Publications by authors named "Andrew Rosenblum"

95 Publications

Web-based cognitive behavior therapy for chronic pain patients with aberrant drug-related behavior: How did it work and for whom?

J Behav Med 2021 Apr 12. Epub 2021 Apr 12.

Graduate School of Public Health and Health Policy, City University of New York, New York, NY, USA.

This study explored mediating pathways, moderating factors, and moderated mediation effects of a web-based, cognitive behavioral therapy (CBT) intervention for chronic pain patients with aberrant drug-related behavior (ADRB). In a 2-arm RCT, patients with chronic pain who screened positive for ADRB received treatment-as-usual (TAU, n = 55) or TAU plus a 12-week, web-based CBT intervention (n = 55). Assessments were conducted at weeks 4, 8, and 12, and at 1- and 3-months post intervention. Web-CBT significantly reduced pain catastrophizing, which, in turn, reduced pain interference and pain severity via a pathway of pain catastrophizing. Web-CBT also significantly reduced ADRB both directly and indirectly by reducing pain catastrophizing. For pain interference and pain severity, web-CBT was more effective than TAU for younger patients (≤ age 50). For pain severity, web-CBT was more effective for both younger patients (≤ age 50), and those with a lifetime substance use disorder. Findings suggest that web-CBT's positive impact on pain outcomes and ADRB are mediated by its effect on pain catastrophizing, and its treatment effects may be most robust for younger patients and those with histories of substance dependence.
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http://dx.doi.org/10.1007/s10865-021-00219-9DOI Listing
April 2021

Vaccine Liability in COVID-19.

J Public Health Manag Pract 2021 Mar 12. Epub 2021 Mar 12.

Johns Hopkins University, Baltimore, Maryland.

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http://dx.doi.org/10.1097/PHH.0000000000001301DOI Listing
March 2021

Factors Associated With Emergency Medical Services Providers' Acceptance of the Seasonal Influenza Vaccine.

Disaster Med Public Health Prep 2021 Mar 17:1-6. Epub 2021 Mar 17.

Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Objective: Influenza vaccination remains the most effective primary prevention strategy for seasonal influenza. This research explores the percentage of emergency medical services (EMS) clinicians who received the seasonal flu vaccine in a given year, along with their reasons for vaccine acceptance and potential barriers.

Methods: A survey was distributed to all EMS clinicians in Virginia during the 2018-2019 influenza season. The primary outcome was vaccination status. Secondary outcomes were attitudes and perceptions toward influenza vaccination, along with patient care behaviors when treating an influenza patient.

Results: Ultimately, 2796 EMS clinicians throughout Virginia completed the survey sufficiently for analysis. Participants were mean 43.5 y old, 60.7% male, and included the full range of certifications. Overall, 79.4% of surveyed EMS clinicians received a seasonal flu vaccine, 74% had previously had the flu, and 18% subjectively reported previous side effects from the flu vaccine. Overall, 54% of respondents believed their agency has influenza or respiratory specific plans or procedures.

Conclusions: In a large, state-wide survey of EMS clinicians, overall influenza vaccination coverage was 79.4%. Understanding the underlying beliefs of EMS clinicians remains a critical priority for protecting these frontline clinicians. Agencies should consider practical policies, such as on-duty vaccination, to increase uptake.
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http://dx.doi.org/10.1017/dmp.2021.44DOI Listing
March 2021

Reexamining Health-Care Coalitions in Light of COVID-19.

Disaster Med Public Health Prep 2020 Nov 4:1-5. Epub 2020 Nov 4.

The National Center for Disaster Medicine and Public Health and the Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.

The national response to the coronavirus disease 2019 (COVID-19) pandemic has highlighted critical weaknesses in domestic health care and public health emergency preparedness, despite nearly 2 decades of federal funding for multiple programs designed to encourage cross-cutting collaboration in emergency response. Health-care coalitions (HCCs), which are funded through the Hospital Preparedness Program, were first piloted in 2007 and have been continuously funded nationwide since 2012 to support broad collaborations across public health, emergency management, emergency medical services, and the emergency response arms of the health-care system within a geographical area. This commentary provides a SWOT (strengths, weaknesses, opportunities, and threats) analysis to summarize the strengths, weaknesses, opportunities, and threats related to the current HCC model against the backdrop of COVID-19. We close with concrete recommendations for better leveraging the HCC model for improved health-care system readiness. These include better evaluating the role of HCCs and their members (including the responsibility of the HCC to better communicate and align with other sectors), reconsidering the existing framework for HCC administration, increasing incentives for meaningful community participation in HCC preparedness, and supporting next-generation development of health-care preparedness systems for future pandemics.
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http://dx.doi.org/10.1017/dmp.2020.431DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7884654PMC
November 2020

Readying for a Post-COVID-19 World: The Case for Concurrent Pandemic Disaster Response and Recovery Efforts in Public Health.

J Public Health Manag Pract 2020 Jul/Aug;26(4):310-313

Department of Environmental Health & Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Dr Barnett); Johns Hopkins University, Baltimore, Maryland (Mr Rosenblum); The National Center for Disaster Medicine and Public Health and the Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland (Ms Strauss-Riggs and Dr Kirsch); and The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Rockville, Maryland (Ms Strauss-Riggs).

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http://dx.doi.org/10.1097/PHH.0000000000001199DOI Listing
May 2020

Applying the Haddon Matrix to Hospital Earthquake Preparedness and Response.

Disaster Med Public Health Prep 2020 Apr 7:1-8. Epub 2020 Apr 7.

Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

Since its 1960s origins, the Haddon matrix has served as a tool to understand and prevent diverse mechanisms of injuries and promote safety. Potential remains for broadened application and innovation of the matrix for disaster preparedness. Hospital functionality and efficiency are particularly important components of community vulnerability in developed and developing nations alike. Given the Haddon matrix's user-friendly approach to integrating current engineering concepts, behavioral sciences, and policy dimensions, we seek to apply it in the context of hospital earthquake preparedness and response. The matrix's framework lends itself to interdisciplinary planning and collaboration between social and physical sciences, paving the way for a systems-oriented reduction in vulnerabilities. Here, using an associative approach to integrate seemingly disparate social and physical science disciplines yields innovative insights about hospital disaster preparedness for earthquakes. We illustrate detailed examples of pre-event, event, and post-event engineering, behavioral science, and policy factors that hospital planners should evaluate given the complex nature, rapid onset, and broad variation in impact and outcomes of earthquakes. This novel contextual examination of the Haddon matrix can enhance critical infrastructure disaster preparedness across the epidemiologic triad, by integrating essential principles of behavioral sciences, policy, law, and engineering to earthquake preparedness.
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http://dx.doi.org/10.1017/dmp.2020.30DOI Listing
April 2020

An Analysis of After Action Reports From Texas Hurricanes in 2005 and 2017.

J Public Health Manag Pract 2021 Mar-Apr 01;27(2):E71-E78

Departments of Environmental Health and Engineering (Dr Barnett) and Health Policy & Management (Dr Barnett), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Uniformed Services University National Center for Disaster Medicine and Public Health, Rockville Maryland (Mss Strauss-Riggs and Klimczak and Dr Kirsch); Henry M. Jackson Foundation for Advancement of Military Medicine, Rockville, Maryland (Mss Strauss-Riggs and Klimczak); and Johns Hopkins University, Baltimore, Maryland (Mr Rosenblum).

Objective: To review and analyze After Action Reports from jurisdictions in Texas following Hurricanes Katrina and Rita in 2005 and Hurricane Harvey in 2017 in order to assess the utility of AARs as a quality improvement measurement tool.

Methods: The authors searched the Homeland Security Digital Library, the Assistant Secretary for Preparedness and Response Technical Resources, Assistance Center, and Information Exchange, and Google Scholar for any AARs that covered the response phase of at least one of the 3 hurricanes, mentioned the state of Texas, and suggested solutions to problems. The authors applied public health emergency management (PHEM) domains, as outlined by Rose et al, to frame the AAR analysis. AARs were coded by 2 reviewers independently, with a third acting as adjudicator. As an example, the problem statements in 2005 and 2017 AARs from 1 statewide agency were compared.

Results: Sixteen AARs met the inclusion criteria. There were 500 identified problem-solution sets mapped to a PHEM domain. The content was unevenly distributed, with most issues coming under PHEM 2: Policies, Plans, Procedures, and Partnerships at 45.2% in the 2005 hurricanes and 39.9% in 2017. AARs lacked consistent format and were often prepared by the response agencies themselves. Five consistent issues were raised in 2005 and again in 2017. These were volunteer management and credential verification, donations management, information sharing, appropriately identifying those requiring a medical needs shelter, and inadequate transportation to support evacuation.

Conclusion: Because of the lack of objective data, inconsistent format, unevenly distributed content, and lack of adherence to any framework, AARs are fraught with shortcomings as a tool for PHEM. Inclusion of more objective reporting measures is urgently needed.
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http://dx.doi.org/10.1097/PHH.0000000000001120DOI Listing
February 2020

An Analysis of After Action Reports From Texas Hurricanes in 2005 and 2017.

J Public Health Manag Pract 2021 Mar-Apr 01;27(2):E71-E78

Departments of Environmental Health and Engineering (Dr Barnett) and Health Policy & Management (Dr Barnett), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Uniformed Services University National Center for Disaster Medicine and Public Health, Rockville Maryland (Mss Strauss-Riggs and Klimczak and Dr Kirsch); Henry M. Jackson Foundation for Advancement of Military Medicine, Rockville, Maryland (Mss Strauss-Riggs and Klimczak); and Johns Hopkins University, Baltimore, Maryland (Mr Rosenblum).

Objective: To review and analyze After Action Reports from jurisdictions in Texas following Hurricanes Katrina and Rita in 2005 and Hurricane Harvey in 2017 in order to assess the utility of AARs as a quality improvement measurement tool.

Methods: The authors searched the Homeland Security Digital Library, the Assistant Secretary for Preparedness and Response Technical Resources, Assistance Center, and Information Exchange, and Google Scholar for any AARs that covered the response phase of at least one of the 3 hurricanes, mentioned the state of Texas, and suggested solutions to problems. The authors applied public health emergency management (PHEM) domains, as outlined by Rose et al, to frame the AAR analysis. AARs were coded by 2 reviewers independently, with a third acting as adjudicator. As an example, the problem statements in 2005 and 2017 AARs from 1 statewide agency were compared.

Results: Sixteen AARs met the inclusion criteria. There were 500 identified problem-solution sets mapped to a PHEM domain. The content was unevenly distributed, with most issues coming under PHEM 2: Policies, Plans, Procedures, and Partnerships at 45.2% in the 2005 hurricanes and 39.9% in 2017. AARs lacked consistent format and were often prepared by the response agencies themselves. Five consistent issues were raised in 2005 and again in 2017. These were volunteer management and credential verification, donations management, information sharing, appropriately identifying those requiring a medical needs shelter, and inadequate transportation to support evacuation.

Conclusion: Because of the lack of objective data, inconsistent format, unevenly distributed content, and lack of adherence to any framework, AARs are fraught with shortcomings as a tool for PHEM. Inclusion of more objective reporting measures is urgently needed.
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http://dx.doi.org/10.1097/PHH.0000000000001120DOI Listing
February 2020

The immediate and lasting impact of Hurricane Sandy on pregnancy complications in eight affected counties of New York State.

Sci Total Environ 2019 Aug 1;678:755-760. Epub 2019 May 1.

Department of Environmental Health Sciences, School of Public Health, University at Albany, State University of New York, Rensselaer, NY, USA. Electronic address:

Background: The frequency and intensity of hurricane have increased greatly. However, whether hurricane exposure is associated with an increased risk of pregnancy complications is less known.

Objective: To assess the immediate impact and lasting impact of Hurricane Sandy (Sandy) on pregnancy complications.

Methods: Using time-series study, we estimated the relative risks (RRs) of emergency department (ED) visits for pregnancy complications in eight affected counties in New York State, based on data of 2005-2014. The immediate impact was estimated by comparing the ED visits of pregnancy complications during the Sandy period to the non-Sandy periods. For the lasting impact of Sandy, we estimated the RRs by contrasting the ED visits in the following 12 months after Sandy with the same months of other years.

Results: We found that ED visits for overall pregnancy complications increased 6.3% (95% confidence interval (CI): 2.2%, 10.5%) during the Sandy month. ED visits increased for threatened abortion (9.9%, 95% CI: 4.4%, 15.7%), threatened labor (10.1%, 95% CI: 1.9%, 18.9%), early onset of delivery (115.9%, 95% CI: 6.9%, 336.3%), renal disease (73.2%, 95% CI: 0.3%, 199.4%), and diabetes (42.3%, 95% CI: 15.0%, 76.0%). Gestational hypertension and renal disease were elevated 7-8 months after Sandy. The ED visits of mental illness increased gradually after Sandy and peaked eight months later with visits increasing 33.2%.

Conclusions: This study suggests that hurricanes may impact pregnancy health immediately and that some negative health may last for months thereafter.
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http://dx.doi.org/10.1016/j.scitotenv.2019.04.436DOI Listing
August 2019

A pilot study comparing peer supported web-based CBT to self-managed web CBT for primary care veterans with PTSD and hazardous alcohol use.

Psychiatr Rehabil J 2019 09 29;42(3):305-313. Epub 2018 Nov 29.

National Development Research Institutes.

Objective: Many combat veterans struggle with posttraumatic stress disorder (PTSD) and hazardous alcohol use and are hesitant to engage in behavioral health services. Combining peer support with an eHealth intervention may overcome many barriers to care. This pilot study investigated the feasibility of adding peer support to a web-based cognitive behavior therapy (CBT) targeting PTSD symptoms and hazardous drinking, called Thinking Forward.

Method: Thirty primary care patients with PTSD and hazardous alcohol use were randomized to receive Thinking Forward with or without peer support. Participants were assessed at pretreatment, posttreatment, and 24-week follow-up. Feasibility was analyzed with descriptive statistics. Preliminary outcomes were analyzed with multilevel modeling and effect sizes are presented.

Results: Peer support specialists can be feasibly trained to support the Thinking Forward intervention with good fidelity. Both participants and peers reported good satisfaction with the protocol; although peers discussed a mismatch between the philosophies of peer support and diagnostically focused CBT. All participants experienced significant improvements in PTSD, quality of life, resiliency, and coping from pre- to posttreatment, with no differences between conditions. Pretreatment patient activation predicted outcomes regardless of whether participants received peer support.

Conclusions And Implications For Practice: Peer support interventions to facilitate eHealth programs should strive to be consistent with the person-centered, recovery orientation of peer support, explicitly focus on patient activation, and consider characteristics of the patients, such as their level of problem recognition and willingness to engage in traditional behavioral health modalities. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/prj0000334DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6541543PMC
September 2019

Eye of the beholder: Risk calculators and barriers to adoption in surgical trainees.

Surgery 2018 11 24;164(5):1117-1123. Epub 2018 Aug 24.

Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD. Electronic address:

Background: Accurate risk assessment before surgery is complex and hampered by behavioral factors. Underutilized risk-based decision-support tools may counteract these barriers. The purpose of this study was to identify perceptions of and barriers to the use of surgical risk-assessment tools and assess the importance of data framing as a barrier to adoption in surgical trainees.

Methods: We distributed a survey and risk assessment activity to surgical trainees at four training institutions. The primary outcomes of this study were descriptive risk assessment practices currently performed by residents, identifiable influences and obstacles to adoption, and the variability of preference sets when comparing modified System Usability Scores of a current risk calculator to a purpose-built calculator revision. Risk calculator comparison responses were compared with simple and multivariable regression to identify predictors for preferentiality.

Results: We collected responses from 124 surgical residents (39% response rate). Participants endorsed familiarity with direct verbal communication (100%), sketch diagrams (87%), and brochures (59%). The most contemporary risk communication frameworks, such as best-worst case scenario framing (38%), case-specific risk calculators (43%), and all-procedure calculators (52%) were the least familiar. Usage favored traditional models of communication with only 26% of residents regularly using a strategy other than direct verbal discussion or anatomic sketch diagrams. Barriers limiting routine use included lack of electronic and clinical workflow integration. The mean modified System Usability Scores domain scores were widely dispersed for all domains, and no domain demonstrated one calculator's superiority over another.

Conclusion: Risk assessment tools are underutilized by trainees. Of importance, preference sets of clinicians appear to be unpredictable and may benefit more from a customizable, bespoke approach.
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http://dx.doi.org/10.1016/j.surg.2018.07.002DOI Listing
November 2018

An Unusual Occurrence of Dual Tachycardia.

JAMA Intern Med 2018 Aug;178(8):1113-1114

Cape Fear Valley Medical Center, Department of Medicine, Campbell University School of Osteopathic Medicine, Fayetteville, North Carolina.

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http://dx.doi.org/10.1001/jamainternmed.2018.2393DOI Listing
August 2018

Corrigendum to "Prescription drug monitoring program utilization among 15 US opioid treatment programs" [J. Subst. Abus. Treat. 85 (2018) 17-20].

J Subst Abuse Treat 2018 Apr 1;87:86. Epub 2018 Feb 1.

American Association for the Treatment of Opioid Dependence, United States.

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http://dx.doi.org/10.1016/j.jsat.2018.01.008DOI Listing
April 2018

Web-Based Cognitive Behavior Therapy for Chronic Pain Patients with Aberrant Drug-Related Behavior: Outcomes from a Randomized Controlled Trial.

Pain Med 2018 12;19(12):2423-2437

National Development and Research Institutes (NDRI), Inc., New York, New York.

Objective: There is high unmet need for effective behavioral treatments for chronic pain patients at risk for or with demonstrated histories of opioid misuse. Despite growing evidence supporting technology-based delivery of self-management interventions for chronic pain, very few such programs target co-occurring chronic pain and aberrant drug-related behavior. This randomized controlled trial evaluated the effectiveness of a novel, web-based self-management intervention, grounded in cognitive behavior therapy, for chronic pain patients with aberrant drug-related behavior.

Methods: Opioid-treated chronic pain patients at a specialty pain practice who screened positive for aberrant drug-related behavior (N = 110) were randomized to receive treatment as usual plus the web-based program or treatment as usual alone. The primary outcomes of pain severity, pain interference, and aberrant drug-related behavior, and the secondary outcomes of pain catastrophizing and pain-related emergency department visits, were assessed during the 12-week intervention and at one and three months postintervention.

Results: Patients assigned to use the web-based program reported significantly greater reductions in aberrant drug-related behavior, pain catastrophizing, and pain-related emergency department visits-but not pain severity or pain interference-relative to those assigned to treatment as usual. The positive outcomes were observed during the 12-week intervention and for three months postintervention.

Conclusions: A web-based self-management program, when delivered in conjunction with standard specialty pain treatment, was effective in reducing chronic pain patients' aberrant drug-related behavior, pain catastrophizing, and emergency department visits for pain. Technology-based self-management tools may be a promising therapeutic approach for the vulnerable group of chronic pain patients who have problems managing their opioid medication.
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http://dx.doi.org/10.1093/pm/pnx334DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6294413PMC
December 2018

Prescription drug monitoring program utilization among 15 US opioid treatment programs.

J Subst Abuse Treat 2018 02 26;85:17-20. Epub 2017 Nov 26.

American Association for the Treatment of Opioid Dependence, United States.

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http://dx.doi.org/10.1016/j.jsat.2017.11.009DOI Listing
February 2018

Racial/Ethnic Differences in Prevalence Trends for Heroin use and Non-Medical use of Prescription Opioids Among Entrants to Opioid Treatment Programs, 2005-2016.

Subst Use Misuse 2018 01 30;53(2):290-300. Epub 2017 Aug 30.

b National Development and Research Institutes, Inc. , New York , New York , USA.

Recent data suggest an increase in use of heroin and non-medical use of prescription opioids (POs) in the United States, but it is unclear if these trends are consistent across racial/ethnic groups. In a nationwide prevalence study, 69,140 patients newly admitted to an opioid treatment program (OTP) completed a brief self-administered survey of past month heroin use and PO misuse from January 2005 through September 2016. We calculated heroin use and PO misuse prevalence rates, and prevalence rate ratios of Black and Latino OTP entrants compared to White entrants over time. Initially, Black and Latino respondents reported much higher prevalence of heroin use and much lower prevalence of PO misuse than White respondents. Heroin use increased among White respondents, while it decreased among Black respondents, resulting in rates that were no longer significantly different. PO misuse prevalence decreased among White respondents while it increased among Black respondents, but remained significantly higher among White respondents. Heroin use decreased and PO misuse increased among Latino respondents during the late 2000s, but these trends largely reversed in more recent years. Among OTP entrants, racially/ethnically disparate rates of heroin use, and to a lesser extent, of PO misuse have become more similar over time. These trends were stronger when analysis was restricted to OTP entrants who either had no previous OTP history or were younger. To understand potential impacts of interventions to deter PO misuse and to maximize the effectiveness of OTPs it is important to consider potential changes in opioid use across racial/ethnic groups.
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http://dx.doi.org/10.1080/10826084.2017.1334070DOI Listing
January 2018

Recent Overdose Experiences in a Community Sample of Military Veterans Who Use Opioids.

J Drug Issues 2017 Jul 22;47(3):479-491. Epub 2017 Mar 22.

Canandaigua VA Medical Center, NY, USA.

Rising rates of overdose mortality underscore the importance of understanding and preventing overdose. We developed a seven-item scale for the assessment of nonfatal opioid-related overdose experiences, adding items on others' perceptions of whether the participant had overdosed and whether an intervention was attempted to frequently used criteria. We administered the scale to 240 primarily male and minority veterans, recruited using venue-based and chain-referral sampling, who separated from the military post-9/11 and reported current opioid use. The items were internally consistent, and correlated well with overdose risk behaviors ( = .13-.45). The new scale detected overdose events in a significantly higher proportion of participants (36.5%) than that using either self-report criterion (18.2%) or difficulty breathing and losing consciousness criteria (23.8%). These experiences or perceptions should be investigated to inform and better tailor the development of more effective overdose prevention and response programs.
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http://dx.doi.org/10.1177/0022042617701255DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5567991PMC
July 2017

Challenges to Opioid Treatment Programs After Hurricane Sandy: Patient and Provider Perspectives on Preparation, Impact, and Recovery.

Subst Use Misuse 2018 01 15;53(2):206-219. Epub 2017 Mar 15.

a National Development and Research Institutes , New York , New York , USA.

Over 300,000 patients with an opioid use disorder (OUD) receive methadone maintenance therapy from opioid treatment programs (OTPs) in the United States. Large numbers of these attend OTPs located in New York and New Jersey, areas (largely but not exclusively coastal) impacted by Hurricane Sandy (Sandy) on October 29th, 2012. Disruption of methadone dispensing and other services can have severe consequences to patients (and treatment seekers) such as relapse, dropping out of treatment and resumption or increase in HIV/HCV injection risk behaviors. To facilitate OTP preparedness and response, we developed recommendations for OTPs for future emergencies. Using both qualitative and quantitative measures, we obtained data from OTP directors, staff, patients and out-of-treatment persons to learn how OTPs prepared for the impending hurricane, whether recovery efforts were successful, and what impact the hurricane has had. We observed a wide range of preparation and recovery efforts among participating programs. Director, staff, and patient perspectives on programs' responses and storm impact often differed. Triangulated data suggest that program responses were adequate for a majority of patients. For a sizeable minority of patients, program responses were very successful; for at least 20% of the clinics, program planning and responses were inadequate to meet the needs of patients. Among the recommendations made for sustaining continuity of care in future emergencies are: a focus on improving communication, procuring transportation, guest dosing, and take home provisions.
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http://dx.doi.org/10.1080/10826084.2016.1267225DOI Listing
January 2018

Web-Delivered CBT Reduces Heavy Drinking in OEF-OIF Veterans in Primary Care With Symptomatic Substance Use and PTSD.

Behav Ther 2017 03 20;48(2):262-276. Epub 2016 Sep 20.

National Development and Research Institutes, Inc., New York.

Veterans from conflicts such as the wars in Iraq and Afghanistan commonly return with behavioral health problems, including posttraumatic stress disorder (PTSD) and hazardous or harmful substance use. Unfortunately, many veterans experience significant barriers to receiving evidence-based treatment, including poor treatment motivation, concerns about stigma, and lack of access to appropriate care. To address this need, the current study developed and evaluated a web-based self-management intervention based on cognitive behavioral therapy (CBT), targeting PTSD symptoms and hazardous substance use in a group of symptomatic combat veterans enrolled in VA primary care. Veterans with PTSD/subthreshold PTSD and hazardous substance use were randomized to primary care treatment as usual (TAU; n = 81) or to TAU plus a web-based CBT intervention called Thinking Forward (n = 81). Thinking Forward consisted of 24 sections (approximately 20 minutes each), accessible over 12 weeks. Participants completed baseline and 4-, 8-, 12-, 16-, and 24-week follow-up assessments. Three primary outcomes of PTSD, alcohol and other drug use, and quality of life were examined. Significant treatment effects were found for heavy drinking, but not for PTSD or quality of life. The effect of the intervention on heavy drinking was mediated by intervening increases in coping, social support, self-efficacy, and hope for the future. These results demonstrate the promise of a web-based, self-management intervention for difficult-to-engage OEF/OIF veterans with behavioral health and substance use concerns.
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http://dx.doi.org/10.1016/j.beth.2016.09.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5345259PMC
March 2017

Development of an opioid-related Overdose Risk Behavior Scale (ORBS).

Subst Abus 2017 Jul-Sep;38(3):239-244. Epub 2017 Jan 23.

a National Development and Research Institutes, Inc. , New York , New York , USA.

Background: Drug overdose has emerged as the leading cause of injury-related death in the United States, driven by prescription opioid (PO) misuse, polysubstance use, and use of heroin. To better understand opioid-related overdose risks that may change over time and across populations, there is a need for a more comprehensive assessment of related risk behaviors. Drawing on existing research, formative interviews, and discussions with community and scientific advisors an opioid-related Overdose Risk Behavior Scale (ORBS) was developed.

Methods: Military veterans reporting any use of heroin or POs in the past month were enrolled using venue-based and chain referral recruitment. The final scale consisted of 25 items grouped into 5 subscales eliciting the number of days in the past 30 during which the participant engaged in each behavior. Internal reliability, test-retest reliability and criterion validity were assessed using Cronbach's alpha, intraclass correlations (ICC) and Pearson's correlations with indicators of having overdosed during the past 30 days, respectivelyInternal reliability, test-retest reliability and criterion validity were assessed using Cronbach's alpha, intraclass correlations (ICC) and Pearson's correlations with indicators of having overdosed during the past 30 days, respectively.

Results: Data for 220 veterans were analyzed. The 5 subscales-(A) Adherence to Opioid Dosage and Therapeutic Purposes; (B) Alternative Methods of Opioid Administration; (C) Solitary Opioid Use; (D) Use of Nonprescribed Overdose-associated Drugs; and (E) Concurrent Use of POs, Other Psychoactive Drugs and Alcohol-generally showed good internal reliability (alpha range = 0.61 to 0.88), test-retest reliability (ICC range = 0.81 to 0.90), and criterion validity (r range = 0.22 to 0.66). The subscales were internally consistent with each other (alpha = 0.84). The scale mean had an ICC value of 0.99, and correlations with validators ranged from 0.44 to 0.56.

Conclusions: These results constitute preliminary evidence for the reliability and validity of the new scale. If further validated, it could help improve overdose prevention and response research and could help improve the precision of overdose education and prevention efforts.
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http://dx.doi.org/10.1080/08897077.2017.1282914DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5522769PMC
May 2018

Abuse and Diversion of Immediate Release Opioid Analgesics as Compared to Extended Release Formulations in the United States.

PLoS One 2016 9;11(12):e0167499. Epub 2016 Dec 9.

Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, Denver, Colorado, United States of America.

Background: Therapeutic use and abuse of prescription opioids in the United States increased substantially between 1990 and 2010. The Centers for Disease Control estimated deaths related to pharmaceutical opioids reached nearly 19,000 in 2014. Of prescription opioids sold, 10% are extended release (ER) and 90% immediate release (IR). However, most regulations and interventions have focused on decreasing ER abuse. Our objective was to compare rates of abuse and diversion of ER and IR opioid analgesics over time using multiple surveillance programs.

Methods: Rates of abuse and diversion of ER and IR opioid formulations were compared using data from four surveillance programs in the Researched Abuse, Diversion and Addiction Related Surveillance (RADARS®) System. Data were evaluated from 2009 through 2015, and Poisson regression used to compare IR and ER opioid cases over time.

Results: From 2009 to 2015, IR opioids were prescribed at a rate 12 to 16 times higher than ER. In the Poison Center Program, population-adjusted rates of Intentional Abuse for IR were 4.6 fold higher than ER opioids (p<0.001). In the Drug Diversion Program, population-adjusted rates of diversion were 6.1 fold higher for IR than ER opioids (p<0.001). In the Opioid Treatment Program, population-adjusted rates of endorsements for abuse were 1.6 fold higher for IR opioids than ER (p = 0.002). In the Survey of Key Informants' Patients Program, population-adjusted rates of endorsements for abuse were 1.5 fold higher for IR opioids than ER (p<0.001).

Conclusions: Between 2009 and 2015, IR opioids were prescribed at a much higher rate than ER opioids. Results from four surveillance programs show population-adjusted rates of prescription opioid abuse were markedly higher for IR than ER medications. For the greatest public health benefit, future interventions to decrease prescription opioid abuse should focus on both IR and ER formulations.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0167499PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5147916PMC
July 2017

Sustained reduction of diversion and abuse after introduction of an abuse deterrent formulation of extended release oxycodone.

Drug Alcohol Depend 2016 Nov 3;168:219-229. Epub 2016 Oct 3.

Rocky Mountain Poison and Drug Center, 777 Bannock Street, Mailcode 0180, Denver, CO, 80204, USA. Electronic address:

Background: The development of abuse deterrent formulations is one strategy for reducing prescription opioid misuse and abuse. A putative abuse deterrent formulation of oxycodone extended release (OxyContin) was introduced in 2010. Early reports demonstrated reduced abuse and diversion, however, an analysis of social media found 32 feasible methods to circumvent the abuse deterrent mechanism. We measured trends of diversion, abuse and street price of OxyContin to assess the durability of the initial reduction in abuse.

Methods: Data from the Poison Center Program, Drug Diversion Program, Opioid Treatment Program, Survey of Key Informant Patients Program and StreetRx program of the Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS) System were used. The average quarterly rates of abuse and diversion for OxyContin were compared from before reformulation to the rate in second quarter 2015. Rates were adjusted for population using US Census data and drug availability.

Results: OxyContin abuse and diversion declined significantly each quarter after reformulation and persisted for 5 years. The rate of abuse of other opioid analgesics increased initially and then decreased, but to lesser extent than OxyContin. Abuse through both oral and non-oral routes of self-administration declined following the reformulation. The geometric mean difference in the street price of reformulated OxyContin was 36% lower than the reformulated product in the year after reformulation.

Discussion: Despite methods to circumvent the abuse deterrent mechanism, abuse and diversion of OxyContin decreased promptly following the introduction of a crush- and solubility- resistant formulation and continued to decrease over the subsequent 5 years.
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http://dx.doi.org/10.1016/j.drugalcdep.2016.09.018DOI Listing
November 2016

Patient vs provider reports of aberrant medication-taking behavior among opioid-treated patients with chronic pain who report misusing opioid medication.

Pain 2016 08;157(8):1791-1798

National Development and Research Institutes, Inc, New York, NY, USA.

During long-term opioid therapy for chronic noncancer pain, monitoring medication adherence of patients with a history of aberrant opioid medication-taking behaviors (AMTB) is an essential practice. There is limited research, however, into the concordance among existing monitoring tools of self-report, physician report, and biofluid screening. This study examined associations among patient and provider assessments of AMTB and urine drug screening using data from a randomized trial of a cognitive-behavioral intervention designed to improve medication adherence and pain-related outcomes among 110 opioid-treated patients with chronic pain who screened positive for AMTB and were enrolled in a pain program. Providers completed the Aberrant Behavior Checklist (ABC) and patients completed the Current Opioid Misuse Measure (COMM) and the Chemical Coping Inventory (CCI). In multivariate analyses, ABC scores were compared with COMM and CCI scores, while controlling for demographics and established risk factors for AMTB, such as pain severity. Based on clinical cutoffs, 84% of patients reported clinically significant levels of AMTB and providers rated 36% of patients at elevated levels. Provider reports of AMTB were not correlated with COMM or CCI scores. However, the ABC ratings of experienced providers (nurse practitioners/attending physicians) were higher than those of less experienced providers (fellows) and were correlated with CCI scores and risk factors for AMTB. Associations between patient- and provider-reported AMTB and urine drug screening results were low and largely nonsignificant. In conclusion, concordance between patient and provider reports of AMTB among patients with chronic pain prescribed opioid medication varied by provider level of training.
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http://dx.doi.org/10.1097/j.pain.0000000000000583DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4949142PMC
August 2016

A Web-Based Self-Management Program for Recent Combat Veterans With PTSD and Substance Misuse: Program Development and Veteran Feedback.

Cogn Behav Pract 2015 Aug;22(3):345-358

National Development Research Institute.

Combat veterans from the wars in Iraq and Afghanistan commonly experience posttraumatic stress disorder (PTSD) and substance use problems. In addition, these veterans often report significant barriers to receiving evidence-based mental health and substance use care, such as individual beliefs that treatment will be unhelpful, inconvenient, or that they should be able to handle their problems on their own. To increase access to treatment for this underserved population, a Web-based patient self-management program that teaches cognitive-behavioral therapy (CBT) skills to manage PTSD symptoms and substance misuse was developed. This paper describes and provides results from an iterative, multistage process for developing the Web-based program and seeks to inform clinicians in the field about the preferences of veterans for using a Web-based CBT program. Systematic feedback was gathered from (a) three expert clinicians in the field, (b) focus groups of combat veterans ( = 18), and (c) individual feedback sessions with combat veterans ( = 34). Clinician feedback led to the incorporation of motivational strategies to increase participant engagement and an optional module that guides written trauma exposure work. Focus group feedback guided the research team to frame the program in a strength-based approach and allows for maximum flexibility, adaptability, interactivity, and privacy for veterans. In individual feedback sessions, veterans generally found the program likable, easy to use, and relevant to their experiences; critiques of the program led to revised content meant to increase clarity and participant interest. Our findings provide specific guidance for clinicians who are interested in developing or providing technology-based treatment, including the need to gather feedback from an intervention's target audience when adapting a psychotherapeutic intervention and that the treatment must be highly interactive and private to engage clients.
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http://dx.doi.org/10.1016/j.cbpra.2014.03.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4480783PMC
August 2015

Conducting Rapid Street Assessment of Drug Users in New York City Using Oral Fluid and Brief Interviews: A Feasibility Study.

J Addict Dis 2015 ;34(2-3):185-97

a National Development and Research Institutes Inc. , New York City , New York , USA.

This study piloted the feasibility of rapidly collecting both self-reports of drug use and saliva specimens for drug toxicology in field settings. The use of oral fluid collection devices to supplement self-reports is unproven in street settings and may pose challenges for field research. Sixty adults who identified as recent illicit drug users were recruited in public settings in New York City and were asked to complete a brief drug screening inventory and provided saliva specimens. Descriptive findings are detailed along with critical best research practices and limitations that provide important directions for researchers looking to employ both toxicology and self-report in rapid field recruitment designs.
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http://dx.doi.org/10.1080/10550887.2015.1059118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4824185PMC
May 2016

Characteristics of Non-Opioid Substance Misusers Among Patients Enrolling in Opioid Treatment Programs: A Latent Class Analysis.

J Addict Dis 2015 ;34(2-3):141-50

a The Institute for Treatment and Services Research, National Development & Research Institutes Inc. (NDRI), New York , New York , USA.

Using latent class analysis, this study examined the pattern of non-opioid substance misuse among 19,101 enrollees into 85 opioid treatment programs. The most frequent non-opioid drugs were cannabis, anti-anxiety medications, and cocaine. Four non-opioid drug use latent classes were identified: low-use (73%), prescription drug use (16%), marijuana and cocaine use (8.5%), and poly-drug use (2.5%). Compared to the low-use class, participants in the other classes were more likely to be female, Caucasian, use tobacco, have chronic pain, and use prescription opioids either with or without heroin. Recognition of characteristics derived from these classes can improve opioid treatment program services.
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http://dx.doi.org/10.1080/10550887.2015.1059226DOI Listing
May 2016

Characteristics of Non-Opioid Substance Misusers Among Patients Enrolling in Opioid Treatment Programs: A Latent Class Analysis.

J Addict Dis 2015 ;34(2-3):141-50

a The Institute for Treatment and Services Research, National Development & Research Institutes Inc. (NDRI), New York , New York , USA.

Using latent class analysis, this study examined the pattern of non-opioid substance misuse among 19,101 enrollees into 85 opioid treatment programs. The most frequent non-opioid drugs were cannabis, anti-anxiety medications, and cocaine. Four non-opioid drug use latent classes were identified: low-use (73%), prescription drug use (16%), marijuana and cocaine use (8.5%), and poly-drug use (2.5%). Compared to the low-use class, participants in the other classes were more likely to be female, Caucasian, use tobacco, have chronic pain, and use prescription opioids either with or without heroin. Recognition of characteristics derived from these classes can improve opioid treatment program services.
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http://dx.doi.org/10.1080/10550887.2015.1059226DOI Listing
May 2016

Risk factors for medication non-adherence among psychiatric patients with substance misuse histories.

Ment Health Subst Use 2014 Nov;7(4):381-390

National Development and Research Institutes, New York, New York, 10010.

Medication non-adherence among psychiatric patients is known to be associated with poorer treatment outcomes. The study examined a comprehensive set of modifiable risk factors for non-adherence in a theoretical framework among a diverse, high risk sample of psychiatric patients with substance misuse histories (N=299). Medication side effects and excessive alcohol use were related to lower medication adherence and higher motivation for mental health treatment and recovery support were related to greater adherence. The results suggest that a multifaceted model for intervention to increase psychiatric medication adherence should be developed and tested.
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http://dx.doi.org/10.1080/17523281.2013.839574DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4191826PMC
November 2014

Gender abuse, depressive symptoms, and substance use among transgender women: a 3-year prospective study.

Am J Public Health 2014 Nov 11;104(11):2199-206. Epub 2014 Sep 11.

At the time of this research, Walter Bockting was with the Division of Gender, Sexuality and Health, New York State Psychiatric Institute/Columbia University, New York, NY. Larry Nuttbrock, Andrew Rosenblum, Mona Mason, Monica Macri, and Jeffrey Becker were with the National Development and Research Institutes, New York, NY. Sel Hwahng is with Columbia University.

Objectives: We examined the effects of gender abuse (enacted stigma), depressive symptoms, and demographic, economic, and lifestyle factors on substance use among transgender women.

Methods: We conducted a 3-year prospective study (December 2004 to September 2007) of 230 transgender women aged 19 to 59 years from the New York Metropolitan Area. Statistical techniques included generalized estimating equations with logistic and linear regression links.

Results: Six-month prevalence of any substance use at baseline was 76.2%. Across assessment points, gender abuse was associated with alcohol, cannabis, cocaine, or any substance use during the previous 6 months, the number of days these substances were used during the previous month, and the number of substances used. Additional modeling associated changes in gender abuse with changes in substance use across time. Associations of gender abuse and substance use were mediated 55% by depressive symptoms. Positive associations of employment income, sex work, transgender identity, and hormone therapy with substance use were mediated 19% to 42% by gender abuse.

Conclusions: Gender abuse, in conjunction with depressive symptoms, is a pervasive and moderately strong risk factor for substance use among transgender women. Improved substance abuse treatment is sorely needed for this population.
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http://dx.doi.org/10.2105/AJPH.2014.302106DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4202966PMC
November 2014

Abuse and diversion of buprenorphine sublingual tablets and film.

J Subst Abuse Treat 2014 Jul 3;47(1):27-34. Epub 2014 Mar 3.

Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, 777 Bannock Street, MC 0180, Denver, CO, 80204, USA. Electronic address:

Buprenorphine abuse is common worldwide. Rates of abuse and diversion of three sublingual buprenorphine formulations (single ingredient tablets; naloxone combination tablets and film) were compared. Data were obtained from the Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS) System Poison Center, Drug Diversion, Opioid Treatment (OTP), Survey of Key Informants' Patients (SKIP), and College Survey Programs through December 2012. To control for drug availability, event ratios (rates) were calculated quarterly, based on the number of patients filling prescriptions for each formulation ("unique recipients of a dispensed drug," URDD) and averaged and compared using negative binomial regression. Abuse rates in the OTP, SKIP, and College Survey Programs were greatest for single ingredient tablets, and abuse rates in the Poison Center Program and illicit diversion rates were greatest for the combination tablets. Combination film rates were significantly less than rates for either tablet formulation in all programs. No geographic pattern could be discerned.
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http://dx.doi.org/10.1016/j.jsat.2014.02.003DOI Listing
July 2014