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5. Evaluating a health system-wide opioid disposal intervention distributing home-disposal bags

Author

Huang, Lyen C., Bleicher, Josh, Torre, Michael, Johnson, Jordan E., Presson, Angela, Millar, Morgan M., Gordon, Adam J., Brooke, Benjamins., Kaphingst, Kimberly A., and Harris, Alex H.S.

Subjects
United States. Food and Drug Administration, Pharmacists -- Usage, Medical research -- Usage, Medicine, Experimental -- Usage, Health surveys -- Usage, Patient satisfaction -- Usage, Opioids -- Usage, Medical records -- Usage, Health care industry -- Usage, Pharmacy -- Usage, Health care industry, Business
Abstract

Objective: To evaluate a health system-wide intervention distributing free homedisposal bags to surgery patients prescribed opioids. Data Sources and Study Setting: We collected patient surveys and electronic medical record data at an academic health system. Study Design: We conducted a prospective observational study. The bags were primarily distributed at pharmacies, though pharmacists delivered bags to some patients. The primary outcome was disposal of leftover opioids (effectiveness). Secondary outcomes were patient willingness to dispose and factors associated with disposal (effectiveness), recalling receipt of the bag (reach), and recalling receipt of bags and disposal over time (maintenance). We used a modified Poisson regression to evaluate the relative risk of disposal. Inverse probability of treatment weighting, based on propensity scores, was used to account for differences between survey responders and non-responders and reduce nonresponse bias. Data Collection/Extraction Methods: From August 2020 to May 2021, we surveyed patients 2 weeks after discharge (allowing for home opioid use). Eligibility criteria were age [greater than or equal to]18, English being primary language, valid email address, hospitalization Principal Findings: We identified 5134 patients with 2174 completing the survey (response rate 42.3%). Among respondents, 1375 (63.8%) recalled receiving the disposal bag. Among 1075 respondents with leftover opioids, 284 (26.4%) disposed, 552 (51.3%) planned to dispose, 79 (7.4%) did not plan to dispose, 69 (6.4%) had undecided, and 91 (8.5%) had not considered disposal. Recalling receipt of the bag (incidence rate ratio [IRR] 1.25, 95% confidence interval [CI] 1.13-1.37) was positively associated with disposal. Patients who used opioids in the last year were less likely to dispose (IRR 0.82, 95% CI 0.73-0.93). Disposal rates remained stable over the study period while recalling receipt of bags trended up. Conclusions: A pragmatic implementation of a disposal intervention resulted in lower disposal rates than prior trials. KEYWORDS health system intervention, implementation, opioids, prevention of opioid-related harms, surgery, 1 | INTRODUCTION More than 64 million operations are performed each year in the United States, and 56%-70% of these patients will be prescribed opioids. (1-4) Although opioid prescribing after [...]

Published
2023
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6. Natural Language Processing and Machine Learning to Identify People Who Inject Drugs in Electronic Health Records

Author

Goodman-Meza, David, Tang, Amber, Aryanfar, Babak, Vazquez, Sergio, Gordon, Adam J, Goto, Michihiko, Goetz, Matthew Bidwell, Shoptaw, Steven, and Bui, Alex AT

Subjects
Biomedical and Clinical Sciences, Clinical Sciences, Infectious Diseases, Emerging Infectious Diseases, Clinical Research, Networking and Information Technology R&D (NITRD), 7.3 Management and decision making, Management of diseases and conditions, Good Health and Well Being, EHR, machine learning, NLP, PWID, Clinical sciences, Medical microbiology
Abstract

BackgroundImproving the identification of people who inject drugs (PWID) in electronic medical records can improve clinical decision making, risk assessment and mitigation, and health service research. Identification of PWID currently consists of heterogeneous, nonspecific International Classification of Diseases (ICD) codes as proxies. Natural language processing (NLP) and machine learning (ML) methods may have better diagnostic metrics than nonspecific ICD codes for identifying PWID.MethodsWe manually reviewed 1000 records of patients diagnosed with Staphylococcus aureus bacteremia admitted to Veterans Health Administration hospitals from 2003 through 2014. The manual review was the reference standard. We developed and trained NLP/ML algorithms with and without regular expression filters for negation (NegEx) and compared these with 11 proxy combinations of ICD codes to identify PWID. Data were split 70% for training and 30% for testing. We calculated diagnostic metrics and estimated 95% confidence intervals (CIs) by bootstrapping the hold-out test set. Best models were determined by best F-score, a summary of sensitivity and positive predictive value.ResultsRandom forest with and without NegEx were the best-performing NLP/ML algorithms in the training set. Random forest with NegEx outperformed all ICD-based algorithms. F-score for the best NLP/ML algorithm was 0.905 (95% CI, .786-.967) and 0.592 (95% CI, .550-.632) for the best ICD-based algorithm. The NLP/ML algorithm had a sensitivity of 92.6% and specificity of 95.4%.ConclusionsNLP/ML outperformed ICD-based coding algorithms at identifying PWID in electronic health records. NLP/ML models should be considered in identifying cohorts of PWID to improve clinical decision making, health services research, and administrative surveillance.

Published
2022

7. Beyond state scope of practice laws for advanced practitioners: Additional supervision requirements for buprenorphine prescribing

Author

Andraka-Christou, Barbara, Gordon, Adam J, Spetz, Joanne, Totaram, Rachel, Golan, Matthew, Randall-Kosich, Olivia, Harrison, Jordan, Calder, Spencer, Kertesz, Stefan G, and Stein, Bradley D

Subjects
Clinical and Health Psychology, Health Services and Systems, Health Sciences, Psychology, Substance Misuse, Clinical Research, Opioids, Opioid Misuse and Addiction, Drug Abuse (NIDA only), Brain Disorders, Good Health and Well Being, Buprenorphine, Humans, Opiate Substitution Treatment, Opioid-Related Disorders, Physician Assistants, Practice Patterns, Physicians', Scope of Practice, United States, Nurse practitioners, Advanced care practitioners, Physician assistants, State law, Waiver, Collaboration, Supervision, Scope of practice, Opioid use disorder, Medications for opioid use disorder, Public Health and Health Services, Substance Abuse, Health services and systems, Clinical and health psychology
Abstract

BackgroundBuprenorphine is a life-saving medication for people with opioid use disorder (OUD). U.S. federal law allows advanced practice clinicians (APCs), such as nurse practitioners (NPs) and physician assistants (PAs), to obtain a federal waiver to prescribe buprenorphine in office-based practices. However, states regulate APCs' scope of practice (SOP) variously, including requirements for physician supervision. States may also have laws entirely banning NP/PA buprenorphine prescribing or requiring that supervising physicians have a federal waiver to prescribe buprenorphine. We sought to identify prevalence of state laws other than SOP laws that either 1) prohibit NP/PA buprenorphine prescribing entirely, or 2) require supervision by a federally waivered physician.MethodsWe searched for state statutes and regulations in all 50 states and Washington D.C. regulating prescribing of buprenorphine for OUD by APCs during summer 2021. We excluded general scope of practice laws, laws only applicable to Medicaid-funded clinicians, laws not applicable to substance use disorder (SUD) treatment, and laws only applicable to NPs/PAs serving licensed SUD treatment facilities. We then conducted content analysis.ResultsOne state prohibits all APCs from prescribing buprenorphine for OUD, even though the state's general SOP laws permit APC buprenorphine prescribing. Five states require PA supervision by a federally waivered physician. Three states require NP supervision by a federally waivered physician.ConclusionsAside from general scope of practice laws, several states have created laws explicitly regulating buprenorphine prescribing by APCs outside of licensed state SUD facilities.

Published
2022

19. Alcohol Use and Antiretroviral Adherence Among Patients Living with HIV: Is Change in Alcohol Use Associated with Change in Adherence?

Author

Williams, Emily C, McGinnis, Kathleen A, Rubinsky, Anna D, Matson, Theresa E, Bobb, Jennifer F, Lapham, Gwen T, Edelman, E Jennifer, Satre, Derek D, Catz, Sheryl L, Richards, Julie E, Bryant, Kendall J, Marshall, Brandon DL, Kraemer, Kevin L, Crystal, Stephen, Gordon, Adam J, Skanderson, Melissa, Fiellin, David A, Justice, Amy C, and Bradley, Katharine A

Subjects
Clinical Research, Aging, Behavioral and Social Science, HIV/AIDS, Substance Misuse, Alcoholism, Alcohol Use and Health, Infectious Diseases, Prevention, Evaluation of treatments and therapeutic interventions, 6.1 Pharmaceuticals, Good Health and Well Being, Aged, Alcohol Drinking, Anti-Retroviral Agents, Cohort Studies, Female, HIV Infections, Humans, Male, Medication Adherence, Middle Aged, HIV, ART, Antiretroviral therapy, Adherence, Alcohol use, Public Health and Health Services, Social Work, Public Health
Abstract

Alcohol use increases non-adherence to antiretroviral therapy (ART) among persons living with HIV (PLWH). Dynamic longitudinal associations are understudied. Veterans Aging Cohort Study (VACS) data 2/1/2008-7/31/16 were used to fit linear regression models estimating changes in adherence (% days with ART medication fill) associated with changes in alcohol use based on annual clinically-ascertained AUDIT-C screening scores (range - 12 to + 12, 0 = no change) adjusting for demographics and initial adherence. Among 21,275 PLWH (67,330 observations), most reported no (48%) or low-level (39%) alcohol use initially, with no (55%) or small (39% ≤ 3 points) annual change. Mean initial adherence was 86% (SD 21%), mean annual change was - 3.1% (SD 21%). An inverted V-shaped association was observed: both increases and decreases in AUDIT-C were associated with greater adherence decreases relative to stable scores [p

Published
2021

27. Outpatient follow-up and use of medications for opioid use disorder after residential treatment among Medicaid enrollees in 10 states

Author

Cole, Evan S., Allen, Lindsay, Austin, Anna, Barnes, Andrew, Chang, Chung-Chou H., Clark, Sarah, Crane, Dushka, Cunningham, Peter, Fry, Carrie E., Gordon, Adam J., Hammerslag, Lindsey, Idala, David, Kennedy, Susan, Kim, Joo Yeon, Krishnan, Sunita, Lanier, Paul, Mahakalanda, Shyama, Mauk, Rachel, McDuffie, Mary Joan, Mohamoud, Shamis, Talbert, Jeff, Tang, Lu, Zivin, Kara, and Donohue, Julie M.

Published
2022
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31. Level of Alcohol Use Associated with HIV Care Continuum Targets in a National U.S. Sample of Persons Living with HIV Receiving Healthcare.

Author

Williams, Emily C, McGinnis, Kathleen A, Edelman, E Jennifer, Matson, Theresa E, Gordon, Adam J, Marshall, Brandon DL, Bryant, Kendall J, Rubinsky, Anna D, Lapham, Gwen T, Satre, Derek D, Richards, Julie E, Catz, Sheryl L, Fiellin, David A, Justice, Amy C, and Bradley, Katharine A

Subjects
Humans, HIV Infections, Anti-HIV Agents, Viral Load, Retrospective Studies, Alcohol Drinking, Health Behavior, Middle Aged, Veterans, Continuity of Patient Care, United States, Female, Male, Medication Adherence, Alcohol, Antiretroviral therapy, Care continuum, HIV, Treatment cascade, Viral suppression, Substance Misuse, Infectious Diseases, Behavioral and Social Science, Brain Disorders, Clinical Research, HIV/AIDS, Health Services, Alcoholism, Alcohol Use and Health, Infection, Oral and gastrointestinal, Good Health and Well Being, Public Health and Health Services, Social Work, Public Health
Abstract

We evaluated associations between levels of alcohol use and HIV care continuum components using national Veterans Aging Cohort Study data for all patients with HIV and AUDIT-C screening (2/1/2008-9/30/2014). Poisson regression models evaluated associations between alcohol use levels (non-drinking, low-, medium-, high-, and very high-level drinking) and: (1) engagement with care (documented CD4 cells/µl or viral load copies/ml labs), (2) ART treatment (≥ 1 prescription), and (3) viral suppression (HIV RNA

Published
2019

34. Twelve-Month Retention in Opioid Agonist Treatment for Opioid Use Disorder Among Patients With and Without HIV

Author

Wyse, Jessica J., McGinnis, Kathleen A., Edelman, E. Jennifer, Gordon, Adam J., Manhapra, Ajay, Fiellin, David A., Moore, Brent A., Korthuis, P. Todd, Kennedy, Amy J., Oldfield, Benjamin J., Gaither, Julie R., Gordon, Kirsha S., Skanderson, Melissa, Barry, Declan T., Bryant, Kendall, Crystal, Stephen, Justice, Amy C., and Kraemer, Kevin L.

Published
2022
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35. Change in Alcohol Use Based on Self-Report and a Quantitative Biomarker, Phosphatidylethanol, in People With HIV

Author

McGinnis, Kathleen A., Tate, Janet P., Bryant, Kendall J., Justice, Amy C., O’Connor, Patrick G., Rodriguez-Barradas, Maria C., Crystal, Stephen, Cutter, Christopher J., Hansen, Nathan B., Maisto, Stephen A., Marconi, Vincent C., Williams, Emily C., Cook, Robert L., Gordon, Adam J., Gordon, Kirsha S., Eyawo, Oghenowede, Edelman, E. Jennifer, and Fiellin, David A.

Published
2022
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38. Rationale, design and methods of VA-BRAVE: a randomized comparative effectiveness trial of two formulations of buprenorphine for treatment of opioid use disorder in veterans

Author

Petrakis, Ismene, Springer, Sandra A., Davis, Cynthia, Ralevski, Elizabeth, Gu, Lucy, Lew, Robert, Hermos, John, Nuite, Melynn, Gordon, Adam J., Kosten, Thomas R., Nunes, Edward V., Rosenheck, Robert, Saxon, Andrew J., Swift, Robert, Goldberg, Alexa, Ringer, Robert, and Ferguson, Ryan

Published
2022
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43. Changes in alcohol use associated with changes in HIV disease severity over time: A national longitudinal study in the Veterans Aging Cohort

Author

Williams, Emily C, McGinnis, Kathleen A, Bobb, Jennifer F, Rubinsky, Anna D, Lapham, Gwen T, Skanderson, Melissa, Catz, Sheryl L, Bensley, Kara M, Richards, Julie E, Bryant, Kendall J, Edelman, E Jennifer, Satre, Derek D, Marshall, Brandon DL, Kraemer, Kevin L, Blosnich, John R, Crystal, Stephen, Gordon, Adam J, Fiellin, David A, Justice, Amy C, and Bradley, Katharine A

Subjects
Biomedical and Clinical Sciences, Public Health, Health Sciences, Alcoholism, Alcohol Use and Health, Substance Misuse, HIV/AIDS, Infectious Diseases, Clinical Research, Oral and gastrointestinal, Stroke, Good Health and Well Being, Adult, Aged, Aging, Alcohol Drinking, Female, HIV Infections, Humans, Longitudinal Studies, Male, Middle Aged, Severity of Illness Index, Veterans, HIV, CD4, Viral load, Alcohol use, Alcohol use disorders, Medical and Health Sciences, Psychology and Cognitive Sciences, Substance Abuse, Biochemistry and cell biology, Pharmacology and pharmaceutical sciences, Epidemiology
Abstract

BackgroundAmong groups of persons living with HIV (PLWH), high-risk drinking trajectories are associated with HIV severity. Whether changes in individuals' alcohol use are associated with changes in HIV severity over the same period is unknown.MethodsVeterans Aging Cohort Study (VACS) data from VA's EHR (2/1/2008-9/30/2016) identified AUDIT-C screens for all PLWH. Pairs of AUDIT-C screens within 9-15 months were included if CD4 and/or viral load (VL) was measured within 9 months after baseline and follow-up AUDIT-Cs. Linear regression assessed change in HIV severity (CD4 and logVL) associated with AUDIT-C change adjusted for confounders. Mean changes in HIV severity were estimated for each AUDIT-C change value. For all measures of change, positive values indicate improvements (lower drinking and improved HIV severity).ResultsAmong PLWH, 21,999 and 22,143 were eligible for CD4 and VL analyses, respectively. Most had non- or low-level drinking and stable consumption over time (mean AUDIT-C change = .08, SD = 1.91). HIV severity improved over time [mean CD4 change = 20.5 (SD 180.8); mean logVL change = 0.12 (SD 0.71)]. AUDIT-C changes were associated non-linearly with changes in CD4 (p = 0.03) and logVL (p

Published
2018

44. Alcohol and Mortality

Author

Eyawo, Oghenowede, McGinnis, Kathleen A, Justice, Amy C, Fiellin, David A, Hahn, Judith A, Williams, Emily C, Gordon, Adam J, Marshall, Brandon DL, Kraemer, Kevin L, Crystal, Stephen, Gaither, Julie R, Edelman, E Jennifer, Bryant, Kendall J, and Tate, Janet P

Subjects
Emerging Infectious Diseases, Clinical Research, Infectious Diseases, Alcoholism, Alcohol Use and Health, Substance Misuse, Digestive Diseases, Liver Disease, Hepatitis - C, Chronic Liver Disease and Cirrhosis, Hepatitis, HIV/AIDS, Prevention, 2.2 Factors relating to the physical environment, Aetiology, Infection, Good Health and Well Being, Adult, Aged, Aged, 80 and over, Alcoholism, Biomarkers, Female, Glycerophospholipids, HIV Infections, Humans, Longitudinal Studies, Male, Middle Aged, Self Report, HIV, HCV, alcohol, mortality, AUDIT-C, phosphatidylethanol, VACS Project team, Clinical Sciences, Public Health and Health Services, Virology
Abstract

BackgroundUnhealthy alcohol use may be particularly detrimental among individuals living with HIV and/or hepatitis C virus (HCV), and is often under-reported. Direct biomarkers of alcohol exposure may facilitate improved detection of alcohol use.MethodsWe evaluated the association of alcohol exposure determined by both self-report [Alcohol Use Disorders Identification Test-Consumption (AUDIT-C)] and a direct biomarker [phosphatidylethanol (PEth)], with mortality among HIV-infected and HIV-uninfected in the Veterans Aging Cohort Study-Biomarker Cohort. We considered PEth

Published
2018

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