Prevention of Hepatocellular Carcinoma (HCC). White Paper of the Texas Collaborative Center for Hepatocellular Cancer (TeCH) Multi-stakeholder Conference.

BACKGROUND & AIMS: Texas has the highest age-adjusted incidence rate of hepatocellular carcinoma (HCC) in the United States. The Cancer Prevention and Research Institute of Texas has funded the Texas Collaborative Center for Hepatocellular Cancer (TeCH) to facilitate HCC research, education, and advocacy activities with the overall goal of reducing HCC mortality in Texas through coordination, collaboration, and advocacy. METHODS: On September 17, 2022, TeCH co-sponsored a multi-stakeholder conference on HCC with the Baker Institute Center for Health and Biosciences. This conference was attended by HCC researchers, policy makers, payers, members from pharmaceutical industry and patient advocacy groups in and outside of Texas. This report summarizes the results of the conference. RESULTS: The goal of this meeting was to identify different strategies for preventing HCC and evaluate their readiness for implementation. CONCLUSIONS: We call for a statewide (1) viral hepatitis elimination program; (2) program to increase nonalcoholic steatohepatitis and obesity awareness; (3) research program to develop health care models that integrate alcohol associated liver disease treatment and treatment for alcohol use disorder; and (4) demonstration projects to evaluate the effectiveness of identifying and linking patient with advanced fibrosis and cirrhosis to clinical care.

The integration of primary care and childhood cancer survivorship care: a scoping review.

PURPOSE: This scoping review describes existing care models that integrate primary care and childhood cancer survivorship care, examines the effectiveness of these models, and characterizes barriers and facilitators to their integration. METHODS: A systematic search (PubMed®, CINAHL®, Embase®) was conducted to identify citations which were evaluated against inclusion criteria using the PICOTTS framework. The PRISMA-ScR extension for scoping reviews was used to report review findings (protocol https://osf.io/92xbg ). RESULTS: Twenty-three studies were included. Three care models integrating primary care and childhood cancer survivorship care were identified: consultative shared care in a primary care setting (N = 3); longitudinal shared care (N = 2); and PCP-led care employing a survivorship care plan (N = 5). While many described risk-adapted care, few used risk stratification approaches to inform care. Measures of model effectiveness varied, with discrepant findings regarding late effects detection in PCP-led approaches. The most frequently cited barriers and facilitators reflected provider- and system-level factors (PCP knowledge/experience identified as greatest barrier (N = 11); clinical information from oncologist identified as greatest facilitator (N = 9)). CONCLUSIONS: Identified models depended on PCP knowledge and healthcare system coordination, and studies suggested the need for strong oncologic involvement in follow-up care. Improved training for PCPs and the coordinated transfer of clinical information could facilitate their involvement in such care. Overall, standardized measures of effectiveness are needed to deliver optimal childhood cancer survivorship care. IMPLICATIONS FOR CANCER SURVIVORS: The literature revealed three care models defined by SCP use, provider involvement, and continuity of care, with several studies recommending oncologic involvement in follow-up care for high-risk survivors.

Integrating primary care and childhood cancer survivorship care: a scoping review protocol.

INTRODUCTION: Improved treatment regimens have led to increased survival rates among childhood cancer survivors (CCS), and more than 84% of all children diagnosed with cancer will experience long-term survival or cure. Survivors are susceptible to late effects of cancer treatment often requiring lifelong follow-up care, as many of these conditions can be prevented or mitigated with surveillance. Integrating primary care (PC) and childhood cancer survivorship care can improve follow-up for survivors, however, little integrative research exists. This scoping review aims to: identify and describe existing models of care that integrate PC and childhood cancer survivorship care, examine the effectiveness of these models of care, and characterise the barriers and facilitators for the integration of PC for CCS. METHODS AND ANALYSIS: A comprehensive empirical literature search of three electronic databases (PubMed, CINAHL, and Embase) was employed to identify potentially relevant citations on 1 October 2020. The population, independent variables/intervention, comparator, outcomes, timing, setting and study design/other limiters (PICOTSS) framework was used to inform protocol development. The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist and explanation will be used to report study findings. The search strategy will be completed again prior to publication to ensure recent empirical research is accounted for. ETHICS AND DISSEMINATION: This research is exempt from Institutional Review Board (IRB) review. Approval from a research ethics board for this study was not required as it does not involve human participants or unpublished secondary data. The findings from this scoping review will be disseminated through peer-reviewed scientific manuscripts, clinical conference presentations, professional networks and digital communications using social media platforms such as Twitter. This study has been registered with Open Science Framework: https://osf.io/92xbg.

Educating Primary Care Providers and Associate Care Providers About Hepatitis C Screening of Baby Boomers: a Multi-practice Study.

Chronic hepatitis C virus (HCV) increases the risk for hepatocellular carcinoma. Despite higher prevalence of HCV in persons born 1945-1965 (baby boomer), screening has not been widely adopted. Both primary care providers (PCPs) and associate care providers (ACPs) need to be educated about the rationale and methods to screen for HCV. In five Federally Qualified Health Centers serving low-income Hispanic communities, PCPs and ACPs attended a 50-min training lecture about HCV epidemiology, screening methods, and evaluation. Using a 12-item questionnaire, knowledge and attitudes were compared for PCPs and ACPs at baseline (pre-test) and following training (post-test). A higher proportion of PCPs correctly answered 3 of 6 knowledge questions on both pre-test and post-test but ACPs' showed more improvement in knowledge (all P < 0.05). ACPs had more favorable attitudes about linking patients to care on pre- and post-tests than PCPs, and ACPs' attitudes improved on all 6 items versus 4 for PCPs. Both PCPs and ACPs improved knowledge and attitudes after training about HCV screening but ACPs had more favorable attitudes than PCPs. Engaging the entire primary care practice team in learning about HCV screening promotes knowledge and attitudes necessary for successful implementation.

Patient and provider-level barriers to hepatitis C screening and linkage to care: A mixed-methods evaluation.

Achieving practice change can be challenging when guidelines shift from a selective risk-based strategy to a broader population health strategy, as occurred for hepatitis C (HCV) screening (2012-2013). We aimed to evaluate patient and provider barriers that contributed to suboptimal HCV screening and linkage-to-care rates after implementation of an intervention to improve HCV screening and linkage-to-care processes in a large, public integrated healthcare system following the guidelines change. As part of a mixed-methods study, we collected data through patient surveys (n = 159), focus groups (n = 9) and structured observation of providers and staff (n = 9). We used these findings to then inform domains for the second phase, which consisted of semi-structured interviews with patients across the screening-treatment continuum (n = 24) and providers and staff at primary care and hepatology clinics (n = 21). We transcribed and thematically analysed interviews using an integrated inductive and deductive framework. We identified lack of clarity about treatment cost, treatment complications and likelihood of cure as ongoing patient-level barriers to screening and linkage to care. Provider-level barriers included scepticism about establishing HCV screening as a quality metric given competing clinical priorities, particularly for patients with multiple comorbidities. However, most felt positively about adding HCV as a quality metric to enhance HCV screening and linkage to care. Provider engagement yielded suggestions for process improvements that resulted in increased stakeholder buy-in and real-time enhancements to the HCV screening process intervention. Systematic data collection at baseline and during practice change implementation may facilitate adoption and adaptation to improve HCV screening guideline implementation. Findings identified several key opportunities and lessons to enhance the impact of practice change interventions to improve HCV screening and treatment delivery.

Hepatitis C Virus Screening and Care: Complexity of Implementation in Primary Care Practices Serving Disadvantaged Populations.

Background: Hepatitis C virus (HCV) disproportionately affects disadvantaged communities. Objective: To examine processes and outcomes of Screen, Treat, Or Prevent Hepatocellular Carcinoma (STOP HCC), a multicomponent intervention for HCV screening and care in safety-net primary care practices. Design: Mixed-methods retrospective analysis. Setting: 5 federally qualified health centers (FQHCs) and 1 family medicine residency program serving low-income communities in diverse locations with largely Hispanic populations. Patients: Persons born in 1945 through 1965 (baby boomers) who had never been tested for HCV and were followed through May 2018. Intervention: The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model guided implementation and evaluation. Test costs were covered for uninsured patients. Measurements: All practices tested patients for anti-HCV antibody (anti-HCV) and HCV RNA. For uninsured patients with chronic HCV in 4 practices, quantitative data also enabled assessment of HCV staging, specialist teleconsultation, direct-acting antiviral (DAA) treatment, and sustained virologic response (SVR). Implementation fidelity and adaptation were assessed qualitatively. Results: Anti-HCV screening was done in 13 334 of 27 700 baby boomers (48.1%, varying by practice from 19.8% to 71.3%). Of 695 anti-HCV-positive patients, HCV RNA was tested in 520 (74.8%; 48.9% to 92.9% by practice), and 349 persons (2.6% of those screened) were diagnosed with chronic HCV. In 4 FQHCs, 174 (84.9%) of 205 uninsured patients with chronic HCV had disease staging, 145 (70.7%) had teleconsultation review, 119 (58.0%) were recommended to start DAA therapy, 82 (40.0%) initiated free DAA therapy, 74 (36.1%) completed therapy (27.8% to 60.0% by practice), and 70 (94.6% of DAA completers) achieved SVR. Implementation was promoted by multilevel practice engagement, patient navigation, and anti-HCV screening with reflex HCV RNA testing. Limitation: No control practices were included, and data were missing for some variables. Conclusion: Despite a similar framework for STOP HCC implementation, performance varied widely across safety-net practices, which may reflect practice engagement as well as infrastructure or cost challenges beyond practice control. Primary Funding Source: Cancer Prevention & Research Institute of Texas and Centers for Medicare & Medicaid Services.

Cost-Effectiveness of Hepatitis C Screening and Treatment in Low-Income, Primarily Hispanic Baby Boomers.

The cost-effectiveness of hepatitis C virus (HCV) screening and treatment was examined in low-income, primarily Hispanic baby boomers born 1945-1965 using a Markov model of the natural history of HCV. The model was parameterized using costs and diagnostic data from 2008-2016 and from literature on disease progression and effectiveness of screening and treatment using direct acting anti-viral (DAA) therapy. The incremental cost-effectiveness ratio (ICER) was computed from the perspective of Medicare as payer, calculated over 20 years, and discounted at 3% per year. In the base case, HCV screening cost $3,334 versus $3,797 for no screening, and yielded more quality-adjusted life years (QALYs; 14.08 vs 13.96, respectively). The ICER for screening was still less than $20,000 per additional QALY with drug costs up to $100,000. Among low-income Hispanics, HCV screening was less costly for Medicare and more effective than no screening under most assumptions. This analysis supports investment in screening and treatment in Hispanics.

Evaluation of a Multifaceted Intervention to Reduce Health Disparities in Hepatitis C Screening: A Pre-Post Analysis.

Hepatitis C virus (HCV) testing in persons born from 1945 to 1965 has had limited adoption despite guidelines, particularly among racial/ethnic minorities and socioeconomically disadvantaged patients, who have a higher prevalence of disease burden. We examined the effectiveness of a multifaceted intervention to improve HCV screening in a large safety-net health system. We performed a multifaceted intervention that included provider and patient education, an electronic medical record-enabled best practice alert, and increased HCV treatment capacity. We characterized HCV screening completion before and after the intervention. To identify correlates of HCV screening, we performed logistic regression for the preintervention and postintervention groups and used a generalized linear mixed model for patients observed in both preintervention and postintervention time frames. Before the intervention, 10.1% of 48,755 eligible baby boomer patients were screened. After the intervention, 34.6% of the 34,093 eligible baby boomers were screened (P < 0.0001). Prior to the intervention, HCV screening was lower among older baby boomers and providers with large patient panels and higher in high-risk subgroups including those with signs of liver disease (e.g., elevated transaminases, thrombocytopenia), human immunodeficiency virus-positive patients, and homeless patients. Postintervention, we observed increased screening uptake in older baby boomers, providers with larger patient panel size, and patients with more than one prior primary care appointment. Conclusion: Our multifaceted intervention significantly increased HCV screening, particularly among older patients, those engaged in primary care, and providers with large patient panels.

Randomized Trial of Chronic Pain Self-Management Program in the Community or Clinic for Low-Income Primary Care Patients.

BACKGROUND: Patients with chronic pain often lack the skills and resources necessary to manage this disease. OBJECTIVE: To develop a chronic pain self-management program reflecting community stakeholders' priorities and to compare functional outcomes from training in two settings. DESIGN: A parallel-group randomized trial. PARTICIPANTS: Eligible subjects were 35-70 years of age, with chronic non-cancer pain treated with opioids for >2 months at two primary care and one HIV clinic serving low-income Hispanics. INTERVENTIONS: In one study arm, the 6-month program was delivered in monthly one-on-one clinic meetings by a community health worker (CHW) trained as a chronic pain health educator, and in the second arm, content experts gave eight group lectures in a nearby library. MAIN MEASURES: Five times Sit-to-Stand test (5XSTS) assessed at baseline and 3 and 6 months. Other reported physical and cognitive measures include the 6-Min Walk (6 MW), Borg Perceived Effort Test (Borg Effort), 50-ft Speed Walk (50FtSW), SF-12 Physical Component Summary (SF-12 PCS), Patient-Specific Functional Scale (PSFS), and Symbol-Digit Modalities Test (SDMT). Intention-to-treat (ITT) analyses in mixed-effects models adjust for demographics, body mass index, maximum pain, study arm, and measurement time. Multiple imputation was used for sensitivity analyses. KEY RESULTS: Among 111 subjects, 53 were in the clinic arm and 58 in the community arm. In ITT analyses at 6 months, subjects in both arms performed the 5XSTS test faster (-4.9 s, P = 0.001) and improved scores on Borg Effort (-1, P = 0.02), PSFS (1.6, P < 0.001), and SDMT (5.9, P < 0.001). Only the clinic arm increased the 6 MW (172.4 ft, P = 0.02) and SF-12 PCS (6.2 points, P < 0.001). 50ftSW did not change (P = 0.15). Results were similar with multiple imputation. Five falls were possible adverse events. CONCLUSIONS: In low-income subjects with chronic pain, physical and cognitive function improved significantly after self-management training from expert lectures in the community and in-clinic meetings with a trained health educator.

Effectiveness of direct-acting antiviral therapy for hepatitis C in difficult-to-treat patients in a safety-net health system: a retrospective cohort study.

BACKGROUND: Direct-acting antivirals (DAAs) have revolutionized chronic hepatitis C (HCV) treatment, but real-world effectiveness among vulnerable populations, including uninsured patients, is lacking. This study was conducted to characterize the effectiveness of DAAs in a socioeconomically disadvantaged and underinsured patient cohort. METHODS: This retrospective observational study included all patients undergoing HCV treatment with DAA-based therapy between April 2014 and June 2016 at a large urban safety-net health system (Parkland Health and Hospital System, Dallas, TX, USA). The primary outcome was sustained virologic response (SVR), with secondary outcomes including treatment discontinuation, treatment relapse, and loss to follow-up. RESULTS: DAA-based therapy was initiated in 512 patients. The cohort was socioeconomically disadvantaged (56% uninsured and 13% Medicaid), with high historic rates of alcohol (41%) and substance (50%) use, and mental health disorders (38%). SVR was achieved in 90% of patients (n = 459); 26 patients (5%) were lost to follow-up. SVR was significantly lower in patients with decompensated cirrhosis (82% SVR; OR 0.37, 95% CI 0.16-0.85) but did not differ by insurance status (P = 0.98) or alcohol/substance use (P = 0.34). Reasons for treatment failure included loss to follow-up (n = 26, 5%), viral relapse (n = 16, 3%), non-treatment-related death (n = 7, 1%), and treatment discontinuation (n = 4, 1%). Of patients with viral relapse, 6 reported non-compliance and have not been retreated, 5 have been retreated and achieved SVR, 4 have undergone resistance testing but not yet initiated retreatment, and 1 was lost to follow-up. CONCLUSIONS: Effective outcomes with DAA-based therapy can be achieved in difficult-to-treat underinsured populations followed in resource-constrained safety-net health systems.

Improving support and education of low-income baby boomers diagnosed with chronic hepatitis C virus infection through universal screening.

AIMS AND OBJECTIVES: To identify support needs of low-income baby boomers recently diagnosed with chronic hepatitis C virus infection. BACKGROUND: The U.S. Preventive Services Task Force has endorsed one-time screening of all baby boomers (born 1945-1965) for hepatitis C because 75% of the estimated 2-3 million persons with chronic infection are in this age range. We hypothesised that persons diagnosed by routine screening would have significant psycho-emotional, cognitive and healthcare challenges that need to be met by collaborative care and services from nurses and other healthcare personnel. DESIGN: Qualitative descriptive study of data from three focus groups with predominantly minority participants (N = 16). Data were analysed using qualitative content analysis, and transcribed data were categorised by three domains in a previously developed model and a new domain identified in this study. Frequencies of unique participants' comments about each theme were calculated. RESULTS: Elucidated domains were as follows: (i) psycho-emotional effects due to social stigma, shame, fear and dealing with risky behaviours; (ii) social effects due to concerns about infecting others; and (iii) cognitive deficits because of poor understanding about hepatitis C virus infection and its care. A new domain related to health care emerged reflecting the following themes: poor access to care, barriers to costly treatment, and navigating complex care for comorbidities. Despite these challenges, participants strongly endorsed universal baby boomer hepatitis C virus screening. CONCLUSIONS: This study describes psycho-emotional and social challenges of people dealing with a hepatitis C diagnosis which are compounded by poor knowledge and barriers to supportive care. RELEVANCE TO CLINICAL PRACTICE: Nursing and other allied health personnel require structured support programmes to assist older persons diagnosed with hepatitis C with addressing these common challenges with the ultimate goal of achieving a cure.

Drug Overdose: Differing Risk Models for Women and Men among Opioid Users with Non-Cancer Pain.

OBJECTIVE: To examine risk factors for drug overdose by sex reflecting differing patterns of opioid and other drug use. DESIGN: National privately insured cohort. SUBJECTS: 206,869 subjects filling ≥2 opioid prescriptions from January 2009 through July 2012. METHODS: Sex-specific prediction models for future drug overdose developed and validated using variables measured within 6 months after starting opioids: demographics, substance use, comorbidities, opioid dose, and psychoactive drugs. Logistic regression and split-sample validation were used. RESULTS: Area under the receiver operating curves (AUCs) for both sex-specific risk models (0.80) were higher (P < 0.001) than for daily opioid dose alone. Risk factors for drug overdose were similar by sex but effects differed. For both sexes, substance use was the strongest predictor but the adjusted odds ratio (AOR) [95% CI] was 5.95 [4.33, 8.06] for women vs. 4.69 [3.24, 6.68] for men. AORs for daily opioid dose rose monotonically in men to 2.42 [1.76, 3.28] for high vs. low dose but were non-monotonic in women with 1.79 [1.35, 2.35] for high dose. AOR for 1-60 days of antidepressants vs. none was significant only in men (1.98 [1.32, 2.9]). AOR for benzodiazepine use was higher in men than women (2.75 vs 2.35, respectively). Zolpidem use was significant only in women. AUCs for sex-specific models were lower for the opposite sex and significantly lower for the men's model in the women's derivation dataset. CONCLUSIONS: These models reveal similar risk factors by sex for drug overdose in opioid users but significant differences in effects that, if validated in other cohorts, may inform differing risk management strategies.

Exposure to High-Risk Medications is Associated With Worse Outcomes in Older Veterans With Chronic Pain.

BACKGROUND: Chronic pain is common, costly and leads to significant morbidity in older adults, yet there are limited data on medication safety. The authors sought to evaluate the association of incident high-risk medication in the elderly (HRME) with mortality, emergency department (ED) or hospital care among older adults with chronic pain. METHODS: A retrospective Veterans Health Administration cohort study was conducted examining older veterans with chronic pain diagnoses and use of incident HRME (opioids, skeletal muscle relaxants, antihistamines and psychotropics). Outcomes evaluated included all-cause mortality, ED visits or inpatient hospital care. Descriptive statistics summarized variables for the overall cohort, the chronic pain cohort and those with and without HRME. Separate generalized linear mixed-effect regression models were used to examine the association of incident HRME on each outcome, controlling for potential confounders. RESULTS: Among 1,807,404 veterans who received Department of Veterans Affairs care in 2005 to 2006, 584,066 (32.3%) had chronic pain; 45,945 veterans with chronic pain (7.9%) had incident HRME exposure. The strongest significant associations of incident HRME were for high-risk opioids with all-cause hospitalizations (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.95-2.23), skeletal muscle relaxants with all-cause ED visits (OR 2.62, 95% CI 2.52-2.73) and mortality (OR 0.80, 95% CI 0.74-0.86), antihistamines with all-cause ED visits (OR 2.82 95% CI 2.72-2.95) and psychotropics with all-cause hospitalizations (OR 2.15, 95% CI 1.96-2.35). CONCLUSIONS: Our data indicate that incident HRME is associated with clinically important adverse outcomes in older veterans with chronic pain and highlight the importance of being judicious with prescribing certain classes of drugs in this vulnerable population.

Implementing hospital-based baby boomer hepatitis C virus screening and linkage to care: Strategies, results, and costs.

BACKGROUND/OBJECTIVE: The US Preventive Services Task Force recommends 1-time hepatitis C virus (HCV) screening of all baby boomers (born 1945-1965). However, little is known about optimal ways to implement HCV screening, counseling, and linkage to care. We developed strategies following approaches used for HIV to implement baby boomer HCV screening in a hospital setting and report results as well as costs. DESIGN/PATIENTS: Prospective cohort of 6140 baby boomers admitted to a safety-net hospital in South Texas from December 1, 2012 to January 31, 2014 and followed to December 10, 2014. PROCEDURES/MEASUREMENTS: The HCV screening program included clinician/staff education, electronic medical record algorithm for eligibility and order entry, opt-out consent, anti-HCV antibody test with reflex HCV RNA, personalized inpatient counseling, and outpatient case management. Outcomes were anti-HCV antibody-positive and HCV RNA-positive results. RESULTS: Of 3168 eligible patients, 240 (7.6%) were anti-HCV positive, which was more likely (P < 0.05) for younger age, men, and uninsured. Of 214 (89.2%) patients tested for HCV RNA, 134 (4.2% of all screened) were positive (chronic HCV). Among patients with chronic HCV, 129 (96.3%) were counseled, 108 (80.6%) received follow-up primary care, and 52 (38.8%) received hepatology care. Five patients initiated anti-HCV therapy. Total costs for start-up and implementation for 14 months were $286,482. CONCLUSIONS: This inpatient HCV screening program diagnosed chronic HCV infection in 4.2% of tested patients and linked >80% to follow-up care. Yet access to therapy is challenging for largely uninsured populations, and most programmatic costs of the program are not currently covered.

Drug Overdose in a Retrospective Cohort with Non-Cancer Pain Treated with Opioids, Antidepressants, and/or Sedative-Hypnotics: Interactions with Mental Health Disorders.

BACKGROUND: Opioid analgesics and other psychoactive drugs may pose an even greater risk for drug overdose in persons with mental health disorders. OBJECTIVE: The purpose of this study was to examine interactions of filled prescriptions for opioids, benzodiazepines, antidepressants, and zolpidem with mental health disorders in regard to drug overdose. DESIGN: The study was a retrospective cohort review. SUBJECTS: Subjects were national HMO beneficiaries aged 18-64 years, enrolled at least 1 year (01/2009 to 07/2012), who filled at least two prescriptions for Schedule II or III opioids for non-cancer pain. MAIN MEASURES: The outcome was the first inpatient or outpatient drug overdose after the first filled opioid prescription. Predictors were calculated in 6-month intervals and exactly 6 months before a drug overdose: opioid use (mean daily morphine-equivalent dose), benzodiazepine use (days' supply), antidepressant use (days' supply), zolpidem use (days' supply), mental health disorders (depression, anxiety/PTSD, psychosis), pain-related conditions, and substance use disorders (alcohol, other drug). KEY RESULTS: A total of 1,385 (0.67%) subjects experienced a drug overdose (incidence rate 421/100,000 person-years). The adjusted odds ratios (AOR) for overdose among all subjects rose monotonically with daily opioid dose, but highest (AOR = 7.06) for persons with depression and a high opioid dose (≥100 mg) versus no depression or opioid use. Longer-term antidepressants (91-180 days) were protective for persons with depression, with 20% lower AORs for overdose versus short-term (1-30 days) or none. For persons without depression, the AORs of overdose were increased for antidepressant use, but greatest (AOR = 1.98) for short-term use versus none. The AORs of overdose increased with the duration of benzodiazepine therapy among all subjects, with over 2.5-fold higher AORs for 91-180 days versus none. CONCLUSIONS: Opioids and longer-duration benzodiazepines were associated with drug overdose among all subjects, but opioid risk was greatest for persons with depression. Antidepressant use > 90 days reduced the odds of overdose for persons with depression, but all antidepressant use increased the risk for persons without depression.

A qualitative study of veterans on long-term opioid analgesics: barriers and facilitators to multimodality pain management.

OBJECTIVE: The aim of this study was to examine barriers and facilitators to multimodality chronic pain care among veterans on high-dose opioid analgesics for chronic non-cancer pain. SETTING: A Veterans Health Administration clinic in San Antonio. PARTICIPANTS: Twenty-five veterans taking at least 50 mg morphine equivalent daily oral opioid doses for more than 6 months. METHODS: Three semi-structured focus groups, each with seven to nine veterans. Interview guide addressed: chronic pain effects on quality of life, attitudes/experiences with multimodality pain care, social support, and interest in peer support. In an iterative process using grounded theory, three reviewers reviewed de-identified transcripts for themes. The theory of planned behavior (TPB) framework was used to classify barriers and facilitators to multimodal pain management. MAIN RESULTS: The 25 participants had a mean age of 54 years (39-70); 32% were women and 24% non-white. The three TPB dimensions (attitudes, social norms, and perceived behavioral control) were reflected in emergent themes: 1) uncontrollable impact of pain in all aspects of life; 2) reliance on opioids and challenges in obtaining these drugs despite ambivalence about benefits; 3) poor access to and beliefs about non-pharmacologic therapies; 4) frustrations with Department of Veterans Affairs health care; and 5) poor social support and isolation reflected by limited interest in peer support. CONCLUSIONS: Veterans with chronic pain on long-term opioids hold pervasive attitudes that prevent them from using multimodality pain management options, lack social support and social norms for non-opioid-based pain treatment options, and have poor perceived control due to poor access to multimodality care.

A qualitative study of family healthy lifestyle behaviors of Mexican-American and Mexican immigrant fathers and mothers.

This study qualitatively examines contrasting parental decision-making styles about family food choices and physical activities as well as willingness to change behaviors among Mexican-American and Mexican immigrant mothers and fathers of school-aged children. Twelve sex-specific focus groups were held in English or Spanish in 2012. Qualitative analysis informed by grounded theory examined parenting styles (ie, authoritative, authoritarian, or permissive), barriers to healthy lifestyle, and parents' stage of change about healthy lifestyles. One third of the 33 participating couples were born in Mexico. The majority of mothers and fathers described being permissive and allowing unhealthy food choices, and a minority of mothers reported more authoritarian approaches to promoting a healthier diet for their children. Mothers were more permissive than fathers about family physical activities and less engaged in these activities. Most mothers and fathers described only contemplating a healthier diet and more physical activity, while wanting their children to have a healthier lifestyle. These data suggest that clinicians need to assess and address differential parental roles when promoting a healthy lifestyle for children. Clinicians should also adopt culturally competent approaches to overcome barriers to parental engagement in diverse aspects of a healthy family lifestyle.