Faculty Bibliography

BACKGROUND:Treatment for opioid use disorder involving opioid-based pharmacotherapies is considered most effective when accompanied by psychosocial interventions. Peer-led support groups are widely available and have been described by many as fundamental to the recovery process. However, some individuals using medications face stigma in these settings, which can be contradictory and counterproductive to their recovery. METHODS:This paper describes the development of the "Ability, Inspiration and Motivation" or "AIM" group, an alternative peer support group that aims to remove medication stigma from peer recovery. Qualitative interviews with staff, peers, and clients of a community-based buprenorphine treatment program were used to establish the core components of the curriculum to support client needs. RESULTS:Staff, peers, and clients of the buprenorphine program indicated a need and desire to establish a peer recovery group that recognizes persons on medication as being in recovery and destigmatizes use of medication to treat opioid addiction. A respectful environment, holistic perspective on health, spirituality, sharing, and celebration were all established as necessary pillars of the AIM group curriculum. CONCLUSIONS:The community-based effort to establish and develop the AIM group demonstrates that combining the strengths of a peer support with evidence-based medication treatment is both possible and desirable. Shifting the culture of peer recovery groups to support the use of medications may have implications for improving treatment retention and should be considered as a potential strategy to reduce the burden of the opioid epidemic.

OBJECTIVES:To present and discuss recent patterns of prescription opioid sales throughout Brazil. METHODS:We graphed linear trends of opioid prescriptions sold from registered pharmacies across Brazil from 2009 to 2015. We then calculated the change in rate of prescriptions sold per 1000 persons in 2015 compared with 2009. RESULTS:Opioid sales increased across Brazil from 1 601 043 prescriptions in 2009 to 9 045 945 prescriptions in 2015, corresponding to a 465% increase in 6 years. The largest absolute increase was for codeine products (rate ratio (RR) = 5.30; 95% confidence interval [CI] = 5.29, 5.31), accounting for more than 98% of prescriptions in both years. Oxycodone had the largest relative increase (RR = 11.39; 95% CI = 11.19, 11.59), and fentanyl products had the smallest absolute and relative increase (RR = 2.91; 95% CI = 2.78, 3.03). CONCLUSIONS:Given rapid increases in opioid sales across Brazil, it is critical to introduce effective prescribing and monitoring methods that allow patients to access necessary medications without escalating risk of opioid misuse and related consequences. Careful surveillance of supply and subsequent outcomes are needed to prevent the development of another devastating opioid epidemic in the Americas.

BACKGROUND:Frequent emergency department (ED) visits often suggest inappropriate use for low acuity needs and multiple comorbidities, including substance use disorders. OBJECTIVE:This study examines associations of individuals and their social networks with high frequency ED use among persons reporting substance use. METHODS:Information was obtained from interview responses from the first 6-month follow-up visit of a longitudinal. Prevalence ratios for the outcome of high frequency ED visits (≥2 in 6 months) were determined with a generalized linear model, log link, Poisson distribution and robust standard errors. RESULTS:Of 653 participants, 131 (20%) had ≥2 ED visits. In multivariable analysis, greater likelihood of high frequency ED visits over 6 months was associated with being homeless (PR: 1.58; 95% CI: 1.19, 2.10), taking ≥3 medications (PR: 1.58; 95% CI: 1.19, 2.10) and having had a hospitalization over the same period (PR: 4.33; 95% CI: 3.26, 7.56). Among social network factors, lower likelihood of high frequency visits was associated with each increasing year of mean alter age (PR: 0.98; 95% CI: 0.6, 0.99) and greater likelihood with having received health-related informational support from ≥2 alters (PR: 1.62; 95% CI: 1.04, 2.53). Conclusions/Importance: Social network factors may play an important role in ED use. Interventions to promote health behaviors through social influence may be helpful in reducing high frequency ED visits.

Medicaid enrollment varies considerably among states. This study examined the association of Medicaid enrollment with the use of substance health services in the longitudinal National Epidemiologic Survey on Alcohol and Related Conditions of 2001-2005. Instrumental variable methods were used to assess endogeneity of individual-level Medicaid enrollment using state-level data as instruments. Compared to the uninsured, Medicaid covered adults were more likely to use substance use disorder treatment services over the next three years. States that have opted to expand Medicaid enrollment under the Affordable Care Act will likely experience further increases in the use of these service over the coming years.

INTRODUCTION:Although prior clinical and population-based studies have demonstrated comorbidity between mood and alcohol use disorders (AUD), there is a paucity of research assessing whether mood disorders predict transition across stages of alcohol involvement. METHOD:Hypothesizing that mood disorders predict transition across sex-specific alcohol involvement stages, we used prospective data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative survey of US adults, which included male (n = 14,564) and female (n = 20,089) participants surveyed in 2001-2 and re-interviewed in 2004-5. Latent class (LCA) and latent transition analyses (LTA) were used to assess patterns of alcohol involvement in the US and the association of lifetime mood disorders at baseline with transition across stages of alcohol involvement during follow-up. RESULTS:A three-class model of AUD criteria was identified (No problems, Moderate problems and Severe problems) for both sexes. Positive cross-sectional associations between mood disorder and problem classes of alcohol involvement were found among both sexes, as were positive longitudinal associations. Propensity score adjustment mitigated the associations of baseline mood disorder with progressive transition for both sexes. However, among females, baseline mood disorder was consistently associated with reduction in remission from Severe to Moderate alcohol problems (aOR = 0.30, CI = 0.09-0.99, p = .048) over time. DISCUSSION:Our study provides evidence that mood disorders impact transition through stages of alcohol involvement and are most strongly associated with hindering remission among females. Findings advance our understanding of these comorbid relationships and have clinical implications for ongoing assessment of drinking patterns among individuals with mood disorders.

Background Agricultural production has expanded dramatically throughout Brazil. Previous research in the Serrana Region found that from 1979 to 1998, agricultural workers experienced high mortality rates from certain cancers compared to non-agricultural workers [Meyer et al. (2003): Environ Res 93:264-271].

Calls to address crack-cocaine use in Brazil among homeless and street-frequenting populations who are in urgent need of health services have questioned the capacity of the Brazilian Unified Health System to attend to the nation's most marginalized citizens. In recent years, Brazil has launched several actions to escalate care for substance users, yet many obstacles hindering accessibility and effectiveness of services remain. Paradoxically, these actions have been implemented in the context of a growing economic crisis, and expanding services for a population of poor and stigmatized substance users while cutting other government programs tends to elicit harsh criticism from citizens. In consequence of such prospects, this commentary aims to discuss barriers marginalized substance users face in accessing health services that are at risk of worsening with government cutbacks. Using Rio de Janeiro as an example, we explore two primary issues: the resource-strained, under-staffed and decentralized nature of the Brazilian Unified Health System and the pervading stigma that bars vulnerable citizens from official structures and services. Abandoning initiated government efforts to increase access to health services would risk maintaining vulnerable citizens at the margins of public structures, inhibiting the opportunity to offer this population humane and urgently needed treatment and care.

PURPOSE/OBJECTIVE:The American Academy of Pediatrics recently recommended that pediatricians consider medication-assisted treatment (MAT) for adolescents with severe opioid use disorders. Little is known about adolescents' current use of MAT. METHODS:We use data on episodes of specialty treatment for heroin or opioid use (n = 139,092) from a database of publicly funded treatment programs in the U.S. We compare the proportions of adolescents and adults who received MAT, first using unadjusted comparison of proportions, then using logistic regression to adjust for potential confounders. RESULTS:Only 2.4% (95% confidence interval [CI], 1.4%-3.7%) of adolescents in treatment for heroin received MAT, as compared to 26.3% (95% CI, 26.0%-26.6%) of adults. Only .4% (95% CI, .2%-.7%) of adolescents in treatment for prescription opioids received MAT, as compared to 12.0% (95% CI, 11.7%-12.2%) of adults. Regression-adjusted results were qualitatively similar. CONCLUSIONS:Regulatory changes and expansions of Medicaid/CHIP coverage for MAT may be needed to improve MAT access.

BACKGROUND:Psychiatric disorders are highly comorbid with substance use disorders and play an important role in their course and recovery. However, the impact of comorbidity on treatment outcomes has not been examined in a U.S. national sample. This study explores the impact of psychiatric comorbidity on treatment completion among individuals admitted to publicly funded substance use treatment facilities across the United States. METHODS:Using data on first-time treatment episodes in the U.S. from the Treatment Episode Dataset-Discharges (TEDS-D) for the years 2009-2011, logistic regression was used to assess the association between psychiatric comorbidity and treatment non-completion, and Cox proportional hazards regression was used to assess the association between comorbidity and rate of attrition. Analyses were performed for all substances together and then stratified by primary substance of abuse (alcohol, cannabis, stimulants, or opioids). RESULTS:Of 856,385 client treatment episodes included in our analysis, 28% had a psychiatric comorbidity and 38% did not complete treatment. After adjusting for socio-demographic and treatment characteristics, clients with psychiatric comorbidity had higher odds of not completing treatment relative to those without comorbidity [OR=1.28 (1.27-1.29)], and had an earlier time to attrition [HR=1.14 (1.13-1.15)]. Psychiatric comorbidity was most strongly associated with treatment non-completion and rate of attrition in those admitted primarily for alcohol [OR=1.37 (1.34-1.39); HR=1.19 (1.17-1.21), respectively]. CONCLUSIONS:Individuals with psychiatric comorbidities receiving treatment for substance use disorders face unique challenges that impact their ability to complete treatment. The findings call for further efforts to integrate treatment for psychiatric comorbidities in substance use treatment settings.