Integrating Buprenorphine for Opioid Use Disorder into Rural, Primary Care Settings.

BACKGROUND: Medications for opioid use disorder (MOUD) including buprenorphine are effective, but underutilized. Rural patients experience pronounced disparities in access. To reach rural patients, the US Department of Veterans Affairs (VA) has sought to expand buprenorphine prescribing beyond specialty settings and into primary care. OBJECTIVE: Although challenges remain, some rural VA health care systems have begun offering opioid use disorder (OUD) treatment with buprenorphine in primary care. We conducted interviews with clinicians, leaders, and staff within these systems to understand how this outcome had been achieved. DESIGN: Using administrative data from the VA Corporate Data Warehouse (CDW), we identified rural VA health care systems that had improved their rate of primary care-based buprenorphine prescribing over the period 2015-2020. We conducted qualitative interviews (n = 30) with staff involved in implementing or prescribing buprenorphine in these systems to understand the processes that had facilitated implementation. PARTICIPANTS: Clinicians, staff, and leaders embedded within rural VA health care systems located in the Northwest, West, Midwest (2), South, and Northeast. APPROACH: Qualitative interviews were analyzed using a mixed inductive/deductive approach. KEY RESULTS: Interviews revealed the processes through which buprenorphine was integrated into primary care, as well as processes insufficient to enact change. Implementation was often initially catalyzed through a targeted hire. Champions then engaged clinicians and leaders one-on-one to "pitch" the case, describe concordance between buprenorphine prescribing and existing goals, and delineate the supportive role that they could provide. Sites were prepared for implementation by developing new clinical teams and redesigning clinical processes. Each of these processes was made possible with the active, instrumental support of leadership. CONCLUSIONS: Results suggest that rural systems seeking to improve buprenorphine accessibility in primary care may need to alter primary care structures to accommodate buprenorphine prescribing, whether through new hires, team development, or clinical redesign.

Optimizing Individual HIV Testing and Counseling for Emerging Adult Sexual Minority Men (Aged 18 to 24) in Relationships: A Pilot Randomized Controlled Trial of Adjunct Communication Components.

The majority of new HIV infections in the US occur among sexual minority men (SMM) with older adolescent and emerging adult SMM at the highest risk. Those in relationships face unique HIV prevention challenges. Existing sexual HIV transmission risk interventions for male couples often encounter implementation challenges and engaging younger SMM early in relationships may be particularly difficult. This pilot randomized controlled trial evaluated the acceptibility and feasibility of We Test HIV testing - a behavioral health intervention tailored for younger SMM in realtionships - and generated preliminary estimates of effect size. The intervention comprises two adjunct moduls - video-based communication skills training as well as communication goal setting and planning - delivered in conjunction with routine HIV testing and counseling in individual or dyadic formats. A sample of 69 SMM aged 17 to 24 were recruited online. Following baseline assessment, youth were randomized to receive either the experimental, We Test, intervention or routine HIV testing (the control condition). Follow-up assessments were completed 3 and 6 months post-baseline. Results suggested the study was feasible and the individually delivered format was acceptible. We Test HIV testing was associated with significant improvements in communication skills. In addition, youth who remained in a relationship experienced an increase in communal coping to reduce HIV infection risk and relationship power. While groups did not differ with respect to condomless anal sex with casual partners, these psycho-social constructs (communication, communal coping with HIV prevention, and relationship power) may serve as mediators of intervention effects on sexual risk reduction in a larger study.

Characterizing and Comparing Evidence-Based Psychotherapy Utilization Among Veterans with Co-occurring PTSD and Substance Use Disorder.

Objective: The current study sought to describe a nationally representative sample of Veterans diagnosed with co-occurring PTSD and substance use disorder (SUD) who initiated and completed evidence-based psychotherapy (EBP) for PTSD, and explored whether completion rates differed by SUD subtype. Methods: Using electronic health record data from the Veterans Health Administration (VHA) Corporate Data Warehouse, Veterans with a dual diagnosis of PTSD and SUD who initiated either Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE) between January 01, 2019 and July 16, 2019 were identified (N = 2,996). Logistic analyses were employed to determine whether there were differences in EBP completion rates among Veterans with an alcohol use disorder (AUD; n = 1,383) versus all other SUDs (n = 1,613). Results: On average, Veterans were 45 years old, and identified as male, White, and non-Hispanic. Logistic regression analyses revealed there was not a significant difference between Veterans with AUD only and other SUDs in the probability of completing EBP treatment, OR = 1.02, 95% CI =0.87, 1.17, p = 0.79. Conclusions: No differences in EBP completion rates were observed between SUD subtypes, indicating that EBPs for PTSD are tolerated well for individuals with various types of SUDs and may be offered as treatment options.

Patient-Provider Shared Decision-Making, Trust, and Opioid Misuse Among US Veterans Prescribed Long-Term Opioid Therapy for Chronic Pain.

BACKGROUND: Patient-provider shared decision-making is associated with better treatment adherence and pain outcomes in opioid-specific pain management. One possible mechanism through which shared decision-making may impact pain management outcomes is trust in one's prescribing provider. Elucidating relationships between factors that enhance the patient-provider relationship, such as shared decision-making and trust, may reduce risks associated with opioid treatment, such as opioid misuse. OBJECTIVE: The purpose of this study was to investigate the mediating effect of trust in one's prescribing provider on the relationship between shared decision-making and current opioid misuse. DESIGN: A secondary analysis of data from a prospective cohort study of US Veterans (N = 1273) prescribed long-term opioid therapy (LTOT) for chronic non-cancer pain. PARTICIPANTS: Eligibility criteria included being prescribed LTOT, ability to speak and read English, and access to a telephone. Veterans were excluded if they had a cancer diagnosis, received opioid agonist therapy for opioid use disorder, or evidence of pending discontinuation of LTOT. Stratified random sampling was employed to oversample racial and ethnic minorities and women veterans. MAIN MEASURES: Physician Participatory Decision-Making assessed level of patient involvement in medical decision-making, the Trust in Provider Scale assessed interpersonal trust in patient-provider relationships, and the Current Opioid Misuse Measure assessed opioid misuse. KEY RESULTS: Patient-provider shared decision-making had a total significant effect on opioid misuse, in the absence of the mediator (c = - 0.243, p < 0.001), such that higher levels of shared decision-making were associated with lower levels of reported opioid misuse. When trust in provider was added to the mediation model, the indirect effect of shared decision-making on opioid misuse through trust in provider remained significant (c' = - 0.147, p = 0.007). CONCLUSIONS: Shared decision-making is associated with less prescription opioid misuse through the trust that is fostered between patients and providers.

Access to Medications for Opioid Use Disorder in Rural Versus Urban Veterans Health Administration Facilities.

BACKGROUND: For patients with opioid use disorder (OUD), medications for OUD (MOUD) reduce morbidity, mortality, and return to use. Nevertheless, a minority of patients receive MOUD, and underutilization is pronounced among rural patients. OBJECTIVE: While Veterans Health Administration (VHA) initiatives have improved MOUD access overall, it is unknown whether access has improved in rural VA health systems specifically. How "Community Care," healthcare paid for by VHA but received from non-VA providers, has affected rural access is also unknown. DESIGN: Data for this observational study were drawn from the VHA Corporate Data Warehouse. Facility rurality was defined by rural-urban commuting area code of the primary medical center. International Classification of Diseases codes identified patients with OUD within each year, 2015-2020. We included MOUD (buprenorphine, methadone, extended-release naltrexone) received from VHA or paid for by VHA but received at non-VA facilities through Community Care. We calculated average yearly MOUD receipt; linear regression of outcomes on study years identified trends; an interaction between year and rural status evaluated trend differences over time. PARTICIPANTS: All 129 VHA Health Systems, a designation that encompasses one or more medical centers and their affiliated community-based outpatient clinics MAIN MEASURES: The average proportion of patients diagnosed with OUD that receive MOUD within rural versus urban VHA health care systems. KEY RESULTS: From 2015 to 2020, MOUD access increased substantially: the average proportion of patients receiving MOUD increased from 34.6 to 48.9%, with a similar proportion of patients treated with MOUD in rural and urban systems in all years. Overall, a small proportion (1.8%) of MOUD was provided via Community Care, and Community Care did not disproportionately benefit rural health systems. CONCLUSIONS: Strategies utilized by VHA could inform other health care systems seeking to ensure that, regardless of geographic location, all patients are able to access MOUD.

"I'm Clean and Sober, But Not Necessarily Free": Perceptions of Buprenorphine Among Patients in Long-Term Treatment.

BACKGROUND: Patients receiving buprenorphine for the treatment of opioid use disorder (OUD) experience a roughly 50% reduction in mortality risk relative to those not receiving medication. Longer periods of treatment are also associated with improved clinical outcomes. Despite this, patients often express desires to discontinue treatment and some view taper as treatment success. Little is known about the beliefs and medication perspectives of patients engaged in long-term buprenorphine treatment that may underlie motivations to discontinue. METHODS: This study was conducted at the VA Portland Health Care System (2019-2020). Qualitative interviews were conducted with participants prescribed buprenorphine for ≥2 years. Coding and analysis were guided by directed qualitative content analysis. RESULTS: Fourteen patients engaged in office-based buprenorphine treatment completed interviews. While patients expressed strong enthusiasm for buprenorphine as a medication, the majority expressed the desire to discontinue, including patients actively tapering. Motivations to discontinue fell into 4 categories. First, patients were troubled by perceived side effects of the medication, including effects on sleep, emotion, and memory. Second, patients expressed unhappiness with being "dependent" on buprenorphine, framed in opposition to personal strength/independence. Third, patients expressed stigmatized beliefs about buprenorphine, describing it as "illicit," and associated with past drug use. Finally, patients expressed fears about buprenorphine unknowns, including potential long-term health effects and interactions with medications required for surgery. CONCLUSIONS: Despite recognizing benefits, many patients engaged in long-term buprenorphine treatment express a desire to discontinue. Findings from this study may help clinicians anticipate patient concerns and can be used to inform shared decision-making conversations regarding buprenorphine treatment duration.

Perioperative Management of Buprenorphine/Naloxone in a Large, National Health Care System: a Retrospective Cohort Study.

BACKGROUND: Medication for opioid use disorder, including buprenorphine and methadone, is considered the gold standard treatment for opioid use disorder (OUD). As the number of patients receiving buprenorphine has grown, clinicians increasingly care for patients prescribed buprenorphine who present for surgery and require management of perioperative pain. OBJECTIVE: To describe practice patterns of perioperative and post-surgical use of buprenorphine among patients prescribed buprenorphine for OUD who experience major surgery. DESIGN: Retrospective cohort study utilizing data from the VA Corporate Data Warehouse (CDW), a national repository of patient-level data. Data not accessible in CDW, including clinical instructions to patients to modify buprenorphine dose, were accessed via chart review. PARTICIPANTS: National sample of patients receiving care through the Veterans Health Administration. MAIN MEASURES: We report descriptive statistics on the incidence of buprenorphine dose hold prior to, during, and immediately following surgery, as well as post-surgical outcomes. Multivariable logistic regression identified socio-demographic and clinical characteristics associated with perioperative hold. KEY RESULTS: Our final sample comprised 183 patients, the majority of whom were white and male. Most patients (66%) experienced a perioperative buprenorphine dose hold: during the pre-operative, day of surgery, and post-operative periods, 40%, 62%, and 55% of patients had buprenorphine held. Buprenorphine dose hold was less likely for patients who had experienced homelessness/housing insecurity in the year prior to surgery (aOR = 0.25; 95% CI 0.10-0.61) as well as patients residing in rural areas (aOR=0.29; 0.12-0.68). Within the 12-month period following surgery, 122 patients (67%) were retained on buprenorphine, 10 patients (5.5%) had experienced an overdose, and 15 (8.2%) had died. CONCLUSIONS: We identified high rates of perioperative buprenorphine dose holds. As holding buprenorphine perioperatively does not align with emerging clinical recommendations and carries significant risks, educational campaigns or other provider-targeted interventions may be needed to ensure patients with OUD receive recommended care.

A Cluster-Randomized Clinical Trial to Decrease Prescription Opioid Misuse: Improving the Safety of Opioid Therapy (ISOT).

BACKGROUND: Interventions to reduce harms related to prescription opioids are needed in primary care settings. OBJECTIVE: To determine whether a multicomponent intervention, Improving the safety of opioid therapy (ISOT), is efficacious in reducing prescription opioid harms. DESIGN: Clinician-level, cluster randomized clinical trial. ( ClinicalTrials.gov : NCT02791399) SETTING: Eight primary care clinics at 1 Veterans Affairs health care system. PARTICIPANTS: Thirty-five primary care clinicians and 286 patients who were prescribed long-term opioid therapy (LTOT). INTERVENTION: All clinicians participated in a 2-hour educational session on patient-centered care surrounding opioid adherence monitoring and were randomly assigned to education only or ISOT. ISOT is a multicomponent intervention that included a one-time consultation by an external clinician to the patient with monitoring and feedback to clinicians over 12 months. MAIN MEASURES: The primary outcomes were changes in risk for prescription opioid misuse (Current Opioid Misuse Measure) and urine drug test results. Secondary outcomes were quality of the clinician-patient relationship, other prescription opioid safety outcomes, changes in clinicians' opioid prescribing characteristics, and a non-inferiority analysis of changes in pain intensity and functioning. KEY RESULTS: ISOT did not decrease risk for prescription opioid misuse (difference between groups = -1.12, p = 0.097), likelihood of an aberrant urine drug test result (difference between groups = -0.04, p=0.401), or measures of the clinician-patient relationship. Participants allocated to ISOT were more likely to discontinue prescription opioids (20.0% versus 8.1%, p = 0.007). ISOT did not worsen participant-reported scores of pain intensity or function. CONCLUSIONS: ISOT did not impact risk for prescription opioid misuse but did lead to increased likelihood of prescription opioid discontinuation. More intensive interventions may be needed to impact treatment outcomes.

Correlates of HIV Testing across the lifespan - adolescence through later adulthood - among sexual minority men in the US who are not on PrEP.

Regular HIV testing is an essential component of the HIV prevention and care cascade. Sexual minority males (SMM) account for most new HIV infections in the US and testing rates among SMM vary substantially across the lifespan. Research has largely overlooked the developmental context of HIV testing. The current study compared correlates of HIV testing among adolescents (aged 13-17; n = 1,641), emerging adults (aged 18-29; n = 50,483), early adults (aged 30-39; n = 25,830), middle adults (aged 40-64; n = 25,326), and late adults (65 and older; n = 1,452) who were recruited online. Overall, HIV testing rates were lowest among adolescent SMM. Having condomless anal sex in the past 3-months was a consistentpredictor of HIV testing across all age cohorts.The association between relationship status and frequency of HIV testing varied across ages. Being in a non-monogamous relationship (versus single) was associated with more frequent HIV testing among adolescent and emerging adult SMM , while being in a monogamous relationship (versus single) was associated with lower odds of HIV testing among early, middle, and late adults.

Long drives and red tape: mapping rural veteran access to primary care using causal-loop diagramming.

BACKGROUND: Rural veterans experience more challenges than their urban peers in accessing primary care services, which can negatively impact their health and wellbeing. The factors driving this disparity are complex and involve patient, clinic, health system, community and policy influences. Federal policies over the last decade have relaxed requirements for some veterans to receive primary care services from community providers through their VA benefits, known as community care. METHODS: We used a participatory systems mapping approach involving causal-loop diagramming to identify interrelationships between variables underlying challenges to veteran access to primary care and potential opportunities for change-known as leverage points in systems science. Our methods involved a secondary analysis of semi-structured qualitative interviews with rural veterans, VA staff, non-VA clinic staff and providers who serve rural veterans, and veteran service officers (VSOs) in the Northwest region of the US, followed by a two-part participatory modeling session with a study advisory board. We then applied Meadows's leverage point framework to identify and categorize potential interventions to improve rural veteran access to primary care. RESULTS: The final model illustrated challenges at the veteran, clinic, and system levels as experienced by stakeholders. Main components of the diagram pertained to the choice of VA or non-VA primary care, veteran satisfaction with the VA, enrollment in VA benefits and other insurance, community care authorization, reimbursement of non-VA care, referrals to specialty care, record sharing and communication between VA and non-VA providers, institutional stability of the VA, and staffing challenges. Fourteen interventions, including administrative and communications changes, were identified by analyzing the model using the leverage points framework. CONCLUSIONS: Our findings illustrate how challenges rural veterans face accessing health care are interconnected and persist despite recent changes to federal law pertaining to the VA health care system in recent years. Systems mapping and modeling approaches such as causal-loop diagramming have potential for engaging stakeholders and supporting intervention and implementation planning.

Differences in the delivery of medications for opioid use disorder during hospitalization by racial categories: A retrospective cohort analysis.

Background: As the drug-related overdose crisis and COVID-19 pandemic continue, communities need increased access to medications for opioid use disorder (MOUD) (i.e., buprenorphine and methadone). Disparities in the type of MOUD prescribed or administered by racial and ethnic categories are well described in the outpatient clinical environment. It is unknown, however, if these disparities persist when MOUD is provided in acute care hospitals. Methods: This study assessed differences in the delivery of buprenorphine versus methadone during acute medical or surgical hospitalizations for veterans with opioid use disorder (OUD) by racial categories (Black Non-Hispanic or Latino vs. White Non-Hispanic or Latino). Data were obtained retrospectively from the Veterans Health Administration (VHA) for federal fiscal year 2017. We built logistic regression models, adjusted for individual and hospital-related covariates, and calculated the predicted probabilities of MOUD delivery by racial categories. Results: The study cohort (n = 1,313 unique patients; N = 107 VHA hospitals) had a mean age of 57 (range 23 to 87 years), was predominantly male (96%), and composed entirely of Black (29%) or White (71%) patients. White patients were 11% more likely than Black patients to receive buprenorphine than methadone during hospitalization (p = 0.010; 95% CI: 2.7%, 20.0%). Among patients on MOUD prior to hospitalization, White patients were 21% more likely than Black patients to receive buprenorphine (p = 0.000; 95% CI: 9.8%, 31.5%). Among patients newly initiated on MOUD during hospitalization, there were no differences by racial categories. Conclusion: We observed disparities in the delivery of buprenorphine versus methadone during hospitalization by racial categories. The observed differences in hospital-based MOUD delivery may be influenced by MOUD received prior to hospitalization within the racialized outpatient addiction treatment system. The VHA and health systems more broadly must address all aspects of racism that contribute to inequitable MOUD access throughout all clinical contexts.

Developmental Barriers to Couples' HIV Testing and Counseling Among Adolescent Sexual Minority Males: A Dyadic Socio-ecological Perspective.

Couples HIV Testing and Counseling (CHTC) is now a standard of care for partnered sexual minority men. While adolescent sexual minority men (ASMM; ages 15-19) face disproportionate HIV risk, the emergent nature of relationships and communication skills may present challenges to accessing and engaging in CHTC. This study utilized qualitative data from 28 ASMM recruited in 4 urban centers in the USA during the formative stage of Adolescent Trials Network study ATN-156. Participants were cis-male, HIV-negative, and in a relationship with a similarly-aged cis-male partner. Thematic analysis indicated low and high levels of commitment were barriers to CHTC. Concerns about caregiver attitudes towards HIV testing were salient. Adolescents' perception of structural barriers highlighted reliance on caregiver resources, which limited access to sexual health services. Prevention programming must address structural barriers to access encountered by adolescents. ASMM in relationships may benefit from programming that includes options for individual and dyadic participation.

Associations of Pain Numeric Rating Scale Scores Collected during Usual Care with Research Administered Patient Reported Pain Outcomes.

OBJECTIVE: The purpose of this study is to examine the extent to which numeric rating scale (NRS) scores collected during usual care are associated with more robust and validated measures of pain, disability, mental health, and health-related quality of life (HRQOL). DESIGN: We conducted a secondary analysis of data from a prospective cohort study. SUBJECTS: We included 186 patients with musculoskeletal pain who were prescribed long-term opioid therapy. SETTING: VA Portland Health Care System outpatient clinic. METHODS: All patients had been screened with the 0-10 NRS during routine outpatient visits. They also completed research visits that assessed pain, mental health and HRQOL every 6 months for 2 years. Accounting for nonindependence of repeated measures data, we examined associations of NRS data obtained from the medical record with scores on standardized measures of pain and its related outcomes. RESULTS: NRS scores obtained in clinical practice were moderately associated with pain intensity scores (B's = 0.53-0.59) and modestly associated with pain disability scores (B's = 0.33-0.36) obtained by researchers. Associations between pain NRS scores and validated measures of depression, anxiety, and health related HRQOL were low (B's = 0.09-0.26, with the preponderance of B's < .20). CONCLUSIONS: Standardized assessments of pain during usual care are moderately associated with research-administered measures of pain intensity and would be improved from the inclusion of more robust measures of pain-related function, mental health, and HRQOL.

Expanding Access to Medications for Opioid Use Disorder: Program and Policy Approaches from Outside the Veterans Health Administration.

To mitigate morbidity and mortality of the drug-related overdose crisis, the Veterans Health Administration (VHA) can increase access to treatments that save lives-medications for opioid use disorder (MOUD). Despite an increasing need, MOUD continues to be underutilized due to multifaceted barriers that exist within broader macro- and microenvironments. To promote MOUD utilization, policymakers and healthcare leaders should (1) identify and implement person-centered MOUD delivery systems (e.g., the Medication First Model, community-informed design); (2) recognize and address MOUD delivery gaps (e.g., the Best-Practice in Oral Opioid Agonist Collaborative); (3) broaden the definition of the MOUD delivery system (e.g., access to MOUD in non-clinical settings); and (4) expand MOUD options (e.g., injectable opioid agonist therapy). Increasing access to MOUD is not a singular fix to the overdose-related crisis. It is, however, a possible first step to mitigate harm, and save lives.

Opioid Agonist Therapy During Hospitalization Within the Veterans Health Administration: a Pragmatic Retrospective Cohort Analysis.

BACKGROUND: Hospitalization of patients with opioid use disorder (OUD) is increasing, yet little is known about opioid agonist therapy (OAT: methadone and buprenorphine) administration during admission. OBJECTIVE: Describe and examine patient- and hospital-level characteristics associated with OAT receipt during hospitalization in the Veterans Health Administration (VHA). PARTICIPANTS: A total of 12,407 unique patients, ≥ 18 years old, with an OUD-related ICD-10 diagnosis within 12 months prior to or during index hospitalization in fiscal year 2017 from 109 VHA hospitals in the continental U.S. MAIN MEASURE: OAT received during hospitalization. KEY RESULTS: Few admissions received OAT (n = 1914; 15%) and when provided it was most often for withdrawal management (n = 834; 7%). Among patients not on OAT prior to admission who survived hospitalization (n = 10,969), 2.0% (n = 203) were newly initiated on OAT with linkage to care after hospital discharge. Hospitals varied in the frequency of OAT delivery (range, 0 to 43% of qualified admissions). Patients with pre-admission OAT (adjusted odds ratio [AOR] = 15.30; 95% CI [13.2, 17.7]), acute OUD diagnosis (AOR = 2.3; 95% CI [1.99, 2.66]), and male gender (AOR 1.52; 95% CI [1.16, 2.01]) had increased odds of OAT receipt. Patients who received non-OAT opioids (AOR 0.53; 95% CI [0.46, 0.61]) or surgical procedures (AOR 0.75; 95% CI [0.57, 0.99]) had decreased odds of OAT receipt. Large-sized (AOR = 2.0; 95% CI [1.39, 3.00]) and medium-sized (AOR = 1.9; 95% CI [1.33, 2.70]) hospitals were more likely to provide OAT. CONCLUSIONS: In a sample of VHA inpatient medical admissions, OAT delivery was infrequent, varied across the health system, and was associated with specific patient and hospital characteristics. Policy and educational interventions should promote hospital-based OAT delivery.

Clinician Referrals for Non-opioid Pain Care Following Discontinuation of Long-term Opioid Therapy Differ Based on Reasons for Discontinuation.

BACKGROUND: Little is known about pain care offered to patients discontinued from long-term opioid therapy (LTOT) by their prescriber due to aberrant behaviors versus other reasons. OBJECTIVE: This study aimed to compare rates of non-opioid analgesic pharmacotherapy initiation and clinician referrals for non-pharmacologic pain treatment, complementary and integrative pain therapies, and specialty mental health and substance use disorder treatment between patients discontinued from opioid therapy due to aberrant behaviors versus other reasons. DESIGN: The design included retrospective manual electronic health record review and administrative data abstraction. PARTICIPANTS: Patients were sampled from a national cohort of US Department of Veterans Affairs patients prescribed continuous opioid therapy in 2011 who subsequently discontinued opioid therapy in 2012. The study sample comprised 509 patients discontinued from LTOT by opioid-prescribing clinicians. MAIN MEASURES: The primary independent variable was reason for discontinuation of LTOT (aberrant behaviors versus other reasons). Pain care dichotomous outcomes included clinician use of an opioid taper; initiating new non-opioid analgesic pharmacotherapy; and referrals for non-pharmacologic pain treatment, complementary and integrative pain therapies, and specialty mental health and substance use disorder treatment. KEY RESULTS: We observed low rates of opioid taper (15% of patients), initiations of new or modifications of existing non-opioid analgesic pharmacotherapy (45% of patients), and clinician referrals for non-pharmacologic pain treatment (58% of patients) and complementary and integrative therapies (25% of patients). Patients discontinued due to aberrant behaviors, relative to patients discontinued for other reasons, were more likely to receive opioid tapers (adjusted OR = 5.60, 95% CI = 2.10-14.93), receive new non-opioid analgesic medications or dose changes to an existing non-opioid analgesic medications (adjusted OR = 2.61, 95% CI = 1.59-4.29), or be referred for specialty substance use disorder treatment (adjusted OR = 7.39, 95% CI = 3.76-14.53). CONCLUSIONS: These findings highlight the variability in referral rates for different types of non-opioid pain treatments and challenges accessing specific types of pain care.

A Randomized Clinical Trial Showing Persisting Reductions in Depressive Symptoms in HIV-Infected Rural Adults Following Brief Telephone-Administered Interpersonal Psychotherapy.

Background: Rural areas account for 5% to 7% of all HIV infections in the USA, and rural people living with HIV (PLHIV) are 1.3 times more likely to receive a depression diagnosis than their urban counterparts. A previous analysis from our randomized clinical trial found that nine weekly sessions of telephone-administered interpersonal psychotherapy (tele-IPT) reduced depressive symptoms and interpersonal problems in rural PLHIV from preintervention through postintervention significantly more than standard care but did not increase perceived social support compared to standard care. Purpose: To assess tele-IPT's enduring effects at 4- and 8-month follow-up in this cohort. Methods: Tele-IPT's long-term depression treatment efficacy was assessed through Beck Depression Inventory self-administrations at 4 and 8 months. Using intention-to-treat and completer-only approaches, mixed models repeated measures, and Cohen's d assessed maintenance of acute treatment gains. Results: Intention-to-treat analyses found fewer depressive symptoms in tele-IPT patients than standard care controls at 4 (d = .41; p < .06) and 8-month follow-up (d =.47; p < .05). Completer-only analyses found similar patterns, with larger effect sizes. Tele-IPT patients used crisis hotlines less frequently than standard care controls at postintervention and 4-month follow-up (ps < .05). Conclusions: Tele-IPT provides longer term depression relief in depressed rural PLHIV. This is also the first controlled trial to find that IPT administered over the telephone provides long-term depressive symptom relief to any clinical population. Trial Registration: ClinicalTrials.gov Identifier: NCT02299453.

Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review.

BACKGROUND: Expert guidelines recommend reducing or discontinuing long-term opioid therapy (LTOT) when risks outweigh benefits, but evidence on the effect of dose reduction on patient outcomes has not been systematically reviewed. PURPOSE: To synthesize studies of the effectiveness of strategies to reduce or discontinue LTOT and patient outcomes after dose reduction among adults prescribed LTOT for chronic pain. DATA SOURCES: MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Library from inception through April 2017; reference lists; and expert contacts. STUDY SELECTION: Original research published in English that addressed dose reduction or discontinuation of LTOT for chronic pain. DATA EXTRACTION: Two independent reviewers extracted data and assessed study quality using the U.S. Preventive Services Task Force quality rating criteria. All authors assessed evidence quality using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Prespecified patient outcomes were pain severity, function, quality of life, opioid withdrawal symptoms, substance use, and adverse events. DATA SYNTHESIS: Sixty-seven studies (11 randomized trials and 56 observational studies) examining 8 intervention categories, including interdisciplinary pain programs, buprenorphine-assisted dose reduction, and behavioral interventions, were found. Study quality was good for 3 studies, fair for 13 studies, and poor for 51 studies. Many studies reported dose reduction, but rates of opioid discontinuation ranged widely across interventions and the overall quality of evidence was very low. Among 40 studies examining patient outcomes after dose reduction (very low overall quality of evidence), improvement was reported in pain severity (8 of 8 fair-quality studies), function (5 of 5 fair-quality studies), and quality of life (3 of 3 fair-quality studies). LIMITATION: Heterogeneous interventions and outcome measures; poor-quality studies with uncontrolled designs. CONCLUSION: Very low quality evidence suggests that several types of interventions may be effective to reduce or discontinue LTOT and that pain, function, and quality of life may improve with opioid dose reduction. PRIMARY FUNDING SOURCE: Veterans Health Administration. (PROSPERO: CRD42015020347).

Medications for opioid use disorder in the Department of Veterans Affairs (VA) health care system: Historical perspective, lessons learned, and next steps.

The US Department of Veterans Affairs (VA), the largest health care system in the US, has been confronted with the health care consequences of opioid disorder (OUD). Increasing access to quality OUD treatment, including pharmacotherapy, is a priority for the VA. We examine the history of medications (e.g., methadone, buprenorphine, injectable naltrexone) used in the treatment of OUD within VA, document early and ongoing efforts to increase access and build capacity, primarily through the use of buprenorphine, and summarize research examining barriers and facilitators to prescribing and medication receipt. We find that there has been a slow but steady increase in the use of medications for OUD and, despite system-wide mandates and directives, uneven uptake across VA facilities and within patient sub-populations, including some of those most vulnerable. We conclude with recommendations intended to support the greater use of medication for OUD in the future, both within VA as well as other large health care systems.

Development of an Algorithm to Identify Cannabis Urine Drug Test Results within a Multi-Site Electronic Health Record System.

With the rapid changes in the legalization of cannabis in the U.S., there is an urgent need to understand clinical outcomes and processes of care among patients who use cannabis, particularly among patients with chronic pain who are high utilizers of cannabis. Electronic health records (EHRs) are a common and convenient mechanism for examining processes of care; however, there is not an indication for cannabis use that does not meet criteria for a diagnostic disorder. We used urine drug test (UDT) results identified through EHRs to identify patients with confirmed cannabis use. We developed and tested an algorithm to identify outcomes of UDT results for cannabis because there is wide variability in reporting methodology, including in multi-site health systems. Among all patients receiving care in the Department of Veterans Affairs (VA) who were prescribed long-term opioid therapy for chronic pain, we identified a random sample who completed UDT for cannabis. Through an iterative process, we developed an algorithm to identify UDT cannabis results. Manual review of EHR data was conducted to verify accuracy of UDT results. The final UDT algorithm correctly identified 99% of cannabis positive UDT results and 100% of cannabis negative UDT results among 200 randomly sampled patients. Study findings suggest a high degree of accuracy for using an algorithm to identify samples of patients with positive cannabis UDT results across multiple institutions with disparate UDT reporting practices. The methodology for testing this algorithm is feasible and may be applied to other multi-site health systems.