Neonatal Abstinence Syndrome (NAS) is the condition which occurs when newborn babies experience withdrawal symptoms from medications taken by their mothers during pregnancy. Prior research suggest NAS is associated with long-term educational difficulties and alterations in neonatal brain structure. Between 2008 and 2017, NAS rates more than tripled in the United States. An epicenter of the NAS epidemic is Southern Appalachia. West Virginia, the only state with all counties located in Southern Appalachia, has an NAS rate roughly seven times the national average, and in 2017, four of the 10 states with the highest NAS rates were part of Southern Appalachia. Upon reviewing Tennessee data, it was noted that increasing NAS rates had a similar curve to buprenorphine prescribing patterns. Buprenorphine is an opioid partial-agonist prescribed in medication assisted therapy (MAT) intended to help individuals, including those pregnant, avoid withdrawal symptoms. Previous research at an East Tennessee clinic identified buprenorphine in urine drug screens of 16% of all pregnant patients; patients admit to both prescribed and illicit use, including snorting, smoking, and injecting. These findings align with a 2017 study suggesting that mothers of NAS infants in eastern Tennessee, compared to mothers across the state, were more likely to use substances prescribed to another person. Despite the drug’s increasing prescribing patterns and popularity for illicit use, its effects on the mother and fetus remain controversial. We therefore felt it appropriate to investigate possible linkages between buprenorphine prescriptions and NAS rates. For the purposes of this study, we define Southern Appalachia as 250 counties from 7 states, including Tennessee, West Virginia, Virginia, North Carolina, Kentucky, Ohio, and Maryland. Annual NAS rates, buprenorphine prescription rates, drug-induced death rates, and opioid prescribing rates from each county in the region were assessed for the years 2008-2018 using data provided by governmental agencies. It was found that buprenorphine prescriptions in the region more than quintupled between 2008 and 2018. NAS rates and drug-induced death rates did not decrease as well; unfortunately, they dramatically increased. We identified a significant linear association between the rate of NAS diagnoses and buprenorphine prescriptions (r = 0.9774, R2 = 0.9553, p-value less than 0.001) and between the rate of buprenorphine prescriptions and drug-induced deaths (r = 0.7129, R2 = 0.5082, p-value .0311). This is the first report which documents a relationship between NAS rates and increasing buprenorphine prescribing. Discussions regarding current policies for buprenorphine management during pregnancy are warranted. We encourage further research on establishing the lowest effective buprenorphine dose for each patient, and we support the CDC’s resumption of tracking the morphine milligram equivalents (MME) of buprenorphine prescribed during pregnancy so that researchers can further study the effect of congenital MME exposure on fetal outcomes.

No description available.

Opioid use disorder (OUD) is a chronic relapsing condition associated with significant patient morbidity and mortality. Patients suffering from OUD have an increased risk of death from suicide, HIV, infectious disease, and trauma, among other causes. Patients suffering from OUD often manage various comorbid psychiatric illnesses and homelessness. From 1999 to 2017, an estimated 400,000 people died from prescription opioid related overdoses. In 2014, there were 28,647 opioid related overdose deaths in the United States. The current standard of care for treatment of OUD is an opioid receptor agonist methadone or buprenorphine combined with a psychosocial intervention, like cognitive behavioral therapy (CBT), contingency management (CM), or motivational interviewing (MI). MI has proven to be effective in treating OUD when combined with methadone and buprenorphine. Other studies have found increased rates of opioid abstinence when study subjects were provided recovery housing contingent on urine that was free of opioids and other substances (CM). Among patients with a history of incarceration and co-morbid OUD, stable housing in some form -- private residence or living with a friend or family -- has been found to be effective in reducing opioid use when compared to homelessness as a control, suggesting homelessness confers a higher risk of opioid use. This prospective observational study aims to evaluate the effect of stable housing on opioid use disorder treatment and recovery. Study subjects will be Boston area residents who are prescribed methadone. Investigators will follow study subjects over six months while they attend weekly motivational interviewing sessions as part of their treatment regime and attend methadone clinics as usual. Once per week, study subjects will submit urine samples to study affiliated Medical Assistants (MA). Urine samples will be sent to LabCorp for toxicology analysis. At the conclusion of the study, investigators will examine which patients had longer time to relapse based on their housing status. We hypothesize that subjects with stable housing will have longer abstinence, as measured by urine toxicology, than subjects without stable housing. Positive findings could be used to help influence policy makers and federal and state legislation to promote stable housing for patients recovering from OUD.

Mental health conditions, particularly substance use disorders, are a growing public health threat that affect millions of Americans. Drug use disorders (DUDs), a subset of substance use disorders, are chronic conditions characterized by clusters of behavioral, cognitive, and physiological symptoms related to the use of opioids, hallucinogens, stimulants, cannabis, anxiolytics/hypnotics/sedatives, inhalants, multiple drugs, other drugs, or unknown drugs. The prevalence of DUDs among older adults ages 65 and older is growing. In 2021, almost 2 million older adults in the United States (U.S.) had a DUD. DUDs have a detrimental effect on health, especially among older adults with DUDs, who are more likely to have comorbid chronic conditions such as chronic obstructive pulmonary disorder, diabetes, and chronic heart failure than older adults without DUDs or other age groups with DUDs. The medications and symptoms of these comorbid conditions can interact with DUD-associated drugs and cause high risk for falls, delirium, medication interactions, chronic disease exacerbations, and acute emergency department (ED) utilization. Thus, in addition to the alarming growth in the prevalence of DUDs in older adults, this population faces additional risks for poor health and acute ED utilization.Despite similar prevalence of DUDs among rural and urban older adults, older adults in rural areas have decreased access to DUD care. In rural areas, there is lower availability of DUD specialists and treatment centers. In 2019, 1,149 rural counties did not have a provider who could prescribe buprenorphine (a medication for opioid use disorder), compared to only 57 urban counties. Rural residents must drive an average of 49.1 minutes to receive DUD treatment, compared to just 7.8 minutes for urban residents. Enhanced availability of DUD treatment in primary care settings may fill the gap in access to mental health and substance use care in rural communities as older adults seek primary care providers for other routine care. Prior studies have shown that patients who seek and receive pharmacologic or psychological interventions in primary care settings may have improved DUD outcomes such as lower rates of relapse, increased retention in treatment, and abstinence. The Affordable Care Act increased funding for rural primary care practices to deliver integrated mental and physical health care, which may improve outcomes for older adults with DUDs. Yet, many rural older adults with DUDs do not receive DUD screening and treatment in primary care. Presently, only 45% of patients are screened for DUDs in the community. Primary care providers often report that they do not have the confidence to address DUDs. While some research shows that organizational support such as DUD-specific training and clinical resources are key to improving primary care provider confidence in addressing opioid use disorder, there is very little research focused on the unique needs of rural primary care providers in delivering DUD services. Research on organizational factors that influence the availability and quality of DUD services in rural primary care practices is needed to bolster primary care capacity to serve older adults with DUDs in rural areas. Rural primary care practices increasingly rely on the growing nurse practitioner (NP) workforce to deliver care. Over one-quarter of the rural primary care workforce is NPs. Most research on the rural primary care NP workforce and DUD services focuses on NP prescribing of buprenorphine, a medication for opioid use disorder. Half of the new buprenorphine providers in rural areas are NPs, and NPs treat more patients with buprenorphine than physicians in rural areas. Despite NPs’ contribution to DUD care for rural patients, studies show that many NPs practice in challenging work environments that negatively impact their ability to deliver patient care. The NP work environment is often characterized by a lack of resources, autonomy, and support, which affects the delivery of patient-centered care, high-quality care, and health services utilization among patients with chronic conditions. Studies have suggested that work environment factors such as teamwork and autonomy may influence NP prescribing of buprenorphine. Yet, no studies have focused on NP work environments in primary care practices and how they affect care for older adults with DUDs in rural areas. The overall purpose of this dissertation is to produce evidence on enhancing the primary care NP workforce’s ability to deliver mental health and DUD services. The first study in this dissertation (Chapter 2) was a systematic review of the literature focused on the effectiveness of NP care for patients with mental health conditions (i.e., anxiety, depression, and substance use disorders) in primary care settings. These conditions were included to identify the state of the literature base focused on NP mental health care delivery in primary care settings, particularly focused on gaps in evidence related to NP care for rural older adults with DUDs. The second study in this dissertation (Chapter 3) conceptualized primary care provider confidence in addressing opioid use disorder to understand how to support providers (i.e., physician, NPs, and physician assistants) in delivering DUD care through policy, practice, and research innovations. The third study of this dissertation (Chapter 4) assessed the relationship between the NP work environment and rural NP practices’ capacity to serve older adults with DUDs. Finally, the fourth study (Chapter 5) examined the impact of the NP work environment in rural primary care practices on ED utilization among older adults with DUDs. Findings from the studies included in this dissertation can be used to improve primary care delivery in rural areas and inform policy and research innovations to address the growing public health threat of DUDs among rural older adults. Materials and Methods This dissertation utilized novel materials and methods to inform the development of policy, practice, and research innovations that enhance the primary care NP workforce’s ability to deliver mental health and DUD services. The following presents the study design of each individual chapter to achieve the study’s aims. Study 1 | Chapter 2: This systematic review of the evidence addressed the effectiveness of NP care for patients with mental health conditions in primary care settings. We followed Joanna Briggs Institute (JBI) Manual for Evidence Synthesis for systematic reviews of effectiveness and reports results according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review protocol is published with PROSPERO (ID = CRD42021269816). Study 2 | Chapter 3: This concept analysis followed the Walker and Avant framework to conceptualize primary care provider confidence in addressing opioid use disorder. Study 3 | Chapter 4: The goal of this study was to assess the impact of the NP work environment on the capacity of rural primary care practices to serve older adults with DUDs in rural areas. To achieve this aim, we conducted a secondary data analysis of cross-sectional NP survey data from 2018-2019 merged with Medicare claims from 2018. We conducted our statistical analysis using fractional logistic regression. Study 4 | Chapter 5: The goal of this study was to examine the association between the NP work environment and ED utilization among older adults with DUDs in rural areas. To achieve this aim, we conducted a secondary data analysis of cross-sectional NP survey data from 2018-2019 merged with Medicare claims from 2018. We conducted our statistical analysis using multilevel logistic regression. Conclusions This dissertation produced evidence that enhances the primary care NP workforce’s ability to deliver mental health and DUD services. In Chapter 2, the systematic review of the literature identified a lack of high-quality research focused on NP primary care for patients with mental health conditions, particularly among patients with substance use disorders in rural areas. Chapter 3 conceptualized primary care provider confidence in addressing opioid use disorder and found that teamwork, organizational culture, resources, and support may uniquely influence provider confidence, which is associated with positive patient outcomes, increased delivery of and access to opioid use disorder services, and provider attitude changes. In Chapters 4 and 5, our studies found that the NP work environment in rural primary care practices is associated with increased practice capacity to serve older adults with DUDs and reduced ED utilization in this population. These dissertation findings provide important insights that will allow policymakers, practice administrators, and researchers to invest in productive efforts to enhance the primary care NP workforce’s ability to deliver mental health and DUD services.

The dissertation is intended to guide the selection and implementation of health department-led interventions with a long-term goal of reducing opioid overdose deaths. This dissertation is comprised of three aims. First, a narrative review describes models of buprenorphine treatment, summarizes retention in buprenorphine treatment, and includes descriptions of how each study defined and measured retention in treatment to aid cross-study comparisons. Trends in buprenorphine retention, as well as heterogeneity in trends, are described, and sub-analyses examine the role clinician experience in inducting patients on buprenorphine treatment may play in promoting retention. Lastly, the effect of a specific intervention—academic detailing—aimed at reducing the prescribing of opioid analgesics is measured using methods aimed at isolating the impact of a policy intervention that occurred at the same time as the detailing campaign. Overall, this dissertation finds a lack of consistency in how retention in buprenorphine treatment is measured, which precludes easy identification of the most effective models and interventions for retention in buprenorphine treatment. Additionally, significant variation in buprenorphine treatment retention and trends in buprenorphine treatment was observed, suggesting opportunities for improvement. From 2015 to 2019, retention in buprenorphine increased among New York City residents; however, in 2019, the predicted prevalence of retention for three months was 52.7% and 34.6% for six months, below rates observed in other studies. Lastly, this dissertation should prompt public health officials to reconsider using academic detailing campaigns to decrease opioid analgesic prescribing, given that decreases in prescribing practices were only observed following one detailing campaign, which coincided with a policy change, and did not occur following another campaign, which took place two years after the policy change.

The primary purpose of this study is to determine the occurrence of drug therapy adjustment in people with substance use disorder receiving medication-assisted treatment when admitted to an acute care facility for a comorbid condition. The secondary purpose is to understand the correlation between the presence of adjustment of therapy for substance use disorder and influence on recovery from comorbid conditions. A literature review exploring drug therapy for addicted individuals during hospitalization was performed using various databases, search terms included *substance use disorder or *substance abuse or *illicit drug use or *drug abuse or *MAT or *maintenance therapy, combined with *inpatient or *hospital or *acute care or *admission. The data was conformed into tables that synthesized the relationship between drug therapy adjustment for individuals with substance use disorder during an acute care admission. Initial review of the articles revealed 78 articles relative to the topic, 16 of those articles met inclusion criteria and were selected for a detailed analysis. Studies suggest the need for provider education and guidelines for treating individuals receiving MAT in an acute care facility. While individuals with substance use disorder often use acute care services, their medication-assisted treatment is rarely acknowledged or adjusted. Many studies focus on individuals with substance use disorder, yet, addressing medication-assisted therapy is still inconsistent, and lacks official guidelines.

No description available.

The thesis focuses on one of the possible methods of the opioid addiction treatment, on the substitution therapy. It also describes specific form of substitution therapy in Ústí nad Labem, part of the particular low-threshold facility for drug users. The paper also briefly discusses opioid addiction and the options of its substitutional therapy in Ústí nad Labem (e.g. methadone therapy, buprenorfine therapy). The aim of this thesis is to evaluate life quality of substitutional therapy's clients in the low-threshold facility in Ústí nad Labem and compare those results with life quality of clients who are using buprenorfine obtained on the black market. Another goal is to use these findings to improve and expand services for this target group. The theoretical part briefly describes the opioid addiction and possible methods of its treatment, mainly substitutional therapy. The research evaluates the life quality of clients who are using buprenorfine and identifies problematic parts of their lives. Data were collected using WHOQOL - BREF questionnaire - anonymous questionnaire of World Health Organization. Sociodemographic and anamnestic data of clients of substitutional therapy were involved. The sample of the clients of substitutional therapy was compared with the control group which consists of...

Increased opioid analgesic (OA) prescribing has been associated with increased risk of prescription opioid diversion, misuse, and abuse. States established prescription drug monitoring programs (PDMPs) to collect and analyze electronic records for dispensed controlled substances to reduce prescription drug abuse and diversion. PDMP data can be used by prescribers for tracking patient’s history of controlled substance prescribing to inform clinical decisions. The studies in this dissertation are focused on the less utilized potential of the PDMP data to enhance public health surveillance to monitor OA prescribing and co-prescribing and association with opioid overdose mortality and morbidity. Longitudinal analysis of OA prescribing and evaluation of the effect of recent policies and opioid prescribing guidelines require consensus measures for OA utilization and computational tools for uniform operationalization by researchers and agencies. Statistical macros and computational tools for OA utilization measures were developed and tested with Kentucky PDMP data. A set of covariate measures using mortality and morbidity surveillance data were also developed as proxy measures for prevalence of painful conditions justifying OA utilization, and availability of heroin and medication treatment for opioid use disorder. A series of epidemiological studies used the developed OA measures as outcomes, and adjusted for time-varying socio-demographic and health care utilization covariates in population-averaged statistical models to assess longitudinal trend and pattern changes in OA utilization in Kentucky in recent years. The first study, “Trends and Patterns of OA Prescribing: Regional and Rural-Urban Variations in Kentucky from 2012 to 2015,” shows significant downward trends in rates of residents with OA prescriptions. Despite the significant decline over time, and after accounting for prevalence of injuries and cancer, the rate of dispensed OA prescriptions among residents in Kentucky Appalachian counties remained significantly higher than the rest of the state. The second study, “Population-Level Measures for High-Risk OA Prescribing: Longitudinal Trends and Relationships with Pain-Associated Conditions,” shows significant reduction in high-risk OA prescribing (e.g., high daily dosage, long-term use, concurrent prescriptions for OA and benzodiazepines) from 2012 to 2016, significantly positive associations between high-risk OA prescribing and cancer mortality rates with no substantial change in the association magnitude over time, and declining strengths of positive associations between high-risk OA prescribing and acute traumatic injuries or chronic non-cancer pain over the study period. The third study, “A Reciprocal Association between Longitudinal Trends of Buprenorphine/Naloxone Prescribing and High-Dose OA Prescribing,” indicates a significant reciprocal relationship between high-dose OA prescribing and buprenorphine/ naloxone prescribing, and a clinically meaningful effect of buprenorphine/naloxone prescribing on reducing OA utilization. The results from the studies advanced the understanding of the epidemiology of opioid use and misuse in Kentucky, and identified actionable risk and protective factors that can inform policy, education, and drug overdose prevention interventions. The developed operational definition inventory and computational tools could stimulate further research in Kentucky and comparative studies in other states.

Aims: Untreated opioid use disorder (OUD) is associated with overdose, premature death and infectious disease, including human immunodeficiency virus (HIV) and Hepatitis C (HCV). While prior studies have shown that educational interventions are associated with improvements in HIV and HCV knowledge and reductions in risk behaviors, those examined to date have typically been time- and resource-intensive. We recently developed an HIV+HCV Education intervention which aims to improve HIV and HCV knowledge in a single visit using an automated iPad platform. In this project, we examined its ability, using a within-subject evaluation, to improve knowledge of HIV and HCV transmission and risks among adults with OUD. Methods: Participants were 25 adults with OUD who were enrolled in a 12-week randomized trial evaluating the efficacy of an Interim Buprenorphine Treatment (IBT) for reducing illicit opioid use while awaiting entry into community-based opioid treatment. Participants completed a baseline HIV+HCV knowledge assessment (Pre-Test) followed by corrective feedback, both administered via iPad. They then completed an interactive HIV flipbook and animated HCV video, also on iPad, followed by a second administration of the knowledge assessment (Post-Test). Finally, to evaluate whether any changes in knowledge persisted over time, the HIV+HCV assessment was administered again at 4 and 12 weeks following study intake. Results: At baseline (Pre-Test), participants answered 69% and 65% of items correctly on the HIV and HCV assessments, respectively. After completing the educational intervention, participants answered 86% of items correctly on both the HIV and HCV assessments (p’s<.001). These improvements in knowledge also persisted throughout the three-month study, with scores at Week 4 and 12 timepoints significantly greater than baseline (p’s<.001). Conclusion: An HIV+Hepatitis Education intervention delivered via a portable, automated iPad platform may produce significant and persistent improvements in HIV and HCV knowledge among adults with OUD. These data provide additional support for the use of mobile educational interventions for enhancing HIV and HCV knowledge in individuals at elevated risk for infectious disease. Support: This trial was supported by NIDA R34 DA3730385 (Sigmon) with additional support by NIDA T32 DA007242 (Higgins).