Development of a Risk Index for Serious Prescription Opioid-Induced Respiratory Depression or Overdose in Veterans' Health Administration Patients.

OBJECTIVE: Develop a risk index to estimate the likelihood of life-threatening respiratory depression or overdose among medical users of prescription opioids. SUBJECTS, DESIGN, AND METHODS: A case-control analysis of administrative health care data from the Veterans' Health Administration identified 1,877,841 patients with a pharmacy record for an opioid prescription between October 1, 2010 and September 30, 2012. Overdose or serious opioid-induced respiratory depression (OSORD) occurred in 817. Ten controls were selected per case (n = 8,170). Items for an OSORD risk index (RIOSORD) were selected through logistic regression modeling, with point values assigned to each predictor. Modeling of risk index scores produced predicted probabilities of OSORD; risk classes were defined by the predicted probability distribution. RESULTS: Fifteen variables most highly associated with OSORD were retained as items, including mental health disorders and pharmacotherapy; impaired drug metabolism or excretion; pulmonary disorders; specific opioid characteristics; and recent hospital visits. The average predicted probability of experiencing OSORD ranged from 3% in the lowest risk decile to 94% in the highest, with excellent agreement between predicted and observed incidence across risk classes. The model's C-statistic was 0.88 and Hosmer-Lemeshow goodness-of-fit statistic 10.8 (P > 0.05). CONCLUSION: RIOSORD performed well in identifying medical users of prescription opioids within the Veterans' Health Administration at elevated risk of overdose or life-threatening respiratory depression, those most likely to benefit from preventive interventions. This novel, clinically practical, risk index is intended to provide clinical decision support for safer pain management. It should be assessed, and refined as necessary, in a more generalizable population, and prospectively evaluated.

Validity of recall of tobacco use in two prospective cohorts.

This project studied the convergent validity of current recall of tobacco-related health behaviors, compared with prospective self-report collected earlier at two sites. Cohorts were from the Oregon Research Institute at Eugene (N = 346, collected 19.5 years earlier) and the University of Pittsburgh, Pennsylvania (N = 294, collected 3.9 years earlier). Current recall was examined through computer-assisted interviews with the Lifetime Tobacco Use Questionnaire from 2005 through 2008. Convergent validity estimates demonstrated variability. Validity estimates of some tobacco use measures were significant for Oregon subjects (age at first cigarette, number of cigarettes/day, quit attempts yes/no and number of attempts, and abstinence symptoms at quitting; all P < 0.03). Validity estimates of Pittsburgh subjects' self-reports of tobacco use and abstinence symptoms were significant (P < 0.001) for all tobacco use and abstinence symptoms and for responses to initial use of tobacco. These findings support the utility of collecting recalled self-report information for reconstructing salient lifetime health behaviors and underscore the need for careful interpretation.

Test-retest reliability of web-based retrospective self-report of tobacco exposure and risk.

BACKGROUND: Retrospectively collected data about the development and maintenance of behaviors that impact health are a valuable source of information. Establishing the reliability of retrospective measures is a necessary step in determining the utility of that methodology and in studying behaviors in the context of risk and protective factors. OBJECTIVE: The goal of this study was to examine the reliability of self-report of a specific health-affecting behavior, tobacco use, and its associated risk and protective factors as examined with a Web-based questionnaire. METHODS: Core tobacco use and risk behavior questions in the Lifetime Tobacco Use Questionnaire-a closed, invitation-only, password-controlled, Web-based instrument-were administered at a 2-month test-retest interval to a convenience sample of 1229 respondents aged 18 to 78 years. Tobacco use items, which covered cigarettes, cigars, smokeless tobacco, and pipe tobacco, included frequency of use, amount used, first use, and a pack-years calculation. Risk-related questions included family history of tobacco use, secondhand smoke exposure, alcohol use, and religiosity. RESULTS: Analyses of test-retest reliability indicated modest (.30 to .49), moderate (.50 to .69), or high (.70 to 1.00) reliability across nearly all questions, with minimal reliability differences in analyses by sex, age, and income grouping. Most measures of tobacco use history showed moderate to high reliability, particularly for age of first use, age of first weekly and first daily smoking, and age at first or only quit attempt. Some measures of family tobacco use history, secondhand smoke exposure, alcohol use, and religiosity also had high test-retest reliability. Reliability was modest for subjective response to first use. CONCLUSIONS: The findings reflect the stability of retrospective recall of tobacco use and risk factor self-report responses in a Web-questionnaire context. Questions that are designed and tested with psychometric scrutiny can yield reliable results in a Web setting.

Validity of retrospective assessments of nicotine dependence: a preliminary report.

Information about levels of nicotine dependence in ex-smokers when they smoked, or in current smokers at an earlier date, is useful for clinical and research purposes. To estimate the accuracy of retrospective reports of dependence, 28 individuals who completed either the Fagerström Tolerance Questionnaire (FTQ) or Fagerström Test for Nicotine Dependence (FTND) in smoking cessation trials conducted 5 to 12 years earlier were asked to respond again to the same questions, thinking back to their smoking behavior just prior to their on-study quit attempt. Concordance and Kappa values for the items ranged from 50.0% to 95.0% and 0.00 to 0.92, respectively. The mean difference between the baseline and follow-up total scale scores was 0.05 for the FTQ and 0.38 for the FTND, and the correlation between these assessments was 0.62 for the FTQ (p<0.005) and 0.72 for the FTND (p<0.05). These preliminary results suggest that retrospectively assessed FTQ/FTND scale scores have acceptable reliability.

Outcomes from a patient-centered residential treatment plan for tobacco dependence.

St. Helena Hospital launched the first US residential stop-smoking program, The St. Helena Center for a Smoke-Free Life, in 1969. This observational report describes the center's treatment outcome rate for using a patient-centered approach to the use of tobacco dependence medications and behavioral treatment for patients who participated in the program from January 1, 2005 through December 31, 2007. A total of 284 patients used long-acting (nicotine patch, bupropion, and varenicline) and/or short-acting medications (nicotine nasal spray, nicotine gum, nicotine lozenge, and nicotine oral inhaler) alone or in combination during treatment and after discharge. Seven patients chose to use no medications. Patients using nicotine patch received a mean ± SD dose of 33.3±15.7 mg of nicotine in 16 hours (range, 5-90 mg). The 12-month 7-day point prevalence smoking abstinence rate after participation in the intensive, 1-week, residential program was 57.0%. Recommendations are discussed for future research and for implementing aspects of the St. Helena program in other treatment settings.

Association of tobacco dependence and quit attempt duration with Rasch-modeled withdrawal sensitivity using retrospective measures.

AIM: To examine whether Rasch modeling would yield a unidimensional withdrawal sensitivity measure correlating with factors associated with successful smoking cessation. DESIGN: The psychometric Rasch modeling approach was applied to estimate an underlying latent construct (withdrawal sensitivity) in retrospective responses from 1644 smokers who reported quitting for 3 or more months at least once. SETTING: Web-based, passcode-controlled self-administered computerized questionnaire. PARTICIPANTS: Randomly selected convenience sample of 1644 adult members of an e-mail invitation-only web panel drawn from consumer databases. MEASUREMENTS: Lifetime Tobacco Use Questionnaire, assessing tobacco use across the life-span, including demographics and respondent ratings of the severity of withdrawal symptoms experienced in respondents' first and most recent quit attempts lasting 3 or more months. FINDINGS: Rasch-modeled withdrawal sensitivity was generally unidimensional and was associated with longer periods of smoking cessation. One latent variable accounted for 74% of the variability in symptom scores. Rasch modeling with a single latent factor fitted withdrawal symptoms well, except for increased appetite, for which the fit was marginal. Demographic variables of education, gender and ethnicity were not related to changes in sensitivity. Correlates of greater withdrawal sensitivity in cessation attempts of at least 3 months included younger age at first quit attempt and indicators of tobacco dependence. CONCLUSION: The relationship between tobacco dependence symptoms and Rasch-model withdrawal sensitivity defines further the relationship between sensitivity and dependence. The findings demonstrate the utility of modeling to create an individual-specific sensitivity measure as a tool for exploring the relationships among sensitivity, dependence and cessation.

Reliability of adult retrospective recall of lifetime tobacco use.

Retrospective assessment of tobacco use underlies much of the data collected in epidemiological and genetic epidemiological research. Although individuals are asked to report lifetime tobacco use for periods spanning months to decades, the test-retest reliability intervals of the instruments often span only a few weeks to several months. The present analyses examined the test-retest reliability of retrospective tobacco use measures, including details of first use, circumstances of first use, and initial subjective reactions. The questions were part of the Lifetime Tobacco Use Questionnaire (LTUQ), a Web-based questionnaire designed to assess use of most forms of tobacco or nicotine retrospectively across the lifespan. A convenience sample of 236 men and women with history of tobacco use (Time 1 mean age, 44.9 years; 74.2% females; 75.1% regular monthly tobacco use) responded verifiably to invitations to self-administer the LTUQ two times, 2 years apart. Test-retest reliability analyses reflected high reliability for salient tobacco-use questions. Acceptable levels of reliability were observed for initial subjective reactions to smoking, if the scaled response options were dichotomized. Few differences in the reliability of recall were apparent between sexes and between age groups. These results indicate that recall of important tobacco use information can form a reliable basis for research.

Adolescent smoking trajectories and nicotine dependence.

The present study correlates empirically constructed prospective adolescent smoking trajectories with indicators of nicotine dependence assessed in adolescence and in adulthood. Excluding individuals who reported no smoking during repeat assessment (nonadopters), we identified five smoking trajectory groups: experimenters (n=116, 48.5%), late increasers (n=39, 16.3%), early increasers (n=37, 15.5%), quitters (n=22, 9.2%), and persistent smokers (n=25, 10.5%). Higher frequency of nicotine dependence symptoms in adolescence occurred in the quitters and persistent smokers groups, who smoked at higher levels relative to the experimenters, late increasers, and early increasers groups, who reported a similar frequency of nicotine dependence symptoms and smoked at low levels. Lifetime nicotine dependence was assessed in adulthood in lifetime daily smokers using the Fagerström Test for Nicotine Dependence (FTND) and the Nicotine Dependence Scale (NDS). Lifetime FTND levels were similar across trajectory groups. Relative to experimenters, all remaining smoking trajectory groups had higher NDS levels that were similar to one another. These results suggest that higher levels of adolescent nicotine dependence were associated with heavier smoking trajectory groups, and that regardless of trajectory group membership, smoking more than a few cigarettes per week throughout adolescence resulted in similar levels of lifetime nicotine dependence as measured by the FTND and NDS.

A multidimensional model for characterizing tobacco dependence.

The standard tool for assessing tobacco dependence is the Fagerström Tolerance Questionnaire (FTQ) or its more recent variant, the Fagerström Test for Nicotine Dependence (FTND). Although both of these scales reportedly assess physiological dependence on nicotine, they might not tap some facets of dependence, particularly psychosocial factors. To determine whether tobacco dependence exhibits multidimensional properties, we examined two existing, independent data sets, one from SRI International (n=443) and another from the University of Michigan (n=445). Based on our knowledge from existing literature, standard psychometric statistical analyses, and results from exploratory factor analysis using SRI's data set, we identified two competing models for dependence representing a hybrid of the FTQ/FTND and the Smoking Motives Questionnaire. We then examined these models using confirmatory factor analysis with data from the University of Michigan. We characterized the final model by five first-order factors, each consisting of two to four items, and one higher-order factor. The first-order factors were termed stimulation, automaticity, sedation, psychosocial motives, and morning smoking; the higher-order factor, tobacco dependence, underlay each of the first-order factors. The ranges of interitem correlations and Cronbach's alpha estimates of internal consistency for the first-order factors were .34 - .68 and .64 - .81, respectively. Results of these analyses support the hypothesis that tobacco dependence is multidimensional.