Rationale: Prescription drug abuse and misuse (PDA/M) is a significant problem in Central Appalachia and continues to grow. Since 2000, Tennessee has seen a 250% increase in prescription overdose deaths. Nationally, most prescription painkillers are prescribed by primary care doctors and dentists, rather than specialists. Objective: To develop and test a survey instrument aimed at understanding family physician knowledge, attitudes, and beliefs about opioid therapy prescribing. Design: Survey development. Setting: Survey questions were developed based on results of five focus groups held in primary care clinics in Northeast Tennessee and Southwest Virginia. Surveys were validated and tested by faculty and residents in three family medicine residency clinics in Northeast Tennessee. Participants: Survey questions were face validated for clarity and relevance by family physician attendings and third year residents (N=29). All faculty attendings and residents (N≈85) at the same family medicine residency clinics will be invited to complete the survey for psychometric testing. Main and Secondary Outcome Measures: Survey questions have been face validated for clarity and relevance. Data from the psychometric testing phase will be analyzed for internal consistency and inter-item correlations. Exploratory factor analysis will be used to identify underlying constructs. Results: Based on the results of the focus groups and physician expertise, a 51-item instrument was developed. Following face validation, wording was clarified on 25 questions, 3 questions were removed, and 5 questions were added, resulting in a 53-item instrument. Psychometric testing has not been completed at this time, but will be completed at the time of presentation. Conclusions: Researchers intend to use the findings to improve policies and practice guidelines for primary care clinics in the Appalachian region. Results will be used to design CME activities to decrease PDA/M and to help foster more effective and responsible prescribing of pain medication.

BACKGROUND: Chronic low back pain (CLBP) is the leading cause of disability in the United States. People suffering from CLBP often have multiple comorbidities including depression, anxiety, and substance use disorder (SUD). Although the opioid epidemic has intensified the search for new treatment options, both pharmacological and other, opioids still remain the most common treatment for chronic pain. Long-term opioid therapy (LTOT) has been shown to lead to opioid-induced hyperalgesia (OIH), an increased sensitivity to painful stimuli. It remains unclear, however, the extent to which reductions in opioid dose impact OIH. METHODS: This is a longitudinal cohort study whose primary aim is to determine how changes in opioid doses are associated with changes in psychosocial and quantitative sensory testing (QST) variables. Participants were 24 adults with CLBP being treated with LTOT and visits were conducted on a monthly basis for six months. All 24 participants were included in the analysis of demographic and psychosocial variables (disability, anxiety, depression, opioid misuse, pain severity, pain interference, and catastrophizing). A subset of 13 participants were included in the analysis of QST variables. RESULTS: We found that pressure pain thresholds at the thumb and the trapezius, and heat pain threshold significantly (p < 0.05) improved between visit 1 and visit 6. We also found that a decrease in morphine equivalent doses (MED) is correlated (coefficient > 0.2) with improvements in punctuate probe rating, pain pressure at the thumb, and maximum cold ratings. DISCUSSION: Our results show that reductions in opioid dose are associated with reduced pain sensitivity, even while the psychosocial variables studied (including subjective pain score, depression, and anxiety) remain stable.

<p>  </p> <p><strong>Background:</strong> Older adults have a higher prevalence of pain compared to other age groups and are more likely to become long-term opioid users. The clinical benefits of long-term opioid therapy (LTOT) are not clearly known, however, LTOT has been found to increase the risk of all-cause mortality, opioid overdose, constipation, fractures, and myocardial infarction. </p> <p><br></p> <p><strong>Objective: </strong>The study was conducted to estimate the incidence of LTOT and risk factors associated with LTOT in older adults aged 65 years and older.</p> <p><br></p> <p><strong>Methods:</strong> This was a retrospective cohort study based on Medicare claims data obtained from Research Data Assistance Center (ResDAC). Opioid naïve older adults filling an opioid prescription between 2014 and 2016 were included. The outcome was LTOT which was defined as an opioid use episode lasting longer than 90 days and having more than 60 cumulative days of supply. The independent variables (risk factors) were patient characteristics (demographics, comorbidities, substance use disorders), characteristics of initial/index opioid dispensed (opioid type, duration of action of opioid, opioid dose, number of days’ supply, concomitant medications), and pain conditions. Multivariable logistic regression was performed to assess the association between the risk factors and LTOT. To address statistical interactions among variables, secondary analyses were conducted after stratifying the dataset by pain conditions.</p> <p><br></p> <p><strong>Results:</strong> Among 162,287 opioid naive patients, 10,296 (6.3%) transitioned to LTOT. Demographic characteristics associated with LTOT were age greater than 85 years (adjusted odds ratios [AOR]: 1.1, 95% confidence interval [CI]:1.03-1.18) and being black (AOR: 1.11, 95% CI: 1.01-1.22). Risk factors related to substance use disorders included drug use disorder (AOR: 1.59, 95% CI: 1.30-1.95), alcohol use disorder (AOR: 1.26, 95% CI: 1.06-1.49), tobacco use disorder (AOR: 1.33, 95% CI: 1.21-1.45), and a history of opioid use disorder (OUD) (AOR: 1.63, 95% CI: 1.34-1.98). Patients with more than 5 comorbidities had 1.56 times higher odds (95% CI: 1.46-1.66) of LTOT compared to patients with 0-2 comorbidities. Characteristics of initial/index opioid associated with LTOT were dispensing long-acting opioids (AOR: 1.73, 95% CI: 1.22-2.46), concomitant use of benzodiazepines (AOR: 1.19, 95% CI: 1.11-1.28), gabapentinoids (AOR: 1.59, 95% CI: 1.49-1.69), and non-steroidal anti-inflammatory drugs (NSAIDs) (AOR: 1.23, 95% CI: 1.16-1.30). Starting therapy with tramadol increased the odds of LTOT compared to hydrocodone in patients with osteoarthritis and joint pain (AOR: 1.22, 95% CI: 1.06-1.41) as well as abdominal and bowel pain (AOR: 1.53, 95% CI: 1.05- 2.22). However, starting therapy with oxycodone decreased the odds of LTOT in patients with osteoarthritis and joint pain (AOR: 0.69, 95% CI: 0.53-0.90). For all pain conditions, initial opioid supply of ≥30 days led to 10-16 times higher odds of LTOT compared to days’ supply of 1-3 days.</p> <p><br></p> <p><strong>Conclusions:</strong> Higher age, black race, comorbidities, substance use disorders, and history of OUD are the patient-related risk factors of LTOT in older adults. Moreover, specific patterns of initial/index opioid prescription/dispensing such as greater number of days’ supply, dispensing long-acting opioids, and concomitant use of benzodiazepines, gabapentinoids, and NSAIDs increase the odds of LTOT. Prescribers should take these factors into consideration when prescribing opioids to older adults.</p>

In the United States (US), substance use, misuse, and substance use disorders are significant public health problems. Additionally, the difference between needing substance use treatment (SUT) and receiving treatment is becoming more pronounced. Therefore, the aims of this dissertation include, 1) to synthesize evidence of barriers and facilitators to integrating SUT into mainstream health care (MHC) after the Affordable Care Act was nationally implemented in 2014, 2) to examine the rate of treatment completion and dropout, along with its associated factors, among youth who received Medication-Assisted Opioid Therapy (MAT), 3) to determine the relationship between prior treatment episodes and length of stay (LOS) among adults in residential rehabilitation facilities (RRF) and explore other predictors of LOS and, 4) to determine whether experiencing multiple treatment episodes and being in certain age groups was associated with longer wait period to enter SUT. The literature synthesis involved data from five databases and was informed by PRISMA. Quantitative analysis (aims 2-4) included log-binomial, Poisson, and logistic regression models using the Treatment Episode Data Set-Admissions and Discharges. Andersen’s Behavioral Model for Health Services was the conceptual framework used to inform aims 2-4. For aim 1, several patient, provider, and program/system-level barriers and facilitators were identified, which highlights the need to use a comprehensive approach to improve SUT adoption in MHC. For aim 2, among youth who received MAT, 43.9% completed treatment and 56.1% dropped out. Factors positively associated with treatment completion included MAT use, males, self-help group participation, admission to detoxification and residential/rehabilitation settings, and being in the Midwest/Western US; while minority races (excluding Blacks/African Americans) and being in the South resulted in lower likelihood. For aim 3, the average LOS in RRF was 16.4 days, and having ≥ 1 prior SUT episode (PSUTE) was associated with slightly higher LOS. Some predictors associated with lower LOS included age (18-34 years), males, being employed, private insurance, and being in the Northeast. For aim 4, a longer wait period was identified among clients 25-49 years and those with ≥5 PSUTEs. These factors should be considered to improve SUT use, and future studies should corroborate these findings.