Pregnancy Rates Among Women Treated with Medication for Opioid Use Disorder.

BACKGROUND: Treatment-seeking people with opioid use disorder (OUD) who are capable of pregnancy need accurate information about the potential impact of medication to treat OUD (MOUD) on fertility to make informed choices about treatment that are consistent with their reproductive wishes. There is a dearth of research on fertility associated with MOUD receipt in birthing people with OUD. OBJECTIVE: To estimate the association between treatment with MOUD and odds of conception among birthing people using national administrative claims. DESIGN: Retrospective case-crossover study using multi-state US administrative data (2006-2016). Dates of conception were estimated from delivery dates and served as "case" days for which MOUD exposures were compared to those on all other ("control") days of insurance enrollment. PARTICIPANTS: Treatment-seeking people with OUD with a delivery during the observation period. MAIN MEASURES: Odds ratios for conception from within-person fixed effects models were modeled as a function of exposure to MOUD (buprenorphine, methadone, extended-release depot naltrexone, or oral naltrexone) using conditional logistic regression. KEY RESULTS: A total of 21,928 births among 19,133 people with OUD were identified. In the sample, 5873 people received buprenorphine, 1825 methadone, 486 extended-release naltrexone, and 714 oral naltrexone. Participants could receive more than one type of MOUD. Mean age was 28.2 years (SD = 2.2; range = 16-45), with 76.2% having Medicaid. vs. commercial insurance. Compared to no MOUD, periods of methadone (aOR = 0.55 [95% CI = 0.48-0.63]) or buprenorphine receipt (aOR = 0.84 [0.77-0.91]) were associated with fewer conceptions. Treatment periods with extended-release depot naltrexone compared to no medication were associated with higher odds of conception (aOR = 1.75 [1.22-2.50]) and there was no significant difference in conception with oral naltrexone (aOR = 1.02 [0.67-1.54]). CONCLUSIONS: The association between MOUD and odds of conception among birthing people varied by type of MOUD, with extended-release naltrexone associated with higher odds of conceiving compared to no treatment. Clinical studies are urgently needed to investigate these findings further.

Depression and Time to Knee Arthroplasty Among Adults Who Have Knee Osteoarthritis.

BACKGROUND: Depression is common in osteoarthritis (OA) and is associated with poor outcomes following total knee arthroplasty (TKA). Depression can increase pain sensitivity and may be related to an increased likelihood of TKA. METHODS: Nationally distributed electronic health record data from 2010 to 2018 were used to identify eligible patients (n = 9,466) who had knee OA and were 45 to 80 years of age. Cox proportional hazard models were computed to estimate the association between depression and incident TKA for all patients and by age group (45 to 54, 55 to 64, and 65 to 80 years of age). Confounding was controlled using entropy balancing. Sensitivity analyses determined if the association between depression and TKA differed when depression occurred in the 12 months occurring 90, 60, 30, and 0 days lag time before TKA. RESULTS: The mean age of the sample was 63 (range, 45 to 80), 64.0% were women, 83.3% were White race, and approximately 50% resided in the Midwest. There was no association between depression and incident TKA (hazard ratio = 0.97; confidence interval = 0.81 to 1.16]). Results did not differ in age-stratified analyses. Sensitivity analyses revealed a higher percentage of TKA among depressed versus nondepressed patients (24.2 versus 21.6%; P = .028) when the patient's depression diagnosis was established in the 12 months with no lag time before TKA. CONCLUSIONS: Patients who have knee OA and comorbid depression, compared to those who have only knee OA, do not have an increased likelihood of TKA. The multifactorial, complex decision to obtain TKA does not appear to be influenced by depression, but depression is a common comorbidity.

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.

Erectile dysfunction associated with undiagnosed prediabetes and type 2 diabetes in young adult males: A retrospective cohort study.

Erectile dysfunction (ED) is a common comorbidity in type 2 diabetes (T2D). ED has been studied as an outcome in diabetes, but it is not known if ED is a risk factor for T2D. We determined if patients with ED have an increased risk for prediabetes and/or T2D and measured the duration between ED and prediabetes/T2D diagnosis. Retrospective cohort study using de-identified medical record data from a large mid-western health care system to measure ED, T2D and potential confounding factors. Patients were 18 to 40 years of age because we were interested in early onset pre-diabetes/T2D. Eligible patients had ED and were free of prediabetes, hyperglycemia and T2D at index. Entropy balancing controlled for confounding. Modified Poisson regression models with robust error variances calculated relative risk (RR) and 95% confidence intervals for the association of ED and pre-diabetes/T2D. Patients' mean age was 28.3 (±7.0) years, 81.7% were White and 14.0% were Black. After controlling for confounding, ED was associated with increased risk for prediabetes/T2D (RR = 1.34; 95%CI:1.16-1.55). This association was similar to that between ED and T2D alone (RR = 1.38; 95% CI: 1.10-1.74). About 30% had ED and prediabetes/T2D diagnosed on the same day and nearly 75% were diagnosed within a year of ED. ED is a marker for undiagnosed prediabetes/T2D and a risk factor for near term onset of prediabetes/T2D. ED may offer the opportunity for earlier detection and diagnoses of T2D, particularly in younger men. Younger patients presenting with ED should be screened for hyperglycemia.

Temporal Location of Changes in the US Suicide Rate by Age, Ethnicity, and Race: A Joinpoint Analysis 1999-2020.

ABSTRACT: Suicide rates differ over time. Our objective was to determine when significant changes occurred by age, race, and ethnicity in the United States between 1999 and 2020. National Center for Health Statistics WONDER data were used in joinpoint regression. The annual percent change in suicide rate increased for all race, ethnic, and age groups, except for those 65 years and older. For American Indian/Alaska Natives, the largest increase occurred between 2010 and 2020 for those with ages 25 to 34 years. For Asian/Pacific Islander, the largest increase occurred among those 15 to 24 years old between 2011 and 2016. For Black/African-Americans, the largest increases occurred between 2010 and 2020 among 15- to 34-year-olds. For Whites, the largest increase occurred between 2014 and 2017 among 15- to 24-year-olds. Between 2018 and 2020, suicide rates significantly declined among Whites 45 to 64 years of age. Among Hispanics, significant increases in suicide rate occurred between 2012 and 2020 among those with ages 15 to 44 years. Between 1999 and 2020, the contour of suicide burden varied by age groups, race, and ethnicity.

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.

Achievement of glycemic control and antidepressant medication use in comorbid depression and type II diabetes.

Context: Limited previous work has suggested that treatment of co-morbid patients with anti-depressant medication (ADM) is associated with improved glycemic control. Objective: To determine the association of ADM treatment on glycemic control at 3 time periods after diagnosis of diabetes. Study Design: Retrospective cohort study. Analysis: Propensity scores (PS) and inverse probability of treatment weighting (IPTW) controlled for confounding. Extended Cox models measured the association between adequate, inadequate vs. no treatment and glycemic control at 0 to 36 months, 36 to 72 months and ≥72 months. Dataset: Optum®, a nationally distributed source dataset with a random sample of 5 million patients ≥18 years of age, from which we used de-identified data for 2011-2017. Population Studied: Eligible patients aged 18-64 had type 2 diabetes (T2DM) with poor glycemic control, and diagnosis of depression at least one year prior to diagnosis of T2DM. Exclusion criteria included steroid use, HIV, cancer, and inadequate data. 7,332 patients meeting inclusion criteria were identified. Intervention: ADM treatment (identified by patient prescriptions within the EHR) was defined as adequately treated (≥12 weeks of antidepressants), inadequately treated (<12 weeks) or untreated. Outcome Measures: Glycemic control was defined as A1c<7.0%. Outcome was achievement of glycemic control at 0 to 36 months, 36 to 72 months and ≥72 months. Results: After controlling for confounding, compared to no ADM treatment, adequate ADM treatment was significantly associated with achieving glycemic control within 36 months (HR 1.17, 95% CI 1.02-1.34). No association was observed beyond 36 months. There was no association between inadequate vs. no treatment and glycemic control. Conclusions: Receipt of adequate ADM therapy is associated with achieving glycemic control in the first 3 years after a T2DM diagnoses with uncontrolled A1c.

Lower dementia risk in patients vaccinated against herpes zoster.

Context: Herpes zoster (HZ) infection increases dementia risk but it is not known if HZ vaccination is associated with lower risk for dementia. Objective: Determine if patients with HZ vaccination vs. those who remain unvaccinated, have a lower risk for dementia in a cohort of Veterans Health Administration (VHA) patients. Replicate results in a private sector, medical claims patient cohort. Study Design: Retrospective cohort. Competing risk (VHA) and Cox proportional hazard (MarketScan) models estimated the association between HZ vaccination and incident dementia in all patients and in age (65-69, 70-74, ≥75) and race (White, Black, Other) sub-groups. Expanded models accounted for the effect of antivirals and HZ infection between index and end of follow-up. Sensitivity analysis measured the association between HZ vaccination and incident Alzheimer's dementia (AD). E-values computed to test for bias due to unmeasured confounding and selection bias. Setting/Data set: VHA cohort (10/1/2008 - 9/30/2019) with replication in MarketScan® commercial and Medicare claims (1/1/2009-12/31/2018). Population studied: Eligible patients (VHA n=136,016; MarketScan n=172,790) were ≥65 years of age and free of dementia for two years prior to baseline. All patients had 3 or more 'well visits' to control for confounding related to use of preventive health care services. Outcome measures: Incident dementia. Results: VHA patients were 75.6 (SD±7.5) years of age, 4% female, and 91.2% were white race. MarketScan patients were 69.8 (SD±5.6) years of age, on average and 65.4% were female. years of age on average, 65.0% were female. After controlling for confounding, HZ vaccination compared with no vaccination, was significantly associated with lower dementia risk (VHA HR= 0.69; 95%CI: 0.67-0.72; MarketScan HR=0.65; 95%CI:0.57-0.74). No difference in outcomes were observed by race and HZ vaccination was associated with lower AD risk. Results were stable after adjusting for antivirals and HZ infection. E-values indicated results are not explained by selection bias or unmeasured confounding. Conclusions: Among patients ≥65 years of age, HZ vaccination is associated with a 31-35% reduced risk of dementia. Confirmation in other study designs is warranted. Results may be explained by nonspecific neuroprotection and vaccination training the immune system to limit damaging inflammation. Results highlight the importance of HZ vaccination.

PTSD symptom improvement and smoking cessation among a sample of veterans.

Context: Poor health behaviors are common in persons with posttraumatic stress disorder (PTSD). PTSD symptom improvement has been followed by better health behaviors such as medication adherence and use of nutrition, weight loss, and substance abuse treatment programs. Whether PTSD improvement is associated with smoking cessation is uncertain. Objective: To determine if patients with, compared to without, clinically meaningful improvement (≥20 points vs. <20 points) in PTSD Checklist (PCL) scores are more likely to stop smoking. Study Design: Retrospective cohort using entropy balancing to control for confounding in Cox proportional hazard models overall and stratified by depression and alcohol abuse/dependence. Dataset: Veterans Health Affairs (VHA) medical record data from 2008-2015. Population studied: Patients aged 18-70 years with PTSD who had ≥ 1 visit to PTSD specialty care with a PCL score ≥50, at least one PCL score from ≥8 weeks to 12 months following first PCL≥50 ('exposure year'), and persistent smokers in the exposure year (n=449). Index date is the end of the exposure year. Intervention/Instrument: Change from first to last PCL score in exposure year classified as clinically meaningful vs. less than clinically meaningful improvement (≥20 point decrease vs. <20 point decrease). Outcome measures. Time to smoking cessation as documented in VHA administrative medical record data in the 2-years after index. Follow-up time was measured as months from index to either smoking cessation or censoring. Results: Overall, patients were 39.4 (±12.9) years old, 71.5% white, 86.6% male, 19.8% had a clinically meaningful PCL score decrease, and 32.7% quit smoking in the 2-years after index. After entropy weighting, PCL decrease ≥ 20 vs. < 20 was associated with a 57% increased likelihood of smoking cessation (HR=1.57; 95% CI=1.04-2.36). The relationship of PTSD improvement with smoking cessation was similar in patients with vs. without depression and with and without alcohol abuse/dependence. Among patients who quit smoking, about half remained non-smokers in the 12-months after initial quit date. Conclusions: A clinically meaningful reduction in PTSD symptoms was associated with smoking cessation in the 2-years after PTSD improvement. Not all patients with PTSD have access to PTSD treatment modalities that integrate smoking cessation therapy; however, PTSD treatment alone may improve patient self-efficacy and enable smoking cessation.

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.

Infant, pediatric and adult well visit trends before and during the COVID-19 pandemic: a retrospective cohort study.

BACKGROUND: Adult well visits declined during COVID-19, but literature is inconsistent in regard to whether childhood well visits declined. We determined if the COVID-19 pandemic was associated with a change in well visits among infants, children, adolescents and adults before, compared to during the COVID-19 pandemic, including through the emergence of the Delta variant. METHODS: De-identified electronic health care data came from a multi-state Midwest health care system. Eligible patients (n = 798,571) had ≥ 1 well visit between 7/1/2018 and 6/30/2021. Trends in well visits per month for children (< 1, 1-4, 5-11, 12-17 years) and adults (18-39, 40-64, ≥ 65 years) over 3-years were assessed using Joinpoint regression models and monthly percent change (MPC). RESULTS: Well visits remained stable for infants (< 1 year of age) (MPC = -0.1; 95% CI = -0.3, 0.1). For children 1-4 years and all adults, visits were stable prior to 2020, decreased from 1/2020 to 4/2020 (MPC range -20 to -40), increased from 4/2020-7/2020 (MPC range 30 to 72), and remained stable after 7/2020. Children 5-17 had seasonal variation in visits where low points occurred in Jan/Feb 2019 and high points in Aug 2019 (start of school year); however, the low point in 2020 occurred in April 2020 and the seasonal variation normalized after this. CONCLUSIONS: In a large Mid-western health care system, infant well visits did not decline at the onset (3/1/2020) of the COVID-19 pandemic. Although well visits for all other ages decreased to a low point in 4/2020, a rapid return to pre-pandemic utilization rates occurred by 7/2020. The brief decrease in preventive care may have had little impact on health.

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.

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.

Risk of incident dementia following metformin initiation compared with noninitiation or delay of antidiabetic medication therapy.

PURPOSE: Emerging evidence suggests metformin compared with sulfonylurea is associated with an 8% to 10% lower risk for dementia. Guidelines recommend metformin as initial diabetes treatment, but there is still the question of treatment timing. Thus, the risk of dementia associated with initiating metformin compared with not initiating or delaying treatment was examined. METHODS: A retrospective cohort study (1996 to 2015) was conducted with electronic health records from Veteran Health Affairs (VHA; n = 112 845) and Kaiser Permanente Washington (KPW; n = 14 333) healthcare systems. Patients were aged ≥50 years, had a hemoglobin A1c (HbA1c) between 6.5 and <9.5 mg/dL, and did not have dementia or fills for antidiabetic medications before cohort entry. Initiators started metformin monotherapy and noninitiators used no antidiabetic medications in the 6 months after the first qualifying HbA1c. The primary outcome was incident dementia. Propensity scores and inverse probability of treatment weighting (IPTW) controlled for confounding in Cox proportional hazards models. RESULTS: During a median follow-up of 6.2 years in VHA and 6.8 years in KPW, there were 7547 new dementia cases in VHA and 1090 in KPW. After IPTW, there was no association between initiation of metformin (vs no initial treatment) and incident dementia in VHA (HR = 1.04; 95% confidence interval [CI]: 0.95-1.13) or KPW (HR = 0.81; 95% CI: 0.51-1.28). Results did not differ by age, baseline HbA1c, or race. CONCLUSIONS: Results do not support initiating metformin earlier to prevent cognitive decline and, thus, may dampen enthusiasm for metformin as a potential antidementia drug. Randomized clinical trials could help clarify the relationship between metformin and cognitive decline.

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.

In sickness and in health: partner's physical and mental health predicts cortisol levels in couples.

Individuals in stable relationships tend to be healthier than those not in stable relationships. Despite this general positive influence of relationships on health, the mechanisms for the impact of relationship quality on health are not clear. Research has focused on many factors to explain this connection, including inter- and intra-couple dynamics of physiology and behavior. To address this issue, we examined the relationship between perceived health, depressive symptoms, and relationship quality on diurnal cortisol in 30 male/female romantic dyads (N = 60). Participants provided saliva samples on two weekdays to assess total cortisol output. Females' lower perceived physical health, lower relationship satisfaction, and higher depression scores were each related to higher cortisol output in their male partners. Males' physical health, relationship satisfaction, and depression scores were unrelated to females' cortisol output. Further, physical health, relationship satisfaction, and depression scores did not predict intra-individual cortisol levels for either sex. Measures of diurnal cortisol slope (DCS) were unrelated to psychosocial factors in males and females. Results provide further support for the interpersonal influence of partners' mental and physical health on physiological outcomes and suggest females may influence their male partners more than vice versa.

Association Between Metformin Initiation and Incident Dementia Among African American and White Veterans Health Administration Patients.

PURPOSE: African American patients are more likely to experience cognitive decline after type 2 diabetes mellitus onset than white patients. Metformin use has been associated with a lower risk of dementia compared with sulfonylureas. Evidence for whether this association differs by race is sparse. METHODS: Veterans Health Administration (VHA) medical record data were obtained for 73,761 African American and white patients aged ≥50 years who used the VHA from fiscal years 2000 to 2015. Patients were free of dementia and diabetes medications during fiscal years 2000 and 2001 and subsequently initiated metformin or sulfonylurea monotherapy. For race and age subgroups, Cox proportional hazards models using propensity scores and inverse probability of treatment weighting to control for confounding were computed to measure the association between metformin vs sulfonylurea initiation and incident dementia. RESULTS: After controlling for confounding, among patients aged ≥50 years, metformin vs sulfonylurea use was associated with a significantly lower risk of dementia in African American patients (hazard ratio [HR] = 0.73; 95% CI, 0.6-0.89) but not white patients (HR = 0.96; 95% CI, 0.9-1.03). The strongest magnitude of association between metformin and dementia was observed among African American patients aged 50 to 64 years (HR = 0.6; 95% CI, 0.45-0.81). Among those aged 65 to 74 years, metformin was significantly associated with lower risk of dementia in both races. Metformin was not associated with dementia in patients aged ≥75 years. CONCLUSIONS: Metformin vs sulfonylurea initiation was associated with a substantially lower risk of dementia among younger African American patients. These results may point to a novel approach for reducing the risk of dementia in African Americans with type 2 diabetes mellitus.

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.

Impact of adherence to antidepressants on long-term prescription opioid use cessation.

BACKGROUND: Depression contributes to persistent opioid analgesic use (OAU). Treating depression may increase opioid cessation. Aims To determine if adherence to antidepressant medications (ADMs) v. non-adherence was associated with opioid cessation in patients with a new depression episode after >90 days of OAU. METHOD: Patients with non-cancer, non-HIV pain (n = 2821), with a new episode of depression following >90 days of OAU, were eligible if they received ≥1 ADM prescription from 2002 to 2012. ADM adherence was defined as >80% of days covered. Opioid cessation was defined as ≥182 days without a prescription refill. Confounding was controlled by inverse probability of treatment weighting. RESULTS: In weighted data, the incidence rate of opioid cessation was significantly (P = 0.007) greater in patients who adhered v. did not adhered to taking antidepressants (57.2/1000 v. 45.0/1000 person-years). ADM adherence was significantly associated with opioid cessation (odds ratio (OR) = 1.24, 95% CI 1.05-1.46). CONCLUSIONS: ADM adherence, compared with non-adherence, is associated with opioid cessation in non-cancer pain. Opioid taper and cessation may be more successful when depression is treated to remission. Declaration of interest None.