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There is an established need to translate evidence-based practices into real-world practice. Community pharmacists and their corresponding pharmacies are well-positioned to be effective partners as researchers seek to study and implement practice-based research. Challenges exist when partnering with community pharmacies which can vary based on the study type, the nature of the community pharmacy, and stakeholder groups (i.e., patients, staff, leadership, physicians). This commentary seeks to describe these challenges and provide recommendations that can help mitigate and/or overcome these challenges. Recommendations are provided for team structure, communication, research tools/technology, motivational factors, workflow, and sustainability. These recommendations are based on the authors' experience in partnering with community pharmacy for opioid-related research in a variety of study types, states, and pharmacy environments. [ABSTRACT FROM AUTHOR]

Objective: To examine the National Institute on Alcohol Abuse and Alcoholism Youth Guide alcohol frequency screening thresholds when applied to Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) diagnostic criteria, and to describe alcohol use patterns and alcohol use disorder (AUD) characteristics in rural youth from primary care settings.Study Design: Adolescents (n = 1193; ages 12 through 20 years) visiting their primary care practitioner for outpatient visits in six rural primary care clinics were assessed prior to their practitioner visit. A tablet computer collected youth self-report of past-year frequency and quantity of alcohol use and DSM-5 AUD symptoms. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were determined.Results: For early adolescents (ages 12 through 14 years), 1.9% met DSM-5 criteria for past-year AUD and ≥3 days with alcohol use in the past year yielded a screen for DSM-5 with optimal psychometric properties (sensitivity: 89%; specificity: 95%; PPV: 37%; NPV: 100%). For middle adolescents (ages 15 through 17 years), 9.5% met DSM-5 AUD criteria, and ≥3 past year drinking days showed optimal screening results (sensitivity: 91%; specificity: 89%; PPV: 50%; NPV: 99%). For late adolescents (ages 18 through 20 years), 10.0% met DSM-5 AUD criteria, and ≥12 past year drinking days showed optimal screening results (sensitivity: 92%; specificity: 75%; PPV: 31%; NPV: 99%). The age stratified National Institute on Alcohol Abuse and Alcoholism frequency thresholds also produced effective results.Conclusion: In rural primary care clinics, 10% of youth over age 14 years had a past-year DSM-5 AUD. These at-risk adolescents can be identified with a single question on alcohol use frequency. [ABSTRACT FROM AUTHOR]

Background: Prescription opioid misuse is a major public health concern in the US. Few resources exist to support community pharmacists engaging patients who misuse or are at risk for misuse.Objectives: This report describes the results of the execution of the ADAPT-ITT model (a model for modifying evidence-based behavioral interventions to new populations and service settings) to guide the development of a behavioral health framework for opioid medication misuse in the community pharmacy setting.Methods: Pharmacy, addiction, intervention, and treatment experts were convened to attend a one-day meeting to review the empirical knowledgebase and discuss adapting the screening, brief intervention, and referral to treatment (SBIRT) protocol for addressing opioid medication misuse in community pharmacy. Qualitative data gathered from the meeting were analyzed by 2 independent coders in a 2-cycle process using objective coding schemes. Percentage of agreement and Cohen's Kappa were calculated to assess coder agreement.Results: First-cycle coding identified 4 distinct themes, with coder percentage of agreement ranging from 93.5 to 99.6% and with Kappa values between 0.81 and 0.93. Second-cycle coding identified 10 sub-themes, with coder percentage of agreement ranging from 83 to 99.8% and with Kappa values between 0.58 and 0.93. Identified themes and sub-themes encompassed patient identification, intervention, prevention, and referral to treatment.Conclusions: Focus of screening efforts in the emerging model should capitalize on pharmacists' knowledge of medication management. Screening likewise should be multidimensional in order to facilitate patient-centered interventions that activate additional disciplines able to interface with patients at risk or involved in medication misuse. [ABSTRACT FROM AUTHOR]

Background: Buprenorphine 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.Methods: We 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.Results: One 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.Conclusions: Aside from general scope of practice laws, several states have created laws explicitly regulating buprenorphine prescribing by APCs outside of licensed state SUD facilities. [ABSTRACT FROM AUTHOR]

Purpose To assess the associations of self-identified lesbian, gay, bisexual, and questioning sexual orientation or transgender status (LGBTQ) and military experience with health indicators. Methods We used data from the Fall 2012 National College Health Assessment. The survey included self-identified sociodemographic characteristics, mental (e.g., depression) and physical (e.g., human immunodeficiency virus) conditions, health risk behaviors (e.g., smoking), and social stressors (e.g., victimization). We used modified Poisson regression models, stratified by self-reported military service, to examine LGBTQ-related differences in health indicators, whereas adjusting for sociodemographic characteristics. Results Of 27,176 in the sample, among the military-experienced group, LGBTQ individuals had increased adjusted risks of reporting a past-year suicide attempt (adjusted risk ratio [aRR] = 4.37; 95% confidence interval [CI] = 1.39–13.67), human immunodeficiency virus (aRR = 9.90; 95% CI = 1.04–79.67), and discrimination (aRR = 4.67; 95% CI = 2.05–10.66) than their non-LGBTQ peers. Among LGBTQ individuals, military experience was associated with a nearly four-fold increased risk of reporting a past-year suicide attempt (aRR = 3.61; 95% CI = 1.46–8.91) adjusting for age, sex, race and ethnicity, marital status, depression, and other psychiatric diagnoses. Conclusions Military experience may moderate health indicators among LGBTQ populations, and likewise, LGBTQ status likely modifies health conditions among military-experienced populations. Results suggest that agencies serving military populations should assess how and if the health needs of LGBTQ individuals are met. [ABSTRACT FROM AUTHOR]

Buprenorphine, an effective opioid use disorder treatment, can be prescribed only by buprenorphine-waivered physicians. We calculated the number of buprenorphine-waivered physicians/100,000 county residents using 2008-11 Buprenorphine Waiver Notification System data, and used multivariate regression models to predict number of buprenorphine-waivered physicians/100,000 residents in a county as a function of county characteristics, state policies and efforts to promote buprenorphine use. In 2011, 43% of US counties had no buprenorphine-waivered physicians and 7% had 20 or more waivered physicians. Medicaid funding, opioid overdose deaths, and specific state guidance for office-based buprenorphine use were associated with more buprenorphine-waivered physicians, while encouraging methadone programs to promote buprenorphine use had no impact. Our findings provide important empirical information to individuals seeking to identify effective approaches to increase the number of physicians able to prescribe buprenorphine. [ABSTRACT FROM AUTHOR]

Abstract: Background: Buprenorphine provides an important option for individuals with opioid dependence who are unwilling or unable to attend a licensed methadone opioid agonist treatment program to receive opioid agonist therapy (OAT). Little empirical information is available, however, about the extent to which buprenorphine has increased the percentage of opioid dependent individuals receiving OAT, nor to what extent buprenorphine is being used in office based settings. Methods: Using administrative data from the largest Medicaid managed behavioral health organization in a large mid-Atlantic state, we used multivariate regression to examine rates and predictors of opioid agonist use and treatment setting for 14,386 new opioid dependence treatment episodes during 2007–2009. Results: Despite an increase in the use of buprenorphine, the percentage of new treatment episodes involving OAT is unchanged due to a decrease in the percentage of episodes involving methadone. Use of buprenorphine was significantly more common in rural communities, and 64% of buprenorphine use was in office-based settings. Conclusion: Buprenorphine use has increased in recent years, with the greatest use in rural communities and in office based settings. However, the percentage of new opioid dependence treatment episodes involving an opioid agonist is unchanged, suggesting the need for further efforts to increase buprenorphine use among urban populations. [Copyright &y& Elsevier]

In a 2007 report, the US Surgeon General called for health care professionals to renew efforts to reduce underage drinking. Focusing on the adolescent patient, this review provides health care professionals with recommendations for alcohol-related screening, brief Intervention, and referral to treatment. MEDLINE and published reviews were used to Identify relevant literature. Several brief screening methods have been shown to effectively Identify underage drinkers likely to have alcohol use disorders. After diagnostic assessment when germane, the Initial intervention typically focuses on education, motivation for change, and consideration of treatment options, Internet-accessible resources providing effective brief interventions are available, along with supplemental suggestions for parents. Recent changes In federal and commercial Insurance reimbursement policies provide some fiscal support for these services, although rate increases and expanded applicability may be required to prompt the participation of many practitioners. Nevertheless, advances In clinical methods and progress on reimbursement policies have made screening and brief Intervention for underage drinking more feasible in general health care practice. [ABSTRACT FROM AUTHOR]

Abstract: Background: Compared to non-veterans, veterans are disproportionately diagnosed with opioid dependence. Sublingual buprenorphine provides greater access to opioid agonist therapy. To understand the diffusion of this innovative treatment within a large healthcare system, we describe the introduction of buprenorphine within the Veterans Health Administration (VHA) during the first 3 years of its approval as a VHA non-formulary medication. Methods: Using VHA pharmacy databases, we examined the number of physicians who have prescribed buprenorphine and the number of veterans who have received office-based buprenorphine within VHA veterans integrated service networks (VISN) from fiscal years (FY) 2003 through FY 2005 (October 2002 through September 2005). Results: From FY2003 through FY2005 the number of veterans with opioid dependence increased from 25,031 to 26,859 (>7.3%) and the number of veterans prescribed office-based buprenorphine increased from 53 to 739. During this interval, 16 of 21 VISNs had prescribed buprenorphine. In FY2005, two VISNs accounted for 31% of buprenorphine prescriptions. The number of buprenorphine prescriptions varied widely by VISN, but increased from 212 to 7076 from FY2003 through FY2005. During this interval, prescriptions per patient increased from 4.0 to 9.6 and physicians prescribing buprenorphine increased from 14 to 170. The ratio of patients prescribed buprenorphine to providers prescribing buprenorphine increased from 3.8 to 4.3 with an average increase of 15.1–41.6 of prescriptions per provider. Conclusions: VHA increased, but not uniformly, the non-formulary use of office-based buprenorphine during the first 3 years of availability. [Copyright &y& Elsevier]

The American College of Cardiology/American Heart Association (ACC/AHA) and the American College of Physicians (ACP) have disseminated guidelines to assess preoperative cardiac risks before noncardiac surgery. The objectives of this study were to determine if these guidelines differ in preoperative recommendations for a group of patients, and whether these recommendations differ from actual provider recommendations. In this retrospective cohort study, patient characteristics and physician recommendations were abstracted from electronic medical records of consecutive patients attending a Veteran Affairs medical preoperative evaluation clinic from January 1 to April 1, 1998. Patient characteristics were used to determine what preoperative cardiac testing should have been ordered if each guideline was followed. Possible recommendations included operation without testing (OWT), noninvasive stress testing (NST), cardiac catheterization (CC), or cancel or delay surgery (OTHER). Recommendations were compared using statistical tests for agreement. Of the 138 patients identified, most underwent moderate-risk surgeries. Recommendations for preoperative testing were discordant between guidelines for 17% of patients (κ = 0.38). Guidelines never agreed on the need for NST. Extreme differences in recommendations (i.e., one recommends OWT, the other CC) occurred in 9 patients (7%). Physicians ordered NST more often (n = 27) than either guideline. In this subgroup of patients where providers ordered a NST, the 2 guidelines significantly differed (κ = 0.26). When applied to real patients being evaluated for surgery, ACC/AHA and ACP guidelines significantly differed in recommendations for preoperative cardiac testing. Results have implications for implementation, management, and practitioner adherence to published guidelines. [Copyright &y& Elsevier]

The U.S. Veterans Health Administration has undertaken several initiatives to improve veterans' access to and retention on buprenorphine because it prevents overdose and reduces drug-related morbidity. We aimed to determine whether improvements in retention duration over time was equitable across veterans of different races and ethnicities. This retrospective cohort study was conducted among veterans who initiated buprenorphine from federal fiscal years (FY) 2006 to 2020 after diagnosis of opioid use disorder. Using an accelerated failure time model, we estimated the association between time to buprenorphine discontinuation and FY of initiation, race and ethnicity, and other control covariates. We followed veterans from buprenorphine initiation until they discontinued or had a censoring event. We then estimated the predicted median days retained on buprenorphine, the average marginal effect of initiating in a later FY, the same measure by race and ethnicity, the incremental effect of the various racial and ethnic identities in contrast to non-Hispanic White, and the total change in the size of the gap over the 15 years of the study between veterans with a minoritized racial or ethnic identity compared to non-Hispanic White veterans. Most of the 31,797 veterans in the sample were non-Hispanic White (74.5 %), from urban areas (83.5 %), male (92.0 %), and had significant comorbidities, most frequently anxiety disorders (51.0 %) and depression (63.0 %). Overall, 49.8 % of veterans were retained at least 180 days. The average marginal effect of FY was 7.0 days [95%CI:5.3, 8.8] but was significantly smaller among veterans identifying as Black or African American [3.2 days; 95%CI:2.4, 4.1] or Asian [3.6 days; 95%CI:1.6, 5.7] compared to veterans who identify as non-Hispanic White [7.9 days; 95%CI:5.9, 9.9]. Additional measures of change were significant for veterans identifying as Hispanic White or with two or more races. Although buprenorphine retention in OUD treatment improved for all veterans over the 15-year study period, veterans from most minoritized racial and ethnic groups fell further behind as gains in duration on therapy accrued primarily to non-Hispanic White veterans. Targeted interventions addressing specific challenges experienced by veterans with minoritized identities are needed to close gaps in retention on buprenorphine. • Buprenorphine retention improved for veterans over the 15-year study period. • The gap in retention times widened between Black and White veterans over time. • The gap also widened between Asian and White veterans over time. [ABSTRACT FROM AUTHOR]

Introduction: Unsheltered homelessness is a strongly debated public issue. The study objective is to identify personal and community characteristics associated with unsheltered homelessness in veterans and to test for interactions between these characteristics.Methods: In a 2018 national survey of U.S. veterans with homeless experiences; investigators assessed unsheltered time; psychosocial characteristics; and community measures of shelter access, weather, and rental affordability. Associations between these characteristics and unsheltered status were tested in July-August 2020. This study also tested whether the count of personal risk factors interacted with community characteristics in predicting unsheltered status.Results: Among 5,406 veterans, 481 (8.9%) reported ≥7 nights unsheltered over 6 months. This group was more likely to report criminal justice history, poor social support, medical and drug problems, financial hardship, and being unmarried. Their communities had poorer shelter access and warmer temperatures. The likelihood of unsheltered experience rose with risk factor count from 2.0% (0-1) to 8.4% (2-3) and to 24.2% (4-11). Interaction tests showed that the increase was greater for communities with warmer weather and higher rents (p<0.05).Conclusions: Among veterans experiencing homelessness, unsheltered experiences correlate with individual and community risk factors. Communities wishing to address unsheltered homelessness will need to consider action at both levels. [ABSTRACT FROM AUTHOR]

Introduction: Infrequent use of and poor retention on evidence-based medications for alcohol use disorder (MAUD) represent a treatment gap, particularly among people living with HIV (PLWH). We examined predictors of MAUD initiation and retention across HIV status.Methods: From Veterans Aging Cohort Study (VACS) data, we identified new alcohol use disorder (AUD) diagnoses from 1998 to 2015 among 163,339 individuals (50,826 PLWH and 112,573 uninfected, matched by age, sex, and facility). MAUD initiation was defined as a prescription fill for naltrexone, acamprosate or disulfiram within 30 days of a new diagnosis. Among those who initiated, retention was defined as filling medication for ≥80% of days over the following six months. We used multivariable logistic regression to assess patient- and facility-level predictors of AUD medication initiation across HIV status.Results: Among 10,603 PLWH and 24,424 uninfected individuals with at least one AUD episode, 359 (1.0%) initiated MAUD and 49 (0.14%) were retained. The prevalence of initiation was lower among PLWH than those without HIV (adjusted odds ratio [AOR] 0.66, 95% confidence interval [CI] 0.51-0.85). Older age (for PLWH: AOR 0.78, 95% CI 0.61-0.99; for uninfected: AOR 0.70, 95% CI 0.61-0.80) and black race (for PLWH: AOR 0.63, 95% CI 0.0.49-0.1.00; for uninfected: AOR 0.63, 95% CI 0.48-0.83), were associated with decreased odds of initiation for both groups. The low frequency of retention precluded multivariable analyses for retention.Conclusions: For PLWH and uninfected individuals, targeted implementation strategies to expand MAUD are needed, particularly for specific subpopulations (e.g. black PLWH). [ABSTRACT FROM AUTHOR]

Introduction: Opioid prescribing safety among individuals with cancer is poorly understood. This study estimates the prevalence of Pharmacy Quality Alliance opioid measures among individuals with cancer undergoing or not undergoing active treatment versus those without cancer.Methods: Pennsylvania Medicaid data (2016) were analyzed in 2018 to identify adults aged 18-64 years with and without cancer diagnoses who had 2 or more opioid prescriptions. Active cancer treatment, defined as having chemotherapy, radiotherapy, cancer surgery, or hospitalization with a primary diagnosis of cancer, was evaluated from October 2015 to December 2016 allowing a ≥3-month look-back period for cancer diagnoses observed in the first quarter of 2016. Opioid dosages (>120 morphine milligram equivalents for ≥90 consecutive days), multiple providers (4 or more prescribers and 4 or more pharmacies), and opioid and benzodiazepines overlapping ≥30 days were evaluated.Results: The sample with opioid prescriptions included 111,491 enrollees without cancer diagnoses and 12,819 with cancer, 58.8% of whom were not in active cancer treatment. Among enrollees undergoing cancer treatment, with cancer but not in active treatment, and without cancer, the prevalence of high morphine milligram equivalents was 7.1%, 6.0%, and 4.7% (p<0.001), respectively. The corresponding prevalence of multiple providers was 6.7%, 4.1%, and 3.4% (p<0.001). Concurrent opioid and benzodiazepine prescriptions occurred in 28.6%, 30.5%, and 26.8% (p<0.001), respectively.Conclusions: Individuals with cancer, regardless of treatment status, had higher-risk opioid use based on Pharmacy Quality Alliance measures versus those without cancer. Their systematic exclusion from opioid quality surveillance could create missed opportunities to identify patients at high risk of adverse opioid-related outcomes. [ABSTRACT FROM AUTHOR]

The opioid epidemic has exacted a significant toll in rural areas, yet adoption of medications for opioid use disorder (MOUD) lags. The Rural Access to Medication Assisted Treatment in Pennsylvania (RAMP) Project facilitated adoption of MOUD in rural primary care clinics. The purpose of this study was to gain a better understanding of the barriers and facilitators operating at multiple levels to access or provide MOUD in rural Pennsylvania. In total, the study conducted 35 semi-structured interviews with MOUD patients and MOUD providers participating in RAMP. Qualitative analysis incorporated both deductive and inductive approaches. The study team coded interviews and performed thematic analysis. Using a modified social-ecological framework, themes from the qualitative interviews are organized in five nested levels: individual, interpersonal, health care setting, community, and public policy. Patients and providers agreed on many barriers (e.g., lack of providers, lack of transportation, insufficient rapport and trust in patient-provider relationship, and cost, etc.); however, their interpretation of the barrier, or indicated solution, diverged in meaningful ways. Patients described their experiences in broad terms pointing to the social determinants of health, as they highlighted their lives outside of the therapeutic encounter in the clinic. Providers focused on their professional roles, responsibilities, and operations within the primary care setting. Providers may want to discuss barriers to treatment related to social determinants of health with patients, and pursue partnerships with organizations that seek to address those barriers. The findings from these interviews point to potential opportunities to enhance patient experience, increase access to and optimize processes for MOUD in rural areas, and reduce stigma against people with opioid use disorder (OUD) in the wider community. • Patient and provider perceived barriers and facilitators to MOUD. • Patients described experiences outside of the therapeutic encounter. • Providers focused on roles and operations within the primary care setting. • Recommend addressing barriers related to the social determinants of health (SDOH). • Recommend providers pursue partnership with organizations addressing SDOH barriers. [ABSTRACT FROM AUTHOR]

Background: Substance use disorders (SUDs) are common in healthcare settings and contribute to poor outcomes, particularly in patients living with HIV. We assessed initiation, engagement, and retention in SUD treatment and pharmacotherapy following an index SUD episode in a national sample of HIV-infected and uninfected patients receiving care in the Department of Veterans Affairs (VA) healthcare system.Methods: We used electronic national VA data (years 2000-2015) from 52,995 HIV-infected and 111,229 age-, race-, gender-, and region-matched uninfected patients. We defined index SUD episodes as outpatient visits or inpatient/residential admissions with associated primary or secondary ICD-9 codes for substance use in patients without SUD-related services or pharmacotherapy in the preceding 5 months.Results: Overall, 57,428 (35%) patients had at least 1 index SUD episode. HIV-infected patients were more likely than uninfected controls to have at least one index SUD episode (35.7% vs. 34.6%; p < .001). Rates of initiation, engagement, and retention in SUD treatment after the index SUD episode were <17% for both groups. In adjusted models, HIV-infected patients were more likely than uninfected patients to be retained in SUD treatment at 6 months (Odds Ratio 1.10; 95% Confidence Interval 1.04-1.16). SUD pharmacotherapy initiation and engagement was uncommon in both HIV-infected and uninfected patients.Conclusions: In this national VA sample, initiation of SUD treatment and pharmacotherapy were uncommon for both HIV-infected and uninfected patients. Interventions to improve initiation, engagement, and retention in the full range of services, including SUD pharmacotherapy, are warranted for all patients with SUD in the VA. [ABSTRACT FROM AUTHOR]

Introduction Transgender individuals experience pronounced disparities in health (e.g., mood disorders, suicide risk) and in the prevalence of social determinants of housing instability, financial strain, and violence. The objectives of this study were to understand the prevalence of social determinants among transgender veterans and assess their associations with medical conditions. Methods This project was a records review using administrative data from the U.S. Department of Veterans Affairs databases for 1997–2014. Transgender veterans (N=6,308) were defined as patients with any of four ICD-9 diagnosis codes associated with transgender status. Social determinants were operationalized using ICD-9 codes and Department of Veterans Affairs clinical screens indicating violence, housing instability, or financial strain. Multiple logistic regression was used to assess the associations of social determinants with medical conditions: mood disorder, post-traumatic stress disorder, alcohol abuse disorder, illicit drug abuse disorder, tobacco use disorder, suicidal risk, HIV, and hepatitis C. Results After adjusting for sociodemographic variables, housing instability and financial strain were significantly associated with all medical conditions except for HIV, and violence was significantly associated with all medical conditions except for tobacco use disorder and HIV. There was a dose response–like relationship between the increasing number of forms of social determinants being associated with increasing odds for medical conditions. Conclusions Social determinants are prevalent factors in transgender patients’ lives, exhibiting strong associations with medical conditions. Documenting social determinants in electronic health records can help providers to identify and address these factors in treatment goals. [ABSTRACT FROM AUTHOR]

Introduction: Individuals with HIV and hepatitis C (HCV) infection, alcohol use disorder, or who are prescribed potentially hepatotoxic medications may be at increased risk for buprenorphine (BUP) associated hepatotoxicity.Materials and Methods: We examined a cohort of HIV-infected and uninfected patients receiving an initial BUP prescription between 2003 and 2012. We compared changes in alanine and aspartate aminotransferases (ALT and AST) and total bilirubin (TB) stratified by HIV status. We identified cases of liver enzyme elevation (LEE), TB elevation (TBE), and conducted chart review to assess for cases of drug induced liver injury (DILI) and death. We examined associations between age, sex, race, HIV-infection, HCV-infection, alcohol use disorder, and prescription of other potentially heptatotoxic medications with the composite endpoint of LEE, TBE, and DILI.Results: Of 666 patients prescribed BUP, 36% were HIV-infected, 98% were male, 60% had RNA-confirmed HCV infection, 50% had a recent diagnosis of alcohol use disorder, and 64% were prescribed other potentially hepatotoxic medications. No clinically significant changes were observed in median ALT, AST and TB and these changes did not differ between HIV-infected and uninfected patients. Compared with uninfected patients, HIV-infected (OR 7.3, 95% CI 2.1-26.1, p=0.002), HCV-infected (OR 4.9 95% CI 1.6-15.2, p=0.007) or HIV/HCV co-infected patients (OR 6.9, 95%CI 2.1-22.2, p=0.001) were more likely to have the composite endpoint of LEE, TB elevation or DILI, in analyses that excluded 60 patients with evidence of pre-existing liver injury. 31 patients had LEE, 14/187 HIV-infected and 17/340 uninfected (p=0.25); 11 had TBE, including 9/186 HIV-infected and 2/329 uninfected (p=0.002); 8 experienced DILI, 4/202 HIV-infected and 4/204 uninfected (p=0.45). There were no significant associations with alcohol use disorder or prescription of other potentially hepatotoxic medications after adjustment for HIV/HCV status.Conclusions: Liver enzymes and TB are rarely elevated in HIV-infected and uninfected patients receiving BUP. Risk of hepatotoxicity was greater in individuals infected with HIV, HCV, or HIV/HCV co-infection, who may benefit from increased monitoring. [ABSTRACT FROM AUTHOR]

Background Although high rates of alcohol consumption and related problems have been observed among HIV-infected men who have sex with men (MSM), little is known about the long-term patterns of and factors associated with hazardous alcohol use in this population. We sought to identify alcohol use trajectories and correlates of hazardous alcohol use among HIV-infected MSM. Methods Sexually active, HIV-infected MSM participating in the Veterans Aging Cohort Study were eligible for inclusion. Participants were recruited from VA infectious disease clinics in Atlanta, Baltimore, New York, Houston, Los Angeles, Pittsburgh, and Washington, DC. Data from annual self-reported assessments and group-based trajectory models were used to identify distinct alcohol use trajectories over an eight-year study period (2002–2010). We then used generalized estimate equations (GEE) to examine longitudinal correlates of hazardous alcohol use (defined as an AUDIT-C score ≥4). Results Among 1065 participants, the mean age was 45.5 (SD = 9.2) and 606 (58.2%) were African American. Baseline hazardous alcohol use was reported by 309 (29.3%). Group-based trajectory modeling revealed a distinct group (12.5% of the sample) with consistently hazardous alcohol use, characterized by a mean AUDIT-C score of >5 at every time point. In a GEE-based multivariable model, hazardous alcohol use was associated with earning <$6000 annually, having an alcohol-related diagnosis, using cannabis, and using cocaine. Conclusions More than 1 in 10 HIV-infected MSM US veterans reported consistent, long-term hazardous alcohol use. Financial insecurity and concurrent substance use were predictors of consistently hazardous alcohol use, and may be modifiable targets for intervention. [ABSTRACT FROM AUTHOR]

>1 in 3 of the 9 million individuals engaged in opioid medication misuse obtain legitimate opioid prescriptions and fill these in community pharmacies, which are subsequently misused. This study is testing the efficacy of a pharmacist-led intervention—Brief Intervention-Medication Therapy Management (BI-MTM)—compared to standard medication counseling (SMC) to address opioid medication misuse. Design. This study is a single-blinded 2-group parallel randomized trial within 13 community pharmacies that will enroll 350 individuals. Participant Recruitment. Pharmacy staff approach patients and ask about interest in completing a brief confidential screening tool, which includes opioid medication misuse assessment. Interested patients who report misuse are asked to provide informed consent. Enrolled patients are assessed for behavioral and physical health at enrollment, 2-months post-enrollment, and 6-months post-enrollment. Interventions. Following baseline assessment, participants are randomized (1:1 ratio) to: SMC , a medication information/counseling intervention or BI-MTM , an intervention comprised by 4 evidence-based components: medication therapy management, brief intervention, naloxone dispensing, and patient navigation. Analyses. Primary analyses involve estimating 3-level generalized linear mixed models to relate repeated assessments across time of opioid medication misuse (i.e., the Prescription Opioid Misuse Index) to the intervention. Study results will provide the first critical step towards integrating a highly accessible, low-cost approach to managing risks related to opioid use. Community pharmacies provide an incredibly important setting in which patients can receive high quality care to support health behavior change. Successfully completing this project sets the stage for a large-scale effectiveness study. (NCT#: NCT05141266). [ABSTRACT FROM AUTHOR]

Background: Persons with HIV (PWH) and opioid use disorder (OUD) can have poor health outcomes. We assessed whether intensity of behavioral treatment for OUD (BOUD) with and without medication for OUD (MOUD) is associated with improved HIV clinical outcomes.Methods: We used Veterans Aging Cohort Study (VACS) data from 2008 to 2017 to identify PWH and OUD with ≥1 BOUD episode. We assessed BOUD intensity and ≥6 months of MOUD (methadone or buprenorphine) receipt during the 12 months after BOUD initiation. Linear regression models assessed the association of BOUD intensity and MOUD receipt with pre-post changes in log viral load (VL), CD4 cell count, VACS Index 2.0, antiretroviral treatment (ART) initiation, and ART adherence.Results: Among 2419 PWH who initiated BOUD, we identified five distinct BOUD intensity trajectories: single visit (39% of sample); low-intensity, not sustained (37%); high-intensity, not sustained (9%); low-intensity, sustained (11%); and high-intensity, sustained (5%). MOUD receipt was low (17%). Among 709 PWH not on ART at the start of BOUD, ART initiation increased with increased BOUD intensity (p < 0.01). Among 1401 PWH on ART at the start of BOUD, ART adherence improved more in higher-intensity BOUD groups (p < 0.01). VL, CD4 count and VACS Index 2.0 did not differ by BOUD or ≥6 months of MOUD treatment.Conclusion: Among PWH and OUD who initiated BOUD, higher intensity BOUD was associated with improved ART initiation and adherence, but neither BOUD alone nor BOUD plus ≥6 months MOUD was associated with improvements in VL, CD4 count or VACS Index 2.0. [ABSTRACT FROM AUTHOR]

Abstract: Background: Opioid agonist treatment (OAT)—through licensed clinic settings (C-OAT) using methadone or buprenorphine or office-based settings with buprenorphine (O-OAT)—is an evidence-based treatment for opioid dependence. Because of limited availability of on-site C-OAT (n =28 of 128 facilities) in the Veterans Health Administration (VHA), O-OAT use has been encouraged. This study examined OAT utilization across VHA facilities and the patient and facility factors related to variability in utilization. Method: We examined 12 months of VHA administrative data (fiscal year [FY] 2008, October 2007 through September 2008) for evidence of OAT utilization and substance use disorder program data from an annual VHA survey. Variability in OAT utilization across facilities and patient and facility factors related to OAT utilization were examined using mixed-effects, logistic regression models. Results: Among 128 VHA facilities, 35,240 patients were diagnosed with an opioid use disorder. Of those, 27.3% received OAT: 22.2% received C-OAT and 5.1% received O-OAT with buprenorphine. Substantial facility-level variability in proportions of patients treated with OAT was found, ranging from 0% to 66% with 44% of facilities treating <5%. Significant patient-level predictors of OAT receipt included being male, age ≥56, and without another mental health diagnosis. Significant facility-level predictors included offering any OAT services (C-OAT or O-OAT) and specialty substance abuse treatment services on weekends. Conclusion: In FY2008, prior to the VHA national mandate of access to buprenorphine OAT, substantial variation in the use of OAT existed, partially explained by patient- and facility-level factors. Implementation efforts should focus on increasing access to this evidence-based treatment, especially in facilities at the low end of the distribution. [Copyright &y& Elsevier]

Abstract: This study characterized the extent and patterns of self-reported drug use among aging adults with and without HIV, assessed differences in patterns by HIV status, and examined pattern correlates. Data derived from 6351 HIV-infected and uninfected adults enrolled in an eight-site matched cohort, the Veterans Aging Cohort Study (VACS). Using clinical variables from electronic medical records and socio-demographics, drug use consequences, and frequency of drug use from baseline surveys, we performed latent class analyses (LCA) stratified by HIV status and adjusted for clinical and socio-demographic covariates. Participants were, on average, age 50 (range 22–86), primarily male (95%) and African-American (64%). Five distinct patterns emerged: non-users, past primarily marijuana users, past multidrug users, current high consequence multidrug users, and current low consequence primarily marijuana users. HIV status strongly influenced class membership. Non-users were most prevalent among HIV uninfected (36.4%) and current high consequence multidrug users (25.5%) were most prevalent among HIV-infected. While problems of obesity marked those not currently using drugs, current users experienced higher prevalences of medical or mental health disorders. Multimorbidity was highest among past and current multidrug users. HIV-infected participants were more likely than HIV-uninfected participants to be current low consequence primarily marijuana users. In this sample, active drug use and abuse were common. HIV-infected and uninfected Veterans differed on extent and patterns of drug use and on important characteristics within identified classes. Findings have the potential to inform screening and intervention efforts in aging drug users with and without HIV. [Copyright &y& Elsevier]

Background: While patients with substance use disorders (SUDs) are thought to encounter poor primary care experiences, the perspectives of patients with opioid use disorder (OUD), specifically, are unknown. This study compares the primary care experiences of patients with OUD, other SUDs and no SUD in the Veterans Health Administration.Methods: The sample included Veterans who responded to the national Patient-Centered Medical Home Survey of Healthcare Experiences of Patients, 2013-2015. Respondents included 3554 patients with OUD, 36,175 with other SUDs, and 756,386 with no SUD; 742 OUD-diagnosed patients received buprenorphine. Multivariable multinomial logistic regressions estimated differences in the probability of reporting positive and negative experiences (0-100 scale) for patients with OUD, compared to patients with other SUDs and no SUD, and for OUD-diagnosed patients treated versus not treated with buprenorphine.Results: Of all domains, patients with OUD reported the least positive experiences with access (31%) and medication decision-making (35%), and the most negative experiences with self-management support (35%) and provider communication (23%). Compared to the other groups, patients diagnosed with OUD reported fewer positive and/or more negative experiences with access, communication, office staff, provider ratings, comprehensiveness, care coordination, and self-management support (adjusted risk differences[aRDs] range from |2.9| to |7.0|). Among OUD-diagnosed patients, buprenorphine was associated with more positive experiences with comprehensiveness (aRD = 8.3) and self-management support (aRD = 7.1), and less negative experiences with care coordination (aRD = -4.9) and medication shared decision-making (aRD = -5.4).Conclusions: In a national sample, patients diagnosed with OUD encounter less positive and more negative experiences than other primary care patients, including those with other SUDs. Buprenorphine treatment relates positively to experiences with care comprehensiveness, medication decisions, and care coordination. As stakeholders encourage more primary care providers to manage OUD, it will be important for healthcare systems to attend to patient access and experiences with care in these settings. [ABSTRACT FROM AUTHOR]

The opioid crisis continues to affect pregnant and postpartum women the United States, with the number of pregnant women diagnosed with opioid use disorder (OUD) quadrupling over the last decade. The associated increase in morbidity and mortality among mother and baby warrants prompt, targeted intervention efforts that improve engagement, linkage of care, and treatment retention. Patient navigation (PN) is a chronic care intervention that can directly address this need by helping women identify medical, behavioral, and psychosocial care goals. Moreover, PN can assist women in preparing for, engaging in, and maintaining patient participation in necessary services. Specifically, PN includes strengths-based case management, 1-1 clinical support, motivational interviewing, and addiction-relapse prevention programming. The objective of this article is to present the study protocol of a pilot multisite randomized clinical trial, entitled: Optimizing Pregnancy and Treatment Interventions for Moms 2.0 (OPTI-Mom 2.0; NCT03833245). In this study, we build upon a proof-of-concept study, employing evidence-informed frameworks for protocol and intervention expansion in order to construct a PN intervention tailored for pregnant women with OUD in central Utah and southwestern Pennsylvania. Our protocol provides an initial framework of a potentially impactful intervention and may guide development of future programs. Importantly, this study further establishes the evidence-base—with potential to ameliorate serious adverse opioid-related outcomes and improve health for women and their children. [ABSTRACT FROM AUTHOR]