders had a greater decrease in receipt of Schedule II vs Schedule IV opioids. Design, Setting, and Participants: Cross-sectional study of Optum's deidentified Integrated Claims-Clinical data set for 5 million US adults 18 months before and 18 months after March 15, 2016. Eligible patients were 18 years or older, free of HIV and cancer diagnoses, and had a noncancer painful condition. Patients received new prescriptions for codeine, hydrocodone, oxycodone, or tramadol. Data were analyzed from September 5, 2014, to September 14, 2017. Exposure: The CDC opioid prescribing guideline published on March 15, 2016. Main Outcomes and Measures: The odds of prescriptions for each Schedule II opioid vs tramadol after guideline publication. Results: Data from 279 435 patients were included in the study. The mean (SD) age of patients was 52.9 (16.5) years; 61% were female and 79.4% were White. The prevalence of new prescriptions for each drug before and after guideline publication was as follows: codeine, 7.1% vs 7.0%; hydrocodone, 47.4% vs 45.6%; oxycodone, 22.4% vs 24.0%; and tramadol, 23.0% vs 23.4%. Overall, the odds of being prescribed hydrocodone or oxycodone vs tramadol significantly decreased after guideline publication (odds ratios, 0.95; 95% CI, 0.91-0.98 and 0.86; 95% CI, 0.82-0.90, respectively). Odds of being prescribed a Schedule II opioid vs tramadol after vs before guideline publication were similar in patients with and without benzodiazepine comedication or psychiatric disorders. Conclusions and Relevance: In the 18 months after compared with the 18 months before publication of the CDC prescribing guideline, a 14% decrease in oxycodone prescriptions was observed relative to tramadol. Little change in prescriptions of other Schedule II opioids was observed. Schedule II opioids continue to be prescribed to high-risk patients 18 months after publication of the CDC guideline.

Methods to identify dementia in the electronic health record: Comparing cognitive test scores with dementia algorithms.

BACKGROUND: Epidemiologic studies often use diagnosis codes to identify dementia outcomes. It remains unknown to what extent cognitive screening test results add value in identifying dementia cases in big data studies leveraging electronic health record (EHR) data. We examined test scores from EHR data and compared results with dementia algorithms. METHODS: This retrospective cohort study included patients 60+ years of age from Kaiser Permanente Washington (KPWA) during 2013-2018 and the Veterans Health Affairs (VHA) during 2012-2015. Results from the Mini Mental State Examination (MMSE) and the Saint Louis University Mental Status Examination (SLUMS) cognitive screening exams, were classified as showing dementia or not. Multiple dementia algorithms were created using combinations of diagnosis codes, pharmacy records, and specialty care visits. Correlations between test scores and algorithms were assessed. RESULTS: 3,690 of 112,917 KPWA patients and 2,981 of 102,981 VHA patients had cognitive test results in the EHR. In KPWA, dementia prevalence ranged from 6.4%-8.1% depending on the algorithm used and in the VHA, 8.9%-12.1%. The algorithm which best agreed with test scores required ≥2 dementia diagnosis codes in 12 months; at KPWA, 14.8% of people meeting this algorithm had an MMSE score, of whom 65% had a score indicating dementia. Within VHA, those figures were 6.2% and 77% respectively. CONCLUSIONS: Although cognitive test results were rarely available, agreement was good with algorithms requiring ≥2 dementia diagnosis codes, supporting the accuracy of this algorithm. IMPLICATIONS: These scores may add value in identifying dementia cases for EHR-based research studies.

Chronic pain diagnoses and opioid dispensings among insured individuals with serious mental illness.

BACKGROUND: Individuals with major depressive disorder (MDD) and bipolar disorder (BD) have particularly high rates of chronic non-cancer pain (CNCP) and are also more likely to receive prescription opioids for their pain. However, there have been no known studies published to date that have examined opioid treatment patterns among individuals with schizophrenia. METHODS: Using electronic medical record data across 13 Mental Health Research Network sites, individuals with diagnoses of MDD (N = 65,750), BD (N = 38,117) or schizophrenia or schizoaffective disorder (N = 12,916) were identified and matched on age, sex and Medicare status to controls with no documented mental illness. CNCP diagnoses and prescription opioid medication dispensings were extracted for the matched samples. Multivariate analyses were conducted to evaluate (1) the odds of receiving a pain-related diagnosis and (2) the odds of receiving opioids, by separate mental illness diagnosis category compared with matched controls, controlling for age, sex, Medicare status, race/ethnicity, income, medical comorbidities, healthcare utilization and chronic pain diagnoses. RESULTS: Multivariable models indicated that having a MDD (OR = 1.90; 95% CI = 1.85-1.95) or BD (OR = 1.71; 95% CI = 1.66-1.77) diagnosis was associated with increased odds of a CNCP diagnosis after controlling for age, sex, race, income, medical comorbidities and healthcare utilization. By contrast, having a schizophrenia diagnosis was associated with decreased odds of receiving a chronic pain diagnosis (OR = 0.86; 95% CI = 0.82-0.90). Having a MDD (OR = 2.59; 95% CI = 2.44-2.75) or BD (OR = 2.12; 95% CI = 1.97-2.28) diagnosis was associated with increased odds of receiving chronic opioid medications, even after controlling for age, sex, race, income, medical comorbidities, healthcare utilization and chronic pain diagnosis; having a schizophrenia diagnosis was not associated with receiving chronic opioid medications. CONCLUSIONS: Individuals with serious mental illness, who are most at risk for developing opioid-related problems, continue to be prescribed opioids more often than their peers without mental illness. Mental health clinicians may be particularly well-suited to lead pain assessment and management efforts for these patients. Future research is needed to evaluate the effectiveness of involving mental health clinicians in these efforts.

Combined effect of posttraumatic stress disorder and prescription opioid use on risk of cardiovascular disease.

AIM: Prescription opioid analgesic use (OAU) is associated with increased risk of cardiovascular disease (CVD). OAU is more common in patients with than without posttraumatic stress disorder (PTSD), and PTSD is associated with higher CVD risk. We determined whether PTSD and OAU have an additive or multiplicative association with incident CVD. METHODS AND RESULTS: Veterans Health Affairs patient medical record data from 2008 to 2015 was used to identify 2861 patients 30-70 years of age, free of cancer, CVD and OAU for 12 months before index date. We defined a four-level exposure variable: 1) no PTSD/no OAU, 2) OAU alone, 3) PTSD alone and 4) PTSD+OAU. Cox proportional hazard models estimated the association between the exposure variable and incident CVD. The mean age was 49.0 (±11.0), 85.7% were male and 58.3% were White, 34.4% had no PTSD/no OAU, 32.9% had PTSD alone, 10.6% had OAU alone, and 22.1% had PTSD+OAU. Compared with patients with no PTSD/no OAU, those with PTSD alone were not at increased risk of incident CVD (hazard ratio = 0.82; 95% confidence interval (CI): 0.63-1.17); however, OAU alone and PTSD+OAU were both significantly associated with incident CVD (hazard ratio = 1.99; 95% CI:1.36-2.92 and hazard ratio = 2.20; 95% CI: 1.61-3.02). There was no significant additive or multiplicative PTSD and OAU association with incident CVD. CONCLUSION: OAU is associated with nearly a two-fold increased risk of CVD in patients with and without PTSD. Despite no additive or multiplicative interaction effects, the high prevalence of OAU in PTSD may represent a novel contributor to the elevated CVD burden among patients with PTSD.

The association between depression and type of treatments received for chronic low back pain.

BACKGROUND: Depression is associated with receipt of opioids in non-cancer pain. OBJECTIVES: To determine whether the receipt of opioid therapy modifies the relationship of depression and use of multiple non-opioid pain treatments. METHODS: Patients (n = 320) with chronic low back pain (CLBP) were recruited from family medicine clinics and completed questionnaires that measured use of home remedies, physical treatments requiring a provider and non-opioid medication treatments. A binary variable defined use (yes/no) of all three non-opioid treatment categories. Depression (yes/no) was measured with the PHQ-2. The use of opioids (yes/no) was determined by medical record abstraction. Unadjusted and adjusted logistic regression models, stratified on opioid use, estimated the association between depression and use of all three non-opioid treatments. RESULTS: Participants were mostly female (71.3%), non-white (57.5%) and 69.4% were aged 18 to 59 years. In adjusted analyses stratified by opioid use, depression was not significantly associated with using three non-opioid treatments (OR = 2.20; 95% CI = 0.80-6.07) among non-opioid users; but among opioid users, depression was significantly associated with using three non-opioid treatments (OR = 3.21; 95% CI: 1.14-8.99). These odds ratios were not significantly different between opioid users and non-users (P = 0.609). CONCLUSION: There is modest evidence to conclude that patients with CLBP and comorbid depression, compared with those without depression, were more likely to try both opioid and non-opioid pain treatments. Non-response to other pain treatments may partly explain why depression is associated with greater prescription opioid use.

Gender-Stratified Prevalence of Psychiatric and Pain Diagnoses in a Primary Care Patient Sample with Fibromyalgia.

OBJECTIVE: Comorbid psychiatric and pain-related conditions are common in patients with fibromyalgia. Most studies in this area have used data from patients in specialty care and may not represent the characteristics of fibromyalgia in primary care patients. We sought to fill gaps in the literature by determining if the association between psychiatric diagnoses, conditions associated with chronic pain, and fibromyalgia differed by gender in a primary care patient population. DESIGN: Retrospective cohort. SETTING AND SUBJECTS: Medical record data obtained from 38,976 patients, ≥18 years of age with a primary care encounter between July 1, 2008, to June 30, 2016. METHODS: International Classification of Diseases-9 codes were used to define fibromyalgia, psychiatric diagnoses, and conditions associated with chronic pain. Unadjusted associations between patient demographics, comorbid conditions, and fibromyalgia were computed using binary logistic regression for the entire cohort and separately by gender. RESULTS: Overall, 4.6% of the sample had a fibromyalgia diagnosis, of whom 76.1% were women. Comorbid conditions were more prevalent among patients with vs without fibromyalgia. Depression and arthritis were more strongly related to fibromyalgia among women (odds ratio [OR] = 2.80, 95% confidence interval [CI] = 2.50-3.13; and OR = 5.19, 95% CI = 4.62-5.84) compared with men (OR = 2.16, 95% CI = 1.71-2.71; and (OR = 3.91, 95% CI = 3.22-4.75). The relationship of fibromyalgia and other diagnoses did not significantly differ by gender. CONCLUSIONS: Except for depression and arthritis, the burden of comorbid conditions in patients with fibromyalgia is similar in women and men treated in primary care. Fibromyalgia comorbidities in primary care are similar to those found in specialty care.

Disability Benefits and Change in Prescription Opioid Dose.

Among chronic low back pain (CLBP) patients, workers' compensation is associated with longer term prescription opioid analgesic use (OAU). The aim was to study the association between receiving Social Security Disability Insurance (SSDI) benefits and course of OAU. This prospective cohort study utilized data from primary care patients diagnosed with non-cancer CLBP. The outcomes were morphine equivalent dose (MED) - categorized as no OAU, 1-50mg MED, or >50mg MED - and change in MED over time using mixed multinomial logistic regression models. Covariates included sociodemographics, pain severity, pain management characteristics, continuity of care with their physician, health-related quality of life, number of comorbid health conditions, obesity, depression, and anxiety. In adjusted analysis, SSDI vs. non-SSDI patients were more likely to be receiving >50mg MED vs. no OAU at baseline (OR = 10.19; 95% CI:1.51-68.83). Differences in OAU trajectory between SSDI groups were nonsignificant (P = 0.204). Collection of SSDI benefits was an independent predictor of higher MED at baseline and persistently higher MED during 2 years of follow-up. Providers should consider the risk of persistent, high-dose opioid use in patients receiving SSDI benefits.