Integrating DATA 2000 waiver training into undergraduate medical education: The time is now.

Background: Medications for opioid use disorder (MOUD) significantly reduce morbidity and mortality from opioid use disorder (OUD). To prescribe MOUD, physicians must obtain a DEA waiver through requirements outlined in the Drug Addiction Treatment Act of 2000 (DATA 2000). We developed an Addiction Medicine curriculum that features DATA 2000 waiver training at the Robert Larner, MD College of Medicine (LCOM). Methods: All third-year medical students completed a virtual DATA 2000 waiver training at the commencement of clinical clerkships. We conducted a curriculum needs assessment followed by pre- and post-training surveys to evaluate MOUD pharmacology knowledge and best prescribing practices. Results: Of LCOM students surveyed, 77.6% reported interest in being waivered to prescribed MOUD for OUD treatment. Third-year medical students demonstrated increases in both MOUD Pharmacology Knowledge from 64.2% to 84.8% (chi-squared = 40.8; p < .001) and MOUD Best Prescribing Practices from 55.9% to 75.2% (chi-squared = 29.9; p < .001). Discussion: Surveys showed the majority of students felt waiver training was relevant to their future practice. An online DATA 2000 waiver training format effectively improved student knowledge of MOUD. Conclusion: This curriculum exposed medical students to DATA 2000 waiver training, MOUD pharmacology and best practices, and increased the number of future physicians eligible to treat OUD using MOUD.

Commentary: Opioid use disorder and suicide: An important opportunity to address two significant public health epidemics.

Nationwide, the opioid epidemic continues to have a significant and widespread adverse impact on morbidity and mortality. The number of individuals dying by suicide and unintentional overdose has continued to increase over the past decade, with opioids being involved in a significant proportion of each category of mortality in 2017. Currently, most strategies for decreasing opioid-overdose deaths do not include systematic screening for suicide risk, nor do they address the necessity to customize interventions for those who misuse opioids to decrease near-term suicide risk (defined here as less than 72 h) factors. Improved screening of near-term and chronic suicide risk along with rapid access to treatment is of critical importance to prevent opioid-related deaths by suicide.

COVID-19: A new barrier to treatment for opioid use disorder in the emergency department.

OBJECTIVE: Start Treatment and Recover (STAR) is an emergency department (ED) program that expands access to medication for opioid use disorder by identifying patients with opioid use disorder and offering ED-initiated buprenorphine/naloxone and rapid access to outpatient treatment. We sought to determine the impacts of the coronavirus disease 2019 pandemic on STAR and the patients with opioid use disorder it serves. METHODS: We conducted a retrospective review of records comparing 2 periods: pre-pandemic (February 1, 2019-February 29, 2020) and pandemic (March 1, 2020-May 31, 2020). Variables evaluated included the number of STAR enrollments, ED census, percentage of census screening positive for opioid use disorder, number and percentage of ED overdose visits, and overdose fatalities by month. All analyses were conducted using 2-sample t tests to calculate the mean and 95% confidence intervals (CIs). RESULTS: Comparing the pre-pandemic to the pandemic period, the mean monthly ED visits decreased from 5126.9 to 3306.7 (difference = -1820.3; 95% CI, -3406.3 to -234.2), STAR mean monthly enrollments decreased from 9.7 to 1.3 (difference = -8.4; 95% CI, -12.8 to -4.0), and statewide monthly opioid-related fatalities increased from 9.4 to 15.3 (difference = 5.9; 95% CI, 0.8 to 11.1). However, the percentage of individuals who presented to the ED with opioid use disorder or overdose remained unchanged. CONCLUSION: Although overall ED visits declined during the pandemic period, the percentage of patients presenting with opioid use disorder or overdose remained constant, yet there was a dramatic decline in enrollment in ED-initiated medication for opioid use disorder and an increase in statewide monthly opioid-related fatalities. Strategies to maintain medication for opioid use disorder treatment options must be implemented for this vulnerable population during the ongoing pandemic.

Prescription opioid policies and associations with opioid overdose and related adverse effects.

BACKGROUND: United States (US) policies to mitigate the opioid epidemic focus on reducing access to prescription opioids to prevent overdoses. We examined the impact of state policies in Vermont (July 2017) and Maine (July 2016) on opioid overdoses and opioid-related adverse effects. METHODS: Study population included patients 15 years and older in all-payer claims of Vermont (N = 597,683; Jan.2016-Dec.2018) and Maine (N = 1,370,960; Oct.2015-Dec.2017). We used interrupted time series analyses to assess the impact of opioid prescribing policies on monthly opioid overdose rate and opioid-related adverse effects rate. We used the International Classification of Disease-10-CM to identify overdoses (T40.0 × 1-T40.4 × 4, T40.601-T40.604, T40.691-T40.694) and adverse effects (T40.0 × 5, T40.2 × 5-T40.4 × 5, T40.605, T40.695). RESULTS: Immediately after the policy, the level of Vermont's opioid overdose rate increased by 34% (95% confidence interval, CI: 1.09, 1.65) while the level of opioid-related adverse effects rate decreased by 29% (95% CI: 0.58, 0.87). In Maine, there was no level change in opioid overdose rate, but the slope of the adverse effects rate after the policy decreased by 3.5% (95% CI: 0.94, 0.99). These results varied within age and rurality subgroups in both states. CONCLUSION: While the decrease in rate of adverse effects following the policy changes is promising, the increase in Vermont's opioid overdose rate may suggest there is an association between policy implementation and short-term risk to public health.

Suicide Risk Assessment in Hospitals: An Expert System-Based Triage Tool.

BACKGROUND: The November 2010 Joint Commission Sentinel Event Alert on the prevention of suicides in medical/surgical units and the emergency department (ED) mandates screening every patient treated as an outpatient or admitted to the hospital for suicide risk. Our aim was to develop a suicide risk assessment tool to (1) predict the expert psychiatrist's assessment for risk of committing suicide within 72 hours in the hospital, (2) replicate the recommended intervention by the psychiatrist, and (3) demonstrate acceptable levels of participant satisfaction. METHODS: The 3 phases of tool development took place between October 2012 and February 2014. An expert panel developed key questions for a tablet-based suicide risk questionnaire. We then performed a randomized cross-sectional study comparing the questionnaire to the interview by a psychiatrist, for model derivation. A neural network model was constructed using 255 ED participants. Evaluation was the agreement between the risk/intervention scores using the questionnaire and the risk/intervention scores given by psychiatrists to the same patients. The model was validated using a new population of 124 participants from the ED and 50 participants from medical/surgical units. RESULTS: The suicide risk assessment tool performed at a remarkably high level. For levels of suicide risk (minimal or low, moderate, or high), areas under the curves were all above 0.938. For levels of intervention (routine, specialized, highly specialized, or secure), areas under the curves were all above 0.914. Participants reported that they liked the tool, and it took less than a minute to use. CONCLUSIONS: An expert-based neural network model predicted psychiatrists' assessments of risk of suicide in the hospital within 72 hours. It replicated psychiatrist-recommended interventions to mitigate risk in EDs and medical/surgical units.

Barriers to pediatric lead screening: implications from a web-based survey of Vermont pediatricians.

The pernicious effects of lead on child health are well documented. The Vermont Department of Health (VDH) recommends screening all 12- and 24-month-old children for elevated blood lead levels (BLL). In 2006, only 41.4% of 24-month-old Vermont children were screened. To identify barriers preventing pediatricians from performing blood lead screening, a survey was distributed to Vermont primary care pediatricians-divided in higher and lower screening groups. Vermont pediatricians were more likely to be lower screeners if they reported negative health outcomes began at BLL >" xbd="641" xhg="618" ybd="1456" yhg="1421"/> 10 microg/dL (odds ratio [OR] = 3.64, 95% confidence interval [CI] = 1.12-11.99), practiced in Chittenden County (OR = 3.34, 95% CI = 1.14-9.78), or disagreed with the VDH's recommendation (OR = 4.90, 95% CI = 1.66-15.50). Adjusted analysis indicated the most significant determinants of lower screening rates were male gender, a perceived dangerous BLL as >10 microg/dL and low self-reported Medicaid population. The VDH may have an opportunity to increase BLL screening emphasizing the significant health risks associated with BLL < or = 10 microg/dL.