Opioid stewardship program implementation in rural and critical access hospitals in Arizona.

OBJECTIVE: The objective of this study is to examine rural hospitals' status in implementing opioid stewardship program (OSP) elements and assess differences in implementation in emergency department (ED) and acute inpatient departments. DESIGN: Health administrator survey to identify the number and type of OSP elements that each hospital has implemented. SETTING: Arizona critical access hospitals (CAHs). PARTICIPANTS: ED and acute inpatient department heads at 17 Arizona CAHs (total of 34 assessments). MAIN OUTCOME MEASURES: Implementation of 11 OSP elements, by department (ED vs inpatient) and prevention orientation (primary vs tertiary). RESULTS: The percentage of implemented elements ranged from 35 to 94 percent in EDs and 24 to 88 percent in acute care departments. Reviewing the prescription drug monitoring program database and offering alternatives to opioids were the most frequently implemented. Assessing opioid use disorder (OUD) and prescribing naloxone were among the least. The number of implemented elements tended to be uniform across departments. We found that CAHs implemented, on average, 67 percent of elements that prevent unnecessary opioid use and 54 percent of elements that treat OUD. CONCLUSIONS: Some OSP elements were in place in nearly every Arizona CAH, while others were present in only a quarter or a third of hospitals. To improve, more attention is needed to define and standardize OSPs. Equal priority should be given to preventing unnecessary opioid initiation and treating opioid misuse or OUD, as well as quality control strategies that provide an opportunity for continuous improvement.

Insufficient Impact: Limited Implementation of Federal Regulatory Changes to Methadone and Buprenorphine Access in Arizona During COVID-19.

Introduction: This study examined the impact of federal regulatory changes on methadone and buprenorphine treatment during COVID-19 in Arizona. Methods: A cohort study of methadone and buprenorphine providers from September 14, 2021 to April 15, 2022 measured the proportion of 6 treatment accommodations implemented at 3 time periods: before COVID-19, during Arizona's COVID-19 shutdown, and at the time of the survey completion. Accommodations included (1) telehealth, (2) telehealth buprenorphine induction, (3) increased multiday dosing, (4) license reciprocity, (5) home medications delivery, and (6) off-site dispensing. A multilevel model assessed the association of treatment setting, rurality, and treatment with accommodation implementation time. Results: Over half (62.2%) of the 74-provider sample practiced in healthcare settings not primarily focused on addiction treatment, 19% practiced in methadone clinics, and 19% practiced in treatment clinics not offering methadone. Almost half (43%) were unaware of the regulatory changes allowing treatment accommodation. Telehealth was most frequently reported, increasing from 30% before COVID-19 to 80% at the time of the survey. Multiday dosing was the only accommodation substantially retracted after COVID-19 shutdown: from 41% to 23% at the time of the survey. Providers with higher patient limits were 2.5-3.2 times as likely to implement telehealth services, 4.4 times as likely to implement buprenorphine induction through telehealth, and 15.2-20.9 times as likely to implement license reciprocity as providers with lower patient limits. Providers of methadone implemented 12% more accommodations and maintained a higher average proportion of implemented accommodations during the COVID-19 shutdown period but were more likely to reduce the proportion of implemented accommodations (a 17-percentage point gap by the time of the survey). Conclusions: Federal regulatory changes are not sufficient to produce a substantive or sustained impact on provider accommodations, especially in methadone medical treatment settings. Practice change interventions specific to treatment settings should be implemented and studied for their impact.

Co-occurrence of chronic pain and anxiety/depression symptoms in U.S. adults: prevalence, functional impacts, and opportunities.

ABSTRACT: Co-occurrence of chronic pain and clinically significant symptoms of anxiety and/or depression is regularly noted in the literature. Yet, little is known empirically about population prevalence of co-occurring symptoms, nor whether people with co-occurring symptoms constitute a distinct subpopulation within US adults living with chronic pain or US adults living with anxiety and/or depression symptoms (A/D). To address this gap, this study analyzes data from the 2019 National Health Interview Survey, a representative annual survey of self-reported health status and treatment use in the United States (n = 31,997). Approximately 12 million US adults, or 4.9% of the adult population, have co-occurring chronic pain and A/D symptoms. Unremitted A/D symptoms co-occurred in 23.9% of US adults with chronic pain, compared with an A/D prevalence of 4.9% among those without chronic pain. Conversely, chronic pain co-occurred in the majority (55.6%) of US adults with unremitted A/D symptoms, compared with a chronic pain prevalence of 17.1% among those without A/D symptoms. The likelihood of experiencing functional limitations in daily life was highest among those experiencing co-occurring symptoms, compared with those experiencing chronic pain alone or A/D symptoms alone. Among those with co-occurring symptoms, 69.4% reported that work was limited due to a health problem, 43.7% reported difficulty doing errands alone, and 55.7% reported difficulty participating in social activities. These data point to the need for targeted investment in improving functional outcomes for the nearly 1 in 20 US adults living with co-occurring chronic pain and clinically significant A/D symptoms.

US-Mexico Border Stress and Daily Substance Use among Latino Youth: a Cross-Sectional Study.

Background: Historically marginalized youth are at risk for daily substance use. Daily use may be associated with social and environmental factors. Methods: In March 2018, we surveyed primarily Latino adolescents ages 14-18 who lived on the US-Mexico border and assessed associations between daily substance use, neighborhood stress, border community and immigration stress, and family support. Results: Of 443 surveyed adolescents, 41 (9%) reported daily use. Those who used daily were more likely to be older, identify as male, and reported lower social support and higher neighborhood and border community stress compared to those who did not use daily. Perceived neighborhood stress (OR = 1.95, 95% CI 1.37-2.80) and border community and immigration stress (OR = 1.55, 95% CI 1.12-2.02) were associated with increased odds of daily substance use. Discussion: Latino adolescents who live near the US-Mexico border experience unique socioenvironmental stress which is associated with daily substance use.

Opportunities and Challenges: Hepatitis C Testing and Treatment Access Experiences Among People in Methadone and Buprenorphine Treatment During COVID-19, Arizona, 2021.

Introduction: The purpose of this study was to characterize hepatitis C virus screening and treatment access experiences among people in treatment for opioid use disorder in Arizona during COVID-19. Methods: Arizonans receiving treatment for opioid use disorder from methadone clinics and buprenorphine providers during COVID-19 were interviewed about hepatitis C virus testing, curative treatment, and knowledge about screening recommendations. Interviews were conducted with 121 people from August 4, 2021 to October 10, 2021. Qualitative data were coded using the categories of hepatitis C virus testing, knowledge of screening recommendations, diagnosis, and experiences seeking curative treatment. Data were also quantitated for bivariate testing with outcome variables of last hepatitis C virus test, diagnosis, and curative treatment process. Findings were arrayed along an adapted hepatitis C virus cascade framework to inform program and policy improvements. Results: Just over half of the sample reported ever having tested for hepatitis C virus (51.2%, n=62) and of this group, 58.1% were tested in the past 12 months. Among those who were ever tested, 54.8% reported a hepatitis C virus diagnosis and 16.1% reported either being in treatment or having been declared cured of the hepatitis C virus. Among those who were diagnosed with hepatitis C, 14.7% indicated that they unsuccessfully tried to access curative treatment and would not attempt to again. Reasons cited for not accessing or receiving curative treatment included beliefs about treatment safety, barriers created by access requirements, natural resolution of the infection, and issues with healthcare coverage and authorization. Conclusions: Structural barriers continue to prevent curative hepatitis C virus treatment access. Given that methadone and buprenorphine treatment providers serve patients who are largely undiagnosed or treated for hepatitis C virus, opportunities exist for them to screen their patients regularly and provide support for and/or navigation to hepatitis C virus curative treatment.

A Diagram of the Social-Ecological Conditions of Opioid Misuse and Overdose.

The United States is experiencing a crisis of opioid misuse and overdose. To understand the underlying factors, researchers have begun looking upstream to identify social and structural determinants. However, no study has yet aggregated these into a comprehensive ecology of opioid overdose. We scoped 68 literature sources and compiled a master list of opioid misuse and overdose conditions. We grouped the conditions and used the Social Ecological Model to organize them into a diagram. We reviewed the diagram with nine subject matter experts (SMEs) who provided feedback on its content, design, and usefulness. From a literature search and SME interviews, we identified 80 unique conditions of opioid overdose and grouped them into 16 categories. In the final diagram, we incorporated 40 SME-recommended changes. In commenting on the diagram's usefulness, SMEs explained that the diagram could improve intervention planning by demonstrating the complexity of opioid overdose and highlighting structural factors. However, care is required to strike a balance between comprehensiveness and legibility. Multiple design formats may be useful, depending on the communication purpose and audience. This ecological diagram offers a visual perspective of the conditions of opioid overdose.

A Study of Arizona Physician Relocation Patterns by Rurality and Primary Care Status.

BACKGROUND AND OBJECTIVES: Physician location is an important element of health care access. However, physician shortages and disparities in geographic distribution exist. This study examines physician locations, relocation patterns, and factors associated with relocating. METHODS: We used Arizona licensure data and rural-urban commuting area (RUCA) codes to identify Arizona physicians and their office or mailing address locations. Our sample included Arizona physicians estimated to be younger than 70 years of age who had an active license between in 2014 and 2019. We used multivariable logistic regression to assess physicians' adjusted odds of relocating in Arizona by RUCA code, primary care status, age, gender, and medical education location. RESULTS: We identified 11,202 Arizona physicians in our sample, 33% of whom changed practice addresses within Arizona between 2014 and 2019. Primary care physicians (PCPs) in large rural areas had lower odds of relocating in Arizona (0.62, 95% CI 0.43-0.90) than PCPs in urban areas. Compared to 64-69-year-old physicians, those less than 34 and 34-43 years old had statistically higher odds of relocating within Arizona. CONCLUSIONS: Primary care status and rurality are important factors consider to understand physician relocation patterns. We found that a substantial number of Arizona physicians relocated within Arizona between 2014 and 2019, and few of those who relocated (2%) moved to a more rural area.

Nothing really changed: Arizona patient experience of methadone and buprenorphine access during COVID.

OBJECTIVE: To understand patient experience of federal regulatory changes governing methadone and buprenorphine (MOUD) access in Arizona during the COVID-19 pandemic. METHODS: This community-based participatory and action research study involved one-hour, audio-recorded field interviews conducted with 131 people who used methadone and/or buprenorphine to address opioid use disorder at some point during COVID (January 1, 2020- March 31, 2021) in Arizona. Transcribed data were analyzed using a priori codes focused on federally recommended flexibilities governing MOUD access. Data were quantitated to investigate associations with COVID risk and services access. RESULTS: Telehealth was reported by 71.0% of participants, but the majority were required to come to the clinic to attend video appointments with an offsite provider. Risk for severe COVID outcomes was reported by 40.5% of the sample. Thirty-eight percent of the sample and 39.7% of methadone patients were required to be at the clinic daily to get medication and 47.6% were at high risk for COVID severe outcomes. About half (54.2%) of methadone patients indicated that some form of multi-day take home dosing was offered at their clinic, and 45.8% were offered an extra day or two of multi-day doses; but no participants received the federally allowed 14- or 28-day methadone take-home doses for unstable and stable patients respectively. All participants expressed that daily clinic visits interrupted their work and home lives and desired more take-home dosing and home delivery options. CONCLUSIONS: MOUD patients in Arizona were not offered many of the federally allowed flexibilities for access that were designed to reduce their need to be at the clinic. To understand the impact of these recommended treatment changes in Arizona, and other states where they were not well implemented, federal and state regulators must mandate these changes and support MOUD providers to implement them.

Medicaid-Insured Client Characteristics and Quit Outcomes at the Arizona Smokers' Helpline.

Medicaid-insured individuals who smoke experience disparities in quitting and are a priority population for assistance. This retrospective cohort study of Arizona Smokers' Helpline clients (Jan 2014-Mar 2019) examined the association between insurance status, treatment, and smoking cessation. When compared to clients with non-Medicaid insurance or no insurance, clients with Medicaid (26%) were more likely to be female, referred directly to the ASHLine by a healthcare or community partner, smoke in the home, and report having a mental health condition. They also were less likely to utilize cessation medication and reported receiving less social support to quit. Controlling for these and other theoretically relevant variables, insurance status was stratified (Medicaid, non-Medicaid, and uninsured), and quit outcomes were compared by level of treatment (4 treatment groups: more and less than 3 coaching sessions and cessation medication use yes/no). Compared to clients who received 3+ coaching sessions, those who had less than 3 coaching sessions had significantly lower adjusted odds of quitting. Results were similar regardless of cessation medication use or insurance status. There is no indication that treatment effects differ by insurance status. While insurance status appears to proxy for other important factors like low social and economic status and higher comorbidity prevalence, in a quitline setting, quitting is associated with additional, high-quality coaching. Where coaching sessions may offset social and economic barriers to quitting, quitlines may consider focusing on assisting Medicaid-insured clients to connect and engage with treatment.

Federally Qualified Health Centers Can Expand Rural Access to Buprenorphine for Opioid Use Disorder in Arizona.

Medication for Opioid Use Disorder (MOUD) is recommended, but not always accessible to those who desire treatment. This study assessed the impact of expanding access to buprenorphine through federally qualified health centers (FQHCs) in Arizona. We calculated mean drive-times to Arizona opioid treatment (OTP) locations, office-based opioid treatment (OBOT) locations, and FQHCs clinics using January 2020 location data. FQHCs were designated as OBOT or non-OBOT clinics to explore opportunities to expand treatment access to non-OBOT clinics (potential OBOTs) to further reduce drive-times for rural and underserved populations. We found that OTPs had the largest mean drive times (16.4 minutes), followed by OBOTs (7.1 minutes) and potential OBOTs (6.1 minutes). Drive times were shortest in urban block groups for all treatment types and the largest differences existed between OTPs and OBOTs (50.6 minutes) in small rural and in isolated rural areas. OBOTs are essential points of care for opioid use disorder treatment. They reduce drive times by over 50% across all urban and rural areas. Expanding buprenorphine through rural potential OBOT sites may further reduce drive times to treatment and address a critical need among underserved populations.

Electronic Cigarette Policy Recommendations: A Scoping Review.

Objective: There is a lack of consensus on whether e-cigarettes facilitate or threaten existing tobacco prevention strategies. This uncertainty is reflected in organizations' conflicting e-cigarette position statements. We conducted a scoping review of position statements in published and gray literature to map the range and frequency of e-cigarette use recommendations. Methods: We collected 81 statements from international health organizations. Two coders independently performed qualitative content analysis to categorize e-cigarette recommendations. We explored differences based on organization type, geography, and the year recommendations were published. Results: We identified 5 recommendation types: encourage smokers to use ecigarettes as a cessation aid or as an alternative source of nicotine (N = 5); support individuals who use e-cigarettes to quit smoking (N = 20); avoid using until more research is available (N = 19); restrict access based on available evidence (N = 30); and prohibit e-cigarette marketing and sale (N = 7). Conclusion: Organizations presented diverse e-cigarette use recommendations. The variation related to organizations' differing tobacco prevention priorities and level of confidence in current e-cigarette research. These differences may create confusion. Additional research can examine whether this variability influences stakeholders' attitudes or behavior.

Higher quality quit-date goal setting enhances quit attempts among quitline callers.

INTRODUCTION: At tobacco quitlines, coaching and cessation medications are commonly structured around setting a date for making a quit attempt. However, limited literature evaluating this practice suggests that callers do not routinely set quit-date goals. High quality goal setting may increase the frequency of caller quit attempts. In this study, we examine the quality of quit-date goal setting and its association with in-program quit attempts and the timing of callers' first quit attempt. METHODS: Using call recordings, we scored the quality of quit-date goal setting among 90 callers enrolled at Arizona Smokers' Helpline between August and December 2017. The primary exposure was quality of quit-date goal setting assessed using the Lorencatto et al. rating scale. Coding reliability was assessed using Cohen's kappa. Multivariable logistic regression was used to examine the association between quality of goal setting and in-program quit attempts (>24 h tobacco free). RESULTS: The mean quality goal setting score was 3.1 (range: -3 to 7). Sixty-nine callers (77%) set a quit date and 39 (43%) made a quit attempt. Compared to callers who experienced low-quality goal setting, the adjusted odds of in-program quitting for high quality goal setting was AOR=3.98 (95% CI: 1.55-10.20) and for making a quit attempt within two weeks OR=6.23 (95% CI: 1.52-25.49). CONCLUSIONS: Quit-date goal setting is an important element of quitline services and callers benefit from high quality quit-date goal setting. Quitlines should establish quality improvement measures to ensure that coaches are trained to provide high quality quit-date goal setting opportunities to all callers.

Factors Predicting Client Re-Enrollment in Tobacco Cessation Services in a State Quitline.

INTRODUCTION: Quitlines are an integral part of tobacco treatment programs and reach groups of smokers who have a wide range of barriers to cessation. Although tobacco dependence is chronic and relapsing, little research exists on factors that predict the likelihood of clients re-engaging and reconnecting with quitlines for treatment. The objective of this study was to describe factors that predict the re-enrollment of clients in Arizona's state quitline. METHODS: This was a retrospective analysis of data collected from clients (N = 49,284) enrolled in the Arizona Smokers' Helpline from January 2011 through June 2016. We used logistic regression to analyze predictors of re-enrollment in services after controlling for theoretically relevant baseline variables (eg, nicotine dependence, smokers in the home) and follow-up variables (eg, program use, quit outcome). RESULTS: Compared with clients who reported being quit after their first enrollment, clients who reported not being quit were almost 3 times as likely to re-enroll (odds ratio = 2.89; 95% confidence interval, 2.54-3.30). Other predictors were having a chronic condition or a mental health condition, greater nicotine dependence, and lower levels of social support. Women and clients not having other smokers in the home were more likely to re-enroll than were men and clients not living with other smokers. CONCLUSION: Understanding baseline and in-program factors that predict client-initiated re-enrollment can help quitlines tailor strategies to proactively re-engage clients who may have difficulty maintaining long-term abstinence.