Medication-based treatment among rural, primary care patients diagnosed with opioid use disorder and alcohol use disorder.

INTRODUCTION: Opioid and alcohol use disorders are increasingly being addressed in primary care, yet how medications to treat these disorders are prescribed in rural regions is unknown. METHODS: We determined prevalence, types, and duration of medication prescription for opioid and/or alcohol use disorder among adult patients in rural primary clinics. The sample included 1874 adult patients who visited one of six rural primary care sites in the Northeastern and Northwestern United States at least once from October 2019 to January 2021 and had a diagnosis code for opioid use disorder (OUD), alcohol use disorder (AUD), or co-occurring opioid and alcohol use disorder (OUD + AUD) during that time. RESULTS: Patients with OUD + AUD were more likely to be prescribed medication for at least one of these disorders (85.3 %) than patients with OUD only (63.7 %) or AUD only (10.3 %). Further, the OUD + AUD group had the highest number of days on medication (M = 264.7), followed by OUD only (M = 220.5), then the AUD only group (M = 62.5). Only 8.8 % of patients with OUD + AUD were prescribed naltrexone or medication for OUD + AUD to treat both substance use disorders. CONCLUSIONS: Medications for treating AUD as well as OUD are available, but few patients with OUD + AUD and even fewer with AUD received pharmacological treatment for AUD. The current work highlights the need for rural clinicians to consider medications for AUD as an important treatment method for patients with AUD only or OUD + AUD.

Social Determinants of Health and Continuity of Medications for Opioid Use Disorder Among Patients Receiving Treatment in Rural Primary Care Settings.

OBJECTIVES: Factors associated with treatment retention on medications for opioid use disorder (MOUD) in rural settings are poorly understood. This study examines associations between social determinants of health (SDoH) and MOUD retention among patients with opioid use disorder (OUD) in rural primary care settings. METHODS: We analyzed patient electronic health records from 6 rural clinics. Participants (N = 575) were adult patients with OUD and had any prescription for MOUD from October 2019 to April 2020. MOUD retention was measured by MOUD days and continuity defined as continuous 180 MOUD days with no more than a 7-day gap. Mixed-effect regressions assessed associations between the outcomes and SDoH (Medicaid insurance, social deprivation index [SDI], driving time from home to the clinic), telehealth use, and other covariates. RESULTS: Mean patient MOUD days were 127 days (SD = 50.7 days). Living in more disadvantaged areas (based on SDI) (adjusted relative risk [aRR]: 0.98; 95% confidence interval [CI], 0.98-0.99) and having more than an hour (compared with an hour or less) driving time from home to clinic (aRR: 0.95; 95% CI, 0.93-0.97) were associated with fewer MOUD days. Using telehealth was associated with more MOUD days (aRR: 1.23; 95% CI, 1.21-1.26). In this cohort, 21.7% of the participants were retained on MOUD for at least 180 days. SDoH and use of telehealth were not associated with having continuity of MOUD. CONCLUSIONS: Addressing SDoH (eg, SDI) and providing telehealth (eg, improvements in public transportation, internet access) may improve MOUD days in rural settings.

Referral of patients from rural primary care clinics to telemedicine vendors for opioid use disorder treatment: A mixed-methods study.

INTRODUCTION: Rural primary care clinics can expand their medication treatment for opioid use disorder (MOUD) capacity by coordinating care with external telemedicine (TM) vendors specializing in addiction medicine. This study used mixed methods to identify factors that influence patient referrals from rural primary care clinics to TM vendors for MOUD. METHODS: Between July/August 2020 and January/February 2021, 582 patients with OUD were identified across six primary care sites; that included 68 referred to an external TM vendor to receive MOUD. Mixed effects logistic regression identified individual and site-level factors associated with being referred to the TM vendor. Clinic providers and staff participated in in-depth interviews and focus groups to discuss their considerations for referring patients to the TM vendor. RESULTS: Patient referrals were positively associated with local household broadband coverage (OR = 2.55, p < 0.001) and negatively associated with local population density (OR = 0.01, p = 0.003) and the number of buprenorphine prescribers in the county (OR = 0.85, p < 0.001). Clinic personnel expressed appreciation for psychiatric expertise and the flexibility to access MOUD brought by the TM vendor. Perceived concerns about TM referral included a lack of trust with external providers, uncertainty about TM service quality, workflow delays, and patients' technological and insurance challenges. CONCLUSION: This study revealed several clinic-level factors that may potentially influence patient referral to TM vendor services for MOUD. To facilitate the referral process and utilization of TM vendors, efforts should be made to foster open communication and trust between clinic providers and TM vendors, streamline workflows, and improve Internet access for patients.

Medication treatment for opioid use disorder among rural primary care patients.

PURPOSE: To investigate the prevalence of opioid use disorder (OUD) and medication treatment for OUD (MOUD) receipt in rural primary care settings and identify characteristics associated with MOUD among patients with OUD. METHODS: Secondary analyses based on electronic health records of all adult patients who visited 1 of the 6 rural primary care clinic sites from October 2019 to January 2021. Mixed effects logistic regression was conducted to assess MOUD receipt (Y/N) in relation to patient characteristics (eg, demographics, other substance use disorders [SUDs], mental health disorders, and chronic pain) and the number of MOUD prescribers per clinic. FINDINGS: The prevalence of OUD varied from 0.7% to 8.2% (Mean [SD] = 3.3% [95% CI: 0.4, 6.1]) among 36,762 primary care patients across 6 clinic sites. Among 1,164 patients with OUD, on average 50.1% received MOUD (95% CI: 28.0, 72.3). Patients in clinics with more than 3 MOUD prescribers had more than 3 times the odds of receiving MOUD (OR = 3.42; 95% CI, 1.22-9.62) as those in clinics with fewer than 3 prescribers. MOUD was positively associated with younger age (18-30 [OR = 6.97; 95% CI, 3.37-14.42], 31-64 [OR = 5.03; 95% CI, 2.64-9.57], relative to those 65 and older), having other co-occurring SUDs (OR = 3.77; 95% CI, 2.57-5.52), being male (OR = 1.50; 95% CI, 1.12-2.01), and negatively associated with having chronic pain disorders (OR = 0.69; 95% CI, 0.50-0.94). CONCLUSIONS: The prevalence of OUD and MOUD are high but vary considerably across rural primary care clinics; primary care MOUD prescribers play a key role on MOUD access in rural settings.

Identifying patients with opioid use disorder using International Classification of Diseases (ICD) codes: Challenges and opportunities.

BACKGROUND AND AIMS: International Classification of Diseases (ICD) diagnosis codes are often used in research to identify patients with opioid use disorder (OUD), but their accuracy for this purpose is not fully evaluated. This study describes application of ICD-10 diagnosis codes for opioid use, dependence and abuse from an electronic health record (EHR) data extraction using data from the clinics' OUD patient registries and clinician/staff EHR entries. DESIGN: Cross-sectional observational study. SETTING: Four rural primary care clinics in Washington and Idaho, USA. PARTICIPANTS: 307 patients. MEASUREMENTS: This study used three data sources from each clinic: (1) a limited dataset extracted from the EHR, (2) a clinic-based registry of patients with OUD and (3) the clinician/staff interface of the EHR (e.g. progress notes, problem list). Data source one included records with six commonly applied ICD-10 codes for opioid use, dependence and abuse: F11.10 (opioid abuse, uncomplicated), F11.20 (opioid dependence, uncomplicated), F11.21 (opioid dependence, in remission), F11.23 (opioid dependence with withdrawal), F11.90 (opioid use, unspecified, uncomplicated) and F11.99 (opioid use, unspecified with unspecified opioid-induced disorder). Care coordinators used data sources two and three to categorize each patient identified in data source one: (1) confirmed OUD diagnosis, (2) may have OUD but no confirmed OUD diagnosis, (3) chronic pain with no evidence of OUD and (4) no evidence for OUD or chronic pain. FINDINGS: F11.10, F11.21 and F11.99 were applied most frequently to patients who had clinical diagnoses of OUD (64%, 89% and 79%, respectively). F11.20, F11.23 and F11.90 were applied to patients who had a diagnostic mix of OUD and chronic pain without OUD. The four clinics applied codes inconsistently. CONCLUSIONS: Lack of uniform application of ICD diagnosis codes make it challenging to use diagnosis code data from EHR to identify a research population of persons with opioid use disorder.

Co-occurring substance use disorders among patients with opioid use disorder in rural primary care clinics.

BACKGROUND: Co-occurring substance use disorders (SUDs) among individuals with opioid use disorder (OUD) are associated with additional impairment, overdose, and death. This study examined characteristics of patients who have OUD with and without co-occurring SUDs in rural primary care clinics. METHODS: Secondary analysis used electronic health record (EHR) data from six rural primary care clinics, including demographics, diagnoses, encounters, and prescriptions of medication for OUD (MOUD), as well as EHR data from an external telemedicine vendor that provided MOUD to some clinic patients. The study population included all adult patients who had a visit to the participating clinics from October 2019 to January 2021. RESULTS: We identified 1164 patients with OUD; 72.6 % had OUD only, 11.5 % had OUD and stimulant use disorder (OUD + StUD), and 15.9 % had OUD and other non-stimulant substance use disorder (OUD + Other). The OUD + StUD group had the highest rates of hepatitis C virus (25.4 % for OUD + StUD, 17.8 % for OUD + Other, and 7.5 % for OUD Only; p < 0.001) and the highest rates of mental health disorders (78.4 %, 69.7 %, and 59.9 %, respectively; p < 0.001). Compared to the OUD Only group, patients in the OUD + StUD and OUD + Other groups were more likely to receive telehealth services provided by clinic staff, in-clinic behavioral health services, and in-clinic MOUD. The OUD + StUD group had the highest proportion of referrals to the external telemedicine vendor. CONCLUSIONS: More than 27 % of patients with OUD in rural primary care clinics had other co-occurring SUDs, and these patients received more healthcare services than those with OUD only. Future studies should examine variations in outcomes associated with these other services among patients with OUD and co-occurring SUDs.

Stakeholder perspectives on a telemedicine referral and coordination model to expand medication treatment for opioid use disorder in rural primary care clinics.

INTRODUCTION: Opioid overdose deaths are increasing rapidly in the United States. Medications for opioid use disorder (MOUD) are effective and can be delivered in primary care, but uptake has been limited in rural communities. Referral to and coordination with an external telemedicine (TM) vendor by rural primary care clinics for MOUD (TM-MOUD) may increase MOUD access for rural patients, but we know little about perspectives on this model among key stakeholders. As part of a TM-MOUD feasibility study, we explored TM-MOUD acceptability and feasibility among personnel and patients from seven rural primary care clinics and a TM-MOUD vendor. METHODS: We conducted virtual interviews or focus groups with clinic administrators (n = 7 interviews), clinic primary care and behavioral health providers (8 groups, n = 30), other clinic staff (9 groups, n = 37), patients receiving MOUD (n = 16 interviews), TM-MOUD vendor staff (n = 4 interviews), and vendor-affiliated behavioral health and prescribing providers (n = 17 interviews). We asked about experiences with and acceptability of MOUD (primarily buprenorphine) and telemedicine (TM) and a TM-MOUD referral and coordination model. We conducted content analysis to identify themes and participants quantitatively rated acceptability of TM-MOUD elements on a 4-item scale. RESULTS: Perceived benefits of vendor-based TM-MOUD included reduced logistical barriers, more privacy and less stigma, and access to services not available locally (e.g., counseling, pain management). Barriers included lack of internet or poor connectivity in patients' homes, limited communication and trust between TM-MOUD and clinic providers, and questions about the value to the clinic of TM-MOUD referral to external vendor. Acceptability ratings for TM-MOUD were generally high; they were lowest among frontline staff. CONCLUSIONS: Rural primary care clinic personnel, TM-MOUD vendor personnel, and patients generally perceived referral from primary care to a TM-MOUD vendor to hold potential for increasing access to MOUD in rural communities. Increasing TM-MOUD uptake requires buy-in and understanding among staff of the TM-MOUD workflow, TM services offered, requirements for patients, advantages over clinic-based or TM services from clinic providers, and identification of appropriate patients. Poverty, along with patient hesitation to initiate treatment, creates substantial barriers to MOUD treatment generally; insufficient internet availability creates a substantial barrier to TM-MOUD.

Augmenting the efficacy of benzodiazepine taper with telehealth-delivered cognitive behavioral therapy for anxiety disorders in patients using prescription opioids: A pilot randomized controlled trial.

The risks of concomitant benzodiazepine (BZ) and opioid use are significant. Despite the urgent need to reduce BZ use among patients taking opioids, no treatment intervention research to our knowledge has addressed treatment for this concurrent, high-risk use. The current study will evaluate the efficacy of augmenting BZ taper procedures with CBT for anxiety disorders that has been adapted specifically for patients with concomitant BZ and opioid use (either use as prescribed or misuse), a high-risk patient population. Research combining rapidly scalable behavioral interventions ancillary to pharmacological approaches delivered via telehealth in primary care settings is innovative and important given concerning trends in rising prevalence of BZ/opioid co-prescription, BZ-associated overdose deaths, and known barriers to implementation of behavioral health interventions in primary care. CBT delivery using telehealth has the potential to aid adherence and promote access and dissemination of procedures in primary care. Lastly, the current study will utilize an experimental therapeutics approach to preliminarily explore the mechanism of action for the proposed interventions. The overall aim of the present pilot randomized controlled trial is to examine the feasibility and preliminary efficacy of a BZ taper with CBT for anxiety disorders adapted for patients with concomitant BZ (BZT + CBT) and opioid use to a BZ taper with a control health education program (BZT + HE) in a sample of individuals (N = 54) who have been prescribed and are taking benzodiazepines and opioids for at least 3 months prior to baseline and experience anxious distress. Screening and outcome measures, methods, and implications are described. Trial Registration: ClinicalTrials.gov (NCT05573906).

Telemedicine-delivered treatment for substance use disorder: A scoping review.

INTRODUCTION: The COVID pandemic prompted a significant increase in the utilization of telemedicine (TM) for substance use disorder (SUD) treatment. As we transition towards a "new normal" policy, it is crucial to comprehensively understand the evidence of TM in SUD treatment. This scoping review aims to summarize existing evidence regarding TM's acceptability, quality, effectiveness, access/utilization, and cost in the context of SUD treatment in order to identify knowledge gaps and inform policy decisions regarding TM for SUDs. METHOD: We searched studies published in 2012-2022 from PubMed, Cochrane Library, Embase, Web of Science, and other sources. Findings were synthesized using thematic analysis. RESULTS: A total of 856 relevant articles were screened, with a final total of 42 articles included in the review. TM in SUD treatment was perceived to be generally beneficial and acceptable. TM was as effective as in-person SUD care in terms of substance use reduction and treatment retention; however, most studies lacked rigorous designs and follow-up durations were brief (≤3 months). Telephone-based TM platforms (vs video) were positively associated with older age, lower education, and no prior overdose. Providers generally consider TM to be affordable for patients, but no relevant studies were available from patient perspectives. CONCLUSIONS: TM in SUD treatment is generally perceived to be beneficial and acceptable and as effective as in-person care, although more rigorously designed studies on effectiveness are still lacking. Access and utilization of TM may vary by platform. TM service quality and costs are the least studied and warrant further investigations.

Psychosis among individuals with methamphetamine use disorder is associated with elevated rates of hospitalizations and emergency department visits across an academic health care system.

INTRODUCTION: Methamphetamine (MA) is increasingly available in the United States and manufactured with increasing potency. Although psychosis is a known harm related to MA use, we know little about the clinical outcomes and prognosis of individuals who use MA and experience psychosis. Some evidence exists that psychosis among people who use methamphetamine leads to a high utilization of emergency and acute inpatient services, but the extent of this use is unclear. METHODS: Using an electronic health record (EHR) database, this study assessed acute care visits of individuals receiving diagnostic codes of the following disorders: methamphetamine use disorder with undifferentiated psychosis (MUDp), schizophrenia (MUDs) and no history of psychosis (MUD) in addition to individuals without MUD diagnosis but with diagnoses of either undifferentiated psychosis (Psy) or schizophrenia (Scz) from 2006 to 2019. The study explored potential clinical risk factors associated with rate of acute care visits. RESULTS: Receiving diagnoses of psychotic disorders and MUD were both associated with high rates of acute care utilization. The incidence rate ratio (IRR) was highest in the MUDp group 6.30 (95% CI: 5.73, 6.93) followed by the MUDs group 4.03 (95% CI: 3.87, 4.20), the Psy group 3.77 (95% CI: 3.45, 4.11), the Scz group 3.11 (95% CI: 2.99, 3.23), and the MUD group 2.17 (95% CI: 2.09, 2.25). Receiving another SUD diagnosis was identified as a risk factor for acute care visits in the MUDp group, and mood and anxiety disorder diagnoses were a risk factor in the MUDs group. CONCLUSIONS: In a general health care system, individuals receiving diagnoses of MUD and co-occurring psychotic disorders were observed to have particularly high rates of acute care service utilization, suggesting a high degree of disease burden and the need for development of targeted treatment interventions with both MUD and psychosis.

Care coordination between rural primary care and telemedicine to expand medication treatment for opioid use disorder: Results from a single-arm, multisite feasibility study.

PURPOSE: The use of telemedicine (TM) has accelerated in recent years, yet research on the implementation and effectiveness of TM-delivered medication treatment for opioid use disorder (MOUD) has been limited. This study investigated the feasibility of implementing a care coordination model involving MOUD delivered via an external TM provider for the purpose of expanding access to MOUD for patients in rural settings. METHODS: The study tested a care coordination model in 6 rural primary care sites by establishing referral and coordination between the clinic and a TM company for MOUD. The intervention spanned approximately 6 months from July/August 2020 to January 2021, coinciding with the peak of the COVID-19 pandemic. Each clinic tracked patients with OUD in a registry during the intervention period. A pre-/post-intervention design (N = 6) was used to assess the clinic-level outcome as patient-days on MOUD based on patient electronic health records. FINDINGS: All clinics implemented critical components of the intervention, with an overall TM referral rate of 11.7% among patients in the registry. Five of the 6 sites showed an increase in patient-days on MOUD during the intervention period compared to the 6-month period before the intervention (mean increase per 1,000 patients: 132 days, P = .08, Cohen's d = 0.55). The largest increases occurred in clinics that lacked MOUD capacity or had a greater number of patients initiating MOUD during the intervention period. CONCLUSIONS: To expand access to MOUD in rural settings, the care coordination model is most effective when implemented in clinics that have negligible or limited MOUD capacity.

Alcohol Use Among Treatment-Seeking Individuals With Opioid Use Disorder.

OBJECTIVE: Individuals in the United States with opioid use disorder (OUD) have high rates of co-occurring alcohol use disorder. However, there is limited research on co-use patterns among opioid and alcohol use. The present study examined the relationship between alcohol and opioid use in treatment-seeking individuals with an OUD. METHOD: The study used baseline assessment data from a multisite, comparative effectiveness trial. Participants with an OUD who had used nonprescribed opioids in the last 30 days (n = 567) reported on their alcohol and opioid use during the past 30 days using the Timeline Followback. Two mixed-effects logistic regression models were used to assess the effect of alcohol use and binge alcohol use (≥4 drinks/day for women and ≥5 drinks/day for men) on opioid use. RESULTS: The likelihood of same-day opioid use was significantly lower on days in which participants drank any alcohol (p < .001) as well as on days in which participants reported binge drinking (p = .01), controlling for age, gender, ethnicity, and years of education. CONCLUSIONS: These findings suggest that alcohol or binge alcohol use is associated with significantly lower odds of opioid use on a given day, which was not related to gender or age. The prevalence of opioid use remained high on both alcohol use and non-alcohol use days. In line with a substitution model of alcohol and opioid co-use, alcohol may be used to treat symptoms of opioid withdrawal and possibly play a secondary and substitutive role in individuals with OUD substance use patterns.

Perceptions of COVID-19 risk during the pandemic: perspectives from people seeking medication for opioid use disorder.

INTRODUCTION: The Coronavirus Disease 2019 (COVID-19) pandemic has had devastating consequences for persons with opioid use disorder (OUD). Yet, little is known about how people seeking treatment for OUD perceive the risks of COVID-19 and how their perception interplays with their health behaviours. METHODS: In-depth interviews were conducted from September 2021 to March 2022 with 32 patients seeking medication treatment for OUD (MOUD) in Southern California. All interviews were conducted virtually and lasted between one and two hours. Interviews were recorded and transcribed verbatim. Two qualitative researchers independently conducted a content analysis of the transcripts to identify themes. RESULTS: Three primary themes were identified: (1) perceptions and beliefs about COVID-19 susceptibility and severity; (2) perceptions of COVID-19 risk compared to substance use behaviours; and (3) vaccine hesitancy. Participants were mixed in their beliefs of susceptibility to contracting COVID-19 and the severity of the disease if contracted. Some participants reported taking precautions to mitigate their chances of acquiring COVID-19, and other participants reported that COVID was not a big concern as substance use took priority. For many of the participants, COVID-19 concerns were overshadowed by the risk of overdosing on substances and other risky substance use behaviour. Most of the participants (n = 23; 72%) had received at least one COVID-19 vaccine by the time of the interview, but over half (n = 19; 59%) expressed vaccine hesitancy. Vaccine hesitancy was driven by concerns about the unknown long-term side effects and potential interactions of the vaccine with MOUD. CONCLUSIONS: Our study provides insight into COVID-19 prevention measures as well as vaccination perceptions and hesitancy among people who received treatment for OUD.Key messagesParticipants expressed diverse perceptions of the seriousness of COVID-19, with some taking precautions to mitigate their chances of acquiring COVID-19 and others perceiving that the risk of contracting COVID-19 was less than the risk of overdosing.Substance use, social isolation, vaccine hesitancy and COVID-19 risk behaviours should be studied as co-occurring phenomena that have potentially overlapping relationships that can influence behaviours that impact health and well-being.

Telemedicine along the cascade of care for substance use disorders during the COVID-19 pandemic in the United States.

BACKGROUND: The COVID-19 pandemic has changed the landscape of healthcare service delivery. This review aims to describe telemedicine-delivered substance use disorder (SUD) treatments and services along the cascade of care in the U.S. after the start of the COVID-19 pandemic. METHODS: A literature review was conducted on PubMed, Embase, Web of Science, and Cochrane Library (Wiley). English-language articles that describe any healthcare services for patients with SUDs using telemedicine in the U.S. since the onset of the COVID-19 pandemic were identified (N = 33). We narratively summarized telemedicine-based service provision along the cascade of SUD care, such as screening/assessment, prescription, monitoring, recovery support, and other services. RESULTS: Soon after the onset of COVID-19 and mandated restrictions, cadres of healthcare providers from different specialties mobilized to ramp up video- and audio-based services to remotely treat patients with SUDs. Medication prescription (48.5%) and individual counseling (39.4%) were the most frequently reported services delivered via telemedicine. Other steps of SUD care delivered by telemedicine characterized in our review included SUD screening and assessment (30.3%), induction (21.2%), medication management (27.3%), monitoring (27.3%), recovery support (15.2%), and referral (24.2%). Feasibility issues and challenges to implementing telemedicine included patients' lack of access to technology and health insurance coverage, providers' capacity limits and concerns, and clinics' financial and office-space constraints. CONCLUSION: The COVID-19 pandemic has offered a window of opportunity to advance telemedicine expertise by formalizing clinical guidance and routinizing provider in-service training in virtual SUD treatment. Findings suggest enhanced efforts to reduce disparities in telemedicine-based services.

Medical conditions of primary care patients with documented cannabis use and cannabis use disorder in electronic health records: a case control study from an academic health system in a medical marijuana state.

BACKGROUND: Approximately 3.8% of adults worldwide have used cannabis in the past year. Understanding how cannabis use is associated with other health conditions is crucial for healthcare providers seeking to understand the needs of their patients, and for health policymakers. This paper analyzes the relationship between documented cannabis use disorders (CUD), cannabis use (CU) and other health diagnoses among primary care patients during a time when medical use of marijuana was permitted by state law in California, United States of America. METHODS: The study utilized primary care electronic health record (EHR) data from an academic health system, using a case-control design to compare diagnoses among individuals with CUD/CU to those of matched controls, and those of individuals with CUD diagnoses with individuals who had CU otherwise documented. Associations of documented CU and CUD with general medical conditions and health conditions associated with cannabis use (both medical and behavioral) were analyzed using conditional logistic regression. RESULTS: Of 1,047,463 patients with ambulatory encounters from 2013-2017, 729 (0.06%) had CUD diagnoses and 3,731 (0.36%) had CU documented in their EHR. Patients with documented CUD and CU patients had significantly (p < 0.01) higher odds of most medical and behavioral diagnoses analyzed. Compared to matched controls, CUD-documented patients had highest odds of other substance use disorders (OR = 21.44: 95% CI 9.43-48.73), any mental health disorder (OR = 6.99; 95% CI 5.03-9.70) social anxiety disorder (OR = 13.03; 95% CI 2.18-77.94), HIV/AIDS (OR = 7.88: 95% CI 2.58-24.08), post-traumatic stress disorder (OR = 7.74: 95% CI 2.66-22.51); depression (OR = 7.01: 95% CI 4,79-10.27), and bipolar disorder (OR = 6.49: 95% CI 2.90-14.52). Compared to matched controls, CU-documented patients had highest odds of other substance use disorders (OR = 3.64; 95% CI 2.53-5.25) and post-traumatic stress disorder (OR = 3.41; 95% CI 2.53-5.25). CUD-documented patients were significantly more likely than CU-documented patients to have HIV/AIDS (OR = 6.70; 95% CI 2.10-21.39), other substance use disorder (OR = 5.88; 95% CI 2.42-14.22), depression (OR = 2.85; 95% CI 1.90-4.26), and anxiety (OR = 2.19: 95% CI 1.57-3.05) diagnoses. CONCLUSION: The prevalence of CUD and CU notation in EHR data from an academic health system was low, highlighting the need for improved screening in primary care. CUD and CU documentation were associated with increased risk for many health conditions, with the most elevated risk for behavioral health disorders and HIV/AIDS (among CUD-documented, but not CU-documented patients). Given the strong associations of CUD and CU documentation with health problems, it is important for healthcare providers to be prepared to identify CU and CUD, discuss the pros and cons of cannabis use with patients thoughtfully and empathically, and address cannabis-related comorbidities among these patients.

The opioid use disorder core outcomes set (OUD-COS) for treatment research: findings from a Delphi consensus study.

BACKGROUND AND AIM: There is no gold-standard and considerable heterogeneity in outcome measures used to evaluate treatments for opioid use disorder (OUD) along the opioid treatment cascade. The aim of this study was to develop the US National Institute on Drug Abuse (NIDA) National Drug Abuse Treatment Clinical Trials Network (CTN) opioid use disorder core outcomes set (OUD-COS). DESIGN: Four-round, e-Delphi expert panel consensus study and plenary research group discussion and targeted consultation. SETTING: United States. PARTICIPANTS: A panel of 25 members including clinical practitioners, clinical researchers and administrative staff from the CTN, the network's affiliated clinical and community sites and the NIDA Centre for the CTN. MEASUREMENTS: From a pool of 24 candidate items in four domains (biomedical/disease status; behaviors, symptoms and functioning; opioid treatment cascade; and morbidity and mortality), the panel completed an on-line questionnaire to rank items with defined specification on a 9-point scale for importance, with a standard 70% consensus criterion. FINDINGS: After the fourth round of the questionnaire and subsequent discussion, consensus was reached for five outcomes: two patient-reported (global impression of improvement and incident non-fatal overdose); one clinician-reported (illicit/non-medical drug toxicology); and two from administrative records (duration of treatment and fatal opioid poisoning). CONCLUSIONS: An e-Delphi consensus study has produced the US National Institute on Drug Abuse (NIDA) National Drug Abuse Treatment Clinical Trials Network opioid use disorder core outcomes set (version 1) for opioid use disorder treatment efficacy and effectiveness research.

The Management of Substance Use Disorders: Synopsis of the 2021 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline.

DESCRIPTION: In August 2021, leadership within the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline (CPG) for the management of substance use disorders (SUDs). This synopsis summarizes key recommendations. METHODS: In March 2020, the VA/DoD Evidence-Based Practice Work Group assembled a team to update the 2015 VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders that included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy CPGs. The guideline panel developed key questions, systematically searched and evaluated the literature, created two 1-page algorithms, and distilled 35 recommendations for care using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. This synopsis presents the recommendations that were believed to be the most clinically impactful. RECOMMENDATIONS: The scope of the CPG is broad; however, this synopsis focuses on key recommendations for the management of alcohol use disorder, use of buprenorphine in opioid use disorder, contingency management, and use of technology and telehealth to manage patients remotely.

Association Between Benzodiazepine and Opioid Prescription and Mortality Among Patients in a Large Healthcare System.

OBJECTIVE: Coprescription of opioids and benzodiazepines (BDZ) is associated with adverse outcomes, including greater healthcare utilization and overdose risk. This study aims to examine opioid and BDZ coprescription, dosing, and mortality among patients with and without opioid use disorder (OUD) in a large healthcare system. METHODS: Using data from the California state Prescription Drug Monitoring Program during 2010 to 2014 linked with a large healthcare system electronic health record database and mortality records from the Centers for Disease Control National Death Index, this study examined 5202 patients (1978 with OUD, 3224 controls). Multiple logistic regression analyses were conducted to examine relationships between most recent BDZ and opioid prescription, and their interaction with respect to mortality. RESULTS: About 10.5% of the sample died on or before December 31, 2014. About 17.7% were prescribed BDZ during the final month of observation. Individuals with OUD were prescribed higher average BDZ and opioid doses than those without OUD. After adjusting for covariates, increased prescribed doses of BDZ (odds ratio [OR]=1.34, 95%CI: 1.15-1.55 per 10 mg/d increment) and opioids (OR = 1.04, 95%CI: 1.02-1.05 per 10 mg/d increment) were positively associated with mortality. Non-OUD patients who received both BDZ and opioid prescriptions had a higher mortality than those who received only BDZ or opioids (The ratio of odds ratio (ROR) = 3.83, 95%CI: 1.78-8.21). CONCLUSIONS: Study findings highlight significant mortality associated with the coprescription of opioids and BDZ in a general healthcare setting. Further research is needed to elucidate factors associated with mortality among non-OUD patients who are co-prescribed opioids and BDZ.

Social Determinants of Mortality of COVID-19 and Opioid Overdose in American Rural and Urban Counties.

OBJECTIVES: Both COVID-19 deaths and opioid overdose deaths continue to increase in the United States. Little is known about the characteristics of counties with high rates of mortality for both. METHODS: We analyzed county-level data on COVID-19 mortality from January 1 to May 31, 2020, and on opioid overdose mortality during 2014-2018. The outcome variable, "high-risk county" was a binary indicator of high mortality rates (above 75% quartile) for both COVID-19 and opioid overdose. We conducted geospatial logistic regression models separately for urban and rural counties to identify social determinants of health associated with being a high-risk county. RESULTS: After adjusting for other covariates, the overall mortality rate of COVID-19 is higher in counties with larger population size and a higher proportion of racial/ethnic minorities, although counties with high rates of opioid overdose mortality have lower proportions of racial/ethnic minorities, a higher proportion of females, and are more economically disadvantaged. Significant predictors of rural counties with high mortality rates for both COVID-19 and opioid overdose include higher proportions of Blacks (Adjusted odds ratio [aOR], 1.04; 95%CI, 1.01-1.07), American Indians and Alaska Natives (aOR, 1.07; 95%CI, 1.02-1.13), and two or more races (aOR, 1.34; 95%CI, 1.13-1.60). Additional predictors for high-risk urban counties include population density (aOR, 1.12; 95%CI, 1.04-1.22) and higher unemployment rates during the COVID-19 pandemic (aOR, 1.23; 95%CI, 1.07-1.41). CONCLUSIONS: Rural counties with high proportions of racial/ethnic minorities and urban counties with high unemployment rates are at high mortality risk for COVID-19 and opioid overdose.