Emotional and Behavioral Health Needs in Elementary School Students in an Underserved Hispanic Community.

High rates of mental health problems in adolescents have been well documented; less is known about elementary school children in disadvantaged communities. We examined emotional and behavioral health needs in 202 third and fourth graders enrolled in a charter school in a largely Hispanic community. The child-reported Revised Child Anxiety and Depression Scale-25 and Teacher's Report Form were used to evaluate mental health needs as perceived by these children and their teachers. The prevalence of teacher-reported depression and child self-reported anxiety was 7.0% and 6.67%, respectively. Living in a single parent household was found to be a specific risk factor in that those children had higher rates of emotional and behavioral problems than children living with both parents. Evidence of higher depression and anxiety identified in this sample compared to national representative data suggests the need for development of culturally sensitive early prevention and intervention in this underserved community.

Hispanic Mothers' Experiences with School-Based Emotional Health Curriculum and Perspectives of Their Own Mental Health Needs.

An Emotional Health Curriculum (EHC) was developed to promote positive mental health in primarily Hispanic elementary school-aged children. In order to further expand the EHC, the mothers' experiences with the curriculum were examined. Eighteen mothers participated in two focus groups. Mothers reported that they valued this curriculum as a preventive program. Importantly, all mothers wished to extend their involvement to not only assisting their child in completing the curriculum homework but also attending a proposed parenting program. This study provides preliminary evidence that mothers embraced the EHC as an accessible community mental health service for their children and sought greater involvement.

Impact of Chronic Opioid Therapy Risk Reduction Initiatives on Opioid Overdose.

We assessed the effects of opioid dose and risk reduction initiatives on opioid overdose rates among patients on chronic opioid therapy (COT). Using an interrupted time series design, we compared trends in overdose rates. We compared patients on COT in settings that implemented a COT dose reduction initiative and then a COT risk stratification/monitoring initiative to similar patients on COT from control settings. From 2006 to 2014, 31,142 patients on COT (22,673 intervention, 8,469 control) experienced 311 fatal or nonfatal opioid overdoses. In primary analyses, changes in opioid overdose rates among patients on COT did not differ significantly between intervention and control settings with the implementation of either dose reduction or risk stratification/monitoring. In planned secondary analyses, overdose rates decreased significantly (17% per year) during the dose reduction initiative among patients on COT in intervention settings (relative annual change, 0.83; 95% confidence interval, 0.70-0.99), but not in control settings (0.98. 95% confidence interval, 0.70-1.39). We conclude that overdose rates among patients on COT were not decreased by risk stratification and monitoring initiatives. Results were inconsistent for COT dose reduction, with no significant difference between intervention and control settings (primary hypothesis test), but a significant decrease in overdose rates within the intervention setting during dose reduction (secondary hypothesis test). PERSPECTIVE: Risk stratification/monitoring interventions among patients on COT did not decrease opioid overdose rates. The effects of COT dose reduction on opioid overdose rates were inconsistent. Greater decreases in COT dose, a larger control group, or both may have been needed to identify conclusive reductions in opioid overdose rates.

Impact of initiatives to reduce prescription opioid risks on medically attended injuries in people using chronic opioid therapy.

PURPOSE: The purpose of the study is to determine whether initiatives to improve the safety of opioid prescribing decreased injuries in people using chronic opioid therapy (COT). METHODS: We conducted an interrupted time series analysis using data from Group Health (GH), an integrated health care delivery system in the United States. In 2007, GH implemented initiatives which substantially reduced daily opioid dose and increased patient monitoring. Among GH members age 18 or older receiving COT between 2006 and 2014, we compared injury rates for patients in GH's integrated group practice (IGP; exposed to the initiatives) vs patients cared for by contracted providers (not exposed). Injuries were identified using a validated algorithm. We calculated injury incidence during the baseline (preintervention) period from 2006 to 2007; the dose reduction period, 2008 to 2010; and the risk stratification and monitoring period, 2010 to 2014. Using modified Poisson regression, we estimated adjusted relative risks (RRs) representing the relative change per year in injury rates. RESULTS: Among 21 853 people receiving COT in the IGP and 8260 in contracted care, there were 2679 injuries during follow-up. The baseline injury rate was 1.0% per calendar quarter in the IGP and 0.9% in contracted care. Risk reduction initiatives did not decrease injury rates: Within the IGP, the RR in the dose reduction period was 1.01 (95% CI, 0.95-1.07) and in the risk stratification and monitoring period, 0.99 (95% CI, 0.95-1.04). Injury trends did not differ between the two care settings. CONCLUSIONS: Risk reduction initiatives did not decrease injuries in people using COT.

Feasibility of an emotional health curriculum for elementary school students in an underserved Hispanic community.

PROBLEM: Hispanic children have greater mental health challenges but fewer received mental health services than other ethnic groups. A classroom-based Emotional Health Curriculum (EHC) was developed to address mental health disparities in an underserved Hispanic community. METHODS: A quasi-experimental design with one group pre- and post-intervention was used to test the feasibility of an 8-week EHC for one hundred 3rd and 4th grade children in a dual-immersion Spanish-English elementary school. Limited efficacy was measured by changes in depression and anxiety scores reported by children and teachers. Acceptance was evaluated by a child-reported satisfaction survey and a focus group in which the four teachers shared their experiences. Implementation was measured by participation, retention, and fidelity rates. FINDINGS: The child-reported depression and anxiety and teacher-reported depression were significantly decreased in at-risk children with the effect size ranging from 0.60 to 1.16 (ps < 0.05). The majority of children (89.7%) enjoyed the EHC and teachers observed that children had acquired skills to manage their emotional distress. The participation, retention, and fidelity rates were 98%, 94%, and 99.13%, respectively. CONCLUSIONS: The results provide promising evidence that the EHC has the potential to improve depression and anxiety symptoms in at-risk children.

The Impact of Opioid Risk Reduction Initiatives on High-Dose Opioid Prescribing for Patients on Chronic Opioid Therapy.

UNLABELLED: Avoiding high opioid doses may reduce chronic opioid therapy (COT) risks, but the feasibility of reducing opioid doses in community practice is unknown. Washington State and a health plan's group practice implemented initiatives to reduce high-dose COT prescribing. The group practice physicians were exposed to both initiatives, whereas contracted physicians were exposed only to statewide changes. Using interrupted time series analyses, we assessed whether these initiatives reduced opioid doses among COT patients in group practice (n = 16,653) and contracted care settings (n = 5,552). From 2006 to June 2014, the percentage of COT patients receiving ≥120 mg morphine equivalent dose declined from 16.8% to 6.3% in the group practice versus 20.6 to 13.6% among COT patients of contracted physicians. The proportion receiving excess opioid days supplied declined from 24.0 to 10.4% among group practice COT patients and from 20.1 to 14.7% among COT patients of contracted physicians. Reductions in prescribing of high opioid dose and excess opioid days supplied followed state and health plan initiatives to change opioid prescribing. Reductions were substantially greater in the group practice setting that implemented additional initiatives to alter shared physician expectations regarding appropriate COT prescribing, compared with the contracted physicians' patients. PERSPECTIVE: Washington State and a health plan's group practice implemented initiatives to reduce high-dose COT prescribing. Group practice physicians were exposed to both initiatives, whereas the health plan's contracted physicians were exposed to only the statewide changes. Reductions in prescribing of high opioid dose, average daily dose, and excess opioid days supplied followed state and health plan initiatives to change opioid prescribing. Reductions were substantially greater in the group practice setting that implemented additional initiatives to alter shared physician expectations regarding appropriate COT prescribing, compared with the contracted physicians' patients.

Predictors of 1-year change in patient activation in older adults with diabetes mellitus and heart disease.

OBJECTIVES: To identify patterns and predictors of 1-year change in patient activation in chronically ill older adults. DESIGN: Prospective cohort study. SETTING: Integrated healthcare delivery system. PARTICIPANTS: Members of an integrated delivery system from 2007 to 2009 in western Washington state aged 65 and older with diabetes mellitus or heart disease; participants responded to baseline and 1-year follow-up mailed surveys about their health and health care (N = 2,341). MEASUREMENTS: Patient activation was measured using the 13-item Patient Activation Measure (PAM) at baseline and follow-up. Automated diagnoses and procedure data were extracted from databases. Multinomial logistic regression, stratified according to baseline activation stage, was used to estimate the odds ratios for increasing or decreasing activation stage associated with participant characteristics and serious adverse health events. RESULTS: Fifty-two percent of participants changed activation stage between baseline and follow-up. Of people who changed stage, 54% increased, and 46% decreased. Older age and worse baseline self-reported health were independent predictors of activation change in multivariate models. Changes in health status or serious adverse health events such as the occurrence of hospitalizations, new major diagnoses, or procedures were not related to changes in activation in this age group. CONCLUSION: Patient activation, as measured using the PAM, changes over time in elderly adults with chronic diseases. Clinicians and researchers who use the PAM for patient care or as an outcome measure in research studies should be aware of its fluctuation over time in chronically ill older persons.

The prescribed opioids difficulties scale: a patient-centered assessment of problems and concerns.

OBJECTIVES: Chronic opioid therapy for chronic noncancer pain has increased dramatically in recent years. Research on associated risks has typically focused on opioid abuse and dependence, and opioid misuse or aberrant drug use behaviors, but these risks have been defined from the providers' perspective. The aim of this article was to develop a psychometrically sound method for assessing difficulties patients attribute to chronic opioid therapy. METHODS: A cross-sectional, observational study of patients prescribed opioids for chronic noncancer pain was conducted in a large integrated service delivery network in Washington State. Data were obtained from a phone interview and electronic health records including pharmacy data. Exploratory and confirmatory factor analyses were conducted using a split sample design. RESULTS: The interview response rate was 56.5% and a total of 1144 patients were included in analyses. A 2 factor solution was obtained and replicated with excellent fit statistics. Two correlated factors were identified-opioid control concerns and psychosocial problems-with 50% of the sample reporting difficulties with prescribed opioids: 24% reported elevated psychosocial problems and 36% reported elevated concerns about controlling their use of prescribed opioids. DISCUSSION: The Prescribed Opioid Difficulties Scale identifies common difficulties that patients ascribe to chronic opioid therapy. This scale may provide both an entry point and a framework for a patient-centered clinical dialog about the pros and cons of use of opioid medicines for managing chronic pain.

Trends in prescribed opioid therapy for non-cancer pain for individuals with prior substance use disorders.

Long-term opioid therapy for non-cancer pain has increased. Caution is advised in prescribing for persons with substance use disorders, but little is known about actual health plan practices. This paper reports trends and characteristics of long-term opioid use in persons with non-cancer pain and a substance abuse history. Using health plan data (1997-2005), the study compared age-sex-standardized rates of incident, incident long-term and prevalent long-term prescription opioid use, and medication use profiles in those with and without substance use disorder histories. The CONsortium to Study Opioid Risks and Trends study included adult enrollees of two health plans, Kaiser Permanente of Northern California (KPNC) and Group Health Cooperative (GH) of Seattle, Washington. At KPNC (1999-2005), prevalence of long-term use increased from 11.6% to 17.0% for those with substance use disorder histories and from 2.6% to 3.9% for those without substance use disorder histories. Respective GH rates (1997-2005), increased from 7.6% to 18.6% and from 2.7% to 4.2%. Among persons with an opioid disorder, KPNC rates increased from 44.1% to 51.1%, and GH rates increased from 15.7% to 52.4%. Long-term opioid users with a prior substance abuse diagnosis received higher dosage levels, were more likely to use Schedule II and long-acting opioids, and were more often frequent users of sedative-hypnotic medications in addition to their opioid use. Since these patients are viewed as higher risk, the increased use of long-term opioid therapy suggests the importance of improved understanding of the benefits and risks of opioid therapy among persons with a history of substance abuse, and the need for more careful screening for substance abuse history than is the usual practice.

De facto long-term opioid therapy for noncancer pain.

OBJECTIVES: This paper describes characteristics of opioid use episodes for noncancer pain and defines thresholds for de facto long-term opioid therapy. METHODS: CONSORT (CONsortium to Study Opioid Risks and Trends) includes adult members of 2 health plans serving over 1% of the US population. Opioid use episodes beginning in the years 1997 to 2005 were classified as acute, episodic, long-term/lower dose, or long-term/higher dose. RESULTS: On the basis of evaluation of the likelihood of opioid use continuing, long-term opioid therapy was defined by episodes lasting longer than 90 days with 10+ opioid prescriptions or 120+ days supply of opioids dispensed. Long-term/higher dose episodes (<1.5% of all opioid use episodes) were characterized by daily or near daily use, a mean duration of about 1000 days, and an average daily dose of about 55 mg. They accounted for more than half the total morphine equivalents dispensed from the years 1997 to 2006. Short-acting, non-Schedule II opioids (eg, hydrocodone with acetaminophen) were, by far, the most commonly prescribed medications for acute, episodic, and long-term episodes. Long-acting (sustained-release) opioids were the predominately prescribed medication in a minority of long-term episodes (6% to 12%). DISCUSSION: Long-term opioid therapy was characterized by the diversity in medications prescribed, dosage levels, and frequency of use. The proposed threshold for long-term opioid therapy provides a checkpoint for physicians to review whether an explicit decision to sustain opioid therapy has been reached, and to ensure that a documented treatment plan and provisions for monitoring medication use and patient outcomes are in place.

Frequency and priority of pain patients' health care use.

BACKGROUND: Increased health care use by pain patients is largely due to conditions other than their identified pain condition, but the kinds of services accounting for increased service use are poorly understood. This study assesses reasons for health care visits of pain patients versus controls, and compares characteristics of pain patients who differ in frequency and priority of service use. METHODS: The study samples included consecutive, primary care back pain (N=807), headache (N=831), and temporomandibular disorder pain (N=372) patients who were interviewed by telephone. Subsequently, age-sex matched controls with a primary care visit in the 6 months before the matched case's pain visit were identified. Over the following 3 years, diagnostic codes for health care visits were classified based on the Oregon Prioritized List of Health Services and case-control differences in major classes of care were compared. Pain patients differing in frequency and priority of service use were compared on measures of pain severity, chronicity, and psychosocial dysfunction. RESULTS: Pain patients' increased health care use was sustained over 3 years. Increased utilization was largely due to symptomatic and ill-defined conditions, lower priority chronic disease, lower and higher priority acute disease, and mental health care. About one-half of the pain patients (vs. one-third of the controls) were frequent health care users. About one-third of the pain patients (vs. one-sixth of the controls) were frequent users who predominantly used medical care for lower priority conditions, and this difference accounted for most of the case-control difference in the prevalence of high users. Pain patients with frequent health care use had more severe pain and greater psychosocial dysfunction than pain patients with less frequent health care use. Among frequent users, pain patients who predominantly used services for lower priority conditions did not differ on measures of pain severity, chronicity, or somatization when compared with frequent users who typically used services for higher priority conditions. CONCLUSIONS: The kind of problems explaining heightened service use of pain patients is more varied and complex than previously understood. These results call for increased attention to the implications of health care providers responding to presenting complaints as if each were a unique problem, without bringing continuity or an integrating perspective to patients' overall experience and management of illness.

Cost-effectiveness of two self-care interventions to reduce disability associated with back pain.

STUDY DESIGN: Two randomized, controlled trials. OBJECTIVE: To evaluate the incremental cost-effectiveness of psychologist-led and lay-led interventions in reducing disability in 2 cohorts of primary care patients with back pain. SUMMARY OF BACKGROUND DATA: Although activating self-care interventions have been advanced as effective tools to reduce back pain-related activity limitations, few studies have evaluated the added costs of these programs relative to their added benefits. METHODS: We estimated the incremental benefits and incremental costs associated with 2 self-care interventions for primary care patients with back pain. Effectiveness was measured as the number of low-impact back pain days (i.e., days when patients were satisfied with their level of back pain) over a 1-year follow-up. Costs of back-pain related services were estimated from health plan cost data. Incremental cost-effectiveness ratios were calculated for each intervention to determine the costs associated with an additional low-impact back pain day. RESULTS: Patients assigned to the lay and psychologist interventions had a mean of 14.3 (95% confidence interval [CI] -2.7 to 30.9) and 26.2 (95% CI 9.1-44.4) additional low-impact back pain days, respectively, compared with patients receiving usual care. The incremental per-person costs of the lay-led and psychologist-led interventions were dollar 139 (95% CI - dollar 62.13 to dollar 321.76) and dollar 161 (95% CI dollar 51.18 to dollar 275.93), respectively. The mean cost of an additional low-impact back pain day was dollar 9.70 for the lay-led intervention and dollar 6.13 for the psychologist-led intervention. CONCLUSIONS: Both the lay and psychologist interventions were associated with modest improvements in outcomes but with somewhat higher costs compared to usual care.

Relationship of pain and symptoms to pubertal development in adolescents.

Temporomandibular disorder (TMD) pain, abdominal pain, migraine and tension-type headache are more prevalent in women than in men. This study assessed the relationship of back pain, headache, abdominal pain, TMD pain, and the presence of multiple pain conditions to gender and pubertal development in a cross-sectional, population-based survey of adolescents. We also examined the association between pubertal development and depressive and somatic symptoms, factors often associated with pain in adults. We hypothesized that prevalence of all pain conditions, as well as rates of other symptoms, would increase as puberty progresses in females, but not males. Subjects (3,101 boys and girls, 11-17 years old, selected from an HMO population) reported on the presence of each pain condition in the prior 3 months and completed scales assessing pubertal development, and depressive and somatic symptoms. Data were analyzed using descriptive statistics and multivariate logistic regression. Prevalence rates were weighted for factors affecting response. Prevalence of back pain, headache and TMD pain increased significantly (odds ratios, OR=1.4-2.0, P<0.001) and stomach pain increased marginally with increasing pubertal development in girls. Rates of somatization, depression and probability of experiencing multiple pains also increased with pubertal development in girls (P<0.0001). For boys, prevalence of back (OR=1.9, P<0.0001) and facial pain (OR=1.5, P<0.01) increased, stomach pain decreased somewhat and headache prevalence was virtually unchanged with increasing maturity. For both sexes, pubertal development was a better predictor of pain than was age. Thus it appears that pain, other somatic symptoms and depression increase systematically with pubertal development in girls.