Faculty Bibliography

BACKGROUND AND AIMS/OBJECTIVE:Evidence from randomized controlled trials establishes that medication treatment with methadone and buprenorphine reduces opioid use and improves treatment retention. However, little is known about the role of such medications compared with non-medication treatments in mitigating overdose risk among US patient populations receiving treatment in usual care settings. This study compared overdose mortality among those in medication versus non-medication treatments in specialty care settings. DESIGN/METHODS:Retrospective cohort study using state-wide treatment data linked to death records. Survival analysis was used to analyze data in a time-to-event framework. SETTING/METHODS:Services delivered by 757 providers in publicly funded out-patient specialty treatment programs in Maryland, USA between 1 January 2015 and 31 December 2016. PARTICIPANTS/METHODS:A total of 48 274 adults admitted to out-patient specialty treatment programs in 2015-16 for primary diagnosis of opioid use disorder. MEASUREMENTS/METHODS:Main exposure was time in medication treatment (methadone/buprenorphine), time following medication treatment, time exposed to non-medication treatments and time following non-medication treatment. Main outcome was opioid overdose death during and after treatment. Hazard ratios were calculated using Cox proportional hazard regression. Propensity score weights were adjusted for patient information on sex, age, race, region of residence, marital and veteran status, employment, homelessness, primary opioid, mental health treatment, arrests and criminal justice referral. FINDINGS/RESULTS:The study population experienced 371 opioid overdose deaths. Periods in medication treatment were associated with substantially reduced hazard of opioid overdose death compared with periods in non-medication treatment [adjusted hazard ratio (aHR) = 0.18, 95% confidence interval (CI) = 0.08-0.40]. Periods after discharge from non-medication treatment (aHR = 5.45, 95% CI = 2.80-9.53) and medication treatment (aHR = 5.85, 95% CI = 3.10-11.02) had similar and substantially elevated risks compared with periods in non-medication treatments. CONCLUSIONS:Among Maryland patients in specialty opioid treatment, periods in treatment are protective against overdose compared with periods out of care. Methadone and buprenorphine are associated with significantly lower overdose death compared with non-medication treatments during care but not after treatment is discontinued.

Over the last decade, Baltimore has become a non-traditional sanctuary city, receiving an unprecedented influx of Latino immigrants, mostly from Central America's Northern Triangle, who are often fleeing violence in their home countries. This study explored the nature and frequency of healthcare utilization for mental health problems among uninsured/uninsurable Latinos who received outpatient care between 2012 and 2015 through an academic hospital-affiliated program that covers primary and specialty services to uninsured patients without regard to documentation status. Encounters for mental health disorders were the most common category, accounting for 14.88% of all visits. Mood (78%) and anxiety disorders (16%) were the most prevalent mental health diagnoses. The most frequent reason to seek care was symptom, signs, and ill-defined conditions (37.47%), and within this subgroup, pain was the leading cause of seeking care (88%), which may indicate high rates of somatization of mental health distress. This study presents a unique opportunity to explore the burden and nature of mental health needs among a population for which healthcare information is rarely attainable and highlights the need for culturally competent screening mechanisms and interventions to address the stressors faced by emergent communities.

OBJECTIVE:To examine the impact of Section 1115 waivers on Medicaid coverage and opioid agonist therapy (OAT) utilization among substance use treatment admissions. DATA SOURCE/METHODS:Treatment Episode Data Set-Admissions (TEDS-A) (2001-2012). STUDY DESIGN/METHODS:We examined effects of 1115 waiver implementation on proportions of substance use treatment admissions with Medicaid and receiving OAT, using random intercept linear regression. PRINCIPAL FINDINGS/RESULTS:1115 waiver implementation was associated with an average of a 6 percentage point increase in proportion of all admissions with Medicaid, and 4 percentage point increase among opioid outpatient admissions. Implementation was not associated with change in proportion of opioid outpatient admissions receiving OAT. CONCLUSIONS:1115 waivers influence Medicaid coverage among substance use treatment admissions. The findings improve our understanding of how state policies impact substance use treatment utilization.

STUDY OBJECTIVE/OBJECTIVE:Persons with substance use disorders frequently utilize emergency department (ED) services, creating an opportunity for intervention and referral to addiction treatment and harm-reduction services. However, EDs may not have the appropriate tools to distinguish which patients are at greatest risk for negative outcomes. We link hospital ED and medical examiner mortality databases in one state to identify individual-level risk factors associated with overdose death among ED patients with substance-related encounters. METHODS:This retrospective cohort study linked Maryland statewide ED hospital claims records for adults with nonfatal overdose or substance use disorder encounters in 2014 to 2015 with medical examiner mortality records in 2015 to 2016. Logistic regression was used to identify factors in hospital records associated with risk of opioid overdose death. Predicted probabilities for overdose death were calculated for hypothetical patients with different combinations of overdose and substance use diagnostic histories. RESULTS:A total of 139,252 patients had substance-related ED encounters in 2014 to 2015. Of these patients, 963 later experienced an opioid overdose death, indicating a case fatality rate of 69.2 per 10,000 patients, 6 times higher than that of patients who used the ED for any cause. Factors most strongly associated with death included having both an opioid and another substance use disorder (adjusted odds ratio 2.88; 95% confidence interval 2.04 to 4.07), having greater than or equal to 3 previous nonfatal overdoses (adjusted odds ratio 2.89; 95% confidence interval 1.54 to 5.43), and having a previous nonfatal overdose involving heroin (adjusted odds ratio 2.24; 95% confidence interval 1.64 to 3.05). CONCLUSION/CONCLUSIONS:These results highlight important differences in overdose risk among patients receiving care in EDs for substance-related conditions. The findings demonstrate the potential utility of incorporating routine data from patient records to assess risk of future negative outcomes and identify primary targets for initiation and linkage to lifesaving care.

INTRODUCTION/BACKGROUND:Prescription Drug Monitoring Program data can provide insights into a patient's likelihood of an opioid overdose, yet clinicians and public health officials lack indicators to identify individuals at highest risk accurately. A predictive model was developed and validated using Prescription Drug Monitoring Program prescription histories to identify those at risk for fatal overdose because of any opioid or illicit opioids. METHODS:From December 2018 to July 2019, a retrospective cohort analysis was performed on Maryland residents aged 18-80 years with a filled opioid prescription (n=565,175) from January to June 2016. Fatal opioid overdoses were identified from the Office of the Chief Medical Examiner and were linked at the person-level with Prescription Drug Monitoring Program data. Split-half technique was used to develop and validate a multivariate logistic regression with a 6-month lookback period and assessed model calibration and discrimination. RESULTS:Predictors of any opioid-related fatal overdose included male sex, age 65-80 years, Medicaid, Medicare, 1 or more long-acting opioid fills, 1 or more buprenorphine fills, 2 to 3 and 4 or more short-acting schedule II opioid fills, opioid days' supply ≥91 days, average morphine milligram equivalent daily dose, 2 or more benzodiazepine fills, and 1 or more muscle relaxant fills. Model discrimination for the validation cohort was good (area under the curve: any, 0.81; illicit, 0.77). CONCLUSIONS:A model for predicting fatal opioid overdoses was developed using Prescription Drug Monitoring Program data. Given the recent national epidemic of deaths involving heroin and fentanyl, it is noteworthy that the model performed equally well in identifying those at risk for overdose deaths from both illicit and prescription opioids.

OBJECTIVE:This qualitative study identifies and describes experiences and challenges to retention of individuals with opioid use disorder (OUD) who participated in a low-threshold combined buprenorphine-peer support treatment program in Baltimore. METHODS:In-depth semi-structured interviews with staff and former clients of the Project Connections Buprenorphine Program (PCBP) (9 people) and focus group discussions with current and previous clients of PCBP (7 people) were conducted. Content analysis was used to extract themes regarding barriers to enrolling and remaining in, and transitioning from the program. RESULTS:Primary challenges identified by the participants included struggles with cravings and symptoms of withdrawal, comorbid mental health issues, criminal justice system involvement, medication stigma, and conflicts over level of flexibility regarding program requirements and the role of employment. CONCLUSIONS:This study identified several obstacles clients face when seeking care through a combined buprenorphine-peer support model. Findings highlight potential programmatic factors that can be improved and additional resources that may support treatment retention rates and better outcomes. Despite challenges, low-threshold and community-based programs can increase access to effective maintenance treatment for OUD, especially among vulnerable populations who may not have access to formal health services.

OBJECTIVE:Understand how insurance impacts access to services among people who have injected drugs. METHODS:1748 adults who have injected drugs were assessed at twice-annual study visits between 2006 and 2017 (18,869 visits). Use of specialty substance use treatment, receipt of buprenorphine, and having a regular source of medical care were assessed for association with concurrent insurance coverage. Random intercept logistic regression was used to adjust for potential confounders. RESULTS:When participants acquired insurance, they were more likely to report specialty substance use treatment (aOR 2.0, 95% CI 1.6 to 2.5), a buprenorphine prescription (aOR 3.3, 95% CI 2.0 to 5.5), and a regular source of medical care (aOR 6.3, 95% CI 5.1 to 7.8). CONCLUSION/CONCLUSIONS:Insurance is associated with increased use of three important services for individuals who inject drugs. IMPLICATIONS/CONCLUSIONS:Expanding insurance may facilitate access to substance use treatment and other needed health services.

Buprenorphine is considered one of the most effective treatments for opioid use disorder and significantly reduces risk of overdose death. However, concerns about its diversion and misuse have often taken center stage in public discourse and in the design of practices and policies regarding its use. This has been to the detriment of many vulnerable patient populations, especially those involved in the criminal justice system. Policies that restrict access to buprenorphine in criminal justice and other settings due to concerns of diversion do not accurately reflect the relative risks and safety profile associated with it, creating unnecessary barriers that drive an illicit market of this much-needed medication. Although proper regulation of all controlled medications should be a priority, in most instances the benefits of buprenorphine highly outweigh its risks. In the midst of a national crisis, efforts should be focused on expanding, and not restricting, access to this lifesaving treatment.

BACKGROUND AND OBJECTIVES/OBJECTIVE:During adolescence, mental health problems may increase the risk of initiating combustible cigarette use. However, it is unknown if this association extends to electronic cigarettes (e-cigarettes). We examined whether internalizing and externalizing problems were associated with initiation of e-cigarette, combustible cigarette, and dual-product use among adolescents. METHODS:Participants were drawn from the Population Assessment of Tobacco and Health Study, a nationally representative longitudinal study of US adolescents followed from 2013 to 2015. The study sample included 7702 adolescents aged 12 to 17 years who at baseline reported no lifetime use of tobacco products. We examined the respective associations between baseline internalizing and externalizing problems and initiating use of e-cigarettes, combustible cigarettes, or both at 1-year follow-up. RESULTS:Compared with adolescents with low externalizing problems, adolescents with high externalizing problems were significantly more likely to initiate use of e-cigarettes (adjusted relative risk ratio [aRRR] = 2.78; 95% confidence interval [CI]: 1.76-4.40), combustible cigarettes (aRRR = 5.59; 95% CI: 2.63-11.90), and both products (aRRR = 2.23; 95% CI: 1.15-4.31). Adolescents with high internalizing problems were at increased risk of initiating use of e-cigarettes (aRRR = 1.61; 95% CI: 1.12-2.33) but not combustible cigarettes or both products. CONCLUSIONS:Mental health problems are associated with increased risk for initiating e-cigarette, combustible cigarette, and dual-product use in adolescence. This association is more consistent for externalizing problems than internalizing problems. Addressing mental health problems could be a promising target for preventing initiation of nicotine- and/or tobacco-product use by adolescents.