Evaluation of intervention components to maximize yoga practice among people with chronic pain taking opioid agonist therapy: A factorial experiment using the multiphase optimization strategy framework.

BACKGROUND: Chronic pain affects up to half of individuals taking opioid agonist therapy (OAT; i.e., methadone and buprenorphine) for opioid use disorder (OUD), and yoga-based interventions may be useful for decreasing pain-related disability. Whereas more yoga practice (i.e., higher "dosage") may improve pain-related outcomes, it can be challenging for people with chronic pain taking OAT to attend class regularly and sustain a regular personal yoga practice. Therefore, we plan to optimize a yoga-based intervention (YBI) package in order to support class attendance and personal practice, thus maximizing the yoga dose received. STUDY DESIGN: Using the Multiphase Optimization Strategy (MOST) framework, we will conduct a factorial experiment to examine four intervention components that may be added to a weekly yoga class as part of a YBI. Components include: 1) personal practice videos featuring study yoga teachers, 2) two private sessions with a yoga teacher, 3) daily text messages to inspire personal practice, and 4) monetary incentives for class attendance. The primary outcome will be minutes per week engaged in yoga (including class attendance and personal practice). We plan to enroll 192 adults with chronic pain who are taking OAT for OUD in this 2x2x2x2 factorial experiment. CONCLUSION: Results of the study will guide development of an optimized yoga-based intervention package that maximizes dosage of yoga received. The final treatment package can be tested in a multisite efficacy trial of yoga to reduce pain interference in daily functioning in people with chronic pain who are taking OAT. TRIAL REGISTRATION: Pre-registration of the study was completed on ClinicalTrials.gov (identifier: NCT04641221).

Pharmacologic and Non-Pharmacologic Treatments for Chronic Pain Used by Patients with Pain, HIV, and Depression.

The objective of this study was to understand pain treatment utilization, perceived efficacy, and differences in utilization by gender, clinic site, chronicity of pain, pain severity, and depression severity among people living with HIV (PLWH), chronic pain, and elevated depression symptoms. Participants included 187 PLWH at three HIV clinics in the U.S. Overall, 85% of participants reported taking a pain medication. One quarter (25%) reported non-pharmacological professional treatments for pain (e.g., massage, physical therapy), 60% reported mind-body treatments, including exercise, meditation, and yoga, and 62% reported other non-pharmacological self-administered treatments (e.g., heat/cold). Most pain treatments were considered "slightly helpful" or "moderately helpful." Non-pharmacological self-administered treatments were more commonly used among women than men and among individuals with constant vs. intermittent pain. Further research is needed to evaluate the efficacy of the preferred analgesic modalities of PLWH.

Integrated substance use and prenatal care delivery in the era of COVID-19.

The COVID-19 pandemic has directly impacted integrated substance use and prenatal care delivery in the United States and has driven a rapid transformation from in-person prenatal care to a hybrid telemedicine care model. Additionally, changes in regulations for take home dosing for methadone treatment for opioid use disorder due to COVID-19 have impacted pregnant and postpartum women. We review the literature on prenatal care models and discuss our experience with integrated substance use and prenatal care delivery during COVID-19 at New England's largest safety net hospital and national leader in substance use care. In our patient-centered medical home for pregnant and postpartum patients with substance use disorder, patients' early responses to these changes have been overwhelmingly positive. Should clinicians continue to use these models, thoughtful planning and further research will be necessary to ensure equitable access to the benefits of telemedicine and take home dosing for all pregnant and postpartum patients with substance use disorder.

Categorizing Cannabis and Alcohol Use Patterns of Emerging Adults in Psychiatric Partial Hospitalization Treatment.

BACKGROUND: Emerging adulthood is a common and problematic time for alcohol and cannabis use. Emerging adulthood also represents a vulnerable time period for anxiety and depression. Substance use and mental health issues are highly comorbid, yet substance use is commonly neglected in psychiatric care. OBJECTIVE: The goal of this study was to categorize the cannabis and alcohol use patterns of emerging adults in psychiatric care and to evaluate relationships with use-related problems, psychiatric symptomatology, and motives for use. METHODS: Participants were emerging adults who were consecutive admissions to a young adult psychiatric partial hospital program from 2017 to 2018. Of 318 participants who completed questionnaires, 244 (76.7%) reported cannabis and/or alcohol use in the previous month. Cluster analyses and analysis of variance tests were conducted to categorize and differentiate between participants who reported use. RESULTS: Results from cluster analyses identified 4 categories of use: low cannabis/high alcohol (35.7%), low cannabis/low alcohol (17.6%), high cannabis/low alcohol (29.1%), and high cannabis/high alcohol (17.6%). Individuals in categories with the highest rates of use and co-use reported more alcohol problems (F=24.31, P<0.001), cannabis problems (F=36.75, P<0.001), depression (F=3.60, P=0.01), and motives: social (F=6.12, P<0.001), coping with anxiety (F=20.43, P<0.001), coping with depression (F=17.80, P<0.001), enhancement (F=7.85, P<0.001), and conformity (F=4.92, P<0.01). CONCLUSIONS/IMPORTANCE: Clear categories of substance use emerged. Participants who were heavier users were more likely to use to alleviate psychiatric symptomatology, yet they also reported greater psychiatric symptomatology and use-related problems. Among a psychiatric sample of emerging adults, cannabis and alcohol use was common and problematic. Thus, substance use should be evaluated for and, if present, targeted with interventions during psychiatric care.

Cost-effectiveness of integrating buprenorphine-naloxone treatment for opioid use disorder into clinical care for persons with HIV/hepatitis C co-infection who inject opioids.

BACKGROUND: Untreated opioid use disorder (OUD) affects the care of HIV/HCV co-infected people who inject opioids. Despite active injection opioid use, there is evidence of increasing engagement in HIV care and adherence to HIV medications among HIV/HCV co-infected persons. However, less than one-half of this population is offered HCV treatment onsite. Treatment for OUD is also rare and largely occurs offsite. Integrating buprenorphine-naloxone (BUP-NX) into onsite care for HIV/HCV co-infected persons may improve outcomes, but the clinical impact and costs are unknown. We evaluated the clinical impact, costs, and cost-effectiveness of integrating (BUP-NX) into onsite HIV/HCV treatment compared with the status quo of offsite referral for medications for OUD. METHODS: We used a Monte Carlo microsimulation of HCV to compare two strategies for people who inject opioids: 1) standard HIV care with onsite HCV treatment and referral to offsite OUD care (status quo) and 2) standard HIV care with onsite HCV and BUP-NX treatment (integrated care). Both strategies assume that all individuals are already in HIV care. Data from national databases, clinical trials, and cohorts informed model inputs. Outcomes included mortality, HCV reinfection, quality-adjusted life years (QALYs), costs (2017 US dollars), and incremental cost-effectiveness ratios. RESULTS: Integrated care reduced HCV reinfections by 7%, cases of cirrhosis by 1%, and liver-related deaths by 3%. Compared to the status quo, this strategy also resulted in an estimated 11/1,000 fewer non-liver attributable deaths at one year and 28/1,000 fewer of these deaths at five years, at a cost-effectiveness ratio of $57,100/QALY. Integrated care remained cost-effective in sensitivity analyses that varied the proportion of the population actively injecting opioids, availability of BUP-NX, and quality of life weights. CONCLUSIONS: Integrating BUP-NX for OUD into treatment for HIV/HCV co-infected adults who inject opioids increases life expectancy and is cost-effective at a $100,000/QALY threshold.

A developmental-based motivational intervention to reduce alcohol and marijuana use among non-treatment-seeking young adults: a randomized controlled trial.

AIMS: To test the hypothesis that among non-treatment-seeking emerging adults (EA) who both use marijuana and have alcohol binges, a brief, longitudinally delivered, developmentally based motivational intervention would show greater reductions in the use of these two substances compared with a health education control condition. DESIGN: Parallel, two-group, randomized controlled trial with follow-up interventions conducted at 1, 3, 6 and 9 months and final assessments at 12 and 15 months. SETTING: Hospital-based research unit in the United States. PARTICIPANTS: Community-based 18-25-year-olds who reported at least monthly binge drinking and at least weekly marijuana use. INTERVENTION: Motivational intervention (EA-MI) focused primarily on themes of emerging adulthood (identity exploration, instability, self-focus, feeling in-between, a sense of possibilities) and the subjects' relationship to substance use (n = 110) compared with an attention-matched health education control condition (n = 116). MEASUREMENTS: The primary outcomes were days of binge alcohol, marijuana and dual use day as measured using the timeline follow-back method analysing the treatment by time interaction to determine relative differences in the rate of change between intervention arms. FINDINGS: At baseline, the mean rate (days/30) of binge drinking was 5.23 (± 4.31) of marijuana use was 19.4 (± 10.0) and of dual (same day) use was 4.11 (± 4.13). Relative to baseline, there were reductions in the rate of binge alcohol use, marijuana use and days of combined binge alcohol and marijuana use (P < 0.001) at all follow-up assessments. However, the treatment × time interaction was not statistically significant for alcohol (P = 0.37), for marijuana (P = 0.07) or for dual use (P = 0.55). Averaged over all follow-ups, mean reductions in binge, marijuana and dual use days were 1.16, 1.45 and 1.08, respectively, in the health education arm, and 1.06, 1.69 and 0.96 in EA-MI. Bayes factors were < 0.01 for frequency of binge alcohol use and frequency of dual binge alcohol and marijuana and 0.016 for marijuana use. CONCLUSIONS: A brief, longitudinally delivered, developmentally based motivational intervention for young adults did not produce reductions in binge alcohol, marijuana use or dual use days relative to a control condition.

Chronic pain and depression among primary care patients treated with buprenorphine.

BACKGROUND: Pain and depression are each prevalent among opioid dependent patients receiving maintenance buprenorphine, but their interaction has not been studied in primary care patients. OBJECTIVE: We set out to examine the relationship between chronic pain, depression, and ongoing substance use, among persons maintained on buprenorphine in primary care settings. DESIGN: Between September 2012 and December 2013, we interviewed buprenorphine patients at three practice sites. PARTICIPANTS: Opioid dependent persons at two private internal medicine offices and a federally qualified health center participated in the study. MAIN MEASURES: Pain was measured in terms of chronicity, with chronic pain being defined as pain lasting at least 6 months; and in terms of severity, as measured by self-reported pain in the past week, measured on a 0-100 scale. We defined mild chronic pain as pain severity between 0 and 39 and lasting at least 6 months, and moderate/severe chronic pain as severity ≥ 40 and lasting at least 6 months. To assess depression, we used the Center for Epidemiologic Studies Depression (CESD) ten-item symptom scale and the two-item Patient Health Questionnaire (PHQ-2). KEY RESULTS: Among 328 participants, 169 reported no chronic pain, 56 reported mild chronic pain, and 103 reported moderate/severe chronic pain. Participants with moderate/severe chronic pain commonly used non-opioid pain medications (56.3%) and antidepressants (44.7%), yet also used marijuana, alcohol, or cocaine (40.8%) to help relieve pain. Mean CESD scores were 7.1 (±6.8), 8.3 (±6.0), and 13.6 (±7.6) in the no chronic, mild, and moderate/severe pain groups, respectively. Controlling for covariates, higher CESD scores were associated with a higher likelihood of moderate/severe chronic pain relative to both no chronic pain (OR = 1.09, p < 0.001) and mild chronic pain (OR = 1.06, p = 0.04). CONCLUSION: Many buprenorphine patients are receiving over-the-counter or prescribed pain medications, as well as antidepressants, and yet continue to have significant and disabling pain and depressive symptoms. There is a clear need to address the pain-depression nexus in novel ways.

Perceived stress and substance use in methadone-maintained smokers.

BACKGROUND: In methadone maintenance treatment programs (MMTPs), 80-90% of participants smoke cigarettes. Patients in MMTPs are at particular risk for life stress, and nicotine, as well as other substances like alcohol, benzodiazepines, cocaine, marijuana, and opiates have been shown to reduce the effects of stress. Use of these addictive substances to cope with stress may precipitate illicit opiate relapse in MMTP patients. In the current study, we examined the relationship between perceived stress and substance abuse. METHODS: Participants were 315 cigarette smokers recruited from nine MMTPs for a smoking cessation study. Logistic regression was used to evaluate the adjusted association of perceived stress with dichotomous indicators of hazardous alcohol use and recent substance use at baseline. RESULTS: After controlling for demographic and smoking-related variables, perceived stress was associated positively and significantly with the likelihood of screening positive for hazardous drinking or alcohol-related problems (OR=1.13, 95%CI 1.02; 1.25), with the likelihood of recent cocaine use (OR=1.18, 95%CI 1.02; 1.37), and with the likelihood of recent benzodiazepine use (OR=1.24, 95%CI 1.07). CONCLUSIONS: Perceived stress may be a marker of patients' risk for illicit substance use, a known risk factor for illicit opiate relapse. These findings indicate that cigarette use might not be sufficient in managing stress and methadone-maintained persons turn to other substances for relief.

Motivational and mindfulness intervention for young adult female marijuana users.

This pilot study tested the efficacy of a brief intervention using motivational interviewing (MI) plus mindfulness meditation (MM) to reduce marijuana use among young adult females. Thirty-four female marijuana users between the ages of 18 and 29 were randomized to either the intervention group (n = 22), consisting of two sessions of MI-MM, or an assessment-only control group (n = 12). The participants' marijuana use was assessed at baseline and at 1, 2, and 3 months posttreatment. Fixed-effects regression modeling was used to analyze treatment effects. Participants randomized to the intervention group were found to use marijuana on 6.15 (z = -2.42, p = .015), 7.81 (z = -2.78, p = .005), and 6.83 (z = -2.23, p = .026) fewer days at Months 1, 2, and 3, respectively, than controls. Findings from this pilot study provide preliminary evidence for the feasibility and effectiveness of a brief MI-MM for young adult female marijuana users.

A brief marijuana intervention for non-treatment-seeking young adult women.

We randomized 332 women, 18-24 years old, who were not explicitly seeking treatment for their marijuana use to either a two-session motivationally focused intervention or an assessment-only condition. Assessed by timeline follow-back methodology, participants reported using marijuana 57% of days in the 3 months prior to study entry. Intervention effects on the likelihood of marijuana use were not statistically significant at 1 month (odds ratio [OR] = 0.77, p = .17), significant at 3 months (OR = 0.53, p = .01), and no longer significant at 6 months (OR = 0.74, p = .20). Among the 61% of participants endorsing any desire to quit using marijuana at baseline, significant intervention effects on the likelihood of marijuana use days were observed at 1 month (OR = 0.42, p = .03), 3 months (OR = 0.31, p = .02), and 6 months (OR = 0.35, p = .03). A two-session brief motivational intervention reduced marijuana use among young women not seeking treatment. Women with a desire to quit showed a greater and more durable response.

Marijuana use among young women in a primary care setting.

OBJECTIVE: To evaluate the prevalence of marijuana use among young women, ages 18-24, within a primary care setting. DESIGN: From 2/05 to 12/05, women completed a brief, anonymous self-report screening instrument in two urban primary care clinics for potential participation in a randomized controlled trial of an intervention to reduce marijuana use and sexual risk-taking behavior. During the last few months of recruitment, women who completed the screening instrument were also asked to provide a urine sample to test for the presence of marijuana and other drugs. RESULTS: Of the 607 women who completed the screening instrument, 38.6% reported lifetime marijuana use, 8.4% used marijuana at least monthly, and 1.7% reported using marijuana daily. Within this ethnically diverse sample (45% Hispanic), women who used marijuana at least monthly were more likely to smoke cigarettes (OR = 2.03, 95% CI = 1.04, 3.96), binge drink at least once a month (OR = 2.66, 95% CI = 1.34, 5.28), and to have ever used other drugs (OR = 2.91, 95% CI = 1.31, 6.45). Of the 67 urine samples provided, 60 (89.6%) were concordant with self-reported use, but six of the seven discordant samples were positive despite negative self-report. CONCLUSIONS: The prevalence of marijuana use and binge drinking in this ethnically diverse sample of young, female primary care patients was lower than rates reported in national surveys. Providers should consider marijuana use as a part of a process that addresses more prevalent high-risk behaviors, bearing in mind that these behaviors may be underreported during routine screening.

Physician attitudes regarding the prescription of medical marijuana.

Surveys of physicians' attitudes regarding the therapeutic value of marijuana are rare. Drawing on a national sample of family physicians, general internists, obstetrician-gynecologists, psychiatrists, and addiction specialists, 960 (adjusted response rate 66%) offered opinions about the legal prescription of marijuana as medical therapy. Thirty-six percent believed prescribed marijuana should be legal and 26% were neutral to the proposition. Non-moralistic attitudes toward substance use were significantly associated with support for physician prescription, as was internal medicine and obstetrics-gynecology specialization. Physicians are, in general, less supportive than the general American public regarding the use of medical marijuana.

Use and assessment of complementary and alternative therapies by intravenous drug users.

Intravenous drug users often have many health conditions in addition to their drug addiction, yet may be isolated from conventional sources of care. They have never before been examined for their use of complementary and alternative medicine (CAM) therapies. Our purpose was to study the prevalence and predictors of CAM use among persons with a history of intravenous drug use through a cross-sectional survey of intravenous drug users examining their utilization of health services, including CAM therapies. A total of 548 persons with a history of intravenous drug use, recruited from a needle-exchange program and a methadone maintenance clinic, both in Providence, Rhode Island, participated. Overall prevalence of any CAM use in the past 6 months, frequency of use of individual named CAM therapies and domains, and demographic and clinical characteristics associated with CAM users, reasons for CAM use and self-perceived effectiveness of CAM were also measured. Of the 548 participants, 45% reported use of at least one CAM therapy. The top three therapies--religious healing, relaxation techniques, and meditation--were all from the mind-body domain. Having a higher education and lower self-rated health were the two strongest predictors of CAM use, followed by having a regular doctor or clinic, being white and younger. There was a high level of self-perceived effectiveness of CAM therapies (4.1 on a scale of 1-5), and CAM users were likely to use CAM for reasons related to their addiction.

Effect of primary medical care on addiction and medical severity in substance abuse treatment programs.

OBJECTIVE: To examine whether the availability of primary medical care on-site at addiction treatment programs or off-site by referral improves patients' addiction severity and medical outcomes, compared to programs that offer no primary care. DESIGN: Secondary analysis of a prospective cohort study of patients admitted to a purposive national sample of substance abuse treatment programs. SETTING: Substance abuse treatment programs in major U.S. metropolitan areas eligible for demonstration grant funding from the federal Substance Abuse and Mental Health Services Administration. RESPONDENTS: Administrators at 52 substance abuse treatment programs, and 2,878 of their patients who completed treatment intake, discharge, and follow-up interviews. MEASUREMENTS: Program administrators reported whether the program had primary medical care available on-site, only off-site, or not at all. Patients responded to multiple questions regarding their addiction and medical status in intake and 12-month follow-up interviews. These items were combined into multi-item composite scores of addiction and medical severity. The addiction severity score includes items measuring alcohol and drug use, employment, illegal activities, legal supervision, family and other social support, housing, physical conditions, and psychiatric status. The medical severity score includes measures of perceived health, functional limitations, and comorbid physical conditions. MAIN RESULTS: After controlling for treatment modality, geographic region, and multiple patient-level characteristics, patients who attended programs with on-site primary medical care experienced significantly less addiction severity at 12-month follow-up (regression coefficient, -25.9; 95% confidence interval [95% CI], -43.2 to -8.5), compared with patients who attended programs with no primary medical care. However, on-site care did not significantly influence medical severity at follow-up (coefficient, -0.28; 95% CI, -0.69 to 0.14). Referral to off-site primary care exerted no detectable effects on either addiction severity (coefficient, -9.0; 95% CI, -26.5 to 8.5) or medical severity (coefficient, -0.03; 95% CI, -0.37 to 0.44). CONCLUSIONS: On-site primary medical care improves substance abuse treatment patients' addiction-related outcomes, but not necessarily their health-related outcomes. Further study is needed to discern the mechanism through which on-site primary care might improve the addiction-related outcomes of substance abuse treatment.

Delay in obtaining conventional healthcare by female internal medicine patients who use herbal therapies.

The use of herbal products has been studied in the general population, but few studies have focused on the prevalence of herbal therapy use for treatment of symptoms or disease among female internal medicine patients or on predictors for delaying obtaining conventional care while using herbal therapy. Cross-sectional 34-item self-report surveys were mailed to female patients in two private practice internal medicine sites and interviewer administered to patients in a resident ambulatory clinic. The survey included sociodemographics, medical problems, use of herbal therapies, and whether conventional care was delayed while using herbal therapy. Of 354 patients, 220 (62%) participated. Their mean age was 51 years, and most were Caucasian (77%) and had more than a high school education (60%). Of these, 81 (37%) women used herbal therapies for treatment of symptoms or disease, and use did not differ by study site. Twenty-six (32%) delayed obtaining conventional care while waiting for an herbal product to work, although most eventually obtained conventional care. In multivariate analysis, predictors for delay of care included negative experience with prescription medicines, history of failed treatments, and desire for increased control over personal healthcare. Among female patients of general internists, there was a high prevalence of herbal therapy use for treatment of illness, and some women delay obtaining conventional care while using an herbal product. Predictors for delay may alert physicians to educate their patients before delaying care.