The current opioid epidemic is devastating our communities. The American Medical Association’s Task Force on opioid addiction has identified stigma as a primary target of intervention for mitigating this epidemic. Stigma is a mark of disgrace or being objectionable. Experiences of stigma and resulting shame serve only to fuel health inequities experienced by people with opioid addiction. Emergency Medical Services (EMS) have an important role to play in mitigating this epidemic as entry-level providers in the healthcare system. The quality of that patient-provider encounter had the potential to shift intrinsic motivation to seek and maintain addiction treatment. Patient-centered care is identified as supporting therapeutic communication and is well-suited for rural EMS operations in Maine. The purpose of this research was to examine predictors of intention to provide patient-centered care to people experiencing opioid addiction and overdose (OAO) among EMS providers in the state of Maine. A cross-sectional online survey of currently licensed EMS providers offered a direct measure of intention to give patient-centered care to people experiencing OAO. Multiple regression analysis identified four predictor variables for intention: job satisfaction, exploring patient perspective, sharing information and power, and dealing with communicative challenges. The fitted model resulted in a significant R2 = .529, (F (4, 734) = 226.381, p < .001) exceeding the critical F statistic (F (4,739) = 2.384, p = .05), thus confirming the predictive value of the coefficients. Results suggested that EMS providers at all license levels will benefit from interventions that expand their knowledge of the medical definition of addiction and patient-centered care. EMS providers will also benefit from adopting approaches that support exploring the patient perspective and sharing information and power such as Motivational Interviewing and human performance strategies to develop awareness of socially conditioned biases that moderate provider attitudes. These evidence-based interventions could elevate the standard of care provided by EMS and reduce experiences of stigma in the patient-provider encounter. Reductions in stigma increase self-worth and prime motivation to seek and maintain treatment, thereby closing the treatment gap that exists for those experiencing opioid addiction in the state of Maine.

Methadone is the foremost, long-standing pharmacological treatment for opioid addiction. It has been shown to have considerable cost benefit to the community and to decrease mortality. Despite methadone's decades-long use, much is still unknown regarding its clinical pharmacology, particularly during the induction phase of Methadone Maintenance Treatment (MMT). Contrary to previous reports, I found systemic methadone clearance does not increase significantly between induction and steady state phases of MMT, and did not approach the previously reported 3-fold increase. Clinical dose prescription based on the premise of metabolism auto-induction could increase risk of respiratory depression. Significant differences between R- and S-methadone pharmacokinetics showed the importance of stereoselective measurement in a clinical situation and significant plasma concentration-effect relationships demonstrated their potential influence on induction pharmacodynamics. Small increases in CYP3A4 activity as measured by the Erythromycin Breath Test from Day 1 to Day 40 of MMT were not correlated with changes in methadone clearance. CYP3A4 activities were informative but would be insufficient for use as a sole predictor of methadone clearance during MMT. Clinically significant respiratory depression occurred in 20% of subjects, at times of peak plasma R-methadone concentrations, after reports of withdrawal symptoms at pre-dose sampling times, and irrespective of illicit opioid use. Utilisation of both respiratory rate and blood oxygen saturation measurements provided a good indication of respiratory risk for individuals. Although prior opioid use was a strong predictor of continued use during MMT, adoption of a new equation ("abc") and comprehensive documentation of each individual's MMT may increase prediction of MMT success. Even in light of recent advances in opioid substitution therapies, MMT's advantages ensure it is still at the forefront of addiction treatment. Careful choice of methodology enabled narrowing of this investigation to those factors most relevant in methadone pharmacology and most responsible for MMT success or failure, and therefore extending previous knowledge of this area. Such data might be utilised to develop a clinically applicable model for MMT, and help provide clients with a safe and uncomplicated transition from heroin use to methadone induction in the future. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1269301 / Thesis (Ph.D.) -- School of Medical Sciences, 2007

Thesis (M.H.P.A.)--Washington State University, May 2010. / Title from PDF title page (viewed on July 22, 2010). "Department of Health Policy and Administration." Includes bibliographical references (p. 42-51).

Abstract available through Clinical Pharmacology in Drug Development.

Abstract available through Clinical Pharmacology in Drug Development.

Thesis (Ph.D.) in Nursing--University of Maine, 2009. / Includes vita. Includes bibliographical references (leaves 134-152).

Abstract Low population density in rural areas makes it difficult to deliver services to people with mental health problems and nonmedical prescription opioid abuse remains a problem in the United States. The purpose of this cross-sectional study was to determine whether a parent's socioeconomic status affected care opportunities for children 12 to 17 years of age and whether bipolar disorder increased the likelihood of substance abuse in those children. The theory of reasoned action/planned behavior provided the framework for the study. Secondary data from the Interuniversity Consortium for Political and Social Research 36361 data system, specifically the National Survey on Drug Use and Health 2014, were collected that included information about the socioeconomic status of adolescents and their parents. Cross-sectional analysis was used to analyze data. The first research examined the extent to which bipolar disorder influenced opioid abuse in those between the ages of 12 and 17. There was a nonsignificant association between the variables: chi-square probability values (p > 0.05) for mental health difficulties and ever-used pain relievers non-medically. There was a significant association between mental health and emotional difficulties at p < 0.05. The second research question examined whether a parent's socioeconomic status impacted the level of care opportunities for those 12 to 17 years' old in relation to bipolar disorder in rural communities. Using multivariate logistic regression analysis, no significance was found between level-of-care opportunities and a parent's socioeconomic status. The findings of this study have potential to bring about social change by increasing clinician skills related to intervention planning related to opioid abuse in rural communities among adolescents with bipolar disorder.

Indiana University-Purdue University Indianapolis (IUPUI) / The aim of this research is to design a new method to identify the opioid use problems (OUP) among long-term opioid therapy patients in Indiana University Health using text mining and machine learning approaches. First, a systematic review was conducted to investigate the current variables, methods, and opioid problem definitions used in the literature. We identified 75 distinct variables in 9 models that majorly used ICD codes to identify the opioid problem (OUP). The review concluded that using ICD codes alone may not be enough to determine the real size of the opioid problem and more effort is needed to adopt other methods to understand the issue. Next, we developed a text mining approach to identify OUP and compared the results with the current conventional method of identifying OUP using ICD-9 codes. Following the institutional review board and an approval from the Regenstrief Institute, structured and unstructured data of 14,298 IUH patients were collected from the Indiana Network for Patient Care. Our text mining approach identified 127 opioid cases compared to 45 cases identified by ICD codes. We concluded that the text mining approach may be used successfully to identify OUP from patients clinical notes. Moreover, we developed a machine learning approach to identify OUP by analyzing patients’ clinical notes. Our model was able to classify positive OUP from clinical notes with a sensitivity of 88% on unseen data. We concluded that the machine learning approach may be used successfully to identify the opioid use problem from patients’ clinical notes. / 2019-06-21

Background: The opioid epidemic in the United States has been on the rise. Acute exacerbations of chronic pancreatitis (AECP) patients are at higher risk for Opioid Use Disorder (OUD). Evidence on OUD's impact on healthcare utilization, especially hospital re-admissions is scarce. We measured the impact of OUD on 30-day readmissions, in patients admitted with AECP from 2010 to 2014. Methods: This is a retrospective cohort study which included patients with concurrently documented CP and acute pancreatitis as first two diagnoses, from the National Readmissions Database (NRD). Pancreatic cancer patients and those who left against medical advice were excluded. We compared the 30-day readmission risk between OUD-vs.-non-OUD, while adjusting for other confounders, using multivariable exact-matched [(EM); 18 confounders; n = 28,389] and non-EM regression/time-to-event analyses. Results: 189,585 patients were identified. 6589 (3.5%) had OUD. Mean age was 48.7 years and 57.5% were men. Length-of-stay (4.4 vs 3.9 days) and mean index hospitalization costs ($10,251 vs. $9174) were significantly higher in OUD-compared to non-OUD-patients (p < 0.001). The overall mean 30-day readmission rate was 27.3% (n = 51,806; 35.3% in OUD vs. 27.0% in non-OUD; p < 0.001). OUD patients were 25% more likely to be re-admitted during a 30-day period (EM-HR: 1.25; 95%CI: 1.16–1.36; p < 0.001), Majority of readmissions were pancreas-related (60%), especially AP. OUD cases’ aggregate readmissions costs were $23.3 ± 1.5 million USD (n = 2289). Conclusion: OUD contributes significantly to increased readmission risk in patients with AECP, with significant downstream healthcare costs. Measures against OUD in these patients, such as alternative pain-control therapies, may potentially alleviate such increase in health-care resource utilization.

While the proportion of U.S. ambulatory, office-based visits with a primary symptom or diagnosis of pain has remained consistent from 2000 to 2010, the frequency of opioid prescribing among these visits nearly doubled from 11.3% to 19.6% [1]. Concurrently, the U.S. experienced an epidemic of opioid-related morbidity and mortality [2]. Medical marijuana, allowed in states with medical marijuana laws (MMLs), may serve as an alternative to opioids in the treatment of severe or chronic pain [3]. If marijuana is a substitute for opioids, MMLs that increase marijuana use may also be inadvertently decreasing opioid use. It has been hypothesized that this mechanism, marijuana for opioid substitution, may also be driving reductions in opioid-related morbidity and mortality [4, 5]. This dissertation has three aims. The first aim is to assess whether the hypothesis, that state MMLs can reduce opioid-related mortality, is plausible and whether it is consistent with the available literature. The second aim is to replicate prior state-level finding using individual-level data among participants surveyed in the National Health Interview Survey (NHIS), between 1986 and 2009. These individuals are followed up for mortality up to December 31st, 2011. The final aim is to assess whether MMLs have a heterogeneous impact across subpopulations defined by age, sex, and/or race/ethnicity. In Chapter 1, we find evidence, from a limited number of quantitative studies, that show associations between more liberal marijuana policies and reductions in opioid prescribing, opioid positivity (i.e., use), opioid-related treatment admissions, and opioid-related overdose. From surveys, we found that a majority of medical marijuana patients use marijuana for indications where opioids are commonly prescribed and report reductions in prescription drug use, including opioids specifically. We found the overall quality of the quantitative studies to be moderate to strong. While results were farily consistent across studies, the reviewed studies all shared similar designs and assumptions. Further, regional heterogentiy in MMLs as well as opioid overdoses is never addressed. In Chapter 2, among all NHIS adult participants eligible for mortality follow-up and surveyed between 1986 and 2009, we observed 791 cases who died of an opioid overdose. Compared to controls, cases were more likely to be male, middle-aged, non-Hispanic White, separated/divorced; less educated, and have a family income below the poverty threshold. After adjusting for matched calendar year, participant sex, age, race/ethnicity, marital status, educational attainment, and poverty level, we find no overall association between state MMLs and the rate of opioid overdose. Adjusting for region depreciated the association towards a protective effect. Upon stratifying by region, we find that state MMLs were associated with a reduced rate of opioid overdoses in the West between 2006-2011, but not in the Northeast. In Chapter 3, we find no evidence that the association between state MMLs and opioid overdose is heterogeneous by race/ethnicity or sex. However, we do find evidence that age-dependent heterogentiy is present, and that this heterogeneity is magnified in the West. We find that Western MMLs are associated with a reduced overdose rate for individuals under the age of 60, but not for older adults. In the final chapter, we provide an overview of our findings in the context of the available literature, a discussion of the major strengths and weakness of our study findings, and a recommendation for the direction of future studies. In conclusion, we find that hypothesis that MMLs can reduce opioid-related mortality is plausible, and that the likely mechanism is substitution. However, in our study, our results were not consistent with this hypothesis overall, and signficant reductions were only present after stratifying by region and by sampling frame. The discrepancy between our findings and prior studies should be explored, particularly in light of how regional variations may impact measures of association.