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Longitudinal trajectories of substance use disorder treatment use: A latent class growth analysis using a national cohort in Chile

Bórquez, Ignacio; Cerdá, Magdalena; González-Santa Cruz, Andrés; Krawczyk, Noa; Castillo-Carniglia, Álvaro
Background and aims: Longitudinal studies have revealed that substance use treatment use is often recurrent among patients; the longitudinal patterns and characteristics of those treatment trajectories have received less attention, particularly in the global south. This study aimed to disentangle heterogeneity in treatment use among adult patients in Chile by identifying distinct treatment trajectory groups and factors associated with them. Design: National-level registry-based retrospective cohort. Setting and participants: Adults admitted to publicly funded substance use disorder treatment programs in Chile from November 2009 to November 2010 and followed for 9 years (n = 6266). Measurements: Monthly treatment use; type of treatment; ownership of the treatment center; discharge status; primary substance used; sociodemographic. Findings: A seven-class treatment trajectory solution was chosen using latent class growth analysis. We identified three trajectory groups that did not recur and had different treatment lengths: Early discontinuation (32%), Less than a year in treatment (19.7%) and Year-long episode, without recurrence (12.3%). We also identified a mixed trajectory group that had a long first treatment or two treatment episodes with a brief time between treatments: Long first treatment, or immediate recurrence (6.3%), and three recurrent treatment trajectory groups: Recurrent and decreasing (14.2%), Early discontinuation with recurrence (9.9%) and Recurrent after long between treatments period (5.7%). Inpatient or outpatient high intensity (vs. outpatient low intensity) at first entry increased the odds of being in the longer one-episode groups compared with the Early discontinuation group. Women had increased odds of belonging to all the recurrent groups. Using cocaine paste (vs. alcohol) as a primary substance decreased the odds of belonging to long one-episode groups. Conclusions: In Chile, people in publicly funded treatment for substance use disorder show seven distinct care trajectories: three groups with different treatment lengths and no recurring episodes, a mixed group with a long first treatment or two treatment episodes with a short between-treatment-episodes period and three recurrent treatment groups.
ISSN: 0965-2140
CID: 5630142

Rural-urban disparities in the availability of hospital-based screening, medications for opioid use disorder, and addiction consult services

Franz, Berkeley; Cronin, Cory E; Lindenfeld, Zoe; Pagan, Jose A; Lai, Alden; Krawczyk, Noa; Rivera, Bianca D; Chang, Ji E
INTRODUCTION/BACKGROUND:Hospitals are an ideal setting to stage opioid-related interventions with patients who are hospitalized due to overdose or other substance use-related complications. Transitional opioid programs-which initiate care and provide linkages upon discharge, such as screening, initiation of medications for opioid use disorder, and addiction consult services-have become the gold standard, but implementation has been uneven. The purpose of this study was to assess disparities in the availability of hospital-based transitional opioid programs, across rural and urban hospital settings in the United States. METHODS:Using hospital administrative data paired with county-level demographic data, we conducted bivariate and regression analyses to assess rural-urban differences in the availability of transitional opioid services including screening, addiction consult services, and MOUD in U.S general medical centers, controlling for hospital- and community-level factors. Our sample included 2846 general medical hospitals that completed the 2021 American Hospital Association (AHA) Annual Survey of Hospitals. Our primary outcomes were five self-reported measures: whether the hospital provided screening in the ED; provided screening in the inpatient setting; whether the hospital provided addiction consult services in the ED; provided addiction consult services in the inpatient setting; and whether the hospital provided medications for opioid use disorder. RESULTS:Rural hospitals did not have lower odds of screening for OUD or other SUDs than urban hospitals, but both micropolitan rural counties and noncore rural counties had significantly lower odds of having addiction consult services in either the ED (OR: 0.74, 95 % CI: 0.58, 0.95; OR: 0.68, 95 % CI: 0.50, 0.91) or inpatient setting (OR: 0.76, 95 % CI: 0.59, 0.97; OR: 0.68, 95 % CI: 0.50, 0.93), respectively, or of offering MOUD (OR: 0.69, 95 % CI: 0.52, 0.90; OR: 0.52, 95 % CI: 0.37, 0.74). CONCLUSIONS:Our study suggests that evidence-based interventions, such as medications for opioid use disorder and addiction consult services, are less often available in rural hospitals, which may contribute to rural-urban disparities in health outcomes secondary to OUD. A priority for population health improvement should be developing implementation strategies to support rural hospital adoption of transitional opioid programs.
PMID: 38142042
ISSN: 2949-8759
CID: 5623392

Jail-based medication for opioid use disorder and patterns of reincarceration and acute care use after release: A sequence analysis

Lim, Sungwoo; Cherian, Teena; Katyal, Monica; Goldfeld, Keith S; McDonald, Ryan; Wiewel, Ellen; Khan, Maria; Krawczyk, Noa; Braunstein, Sarah; Murphy, Sean M; Jalali, Ali; Jeng, Philip J; Rosner, Zachary; MacDonald, Ross; Lee, Joshua D
BACKGROUND:Treatment with methadone and buprenorphine medications for opioid use disorder (MOUD) during incarceration may lead to better community re-entry, but evidence on these relationships have been mixed. We aimed to identify community re-entry patterns and examine the association between in-jail MOUD and a pattern of successful reentry defined by rare occurrence of reincarceration and preventable healthcare utilization. METHODS:Data came from a retrospective, observational cohort study of 6066 adults with opioid use disorder who were incarcerated in New York City jails and released to the community during 2011-14. An outcome was community re-entry patterns identified by sequence analysis of 3-year post-release reincarceration, emergency department visits, and hospitalizations. An exposure was receipt of in-jail MOUD versus out-of-treatment (42 % vs. 58 %) for the last 3 days before discharge. The study accounted for differences in baseline demographic, clinical, behavioral, housing, and criminal legal characteristics between in-jail MOUD and out-of-treatment groups via propensity score matching. RESULTS:This study identified five re-entry patterns: stability (64 %), hospitalization (23 %), delayed reincarceration (7 %), immediate reincarceration (4 %), and continuous incarceration (2 %). After addressing confounding, 64 % and 57 % followed the stability pattern among MOUD and out-of-treatment groups who were released from jail in 2011, respectively. In 2012-14, the prevalence of following the stability pattern increased year-by-year while a consistently higher prevalence was observed among those with in-jail MOUD. CONCLUSIONS:Sequence analysis helped define post-release stability based on health and criminal legal system involvement. Receipt of in-jail MOUD was associated with a marker of successful community re-entry.
PMID: 38072387
ISSN: 2949-8759
CID: 5589462

Utilization and disparities in medication treatment for opioid use disorder among patients with comorbid opioid use disorder and chronic pain during the COVID-19 pandemic

Perry, Allison; Wheeler-Martin, Katherine; Hasin, Deborah S; Terlizzi, Kelly; Mannes, Zachary L; Jent, Victoria; Townsend, Tarlise N; Pamplin, John R; Crystal, Stephen; Martins, Silvia S; Cerdá, Magdalena; Krawczyk, Noa
BACKGROUND:The COVID-19 pandemic's impact on utilization of medications for opioid use disorder (MOUD) among patients with opioid use disorder (OUD) and chronic pain is unclear. METHODS:We analyzed New York State (NYS) Medicaid claims from pre-pandemic (August 2019-February 2020) and pandemic (March 2020-December 2020) periods for beneficiaries with and without chronic pain. We calculated monthly proportions of patients with OUD diagnoses in 6-month-lookback windows utilizing MOUD and proportions of treatment-naïve patients initiating MOUD. We used interrupted time series to assess changes in MOUD utilization and initiation rates by medication type and by race/ethnicity. RESULTS:Among 20,785 patients with OUD and chronic pain, 49.3% utilized MOUD (versus 60.3% without chronic pain). The pandemic did not affect utilization in either group but briefly disrupted initiation among patients with chronic pain (β=-0.009; 95% CI [-0.015, -0.002]). Overall MOUD utilization was not affected by the pandemic for any race/ethnicity but opioid treatment program (OTP) utilization was briefly disrupted for non-Hispanic Black individuals (β=-0.007 [-0.013, -0.001]). The pandemic disrupted overall MOUD initiation in non-Hispanic Black (β=-0.007 [-0.012, -0.002]) and Hispanic individuals (β=-0.010 [-0.019, -0.001]). CONCLUSIONS:Adults with chronic pain who were enrolled in NYS Medicaid before the COVID-19 pandemic had lower MOUD utilization than those without chronic pain. MOUD initiation was briefly disrupted, with disparities especially in racial/ethnic minority groups. Flexible MOUD policy initiatives may have maintained overall treatment utilization, but disparities in initiation and care continuity remain for patients with chronic pain, and particularly for racial/ethnic minoritized subgroups.
PMID: 37984034
ISSN: 1879-0046
CID: 5608272

Evaluating chronic pain as a risk factor for COVID-19 complications among New York State Medicaid beneficiaries: a retrospective claims analysis

Perry, Allison; Wheeler-Martin, Katherine; Terlizzi, Kelly; Krawczyk, Noa; Jent, Victoria; Hasin, Deborah S; Neighbors, Charles; Mannes, Zachary L; Doan, Lisa V; Pamplin Ii, John R; Townsend, Tarlise N; Crystal, Stephen; Martins, Silvia S; Cerdá, Magdalena
OBJECTIVE:To assess whether chronic pain increases the risk of COVID-19 complications and whether opioid use disorder (OUD) differentiates this risk among New York State Medicaid beneficiaries. DESIGN, SETTING, AND SUBJECTS/METHODS:This was a retrospective cohort study of New York State Medicaid claims data. We evaluated Medicaid claims from March 2019 through December 2020 to determine whether chronic pain increased the risk of COVID-19 emergency department (ED) visits, hospitalizations, and complications and whether this relationship differed by OUD status. We included beneficiaries 18-64 years of age with 10 months of prior enrollment. Patients with chronic pain were propensity score-matched to those without chronic pain on demographics, utilization, and comorbidities to control for confounders and were stratified by OUD. Complementary log-log regressions estimated hazard ratios (HRs) of COVID-19 ED visits and hospitalizations; logistic regressions estimated odds ratios (ORs) of hospital complications and readmissions within 0-30, 31-60, and 61-90 days. RESULTS:Among 773 880 adults, chronic pain was associated with greater hazards of COVID-related ED visits (HR = 1.22 [95% CI: 1.16-1.29]) and hospitalizations (HR = 1.19 [95% CI: 1.12-1.27]). Patients with chronic pain and OUD had even greater hazards of hospitalization (HR = 1.25 [95% CI: 1.07-1.47]) and increased odds of hepatic- and cardiac-related events (OR = 1.74 [95% CI: 1.10-2.74]). CONCLUSIONS:Chronic pain increased the risk of COVID-19 ED visits and hospitalizations. Presence of OUD further increased the risk of COVID-19 hospitalizations and the odds of hepatic- and cardiac-related events. Results highlight intersecting risks among a vulnerable population and can inform tailored COVID-19 management.
PMID: 37651585
ISSN: 1526-4637
CID: 5599602

Retention and critical outcomes among new methadone maintenance patients following extended take-home reforms: a retrospective observational cohort study

Williams, Arthur Robin; Krawczyk, Noa; Hu, Mei-Chen; Harpel, Lexa; Aydinoglo, Nicole; Cerda, Magdalena; Rotrosen, John; Nunes, Edward V
BACKGROUND/UNASSIGNED:Approximately 1800 opioid treatment programs (OTPs) in the US dispense methadone to upwards of 400,000 patients with opioid use disorder (OUD) annually, operating under longstanding highly restrictive guidelines. OTPs were granted novel flexibilities beginning March 15, 2020, allowing for reduced visit frequency and extended take-home doses to minimize COVID exposure with great variation across states and sites. We sought to use electronic health records to compare retention in treatment, opioid use, and adverse events among patients newly entering methadone maintenance in the post-reform period in comparison with year-ago, unexposed, controls. METHODS/UNASSIGNED:Retrospective observational cohort study across 9 OTPs, geographically dispersed, in the National Institute of Drug Abuse (NIDA) Clinical Trials Network. Newly enrolled patients between April 15 and October 14, 2020 (post-COVID, reform period) v. March 15-September 14, 2019 (pre-COVID, control period) were assessed. The primary outcome was 6-month retention. Secondary outcomes were opioid use and adverse events including emergency department visits, hospitalizations, and overdose. FINDINGS/UNASSIGNED: INTERPRETATION/UNASSIGNED:Policies allowing for extended take-home schedules were not associated with worse retention or adverse events despite slightly elevated rates of measured opioid use while in care. Relaxed guidelines were not associated with measurable increased harms and findings could inform future studies with prospective trials. FUNDING/UNASSIGNED:USDHHSNIDACTNUG1DA013035-15.
PMID: 38152421
ISSN: 2667-193x
CID: 5623252

Exploring trauma and wellbeing of people who use drugs after witnessing overdose: A qualitative study

Song, Minna; Desai, Isha K; Meyer, Avery; Shah, Hridika; Saloner, Brendan; Sherman, Susan G; Allen, Sean T; Tomko, Catherine; Schneider, Kristin E; Krawczyk, Noa; Whaley, Sara; Churchill, Jade; Harris, Samantha J
BACKGROUND:The national overdose crisis is often quantified by overdose deaths, but understanding the traumatic impact for those who witness and respond to overdoses can help elucidate mental health needs and opportunities for intervention for this population. Many who respond to overdoses are people who use drugs. This study adds to the literature on how people who use drugs qualitatively experience trauma resulting from witnessing and responding to overdose, through the lens of the Trauma-Informed Theory of Individual Health Behavior. METHODS:We conducted 60-min semi-structured, in-depth phone interviews. Participants were recruited from six states and Washington, DC in March-April 2022. Participants included 17 individuals who witnessed overdose(s) during the COVID-19 pandemic. The interview guide was shaped by theories of trauma. The codebook was developed using a priori codes from the interview guide; inductive codes were added during content analysis. Transcripts were coded using ATLAS.ti. RESULTS:A vast majority reported trauma from witnessing overdoses. Participants reported that the severity of trauma varied by contextual factors such as the closeness of the relationship to the person overdosing or whether the event was their first experience witnessing an overdose. Participants often described symptoms of trauma including rumination, guilt, and hypervigilance. Some reported normalization of witnessing overdoses due to how common overdoses were, while some acknowledged overdoses will never be "normal." The impacts of witnessing overdose on drug use behaviors varied from riskier substance use to increased motivation for treatment and safer drug use practices. CONCLUSION/CONCLUSIONS:Recognizing the traumatic impact of witnessed overdoses is key to effectively addressing the full range of sequelae of the overdose crisis. Trauma-informed approaches should be central for service providers when they approach this subject with clients, with awareness of how normalization can reduce help-seeking behaviors and the need for psychological aftercare. We found increased motivation for behavior change after witnessing, which presents opportunity for intervention.
PMID: 37890394
ISSN: 1873-4758
CID: 5613012

Initiatives to Support the Transition of Patients With Substance Use Disorders From Acute Care to Community-based Services Among a National Sample of Nonprofit Hospitals

Krawczyk, Noa; Rivera, Bianca D; Chang, Ji E; Lindenfeld, Zoe; Franz, Berkeley
BACKGROUND:Hospitals are a key touchpoint to reach patients with substance use disorders (SUDs) and link them with ongoing community-based services. Although there are many acute care interventions to initiate SUD treatment in hospital settings, less is known about what services are offered to transition patients to ongoing care after discharge. In this study, we explore what SUD care transition strategies are offered across nonprofit US hospitals. METHODS:We analyzed administrative documents from a national sample of US hospitals that indicated SUD as a top 5 significant community need in their Community Health Needs Assessment reports (2019-2021). Data were coded and categorized based on the nature of described services. We used data on hospitals and characteristics of surrounding counties to identify factors associated with hospitals' endorsement of transition interventions for SUD. RESULTS:Of 613 included hospitals, 313 prioritized SUD as a significant community need. Fifty-three of these hospitals (17%) offered acute care interventions to support patients' transition to community-based SUD services. Most (68%) of the 53 hospitals described transition strategies without further detail, 23% described scheduling appointments before discharge, and 11% described discussing treatment options before discharge. No hospital characteristics were associated with offering transition interventions, but such hospitals were more likely to be in the Northeast, in counties with higher median income, and states that expanded Medicaid. CONCLUSIONS:Despite high need, most US hospitals are not offering interventions to link patients with SUD from acute to community care. Efforts to increase acute care interventions for SUD should identify and implement best practices to support care continuity.
PMID: 38015653
ISSN: 1935-3227
CID: 5617392

Strategies to support substance use disorder care transitions from acute-care to community-based settings: a scoping review and typology

Krawczyk, Noa; Rivera, Bianca D; Chang, Ji E; Grivel, Margaux; Chen, Yu-Heng; Nagappala, Suhas; Englander, Honora; McNeely, Jennifer
BACKGROUND:Acute-care interventions that identify patients with substance use disorders (SUDs), initiate treatment, and link patients to community-based services, have proliferated in recent years. Yet, much is unknown about the specific strategies being used to support continuity of care from emergency department (ED) or inpatient hospital settings to community-based SUD treatment. In this scoping review, we synthesize the existing literature on patient transition interventions, and form an initial typology of reported strategies. METHODS:We searched Pubmed, Embase, CINAHL and PsychINFO for peer-reviewed articles published between 2000 and 2021 that studied interventions linking patients with SUD from ED or inpatient hospital settings to community-based SUD services. Eligible articles measured at least one post-discharge treatment outcome and included a description of the strategy used to promote linkage to community care. Detailed information was extracted on the components of the transition strategies and a thematic coding process was used to categorize strategies into a typology based on shared characteristics. Facilitators and barriers to transitions of care were synthesized using the Consolidated Framework for Implementation Research. RESULTS:Forty-five articles met inclusion criteria. 62% included ED interventions and 44% inpatient interventions. The majority focused on patients with opioid (71%) or alcohol (31%) use disorder. The transition strategies reported across studies were heterogeneous and often not well described. An initial typology of ten transition strategies, including five pre- and five post-discharge transition strategies is proposed. The most common strategy was scheduling an appointment with a community-based treatment provider prior to discharge. A range of facilitators and barriers were described, which can inform efforts to improve hospital-to-community transitions of care. CONCLUSIONS:Strategies to support transitions from acute-care to community-based SUD services, although critical for ensuring continuity of care, vary greatly across interventions and are inconsistently measured and described. More research is needed to classify SUD care transition strategies, understand their components, and explore which lead to the best patient outcomes.
PMID: 37919755
ISSN: 1940-0640
CID: 5609752

Trends in Fentanyl Content on Reddit Substance Use Forums, 2013-2021

Bunting, Amanda M; Krawczyk, Noa; Lippincott, Thomas; Gu, Yuanqi; Arya, Simran; Nagappala, Suhas; Meacham, Meredith C
BACKGROUND:Fentanyl is a pressing concern in the current drug supply. Social media data can provide access to near real-time understanding of drug trends that may complement official mortality data. DESIGN/METHODS:The total number of fentanyl-related posts and the total number of posts for eight drug subreddit categories (alcohol, cannabis, hallucinogens, multi-drug, opioids, over the counter, sedatives, stimulants) were collected from 2013 to 2021 using the Pushshift Reddit dataset. The proportion of fentanyl-related posts as a fragment of total subreddit posts was examined. Linear regressions described the rate of change in post volume over time. RESULTS:Overall, fentanyl-related content increased across drug-related subreddits from 2013 to 2021 (1292% increase, linear trend p ≤ 0.001). Opioid subreddits (30.62 per 1000 posts, linear trend p ≤ 0.001) had the most fentanyl-related content during the examined time period. Multi-drug (5.95 per 1000; p ≤ 0.01), sedative (3.23 per 1000, p ≤ 0.01), and stimulant (1.60 per 1000, p ≤ 0.01) subreddits also had substantial increases in fentanyl-related content. The greatest increases occurred in the multi-drug (1067% 2013:2021) and stimulant (1862% 2014:2021) subreddits. CONCLUSION/CONCLUSIONS:Fentanyl-related posts on Reddit trended upward, with the fastest rate of change for multi-substance and stimulant subreddits. Beyond opioids, harm reduction and public health messaging should ensure inclusion of individuals who use other drugs.
PMID: 37296360
ISSN: 1525-1497
CID: 5611312