Association of Recent SARS-CoV-2 Infection With New-Onset Alcohol Use Disorder, January 2020 Through January 2022.

Importance: The COVID-19 pandemic affects many diseases, including alcohol use disorders (AUDs). As the pandemic evolves, understanding the association of a new diagnosis of AUD with COVID-19 over time is required to mitigate negative consequences. Objective: To examine the association of COVID-19 infection with new diagnosis of AUD over time from January 2020 through January 2022. Design, Setting, and Participants: In this retrospective cohort study of electronic health records of US patients 12 years of age or older, new diagnoses of AUD were compared between patients with COVID-19 and patients with other respiratory infections who had never had COVID-19 by 3-month intervals from January 20, 2020, through January 27, 2022. Exposures: SARS-CoV-2 infection or non-SARS-CoV-2 respiratory infection. Main Outcomes and Measures: New diagnoses of AUD were compared in COVID-19 and propensity score-matched control cohorts by hazard ratios (HRs) and 95% CIs from either 14 days to 3 months or 3 to 6 months after the index event. Results: This study comprised 1 201 082 patients with COVID-19 (56.9% female patients; 65.7% White; mean [SD] age at index, 46.2 [18.9] years) and 1 620 100 patients with other respiratory infections who had never had COVID-19 (60.4% female patients; 71.1% White; mean [SD] age at index, 44.5 [20.6] years). There was a significantly increased risk of a new diagnosis of AUD in the 3 months after COVID-19 was contracted during the first 3 months of the pandemic (block 1) compared with control cohorts (HR, 2.53 [95% CI, 1.82-3.51]), but the risk decreased to nonsignificance in the next 3 time blocks (April 2020 to January 2021). The risk for AUD diagnosis increased after infection in January to April 2021 (HR, 1.30 [95% CI, 1.08-1.56]) and April to July 2021 (HR, 1.80 [95% CI, 1.47-2.21]). The result became nonsignificant again in blocks 7 and 8 (COVID-19 diagnosis between July 2021 and January 2022). A similar temporal pattern was seen for new diagnosis of AUD 3 to 6 months after infection with COVID-19 vs control index events. Conclusions and Relevance: Elevated risk for AUD after COVID-19 infection compared with non-COVID-19 respiratory infections during some time frames may suggest an association of SARS-CoV-2 infection with the pandemic-associated increase in AUD. However, the lack of excess hazard in most time blocks makes it likely that the circumstances surrounding the pandemic and the fear and anxiety they created also were important factors associated with new diagnoses of AUD.

Buprenorphine/Naloxone Maintenance Therapy: an Observational Retrospective Report on the Effect of Dose on 18 months Retention in an Office-Based Treatment Program.

CONTEXT AND OBJECTIVE: Buprenorphine has been available with few reports of the dose range necessary to adequately maintain patients. We report on the effect of 8 mg/d versus 16 mg/d of buprenorphine on long-term patient retention in office-based opioid maintenance (OBOMT). DESIGN SETTING AND PARTICIPANTS: Case series, at an urban hospital-based primary care clinic providing OBOMT to 157 opiate-dependent, low socioeconomic status, uninsured, nonhomeless patients. INTERVENTION: The OBOMT program operated by a comprehensive sobriety treatment program experienced State funding cuts. Thus, after 2 years, the program was required by the State funder to decrease the buprenorphine maintenance dose from 16 to 8 mg/d for all new admissions. We report on patient retention before and after dose reduction. MAIN OUTCOME MEASURES: The primary outcomes of this study were to measure and compare patient retention in the 2 cohorts at each point of treatment transition over the 18 months following OBOMT initiation. RESULTS: No significant differences in patient retention were observed between the 16 and 8 mg/d patient cohorts. Lower dose buprenorphine maintenance (8 mg/d) in uninsured patients enrolled in publicly funded long-term OBOMT combined with comprehensive sobriety counseling was as effective as higher dose therapy (16 mg/d) in promoting patient retention throughout the study period. This lower dose resulted in a substantial saving to the public funding agency. CONCLUSIONS: In an observational retrospective report, retention in treatment of opiate-addicted patients was the same at 8 and 16 mg/d buprenorphine doses after 18 months. These data have implications for public and managed care funding of OBOMT, for the general prescribing of buprenorphine in outpatient care, and may be instructive in the ongoing debate about the relationship between buprenorphine dose.

Access to and Payment for Office-Based Buprenorphine Treatment in Ohio.

IMPORTANCE: Office-based opiate agonist therapy has dramatically expanded access to medication-assisted treatment over the past decade but has also led to increased buprenorphine diversion. OBJECTIVE: Our study sought to characterize physicians who participate in office-based therapy (OBT) to assess patient access to OBT in Ohio 10 years after its introduction. DESIGN/SETTING/PARTICIPANTS: Cross-sectional telephone survey of Drug Addiction Treatment Act-waivered physicians in Ohio listed by the Center for Substance Abuse Treatment (CSAT). MAIN OUTCOMES: This study sought to determine what proportion of eligible physicians are actively prescribing buprenorphine, whether they accept insurance for OBT, and whether they accept insurance for non-OBT services. In addition, we evaluated what physician characteristics predicted those primary outcomes. We hypothesized that a significant minority of eligible physicians are not active prescribers of buprenorphine. In addition, we expected that a significant minority of OBT prescribers do not accept insurance, further restricting patient access. We further hypothesized that a large subset of OBT prescribers accept insurance in their regular practices but do not take insurance for OBT. RESULTS: Of the 466 listed physicians, 327 (70.2%) practice representatives were reached for interview. Thirty-three physicians were excluded, with a true response rate of 75.5%. In total, 80.7% of providers reached were active OBT prescribers. Of these, 52.7% accepted insurance for OBT, 20.8% accepted insurance for non-OBT services but not for OBT, and 26.5% did not accept insurance for any services. Practices who did not accept insurance were more likely among dedicated addiction clinics located outside of Ohio's 6 major cities. Practices who normally accepted insurance but did not for OBT services were more likely in urban locations and were not associated with dedicated addiction practices. Neither business practice was associated with physician specialty. CONCLUSIONS AND RELEVANCE: Access to OBT in Ohio is far lower than what the 466 listed physicians suggests. Nearly 1 in 5 of those physicians are not active OBT prescribers, and 1 in 2 active prescribers do not accept insurance for OBT. Further research is needed to determine whether practices who do not accept insurance provide care consistent with CSAT guidelines and whether such practice patterns contribute to buprenorphine diversion.

Evolution of a remedial CME course in professionalism: addressing learner needs, developing content, and evaluating outcomes.

INTRODUCTION: Scant information is available about the nature of the professional violations resulting in referral of physicians for remedial continuing medical education (CME). The CME program at Case Western Reserve University (CWRU) School of Medicine has developed the Intensive Course in Medical Ethics, Boundaries, and Professionalism (medical ethics course) for physician referrals due to ethical breaches. In this report, the authors present 7 years of data regarding the type of behavior that resulted in course referral as well as information regarding course and outcome evaluation development and participant demographics. METHODS: The medical ethics course has been designed in consultation with licensure agencies to address the learning needs of physicians with problems in the areas of boundary maintenance and ethics. Teaching methods and outcome evaluations include lectures, case discussions, multiple-choice question tests, skill practice sessions, and writing a reflective essay based on the participants' ethical lapse. Information is also gathered regarding participant demographics, training, and practice characteristics. RESULTS: Between September 2005 and February 2012, 358 learners participated in the course. The average age was 52 years and 73% were board certified. Of the 269 physicians who wrote a reflective essay, the reasons for referral included prescribing of controlled drugs, sexual boundary issues, providing services to family or friends, not maintaining proper medical records, and billing issues. DISCUSSION: This report outlines the strategies used by CWRU to develop remedial CME courses using the medical ethics course as an example for course and outcome evaluation development. This is the first report characterizing the type and frequency of the medical ethics violations that result in mandatory participation in remedial CME.

Tramadol versus buprenorphine for the management of acute heroin withdrawal: a retrospective matched cohort controlled study.

Many medications have been used over the past thirty years for the treatment of opioid withdrawal, including propoxyphene, methadone, clonidine, parenteral buprenorphine, and, more recently, sublingual buprenorphine. Each has been found to have clinical strengths and limitations. Tramadol is a centrally acting synthetic analgesic with opiate activity primarily due to the binding of a metabolite to the micro receptor. Despite this micro receptor activity, tramadol appears to have low abuse potential and is a non-scheduled analgesic. The pharmacologic profile of tramadol makes it a candidate for opiate withdrawal treatment. A chart review was undertaken to retrospectively compare treatment outcomes of heroin-dependent patients when detoxified with parenteral buprenorphine (1996-1997) versus tramadol (1999-2000). Inclusion criteria for this study were heroin as drug of choice, current opioid physical dependence (ie, withdrawal symptoms), no current abuse of oral opioid analgesics, and no alcohol or benzodiazepine withdrawal symptoms. Patient cases that met inclusion criteria were group-matched between buprenorphine and tramadol on the basis of age, sex, and amount of heroin used (bags/day). Charts were audited for patient demographics, daily heroin use at admission, withdrawal symptoms, and discharge status. In total, 129 patient charts were reviewed, and 115 met all inclusion criteria and were group-matched (45 patients in the buprenorphine group, seventy in the tramadol group). There were no differences in demographics between the two groups of patients. Fifty-six percent of the buprenorphine group and 71% of the tramadol group completed detoxification; tramadol-treated patients had significantly higher average withdrawal symptoms when compared to the buprenorphine group and a greater reduction in withdrawal symptoms over time. Finally, the number of side effects was small and did not differ between the groups. The results of this study are consistent with previous pilot reports that indicated few clinical differences between parenteral buprenorphine and oral tramadol protocols when used in the management of acute heroin withdrawal. As a consequence, tramadol shows some promise as an opioid withdrawal management medication.

Inpatient initiation of buprenorphine maintenance vs. detoxification: can retention of opioid-dependent patients in outpatient counseling be improved?

Buprenorphine-naloxone is an office-based opioid agonist released in 2003 in the United States for the maintenance of heroin- and other opioid-dependent patients. Concern has been raised that the medication will distract or otherwise inhibit patients from participating in a holistic recovery program or abstinence-based counseling. Using a retrospective chart review, the first thirty opioid-dependent patients induced on buprenorphine maintenance therapy in an inpatient detoxification unit were compared to thirty age- and gender-matched patients who underwent detoxification (with a tramadol taper) and referral to intensive outpatient treatment. The clinical outcomes were a comparison of completion rates for an intensive outpatient program (IOP) and retention in treatment after twelve weeks of aftercare therapy. Patients induced on buprenorphine maintenance over three days had similar relief of withdrawal symptoms to patients detoxified from opioids over five days with tramadol. Patients maintained on buprenorphine had a markedly increased initiation of IOP and remained in outpatient treatment longer than patients who were detoxified (8.5 wks vs. 0.4 wks, p < 0.001). This study indicates that induction and maintenance on buprenorphine may be more effective than detoxification for engaging and retaining patients in abstinence-based comprehensive outpatient addiction treatment.

Is screening and brief advice for problem drinkers by clergy feasible? A survey of clergy.

Routine screening for alcohol abuse in primary care, with brief advice to stop drinking for those screening positive, can detect individuals with alcohol problems and reduce alcohol use and alcohol induced problems in those detected. Not everyone with alcohol problems sees a physician regularly, however, and not all respond to a physician's brief advice. To explore the feasibility of expanding screening for alcohol problems to clergy, we did a mailed survey to 315 clergy at Christian churches in Cleveland, Ohio. Clergy reported a variety of views about alcohol use and abuse, but most agreed that alcoholism is a disease. They indicated counseling a significant number of parishioners, and were receptive to learning brief screening questions to detect alcohol problems. We conclude that many clergy would be interested in a strategy of screening and then giving brief advice or referral to individuals found to have alcohol problems.

Tramadol versus buprenorphine for the treatment of opiate withdrawal: a retrospective cohort control study.

Various drugs have been used for the treatment of opioid withdrawal, e.g., methadone, buprenorphine, and clonidine. Tramadol is a centrally acting synthetic analgesic agent with opiate activity due to low affinity binding of the parent compound and higher affinity binding of the O-demethylated metabolite M1 to mu opioid receptors. As a consequence, there may be a role for the use of tramadol in the treatment of opiate withdrawal. We attempt to assess the efficacy of tramadol in treating moderate heroin withdrawal through a retrospective cohort control study, conducted in a detoxification unit in a community teaching hospital. Out of 100 heroin abusers admitted for detoxification during the review period, 64 patients who were treated either with buprenorphine or tramadol, were included in this study, with 20 participants in the buprenorphine group and 44 in the tramadol group. Both groups were matched for age, sex, and self-reported average quantity of heroin used per day. In the tramadol group, the average CINA maximum was 9.0, and in the buprenorphine group it was 11.2 (P = 0.07). The use of oral clonidine per patient in the tramadol group was 1.6 tablets, and in the buprenorphine group 0.1 tablets (P = 0.002). The length of stay was 3.7 days in the tramadol group and 4.1 days in the buprenorphine group (P = 0.5). Four participants in the tramadol group received three or more doses of buprenorphine because their symptoms were not controlled, and were considered as treatment failures. These preliminary data suggest that tramadol may be comparable to buprenorphine in the management of mild to moderately severe heroin withdrawal. These findings, if reproduced in larger studies with stronger research designs, have potentially great implications for the management of opioid withdrawal in both the inpatient and outpatient setting.

The use of tramadol for acute heroin withdrawal: a comparison to clonidine.

Using a retrospective chart review, 59 patients detoxified with tramadol were compared to 85 patients detoxified with clonidine on rates of leaving against medical advice (AMA) and control of withdrawal symptoms. Patients detoxified with tramadol had 23% (95% CI, 0.09-0.59; P < .01) the risk of leaving AMA and scored an average of 0.24 points lower (95% CI, 0.08-0.41; P < .01) on a 0-3 point withdrawal symptom scale compared to patients detoxified with clonidine. This preliminary study indicates that tramadol is more effective in managing withdrawal than clonidine, and may be especially useful in outpatient detoxification.