Publications by authors named "Benjamin J Oldfield"

37 Publications

Social Determinants and COVID-19 in a Community Health Center Cohort.

J Immigr Minor Health 2021 Nov 30. Epub 2021 Nov 30.

Fair Haven Community Health Care, 374 Grand Avenue, New Haven, CT, 06513, USA.

Associations between social determinants of health (SDOH), demographic factors including preferred language, and SARS-CoV-2 detection are not clear. We conducted a retrospective cohort study among those seeking testing for SARS-CoV-2 at a multi-site, urban community health center. Logistic regression and exact matching methods were used to identify independent predictors of SARS-CoV-2 detection among demographic, SDOH, and neighborhood-level variables. Of 1,361 included individuals, SARS-CoV-2 was detected among 266 (19.5%). Logistic regression demonstrated that SARS-CoV-2 detection was less likely in White participants relative to Hispanic participants (adjusted odds ratio [aOR] 0.18, 95% confidence interval [CI] 0.05-0.46). and more likely in patients who prefer Spanish relative to those that prefer English (aOR 2.04, 95% CI 1.43-2.96). No observed SDOH predicted SARS-CoV-2 detection in adjusted models. A robustness analysis using a matched subset of the study sample produced findings similar to those in the main analysis. Preferring to receive care in Spanish is an independent predictor of SARS-CoV-2 detection in a community health center cohort.
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http://dx.doi.org/10.1007/s10903-021-01320-6DOI Listing
November 2021

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

AIDS Behav 2021 Sep 8. Epub 2021 Sep 8.

Center for Research on Health Care, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.

Although opioid agonist therapy (OAT) is associated with positive health outcomes, including improved HIV management, long-term retention in OAT remains low among patients with opioid use disorder (OUD). Using data from the Veterans Aging Cohort Study (VACS), we identify variables independently associated with OAT retention overall and by HIV status. Among 7,334 patients with OUD, 13.7% initiated OAT, and 27.8% were retained 12-months later. Likelihood of initiation and retention did not vary by HIV status. Variables associated with improved likelihood of retention included receiving buprenorphine (relative to methadone), receiving both buprenorphine and methadone at some point over the 12-month period, or diagnosis of HCV. History of homelessness was associated with a lower likelihood of retention. Predictors of retention were largely distinct between patients with HIV and patients without HIV. Findings highlight the need for clinical, systems, and research initiatives to better understand and improve OAT retention.
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http://dx.doi.org/10.1007/s10461-021-03452-0DOI Listing
September 2021

Demographic and Clinical Correlates of the Cost of Potentially Preventable Hospital Encounters in a Community Health Center Cohort.

Popul Health Manag 2021 Aug 31. Epub 2021 Aug 31.

Fair Haven Community Health Care, New Haven, Connecticut, USA.

This study sought to describe the cost of hospital care for ambulatory care-sensitive conditions (ACSCs) and to identify independent predictors of high-cost hospital encounters related to an ACSC among an urban community health center cohort. The authors conducted a retrospective cohort study of individuals engaged in care in a large, multisite community health center in New Haven, Connecticut, with any Medicaid claims between June 1, 2018 and March 31, 2020. Prevention Quality Indicators of the Agency for Healthcare Research and Quality were used to identify ACSCs. The primary outcome was a high-cost episode of care for an ACSC (in the top quartile within a 7-day period). Multivariable logistic regression was used to identify independent predictors of high-cost episodes by ACSCs among sociodemographic and clinical variables as covariates. Among 8019 included individuals, a total of 751 episodes of hospital care involving ACSCs were identified. The median episode cost was $793, with the highest median cost of care related to heart failure ($4992), followed by diabetes ($1162), and chronic obstructive pulmonary disease ($1141). In adjusted analyses, male gender ( < 0.01), increasing age ( = 0.02), and ACSC type ( < 0.01) were associated with higher costs of care; race/ethnicity was not. Community health centers in urban settings seeking to reduce the cost of care of potentially preventable hospitalizations may target disease-/condition-specific groups, particularly individuals of increasing age with congestive heart failure and diabetes mellitus. These findings may inform return-on-investment calculations for care coordination and other enabling services programming.
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http://dx.doi.org/10.1089/pop.2021.0169DOI Listing
August 2021

Sociodemographic and clinical correlates of gabapentin receipt with and without opioids among a national cohort of patients with HIV.

AIDS Care 2021 Jun 11:1-11. Epub 2021 Jun 11.

Yale School of Medicine, New Haven, CT, USA.

Gabapentin is commonly prescribed for chronic pain, including to patients with HIV (PWH). There is growing concern regarding gabapentin's potential for harm, particularly in combination with opioids. Among PWH, we examined factors associated with higher doses of gabapentin receipt and determined if receipt varied by opioid use. We examined data from the Veterans Aging Cohort Study, a national prospective cohort including PWH, from 2002 through 2017. Covariates included prescribed opioid dose, self-reported past year opioid use, and other sociodemographic and clinical variables. We used multinomial logistic regression to determine independent predictors of gabapentin receipt. Among 3,702 PWH, 902 (24%) received any gabapentin during the study period at a mean daily dose of 1,469 mg. In the multinomial model, high-dose gabapentin receipt was associated with high-dose benzodiazepine receipt (adjusted odds ratio [aOR], 95% confidence interval [CI]= 1.53, [1.03-2.27]), pain interference (1.65 [1.39-1.95]), and hand or foot pain (1.81, [1.45-2.26]). High-dose gabapentin receipt was associated with prescribed high-dose opioids receipt (2.66 [1.95-3.62]) but not self-reported opioid use (1.03 [0.89-1.21]). PWH prescribed gabapentin at higher doses are more likely to receive high-dose opioids and high-dose benzodiazepines, raising safety concerns.
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http://dx.doi.org/10.1080/09540121.2021.1939851DOI Listing
June 2021

Addiction Screening-The A Star Is Born Movie Series and Destigmatization of Substance Use Disorders.

JAMA 2021 Mar;325(10):915-917

Department of Medicine, Yale School of Medicine, New Haven, Connecticut.

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http://dx.doi.org/10.1001/jama.2020.25256DOI Listing
March 2021

Readiness to Provide Medications for Addiction Treatment in HIV Clinics: A Multisite Mixed-Methods Formative Evaluation.

J Acquir Immune Defic Syndr 2021 07;87(3):959-970

Program in Addiction Medicine, Yale School of Medicine, New Haven, CT.

Background: We sought to characterize readiness, barriers to, and facilitators of providing medications for addiction treatment (MAT) in HIV clinics.

Setting: Four HIV clinics in the northeastern United States.

Methods: Mixed-methods formative evaluation conducted June 2017-February 2019. Surveys assessed readiness [visual analog scale, less ready (0-<7) vs. more ready (≥7-10)]; evidence and context ratings for MAT provision; and preferred addiction treatment model. A subset (n = 37) participated in focus groups.

Results: Among 71 survey respondents (48% prescribers), the proportion more ready to provide addiction treatment medications varied across substances [tobacco (76%), opioid (61%), and alcohol (49%) treatment medications (P values < 0.05)]. Evidence subscale scores were higher for those more ready to provide tobacco [median (interquartile range) = 4.0 (4.0, 5.0) vs. 4.0 (3.0, 4.0), P = 0.008] treatment medications, but not significantly different for opioid [5.0 (4.0, 5.0) vs. 4.0 (4.0, 5.0), P = 0.11] and alcohol [4.0 (3.0, 5.0) vs. 4.0 (3.0, 4.0), P = 0.42] treatment medications. Median context subscale scores ranged from 3.3 to 4.0 and generally did not vary by readiness status (P values > 0.05). Most favored integrating MAT into HIV care but preferred models differed across substances. Barriers to MAT included identification of treatment-eligible patients, variable experiences with MAT and perceived medication complexity, perceived need for robust behavioral services, and inconsistent availability of on-site specialists. Facilitators included knowledge of adverse health consequences of opioid and tobacco use, local champions, focus on quality improvement, and multidisciplinary teamwork.

Conclusions: Efforts to implement MAT in HIV clinics should address both gaps in perspectives regarding the evidence for MAT and contextual factors and may require substance-specific models.
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http://dx.doi.org/10.1097/QAI.0000000000002666DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8192340PMC
July 2021

Long-term Patterns of Self-reported Opioid Use, VACS Index, and Mortality Among People with HIV Engaged in Care.

AIDS Behav 2021 Sep 10;25(9):2951-2962. Epub 2021 Feb 10.

Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.

Longitudinal analyses of opioid use and overall disease severity among people with HIV (PWH) are lacking. We used joint-trajectory and Cox proportional hazard modeling to examine the relationship between self-reported opioid use and the Veterans Aging Cohort Study (VACS) Index 2.0, a validated measure of disease severity and mortality, among PWH engaged in care. Using data from 2002 and 2018, trajectory modeling classified 20% of 3658 PWH in low (i.e., lower risk of mortality), 40% in moderate, 28% in high, and 12% in extremely high VACS Index trajectories. Compared to those with moderate VACS Index trajectory, PWH with an extremely high trajectory were more likely to have high, then de-escalating opioid use (adjusted odds ratio [AOR], 95% confidence interval [CI] 5·17 [3·19-8·37]) versus stable, infrequent use. PWH who report high frequency opioid use have increased disease severity and mortality risk over time, even when frequency of opioid use de-escalates.
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http://dx.doi.org/10.1007/s10461-021-03162-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8442670PMC
September 2021

Addressing Unhealthy Alcohol Use and the HIV Pre-exposure Prophylaxis Care Continuum in Primary Care: A Scoping Review.

AIDS Behav 2021 Jun 20;25(6):1777-1789. Epub 2020 Nov 20.

Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, USA.

Individuals with unhealthy alcohol use are at increased risk for HIV acquisition and may benefit from receiving HIV pre-exposure prophylaxis (PrEP) in primary care settings. To date, literature synthesizing what is known about the impact of unhealthy alcohol use on the PrEP care continuum with a focus on considerations for primary care is lacking. We searched OVID Medline and Web of Science from inception through March 19, 2020, to examine the extent, range, and nature of research on PrEP delivery among individuals with unhealthy alcohol use in primary care settings. We identified barriers and opportunities at each step along the PrEP care continuum, including for specific populations: adolescents, people who inject drugs, sex workers, and transgender persons. Future research should focus on identification of candidate patients, opportunities for patient engagement in novel settings, PrEP implementation strategies, and stigma reduction.
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http://dx.doi.org/10.1007/s10461-020-03107-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8084877PMC
June 2021

Improving Guideline Adherence for Opioid Prescribing in Community Health Centers.

Pain Med 2020 09;21(9):1739-1741

Yale School of Medicine, New Haven, Connecticut.

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http://dx.doi.org/10.1093/pm/pnaa247DOI Listing
September 2020

Construction of a Pediatrics Risk Score to Predict High Health Care Costs Among a Community Health Center Cohort.

Popul Health Manag 2021 06 7;24(3):345-352. Epub 2020 Jul 7.

Fair Haven Community Health Care, New Haven, Connecticut, USA.

Risk-stratification strategies are needed for ambulatory pediatric populations. The authors sought to develop age-specific risk scores that predict high health care costs among an urban population. A retrospective cohort study was performed of children ages 1-18 years who received care at Fair Haven Community Health Care (FHCHC), a community health center in New Haven, Connecticut. Cost was estimated from charges in the electronic health record (EHR), which is shared with the only hospital system in the city. Using multivariable logistic regression models, independent predictors of being in the top decile of total charges during the 2017 calendar year were identified, drawing from covariates collected from the EHR prior to 2017. Random forest modeling was used to verify the feature importance of significant covariates and model performance from 2017 cost data were compared to those using 2018 cost data. Regression models were used to construct age-specific nomograms to predict cost. Among 8960 children who received care at FHCHC in the 18 months prior to 2017, covariate frequencies clustered in age groups 1-5 years, 6-11 years, and 12-18 years, so 3 age-specific models were constructed. Prior utilization variables predicted future costs, as did younger children who received specialty care and older children with behavioral health diagnoses. Final models for each age group had C statistics ≥0.68 using both 2017 and 2018 cost data. Prediction models can draw from elements accessible in the EHR to predict cost of ambulatory pediatric patients. Strategies to impact utilization among high-risk children are needed.
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http://dx.doi.org/10.1089/pop.2020.0035DOI Listing
June 2021

Inpatient adoption of medications for alcohol use disorder: A mixed-methods formative evaluation involving key stakeholders.

Drug Alcohol Depend 2020 Jun 2;213:108090. Epub 2020 Jun 2.

Department of Internal Medicine, Yale School of Medicine, Yale University, 367 Cedar Street, New Haven, CT, United States.

Background: Although the inpatient setting presents an important opportunity for medications for alcohol use disorder (MAUD) adoption, this infrequently occurs. We aimed to develop a comprehensive understanding of barriers and facilitators of inpatient MAUD adoption.

Methods: A convergent mixed-method study conducted from April to September 2018 of non-prescribing (registered nurse, pharmacist, and social work) and prescribing (physician or advanced practice provider hospitalist, general internist, and psychiatrist) professionals at a large urban academic medical center. Survey assessed organizational readiness to adopt MAUD and focus groups guided by the Consolidated Framework for Implementation Research (CFIR) analyzed using directed content analysis.

Results: Fifty-seven participants completed surveys and one of seven focus groups. Health professionals perceived clinical evidence (mean 4.0, 95 % confidence interval [CI]: 3.9, 4.2) as supportive and patient preferences (mean 3.4, 95 % CI: 3.2, 3.6) and availability of resources (mean 3.1, 95 % CI: 2.8, 3.3) as less supportive of MAUD adoption. Stakeholders identified barriers across CFIR constructs; 1) Intervention characteristics: limited knowledge of MAUD effectiveness and concerns about side effects, 2) Outer setting: perceived patient vulnerability to care interruptions and a lack of external incentives, 3) Inner setting: a lack of organizational prioritization, and 4) Characteristics of individuals: stigma of people with AUD. Facilitators included: 1) Intervention characteristics: adaptation of workflows and 2) Characteristics of individuals: harm reduction as treatment goal.

Conclusions: This study identified multiple intersecting barriers and facilitators of inpatient MAUD adoption. Implementation interventions should prioritize strategies that increase health professional knowledge of MAUD and organizational prioritization of treating AUD.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7375447PMC
June 2020

Trajectories of Self-Reported Opioid Use Among Patients With HIV Engaged in Care: Results From a National Cohort Study.

J Acquir Immune Defic Syndr 2020 05;84(1):26-36

Department of Epidemiology, Brown University School of Public Health, Providence, RI.

Background: No prior studies have characterized long-term patterns of opioid use regardless of source or reason for use among patients with HIV (PWH). We sought to identify trajectories of self-reported opioid use and their correlates among a national sample of PWH engaged in care.

Setting: Veterans Aging Cohort Study, a prospective cohort including PWH receiving care at 8 US Veterans Health Administration (VA) sites.

Methods: Between 2002 and 2018, we assessed past year opioid use frequency based on self-reported "prescription painkillers" and/or heroin use at baseline and follow-up. We used group-based trajectory models to identify opioid use trajectories and multinomial logistic regression to determine baseline factors independently associated with escalating opioid use compared to stable, infrequent use.

Results: Among 3702 PWH, we identified 4 opioid use trajectories: (1) no lifetime use (25%); (2) stable, infrequent use (58%); (3) escalating use (7%); and (4) de-escalating use (11%). In bivariate analysis, anxiety; pain interference; prescribed opioids, benzodiazepines and gabapentinoids; and marijuana use were associated with escalating opioid group membership compared to stable, infrequent use. In multivariable analysis, illness severity, pain interference, receipt of prescribed benzodiazepine medications, and marijuana use were associated with escalating opioid group membership compared to stable, infrequent use.

Conclusion: Among PWH engaged in VA care, 1 in 15 reported escalating opioid use. Future research is needed to understand the impact of psychoactive medications and marijuana use on opioid use and whether enhanced uptake of evidence-based treatment of pain and psychiatric symptoms can prevent escalating use among PWH.
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http://dx.doi.org/10.1097/QAI.0000000000002310DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7147724PMC
May 2020

Update on the Feasibility, Acceptability, and Impact of Group Well-Child Care.

Acad Pediatr 2020 08 28;20(6):731-732. Epub 2020 Feb 28.

University of Washington School of Medicine (TR Coker), Seattle, Wash; Seattle Children's Research Institute (TR Coker), Seattle, Wash.

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http://dx.doi.org/10.1016/j.acap.2020.02.029DOI Listing
August 2020

Screening for Social Determinants of Health Among Children: Patients' Preferences for Receiving Information to Meet Social Needs and a Comparison of Screening Instruments.

Popul Health Manag 2021 02 25;24(1):141-148. Epub 2020 Feb 25.

Fair Haven Community Health Care, New Haven, Connecticut, USA.

To characterize optimal strategies for screening for social determinants of health (SDOH) among children, the authors performed a cross-sectional study of parents and adolescents ages ≥13 years in a community health center. Participants were queried about how they prefer to receive information about social needs resources and 2 screening instruments were compared: Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education (WE CARE) and Accountable Health Communities (AHC). In July 2019, 154 parents and 21 adolescents were surveyed. Surveys were administered via tablet and required 5.6 minutes (standard deviation [SD] 3.9 minutes) for parents and 3.9 minutes (SD 1.4 minutes) for adolescents to complete. Parents identified technology (text message, email) and informational printouts as preferred mechanisms for information receipt (58% and 32% of participants, respectively); adolescents preferred text message (57%) and printouts (19%). Few (<10% overall) preferred in-person consultation with a care coordinator. Adolescent/parent pairs (n = 19 pairs) agreed, on average across SDOH, 82% of the time for WE CARE and 85% for AHC. AHC elicited more positive screens than WE CARE for housing insecurity (12% of parents versus 7%) and food insecurity (47% versus 16%) but fewer positive screens than WE CARE for difficulties paying for utilities (27% versus 39%). Routine screening for SDOH in children requires 2-3 minutes per screening instrument. Screening can target parents of young children and either adolescents themselves or their parents. Families prefer to receive information about meeting social needs via technologically-based methods as opposed to in-person consultation with enabling services providers.
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http://dx.doi.org/10.1089/pop.2019.0211DOI Listing
February 2021

The Association of Loneliness and Non-prescribed Opioid Use in Patients With Opioid Use Disorder.

J Addict Med 2020 12;14(6):489-493

Fair Haven Community Health Care (JM, CBW, BJO, DCJ, DPO).

Objective: To investigate the relationship between loneliness and non-prescribed opioid use in patients diagnosed with opioid use disorder (OUD).

Methods: This was a cohort study conducted at a federally qualified health center (FQHC) in New Haven, CT. Patients who were treated for OUD by health center providers and prescribed buprenorphine were eligible. Participants were asked to complete the UCLA-Loneliness Scale Version 3. From the electronic medical record, we collected patient demographic and clinical characteristics as well as the results of biological fluid testing obtained throughout their treatment course since entry into care. Multivariable logistic regression was performed to identify independent predictors of the detection of non-prescribed opioids within biological fluid.

Results: Of the 82 patients enrolled in the study, 33 (40.3%) of the participants had at least 1 biological fluid test positive for non-prescribed opioids after maintenance onto buprenorphine treatment. A higher loneliness score was associated with increased odds of non-prescribed opioids (adjusted odds ratio 1.16; 95% confidence interval 1.06-1.27). Patient age, the number of problems on the problems list, and cocaine use were also positively associated with the presence of non-prescribed opioids whereas having diabetes was negatively associated.

Conclusions: Among the individuals being treated with buprenorphine for OUD, loneliness may be a risk factor for the use of non-prescribed opioids or treatment failure.
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http://dx.doi.org/10.1097/ADM.0000000000000629DOI Listing
December 2020

Guidance for Writing Case Reports in Addiction Medicine.

J Addict Med 2020 Mar/Apr;14(2):89-92

Departments of Medicine and Pediatrics, Yale School of Medicine, New Haven, CT (BJO); Fair Haven Community Health Care, New Haven, CT (BJO); Clinical Addiction Research and Education (CARE) Unit, Section of General Internal, Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical, Boston, MA (RS); Department of Community Health Sciences, Boston University School of Public Health, Boston, MA (RS).

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http://dx.doi.org/10.1097/ADM.0000000000000632DOI Listing
June 2021

Predictors of initiation of and retention on medications for alcohol use disorder among people living with and without HIV.

J Subst Abuse Treat 2020 02 6;109:14-22. Epub 2019 Nov 6.

Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America.

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).
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http://dx.doi.org/10.1016/j.jsat.2019.11.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6982467PMC
February 2020

Opioids Are Not Better than Non-opioid Pain Medications for Chronic Back, Hip, or Knee Pain.

J Gen Intern Med 2019 09;34(9):1854-1856

Department of Medicine, Yale School of Medicine, New Haven, CT, USA.

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http://dx.doi.org/10.1007/s11606-019-05016-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6712132PMC
September 2019

Group Well-Child Care and Health Services Utilization: A Bilingual Qualitative Analysis of Parents' Perspectives.

Matern Child Health J 2019 Nov;23(11):1482-1488

Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA.

Objective Alternative primary care structures such as group well-child care (GWCC) may enhance care for families, particularly those subject to structural vulnerabilities such as poverty or restrictive immigration policies. The purpose of this study was to characterize how group dynamics in GWCC impact the perceptions of low-income, immigrant, and/or Spanish-speaking parents of health services. Methods Using Spanish and English interview guides that were conceptually identical, we conducted semi-structured interviews with parents who elected to participate in GWCC at an urban academic center. We drew from directed content analysis, grounded theoretically in the Andersen model of health services utilization. Modeling a bilingual, multicultural analytic strategy, we preserved the narrative of participants in the source language through all stages of analysis. Results From March through August 2017, we interviewed 22 caregivers in their preferred language. Most (82%) were mothers and half spoke Spanish only. Three themes emerged: participants perceived that (1) GWCC facilitates their and their peers' discovery of inherent expertise, which moderates parents' use of health services, (2) GWCC encourages rearrangements of hierarchies of knowledge, professional roles and genders; and (3) in the context of structural vulnerabilities, relationships formed in GWCC facilitate collective efficacy. Conclusions for Practice By considering the self and peer as sources of health-related expertise, GWCC may extend current theoretical models of health services utilization. GWCC provides opportunities to impact health services utilization among families subject to structural vulnerabilities.
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http://dx.doi.org/10.1007/s10995-019-02798-1DOI Listing
November 2019

News Media Recommendations for Opioid Disposal: Keeping Flush with the Guidelines?

Pain Med 2019 09;20(9):1645-1646

Department of Medicine, Yale School of Medicine, New Haven, Connecticut.

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http://dx.doi.org/10.1093/pm/pnz141DOI Listing
September 2019

Opioid overdose prevention education for medical students: Adopting harm reduction into mandatory clerkship curricula.

Subst Abus 2020 18;41(1):29-34. Epub 2019 Jun 18.

Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA.

Opioid overdose deaths constitute a public health crisis in the United States. Strategies for reducing opioid-related harm are underutilized due in part to clinicians' low knowledge about harm reduction theory and limited preparedness to prescribe naloxone. Educational interventions are needed to improve knowledge and attitudes about, and preparedness to address, opioid overdoses among medical students. Informed by the Department of Veterans Affairs' Overdose Education and Naloxone Distribution (OEND) program and narrative medicine, we developed and led a mandatory workshop on harm reduction for clerkship medical students. Using validated scales, we assessed students' knowledge and attitudes about, and preparedness to address, opioid overdoses before the workshop and 6 weeks after. Of 75 participating students from February through December 2017, 55 (73%) completed pre-workshop and 38 (51%) completed both pre- and post-workshop surveys. At baseline, 40 (73%) encountered patients with perceived at-risk opioid use in the previous 6 weeks, but only 11 (20%) recalled their teams prescribing naloxone for overdose prevention. Among those completing both surveys, knowledge about and preparedness to prevent overdose showed large improvement (Cohen's  = 0.85,  < .001; Cohen's  = 1.24,  < .001, respectively) and attitudes showed moderate improvement (Cohen's  = 0.32, = .04). Educational interventions grounded in harm reduction theory can increase students' knowledge and attitudes about, and preparedness to address, opioid overdoses.
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http://dx.doi.org/10.1080/08897077.2019.1621241DOI Listing
February 2021

Integration of care for HIV and opioid use disorder.

AIDS 2019 04;33(5):873-884

Department of Medicine.

Objective: We sought to identify optimal strategies for integrating HIV- and opioid use disorder-(OUD) screening and treatment in diverse settings.

Design: Systematic review.

Methods: We searched Ovid MEDLINE, PubMed, Embase, PsycINFO and preidentified websites. Studies were included if they were published in English on or after 2002 through May 2017, and evaluated interventions that integrated, at an organizational level, screening and/or treatment for HIV and OUD in any care setting in any country.

Results: Twenty-nine articles met criteria for inclusion, including 23 unique studies: six took place in HIV care settings, 12 in opioid treatment settings, and five elsewhere. Eight involved screening strategies, 22 involved treatment strategies, and seven involved strategies that encompassed screening and treatment. Randomized controlled studies demonstrated low-to-moderate risk of bias and observational studies demonstrated fair to good quality. Studies in HIV care settings (n = 6) identified HIV-related and OUD-related clinical benefits with the use of buprenorphine/naloxone for OUD. No studies in HIV care settings focused on screening for OUD. Studies in opioid treatment settings (n = 12) identified improving HIV screening uptake and clinical benefits with antiretroviral therapy when provided on-site. Counseling intensity for OUD medication adherence or HIV-related risk reduction was not associated with clinical benefits.

Conclusion: Screening for HIV can be effectively delivered in opioid treatment settings, yet there is a need to identify optimal OUD screening strategies in HIV care settings. Strategies integrating the provision of medications for HIV and for OUD should be expanded and should not be contingent on resources available for behavioral interventions.

Registration: A protocol for record eligibility was developed a priori and was registered in the PROSPERO database of systematic reviews (registration number CRD42017069314).
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http://dx.doi.org/10.1097/QAD.0000000000002125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6588508PMC
April 2019

"No more falling through the cracks": A qualitative study to inform measurement of integration of care of HIV and opioid use disorder.

J Subst Abuse Treat 2019 02 20;97:28-40. Epub 2018 Nov 20.

Department of Medicine, Yale School of Medicine, New Haven, CT, United States of America; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, United States of America.

Introduction: Integration of HIV- and opioid use disorder (OUD)-related care is associated with improved patient outcomes. Our goal was to develop a novel instrument for measuring quality of integration of HIV and OUD-related care that would be applicable across diverse care settings.

Methods: Grounded in community-based participatory research principles, we conducted a qualitative study from August through November 2017 to inform modification of the Behavioral Health Integration in Medical Care (BHIMC) instrument, a validated measure of quality of integration of behavioral health in primary care. We conducted semi-structured interviews of patients (n = 22), focus groups with clinical staff (n = 24), and semi-structured interviews of clinic leadership (n = 5) in two urban centers in Connecticut.

Results: We identified three themes that characterize optimal integration of HIV- and OUD-related care: (1) importance of mitigating mismatches in resources and knowledge, particularly resources to address social risks and knowledge gaps about evidence-based treatments for OUD; (2) need for patient-centered policies and inter-organization communication, and (3) importance of meeting people where they are, geographically and at their stage of change. These themes highlighted aspects of integrated care for HIV and OUD not captured in the original BHIMC.

Conclusions: Patients, clinical staff, and organization leadership perceive that addressing social risks, communication across agencies, and meeting patients in their psychosocial and structural context are important for optimizing integration of HIV and OUD-related care. Our proposed, novel instrument is a step towards measuring and improving service delivery locally and nationally for this vulnerable population.
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http://dx.doi.org/10.1016/j.jsat.2018.11.007DOI Listing
February 2019

Multimodal Treatment Options, Including Rotating to Buprenorphine, Within a Multidisciplinary Pain Clinic for Patients on Risky Opioid Regimens: A Quality Improvement Study.

Pain Med 2018 09;19(suppl_1):S38-S45

VA Connecticut Health Care System, West Haven, Connecticut.

Objectives: We aimed to evaluate a novel clinical program designed to address unsafe use of opioids prescribed for pain-the Opioid Reassessment Clinic (ORC)-to inform practice and health system improvement.

Design: Controlled, retrospective cohort study.

Setting: The ORC is a multidisciplinary clinic in a primary care setting in a Veterans Health Administration hospital designed to perform longitudinal treatment of patients with unsafe use of opioids prescribed for pain, including tapering or rotating to the partial opioid agonist buprenorphine.

Subjects: We included patients referred to the ORC from March 1, 2016, to March 1, 2017, who had an intake appointment (intervention group) and who did not (control group).

Methods: We compared a priori-defined metrics at the patient, clinic process, and health system levels and compared metrics between groups.

Results: During the study period, 114 veterans were referred to the ORC, and 71 (62%) of these had an intake appointment. Those in the intervention group were more likely to trial buprenorphine (N = 41, 62% vs N = 1, 2%, P < 0.01) and had greater reductions in their full agonist morphine equivalent daily dose than those in the control group (30 mg [interquartile range {IQR} = 0-120] vs 0 mg [IQR = 0-20] decrease, P < 0.01). Of those engaging in the ORC, 20 (30%) had not transitioned chronic pain management back to their primary care providers (PCPs) by the end of follow-up. Only one patient transitioned the management of buprenorphine to the PCP.

Conclusions: Results suggest the ORC was effective in reducing total prescribed opioid doses and in transitioning patients to partial-agonist therapy, but PCP adoption strategies are needed.
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http://dx.doi.org/10.1093/pm/pny086DOI Listing
September 2018

Patient, Family, and Community Advisory Councils in Health Care and Research: a Systematic Review.

J Gen Intern Med 2019 07 26;34(7):1292-1303. Epub 2018 Jul 26.

Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA.

Background: Patient-centeredness is a characteristic of high-quality medical care and requires engaging community members in health systems' decision-making. One key patient engagement strategy is patient, family, and community advisory boards/councils (PFACs), yet the evidence to guide PFACs is lacking. Systematic reviews on patient engagement may benefit from patient input, but feasibility is unclear.

Methods: A team of physicians, researchers, and a PFAC member conducted a systematic review to examine the impact of PFACs on health systems and describe optimal strategies for PFAC conduct. We searched MEDLINE, Embase, PsycINFO, CINAHL, Scopus, and Social Science Citation Index from inception through September 2016, as well as pre-identified websites. Two reviewers independently screened and abstracted data from studies, then assessed randomized studies for risk of bias and observational studies for quality using standardized measures. We performed a realist synthesis-which asks what works, for whom, under what circumstances-of abstracted data via 12 monthly meetings between investigators and two feedback sessions with a hospital-based PFAC.

Results: Eighteen articles describing 16 studies met study criteria. Randomized studies demonstrated moderate to high risk of bias and observational studies demonstrated poor to fair quality. Studies engaged patients at multiple levels of the health care system and suggested that in-person deliberation with health system leadership was most effective. Studies involving patient engagement in research focused on increasing study participation. PFAC recruitment was by nomination (n = 11) or not described (n = 5). No common measure of patient, family, or community engagement was identified. Realist synthesis was enriched by feedback from PFAC members.

Discussion: PFACs engage communities through individual projects but evidence of their impact on outcomes is lacking. A paucity of randomized controlled trials or high-quality observational studies guide strategies for engagement through PFACs. Standardized measurement tools for engagement are needed. Strategies for PFAC recruitment should be investigated and reported. PFAC members can feasibly contribute to systematic reviews.

Registration And Funding Source: A protocol for record eligibility was developed a priori and was registered in the PROSPERO database of systematic reviews (registration number CRD42016052817). The Department of Veterans Affairs' Office of Academic Affiliations, through the National Clinician Scholars Program, funded this study.
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http://dx.doi.org/10.1007/s11606-018-4565-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6614241PMC
July 2019

Office-Based Addiction Treatment in Primary Care: Approaches That Work.

Med Clin North Am 2018 Jul;102(4):635-652

Department of Internal Medicine, Yale University School of Medicine, 367 Cedar Street, Suite 305, New Haven, CT 06510, USA.

Primary care is an important setting for delivering evidence-based treatment to address substance use disorders. To date, effective approaches to treat, care largely incorporate pharmacotherapy with counseling-based interventions and rely on multidisciplinary teams. There is strong support for primary care-based approaches to address alcohol and opioid use disorder with growing data focused on people living with human immunodeficiency virus and those experiencing incarceration. Future work should focus on the implementation of these effective approaches to decrease health disparities among people with substance use and to identify optimal approaches to address substance use in primary care and specialty settings.
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http://dx.doi.org/10.1016/j.mcna.2018.02.007DOI Listing
July 2018

Partnering with youth in community-based participatory research to address violence prevention.

Pediatr Res 2018 08 13;84(2):155-156. Epub 2018 Jun 13.

Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA.

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http://dx.doi.org/10.1038/s41390-018-0074-0DOI Listing
August 2018

When You Got the Yams-Kendrick Lamar and the Language of Power in Clinical Encounters.

JAMA 2018 04;319(16):1642-1643

National Clinician Scholars Program, Departments of Medicine and Pediatrics, Yale School of Medicine, New Haven, Connecticut.

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http://dx.doi.org/10.1001/jama.2018.3768DOI Listing
April 2018
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