Publications by authors named "Jennifer Havens"

129 Publications

Changes in Attitudes and Knowledge after Trainings in a Clinical Care Pathway for Autism Spectrum Disorder.

J Autism Dev Disord 2020 Nov 17. Epub 2020 Nov 17.

Child Study Center, Department of Child and Adolescent Psychiatry, NYU Langone, New York, NY, 10016, USA.

Caring for individuals with autism spectrum disorder (ASD) can be complicated, especially when challenging behaviors are present. Providers may feel unprepared to work with these individuals because specialized training for medical and social service providers is limited. To increase access to specialized training, we modified an effective half-day ASD-Care Pathway training (Kuriakose et al. 2018) and disseminated it within five different settings. This short, focused training on strategies for preventing and reducing challenging behaviors of patients with ASD resulted in significant improvements in staff perceptions of challenging behaviors, increased comfort in working with the ASD population, and increased staff knowledge for evidence-informed practices. Implications, including the impact of sociodemographic characteristics on pre/post changes, and future directions are discussed.
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http://dx.doi.org/10.1007/s10803-020-04775-yDOI Listing
November 2020

Social network predictors of recent and sustained injection drug use cessation: findings from a longitudinal cohort study.

Addiction 2021 04 14;116(4):856-864. Epub 2020 Sep 14.

Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, KY, USA.

Background And Aims: The US opioid crisis has led to increases in overdose fatalities and the incidence of HIV, hepatitis C and other infections. This analysis examines social network predictors of recent (self-report injection followed by non-injection) and sustained (self-report non-injection at two consecutive visits among those who previously injected) injection cessation in Appalachian Kentucky.

Design: Data were collected through bi-annual longitudinal assessments for Social Networks among Appalachian People (SNAP; 2008-17). Using logistic regression with generalized estimating equations that clustered on individuals, we regressed non-injection status on the number of social network members who (a) did not inject and (b) recently stopped injecting and tested for interactions between each social network exposure and prior non-injection status. Social network exposures were self-reported.

Setting: Rural eastern Kentucky, USA.

Participants: Participants entered the analysis only after reporting recent injection and had to have had at least two consecutive study visits (n = 326).

Measurements: Interviewer-administered surveys collected individual-level socio-demographics, recent (past 6 months) drug use behaviors and the names of recent social support, sex and drug-use partners.

Findings: After adjusting for confounders, the number of non-injecting social network members was positively associated with recent/sustained injection cessation (adjusted odds ratio = 1.27; 95% confidence interval = 1.13-1.42) and having more social network members was associated with reduced odds of recent/sustained injection cessation. The number of previously injecting social network members who had recently stopped injecting was not statistically significantly associated with injection cessation. Neither of the interactions we tested for was statistically significant, suggesting that the relationships may be similar for those who recently stopped injecting versus had not injected for at least 1 year.

Conclusions: For each additional network member who did not inject drugs, there was an increased odds of recent and sustained injection cessation among people with a history of injection drug use in Appalachian Kentucky.
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http://dx.doi.org/10.1111/add.15218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7889767PMC
April 2021

Longitudinal trends in nonmedical prescription opioid use in a cohort of rural Appalachian people who use drugs.

Prev Med 2020 11 9;140:106194. Epub 2020 Jul 9.

Center on Drug and Alcohol Use, University of Kentucky College of Medicine, United States of America; Department of Behavioral Science, University of Kentucky College of Medicine, United States of America.

Rural Appalachia remains an epicenter of the prescription opioid epidemic. In 2008, a cohort study was undertaken to examine longitudinal trends in nonmedical prescription opioid use (NMPOU). Eight waves of data (2008-2020) from the Social Networks among Appalachian People (SNAP) cohort were utilized for the current analysis. Only those who reported recent (past 6-month) NMPOU at baseline are included (n = 498, 99%). Mixed-effects logistic regression was used to model factors associated with NMPOU over time. Recent NMPOU declined significantly over the past decade (p < .001). However, 54.1% of participants still engaged in NMPOU at their most recent follow-up. Receipt of benefits for a physical or mental disability (adjusted odds ratio [aOR]: 3.11, 95% Confidence Interval [CI]: 1.98, 4.90) and self-described poor health status (aOR: 3.67, 95% CI: 1.61, 8.37) were both associated with NMPOU. All treatment modalities (methadone maintenance, residential, outpatient counseling) tested in the model, with the notable exception of detoxification, were associated with significantly lower odds of NMPOU. Although significant declines in prescription opioid misuse were observed in the cohort, more than half of all participants were engaged in NMPOU more than a decade after entering the study. Substance use disorder (SUD) treatment (excluding detoxification) was shown associated with reduced odds of continued NMPOU; therefore, increasing access to evidence-based treatments should be a priority in rural areas affected by the ongoing opioid epidemic.
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http://dx.doi.org/10.1016/j.ypmed.2020.106194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7680378PMC
November 2020

Staff Perceptions and Implementation Fidelity of an Autism Spectrum Disorder Care Pathway on a Child/Adolescent General Psychiatric Inpatient Service.

J Autism Dev Disord 2021 Jan;51(1):158-168

Department of Child and Adolescent Psychiatry, Child Study Center, Hassenfeld Children's Hospital at NYU Langone, One Park Avenue, 7th Floor, New York, NY, 10016, USA.

While youth with autism spectrum disorder (ASD) are psychiatrically hospitalized at high rates, general psychiatric settings are not designed to meet their unique needs. Previous evaluations of an ASD-Care Pathway (ASD-CP) on a general psychiatric unit revealed sustained reductions in crisis interventions (intramuscular medication use, holds/restraints; Cervantes et al. in J Autism Dev Disord 49(8):3173-3180, https://doi.org/10.1007/s10803-019-04029-6 , 2019; Kuriakose et al. in J Autism Dev Disord 48(12):4082-4089, https://doi.org/10.1007/s10803-018-3666-y , 2018). The current study investigated staff perceptions of the ASD-CP (N = 30), and examined rates of ASD-CP implementation fidelity in relation to patient outcomes (N = 28). Staff identified visual communication aids and reward strategies as most helpful. The number of days of reward identification early in the inpatient stay was associated with fewer crisis interventions later in a patient's stay.
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http://dx.doi.org/10.1007/s10803-020-04509-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8034489PMC
January 2021

Aromatherapy as an adjunctive therapy for neonatal abstinence syndrome: A pilot study.

J Opioid Manag 2020 Mar/Apr;16(2):119-125

Professor of Pediatrics, Division of Neonatology, College of Medicine, Kentucky Children's Hospital, University of Kentucky, Lexington, Kentucky.

Objective: To determine if aromatherapy added to the current standard of care for opioid withdrawal syndrome decreases hospitali-zation and need for opioid replacement in neonates.

Design: Nonblinded, randomized control trial.

Setting: Level 4 neonatal intensive care unit (NICU).

Patients And Participants: Thirty eight patients met inclusion criteria of greater than or equal to 36 weeks of gestation, history of in-trauterine opioid exposure, primary diagnosis of neonatal abstinence syndrome (NAS), and parental permission to participate.

Interventions: Infants were randomized to either a standard therapy group or a standard therapy plus aromatherapy.

Main Outcome Measure(s): Duration of therapy and length of stay.

Results: Our pilot study showed that the use of aromatherapy in conjunction with standard therapy reduced the duration of medica-tion treatment by 41 percent and hospital length of stay in the NICU by 36 percent.

Conclusions: The use of aromatherapy appears to help mitigate symptoms of NAS and offers to be a viable treatment modality when used with conventional therapy.
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http://dx.doi.org/10.5055/jom.2020.0558DOI Listing
October 2020

Modeling the role of incarceration in HCV transmission and prevention amongst people who inject drugs in rural Kentucky.

Int J Drug Policy 2021 Feb 6;88:102707. Epub 2020 Mar 6.

Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK.

Background: People who inject drugs (PWID) experience high incarceration rates, with current/recent incarceration being associated with increased hepatitis C virus (HCV) transmission. We assess the contribution of incarceration to HCV transmission amongst PWID in Perry County (PC), Kentucky, USA, and the impact of scaling-up community and in-prison opioid substitution therapy (OST), including the potential for reducing incarceration.

Methods: A dynamic model of incarceration and HCV transmission amongst PWID was calibrated in a Bayesian framework to epidemiological and incarceration data from PC, incorporating an empirically estimated 2.8-fold (95%CI: 1.36-5.77) elevated HCV acquisition risk amongst currently incarcerated or recently released (<6 months) PWID compared to other PWID. We projected the percentage of new HCV infections that would be prevented among PWID over 2020-2030 if incarceration no longer elevated HCV transmission risk, if needle and syringe programmes (NSP) and OST are scaled-up, and/or if drug use was decriminalized (incarceration/reincarceration rates are halved) with 50% of PWID that would have been imprisoned being diverted onto OST. We assume OST reduces reincarceration by 10-42%.

Results: Over 2020-2030, removing the effect of incarceration on HCV transmission could prevent 42.7% (95% credibility interval: 15.0-67.4%) of new HCV infections amongst PWID. Conversely, scaling-up community OST and NSP to 50% coverage could prevent 28.5% (20.0-37.4%) of new infections, with this increasing to 32.7% (24.5-41.2%) if PWID are retained on OST upon incarceration, 36.4% (27.7-44.9%) if PWID initiate OST in prison, and 45.3% (35.9-54.1%) if PWID are retained on OST upon release. decriminalization (with diversion to OST) could further increase this impact, preventing 56.8% (45.3-64.5%) of new infections. The impact of these OST interventions decreases by 2.1-28.6% if OST does not reduce incarceration.

Conclusion: Incarceration is likely to be an important contributor to HCV transmission amongst PWID in PC. Prison-based OST could be an important intervention for reducing this risk.
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http://dx.doi.org/10.1016/j.drugpo.2020.102707DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7483428PMC
February 2021

Peer influence of injection drug use cessation among dyads in rural eastern Kentucky.

Int J Drug Policy 2020 11 15;85:102604. Epub 2019 Nov 15.

Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, KY, United States.

Background: This analysis aims to assess whether injection drug use cessation among peers predicts injection drug use cessation among individuals and explores whether this association varies by relationship type and strength.

Methods: Data were collected through baseline and 6-month assessments for the Social Networks among Appalachian People study (2008-2011). Interviewer-administered surveys collected sociodemographic and drug use behaviors (past 6 months and lifetime). Participants also listed sex, drug use, and social support partners (past 6 months). Listed names were cross-referenced with survey participants to identify relationships between study participants. The analytic sample was further restricted to include only those relationship pairs where both individuals reported a history of injection drug use at baseline (n = 244 unique individuals and 746 dyads). We fit a generalized estimating equations logistic regression model to (1) assess the relationship between peer injection cessation and individual injection cessation and (2) determine whether the strength of this association differs by relationship-level variables (i.e., relationship role, relationship type, relationship duration, frequency of interaction, residential proximity).

Results: Overall, those with a network member who ceased injection drug use were more likely to stop injecting over the following 6-month period (AOR=1.65). The magnitude of this association was greater for social support partners (AOR=2.95), family members (AOR=3.56), those with whom the participant interacted at least daily (AOR=2.17), and those who the participant knew longer (AOR=2.09). Further, among family members, the effect size was greater when relationships were further restricted to immediate family members (AOR=5.35).

Conclusion: Our findings suggest that in this rural community, closer, more supportive relationships, may be more influential for modeling injection cessation; however, relationship-types were not mutually exclusive so differences in effect size across strata may not be statistically significant. In this setting, social support through the recovery process (including cessation attempts with peers) may increase likelihood of injection cessation.
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http://dx.doi.org/10.1016/j.drugpo.2019.11.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7784371PMC
November 2020

Gabapentin drug misuse signals: A pharmacovigilance assessment using the FDA adverse event reporting system.

Drug Alcohol Depend 2020 01 2;206:107709. Epub 2019 Nov 2.

Department of Epidemiology, University of Kentucky College of Public Health, 111 Washington Avenue, Lexington, KY 40536, USA; Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky College of Medicine, 845 Angliana Avenue, Lexington, KY 40508, USA.

Background: Although there have been increasing reports of intentional gabapentin misuse, epidemiological evidence for the phenomenon is limited. The purpose of this study was to determine whether there are pharmacovigilance abuse signals for gabapentin.

Methods: Using FDA Adverse Events Reporting System reports from January 1, 2005 to December 31, 2015, we calculated pharmacovigilance signal measures (i.e., reporting odds ratio, proportional reporting ratio, information component, and empirical Bayes geometric mean) for abuse-related adverse event (AR-AE)-gabapentin pairs. Loglinear modeling assessed the frequency of concurrent reporting of abuse-related and abuse-specific AEs (AS-AEs) associated with gabapentin. Findings were compared to a positive (pregabalin) and negative (duloxetine) control.

Results: From 2005-2015 there were 5,951,229 unique AE reports submitted to the FDA including 99,977 for gabapentin, 73,977 for duloxetine, and 97,813 for pregabalin. Significant drug-AR-AE pair signals involving gabapentin included: drug abuser, multiple drug overdose, and substance-induced psychotic disorder. Significant drug AR-AE signals involving gabapentin and pregabalin, but not duloxetine, were: ataxia, dependence, drug abuse, increased drug tolerance, and overdose. Compared to duloxetine, gabapentin had significantly greater odds of a co-report for an AS-AE with drug withdrawal syndrome (OR: 6.55), auditory hallucinations (OR: 4.57), delusions (OR: 2.36), euphoric mood (OR: 5.45), ataxia (OR: 2.85), drug abuser (OR: 3.01), aggression (OR: 1.98), psychotic disorder (OR: 1.96), and feeling abnormal (OR: 1.31).

Conclusions: We identified abuse-related signals for gabapentin and highlighted several CNS effects that may be associated with its abuse. Gabapentin prescribers should be aware of the drug's abuse liability and effects that may accompany its use.
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http://dx.doi.org/10.1016/j.drugalcdep.2019.107709DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7762328PMC
January 2020

A nationally representative analysis of "twin epidemics": Rising rates of methamphetamine use among persons who use opioids.

Drug Alcohol Depend 2019 11 27;204:107592. Epub 2019 Sep 27.

Department of Behavioral Science, University of Kentucky College of Medicine, 1100 Veterans Drive, Medical Behavioral Science Building Room 140, Lexington, KY 40536, USA; Center on Drug and Alcohol Research, University of Kentucky College of Medicine, 845 Angliana Ave, Lexington, KY 40508, USA; Department of Psychology, University of Kentucky College of Arts and Sciences, 110 Kastle Hall Lexington, KY 40506, USA; Department of Psychiatry, University of Kentucky College of Medicine, 3470 Blazer Parkway, Lexington, KY 40509, USA.

Background: Recent data suggest increases in methamphetamine potency, affordability, and availability in the US. Other data indicate rising rates of methamphetamine use among patients seeking treatment for opioid use disorder. The extent to which similar increases in methamphetamine use have occurred for populations outside of a treatment context and for those reporting other substance use is unknown.

Purpose: The current analysis used a nationally representative data source to evaluate recent trends in past month methamphetamine use based on opioid use history.

Methods: Data from the 2015-2017 National Survey on Drug Use and Health (NSDUH) were analyzed for yearly variations in past month methamphetamine use by opioid use history. Sensitivity analyses assessed if these trends were specific to methamphetamine use and to persons reporting opioid use.

Results: Significant increases in past month methamphetamine use were observed for persons reporting past month heroin use, past year heroin use disorder, and past year prescription opioid use disorder. Among individuals reporting past month heroin use, for example, methamphetamine use tripled from 9.0% in 2015 to 30.2% in 2017. These associations were specific to methamphetamine with little change in other substance use. Similar increases in methamphetamine use were not observed for populations reporting other illicit substance use with the exception of prescription tranquilizers.

Conclusions: These results provide data corroborating evidence of emergent concerns related to methamphetamine use in the US. Such findings highlight the importance of considering global drivers of substance use to avoid cyclic waves of new and emerging substance use crises.
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http://dx.doi.org/10.1016/j.drugalcdep.2019.107592DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6884137PMC
November 2019

An ethnographic decision model of the initiation of gabapentin misuse among prescription and/or illicit opioid (mis)user.

Drug Alcohol Depend 2019 11 13;204:107554. Epub 2019 Sep 13.

Department of Behavioral Science, University of Kentucky, 333 Waller Ave., Suite 480, Lexington, KY 40504, USA.

Aims: Gabapentin is used in the treatment of seizures and neuralgia, and it is prescribed off-label to treat substance use disorders and withdrawal symptoms. Recent research documents misuse of gabapentin, especially among prescription opioid misusers. The present study contributes to this literature by examining the initiation of gabapentin misuse.

Methods: Qualitative interviews were conducted with prescription and/or illicit opioid (mis)users who reported a history of gabapentin misuse (N = 62) and who did not (N = 29). During semi-structured interviews, respondents provided descriptions of the first time they misused gabapentin. An ethnographic decision model was constructed to illustrate the factors that influence the initiation decision.

Results: Multiple individual, social, and environmental factors influence the decision to initiate gabapentin misuse. Respondents described the initiation decision related to: a) wanting to feel a psychoactive high during times of limited access to one's preferred drug because of institutional barriers (e.g., substance abuse treatment; jail; transitional living facility; N = 18); b) the desire to use multiple drugs, including for experimentation or to potentiate another substance (N = 18); and c) the need to self-treat withdrawal symptoms during periods of opioid nonuse or when opioids were unavailable (N = 16). Respondents also initiated gabapentin misuse to self-treat physical pain (N = 10).

Conclusions: Multiple approaches are needed to mitigate gabapentin misuse, including limiting availability in institutional settings and informal channels as well as addressing the needs of drug users who experience physical pain and withdrawal symptoms. Continued research is needed to examine therapeutic uses of gabapentin and behaviors related to misuse.
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http://dx.doi.org/10.1016/j.drugalcdep.2019.107554DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6905052PMC
November 2019

Cost-effectiveness of scaling-up HCV prevention and treatment in the United States for people who inject drugs.

Addiction 2019 12 2;114(12):2267-2278. Epub 2019 Aug 2.

University of Bristol, Bristol, UK.

Aims: To examine the cost-effectiveness of hepatitis C virus (HCV) treatment of people who inject drugs (PWID), combined with medication-assisted treatment (MAT) and syringe-service programs (SSP), to tackle the increasing HCV epidemic in the United States.

Design: HCV transmission and disease progression models with cost-effectiveness analysis using a health-care perspective.

Setting: Rural Perry County, KY (PC) and urban San Francisco, CA (SF), USA. Compared with PC, SF has a greater proportion of PWID with access to MAT or SSP. HCV treatment of PWID is negligible in both settings.

Participants: PWID data were collected between 1998 and 2015 from Social Networks Among Appalachian People, U Find Out, Urban Health Study and National HIV Behavioral Surveillance System studies.

Interventions And Comparator: Three intervention scenarios modeled: baseline-existing SSP and MAT coverage with HCV screening and treatment with direct-acting antiviral for ex-injectors only as per standard of care; intervention 1-scale-up of SSP and MAT without changes to treatment; and intervention 2-scale-up as intervention 1 combined with HCV screening and treatment for current PWID.

Measurements: Incremental cost-effectiveness ratios (ICERs) and uncertainty using cost-effectiveness acceptability curves. Benefits were measured in quality-adjusted life-years (QALYs).

Findings: For both settings, intervention 2 is preferred to intervention 1 and the appropriate comparator for intervention 2 is the baseline scenario. Relative to baseline, for PC intervention 2 averts 1852 more HCV infections, increases QALYS by 3095, costs $21.6 million more and has an ICER of $6975/QALY. For SF, intervention 2 averts 36 473 more HCV infections, increases QALYs by 7893, costs $872 million more and has an ICER of $11 044/QALY. The cost-effectiveness of intervention 2 was robust to several sensitivity analysis.

Conclusions: Hepatitis C screening and treatment for people who inject drugs, combined with medication-assisted treatment and syringe-service programs, is a cost-effective strategy for reducing hepatitis C burden in the United States.
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http://dx.doi.org/10.1111/add.14731DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7751348PMC
December 2019

Impact of a Trauma-Informed Intervention for Youth and Staff on Rates of Violence in Juvenile Detention Settings.

J Interpers Violence 2019 Jun 28:886260519857163. Epub 2019 Jun 28.

1 New York University School of Medicine, New York City, USA.

The majority of youth in the juvenile justice system have experienced multiple traumatic events in their lives, including community violence, physical abuse, neglect, and traumatic loss. These high prevalence rates, coupled with the known negative consequences of trauma in childhood and adolescence, have led to a greater emphasis on implementing trauma-informed services and practices within juvenile justice settings. However, although many stakeholders and government entities have expressed support for creating more trauma-informed juvenile justice systems, there is still limited empirical knowledge about which interventions are most effective at improving outcomes, particularly at the organizational or facility level. In an effort to fill this gap, the current study evaluated the impact of a trauma-informed milieu intervention, including skills training for youth and training for staff, on rates of violence at two secure juvenile detention facilities ( = 14,856) located in a large Northeastern city. The analyses revealed that the intervention was significantly related to a reduction of violent incidents in Facility A, with no impact on incidents in Facility B. Follow-up analyses revealed that a larger proportion of eligible youth in Facility A completed the skills group program as compared with eligible youth in Facility B (16% vs. 9%). This finding has important implications for the implementation of trauma-informed interventions for youth in juvenile detention settings, as it suggests that to impact outcomes at the facility level, a minimum threshold of youth may need to be exposed to the intervention. In addition, reductions in violence at Facility A were only realized after both staff training and youth skills components were implemented, suggesting that both components are necessary to create change at the facility level. Future research is needed to further explore the impact of organizational and implementation-level factors on trauma-informed care outcomes in juvenile justice settings.
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http://dx.doi.org/10.1177/0886260519857163DOI Listing
June 2019

Scaling Up Hepatitis C Prevention and Treatment Interventions for Achieving Elimination in the United States: A Rural and Urban Comparison.

Am J Epidemiol 2019 08;188(8):1539-1551

Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom.

In the United States, hepatitis C virus (HCV) transmission is rising among people who inject drugs (PWID). Many regions have insufficient prevention intervention coverage. Using modeling, we investigated the impact of scaling up prevention and treatment interventions on HCV transmission among PWID in Perry County, Kentucky, and San Francisco, California, where HCV seroprevalence among PWID is >50%. A greater proportion of PWID access medication-assisted treatment (MAT) or syringe service programs (SSP) in urban San Francisco (established community) than in rural Perry County (young, expanding community). We modeled the proportion of HCV-infected PWID needing HCV treatment annually to reduce HCV incidence by 90% by 2030, with and without MAT scale-up (50% coverage, both settings) and SSP scale-up (Perry County only) from 2017. With current MAT and SSP coverage during 2017-2030, HCV incidence would increase in Perry County (from 21.3 to 22.6 per 100 person-years) and decrease in San Francisco (from 12.9 to 11.9 per 100 person-years). With concurrent MAT and SSP scale-up, 5% per year of HCV-infected PWID would need HCV treatment in Perry County to achieve incidence targets-13% per year without MAT and SSP scale-up. In San Francisco, a similar proportion would need HCV treatment (10% per year) irrespective of MAT scale-up. Reaching the same impact by 2025 would require increases in treatment rates of 45%-82%. Achievable provision of HCV treatment, alongside MAT and SSP scale-up (Perry County) and MAT scale-up (San Francisco), could reduce HCV incidence.
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http://dx.doi.org/10.1093/aje/kwz097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7415256PMC
August 2019

Sustainability of a Care Pathway for Children and Adolescents with Autism Spectrum Disorder on an Inpatient Psychiatric Service.

J Autism Dev Disord 2019 Aug;49(8):3173-3180

Department of Child and Adolescent Psychiatry, Child Study Center, Hassenfeld Children's Hospital, NYU Langone Health, New York, NY, USA.

Children with autism spectrum disorder (ASD) are frequently hospitalized within general psychiatric settings, which are not usually designed to meet their needs. An initial evaluation of a care pathway developed for youth with ASD receiving services in a general psychiatric inpatient unit (ASD-CP) showed promise in improving outcomes while using few resources (Kuriakose et al. in J Autism Dev Disord 48:4082-4089, 2018). As sustainability of inpatient psychiatric initiatives is imperative but rarely investigated, this study examined the stability of ASD-CP outcomes during an 18-month follow-up period (n = 15) compared to the 18-month initial evaluation (n = 20) and 18-month pre-implementation (n = 17) periods. Decreased use of crisis interventions, including holds/restraints and intramuscular medication use, was sustained in the 18 months after the initial implementation period. Implications and limitations are discussed.
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http://dx.doi.org/10.1007/s10803-019-04029-6DOI Listing
August 2019

Impact of health reform on health insurance status among persons who use opioids in eastern Kentucky: A prospective cohort analysis.

Int J Drug Policy 2019 08 1;70:8-14. Epub 2019 May 1.

Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, 845 Angliana Avenue, Room 201, Lexington, KY, 40508, USA. Electronic address:

Background: Health insurance improves health and reduces mortality. Expanding insurance is a central feature of the Affordable Care Act (ACA). Persons who use drugs (PWUDs) have historically been at high risk of being uninsured. It is unknown if Appalachian PWUDs, who live in an extremely economically distressed region, are more likely to be insured since implementation of the ACA.

Methods: Data from a cohort of 503 PWUDs from eastern Appalachian Kentucky, who were interviewed at seven time-points between 2008 and 2017, were analysed using mixed effects regression models.

Results: At baseline, only 33.8% of participants were insured, which increased to 87.3% of the cohort at the last follow-up interview. The final multivariate model, which included baseline characteristics and interactions by time, indicated there were significant baseline differences in insurance status by gender, age, education, income, and history of injection. Differences in the predictive margin probabilities of being insured across these groups had dissipated by the final follow-up interview.

Conclusions: After Kentucky's implementation of the ACA, this cohort of Appalachian PWUDs made substantial gains in obtaining insurance that far exceeded the increases reported in national studies.
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http://dx.doi.org/10.1016/j.drugpo.2019.04.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6682430PMC
August 2019

Post-traumatic stress and related symptoms among juvenile detention residents: Results from intake screening.

Child Abuse Negl 2019 06 20;92:22-31. Epub 2019 Mar 20.

New York University School of Medicine, Department of Child and Adolescent Psychiatry, New York, NY, United States.

Background: Juvenile justice-involved youth have high rates of trauma exposure, physical and sexual abuse and PTSD. Several factors have been found to be related to PTSD symptoms in youth including number and chronicity of traumatic events.

Objective: To simultaneously examine the relationships between allostatic load (defined here as number of traumatic experiences), poly-victimization (exposure to two or more forms of victimization based on 5 of the 6 categories in Ford et al.'s 2010 study), physical/sexual abuse and PTSD in justice-involved youth.

Participants And Setting: The sample consisted of 1984 youth in juvenile detention in a Northeastern city. The sample was 73.4% male and the majority of youth were either African American or Hispanic.

Methods: Clinicians collected demographic and psychosocial information, and measured symptoms of PTSD, depression, and problematic substance use.

Results: Results showed that youth with more traumas, those who experienced poly-victimization and those who experienced physical/sexual assault/abuse were not only more likely to have PTSD, but also more likely to have depression, thoughts of suicide/self-harm, and problematic substance use (as indicated by the presence of 2 or more of 6 possible indicators). Poly-victimization was a stronger correlate of PTSD than number of traumas or physical/sexual assault/abuse. However, among youth with PTSD, number of traumas was associated with co-occurring problems while poly-victimization and physical/sexual assault/abuse were not.

Conclusions: Findings can be used to help direct resources to juvenile justice-involved youth who are most in need of treatment.
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http://dx.doi.org/10.1016/j.chiabu.2019.03.011DOI Listing
June 2019

Using Network and Spatial Data to Better Target Overdose Prevention Strategies in Rural Appalachia.

J Urban Health 2019 02;96(1):27-37

Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, KY, USA.

This analysis uses network and spatial data to identify optimal individuals to target with overdose prevention interventions in rural Appalachia. Five hundred and three rural persons who use drugs were recruited to participate in the Social Networks among Appalachian People Study (2008-2010). Interviewer-administered surveys collected information on demographic characteristics, risk behaviors (including overdose history), network members, and residential addresses. We restricted the sample to individuals with at least one confirmed relationship to another study participant (N = 463). Using dyadic analyses (N = 1428 relationships), we identified relationship-level correlates of relationships with network members who have previously overdosed. We then examined individual- and network-level factors associated with (1) having at least one first-degree alter (i.e., network member) with a prior overdose and (2) each additional network member with a prior overdose (N = 463 study participants). Overall, 28% of the sample had previously overdosed and 57% were one-degree away from someone who previously overdosed. Relationships with those who had overdosed were characterized by closer residential proximity. Those with at least one network member who previously overdosed were more geographically central and occupied more central network positions. Further, the number of network members with an overdose history increased with decreasing distance to the town center, increasing network centrality, and prior enrollment in an alcohol detox program. Because fatal overdoses can be prevented through bystander intervention, these findings suggest that strategies that target more central individuals (both geographically and based on their network positions) and those who have previously enrolled in alcohol detox programs with overdose prevention training and naloxone may optimize intervention reach and have the potential to curb overdose fatalities in this region.
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http://dx.doi.org/10.1007/s11524-018-00328-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6391296PMC
February 2019

Incarceration history and risk of HIV and hepatitis C virus acquisition among people who inject drugs: a systematic review and meta-analysis.

Lancet Infect Dis 2018 12 29;18(12):1397-1409. Epub 2018 Oct 29.

Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.

Background: People who inject drugs (PWID) experience a high prevalence of incarceration and might be at high risk of HIV and hepatitis C virus (HCV) infection during or after incarceration. We aimed to assess whether incarceration history elevates HIV or HCV acquisition risk among PWID.

Methods: In this systematic review and meta-analysis, we searched MEDLINE, Embase, and PsycINFO databases for studies in any language published from Jan 1, 2000 until June 13, 2017 assessing HIV or HCV incidence among PWID. We included studies that measured HIV or HCV incidence among community-recruited PWID. We included only studies reporting original results and excluded studies that evaluated incident infections by self-report. We contacted authors of cohort studies that met the inclusion or exclusion criteria, but that did not report on the outcomes of interest, to request data. We extracted and pooled data from the included studies using random-effects meta-analyses to quantify the associations between recent (past 3, 6, or 12 months or since last follow-up) or past incarceration and HIV or HCV acquisition (primary infection or reinfection) risk among PWID. We assessed the risk of bias of included studies using the Newcastle-Ottawa Scale. Between-study heterogeneity was evaluated using the I statistic and the P-value for heterogeneity.

Findings: We included published results from 20 studies and unpublished results from 21 studies. These studies originated from Australasia, western and eastern Europe, North and Latin America, and east and southeast Asia. Recent incarceration was associated with an 81% (relative risk [RR] 1·81, 95% CI 1·40-2·34) increase in HIV acquisition risk, with moderate heterogeneity between studies (I=63·5%; p=0·001), and a 62% (RR 1·62, 95% CI 1·28-2·05) increase in HCV acquisition risk, also with moderate heterogeneity between studies (I=57·3%; p=0·002). Past incarceration was associated with a 25% increase in HIV (RR 1·25, 95% CI 0·94-1·65) and a 21% increase in HCV (1·21, 1·02-1·43) acquisition risk.

Interpretation: Incarceration is associated with substantial short-term increases in HIV and HCV acquisition risk among PWID and could be a significant driver of HCV and HIV transmission among PWID. These findings support the need for developing novel interventions to minimise the risk of HCV and HIV acquisition, including addressing structural risks associated with drug laws and excessive incarceration of PWID.

Funding: Engineering and Physical Sciences Research Council, National Institute for Health Research, National Institutes of Health.
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http://dx.doi.org/10.1016/S1473-3099(18)30469-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6280039PMC
December 2018

Privacy, Confidentiality, and Safety Considerations for Conducting Geographic Momentary Assessment Studies Among Persons Who Use Drugs and Men Who Have Sex with Men.

J Urban Health 2020 04;97(2):306-316

Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, KY, 405308, USA.

Geographic momentary assessments (GMA) collect real-time behavioral data in one's natural environment using a smartphone and could potentially increase the ecological validity of behavioral data. Several studies have evaluated the feasibility and acceptability of GMA among persons who use drugs (PWUD) and men who have sex with men (MSM), but fewer have discussed privacy, confidentiality, and safety concerns, particularly when illegal or stigmatized behavioral data were collected. This study explores perceptions regarding privacy, confidentiality, and safety of GMA research among PWUD and MSM recruited in three different settings (rural Appalachia, a mid-sized city in the South, and a mid-Atlantic city). Between November 2014 and April 2017, we recruited 35 PWUD from rural Appalachian Kentucky (N = 20) and Baltimore, Maryland (N = 15) and 20 MSM from Lexington, Kentucky to complete semi-structured qualitative interviews. Through thematic analyses, we identified and compared privacy, confidentiality, and safety concerns by demographic characteristics, risk behaviors, and setting. Privacy, confidentiality, and safety concerns varied by setting, age, smartphone ownership, use of illegal drugs, and history of drug-related arrests. Among those who used drugs, participants reported concerns with being tracked and burden associated with carrying and safeguarding study phones and responding to survey prompts. Privacy and confidentiality concerns were noted in each setting, but tracking concerns were greatest among Baltimore participants and led many to feel that they (or others) would be unwilling to participate or comply with study procedures. While locations considered to be sensitive varied by setting, participants in all settings said they would take measures to prevent sensitive information from being collected (i.e., intentionally disable devices, leave phones at home, alter response times). Privacy, confidentiality, and safety concerns may limit the accuracy of risk location information, study compliance, and participation. As concerns were often greatest among those engaging in illegal behaviors and with the highest risk behaviors, selection bias and non-response bias could negatively influence the representativeness and validity of study findings.
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http://dx.doi.org/10.1007/s11524-018-0315-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7101455PMC
April 2020

Does an Autism Spectrum Disorder Care Pathway Improve Care for Children and Adolescents with ASD in Inpatient Psychiatric Units?

J Autism Dev Disord 2018 Dec;48(12):4082-4089

Department of Child and Adolescent Psychiatry, Child Study Center, Hassenfeld Children's Hospital at NYU Langone Health, 1 Park Avenue, 7th Floor, New York, NY, 10016, USA.

Youth with autism spectrum disorder (ASD) are psychiatrically hospitalized at high rates. Though specialized psychiatric units are effective, few specialized units exist. The ASD Care Pathway (ASD-CP) was developed as a scalable approach to improving care in general psychiatric units through staff training and a package of autism-specific intervention strategies. An evaluation of the effectiveness of the ASD-CP in a public hospital child psychiatric service compared 18 months (n = 17) versus 18 months (n = 20) post implementation. Average length of hospital stay decreased 40% (22.4-13.4 days) and use of crisis interventions decreased 77% (holds/restraints; 0.65/day to 0.15/day), though each result only approached statistical significance (p = 0.07; 0.057). This study provides preliminary evidence for improved outcomes after implementation of an ASD-CP.
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http://dx.doi.org/10.1007/s10803-018-3666-yDOI Listing
December 2018

Implementing Treatment of Opioid-Use Disorder in Rural Settings: a Focus on HIV and Hepatitis C Prevention and Treatment.

Curr HIV/AIDS Rep 2018 08;15(4):315-323

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

Purpose Of Review: To describe the epidemiology of opioid-use disorder in the rural United States (U.S.) as it pertains to HIV and hepatitis C transmission and treatment resources.

Recent Findings: Heroin and fentanyl analogs have surpassed prescription opioids in their availability in rural opioid markets adding to HIV and hepatitis C (HCV) and overdose risks. Only 18% of rural individuals live in towns with inpatient services which are of limited quality and utility. Opioid treatment programs that provide methadone are not located in rural areas and only 3% of the primary care providers have the ability to prescribe buprenorphine. National models and resources have been established but lack implementation in rural areas leading to ongoing HIV and HCV transmission and overdose. Addressing the adverse impact of opioids in the rural U.S. will require a concerted effort to implement effective treatments according to national standards.
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http://dx.doi.org/10.1007/s11904-018-0402-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6260984PMC
August 2018

The State of Emergency Child and Adolescent Psychiatry: Raising the Bar.

Child Adolesc Psychiatr Clin N Am 2018 07 12;27(3):357-365. Epub 2018 Apr 12.

Department of Child and Adolescent Psychiatry, NYU Langone Health, One Park Avenue, 7th Floor, New York, NY 10016, USA; Department of Child and Adolescent Psychiatry, Bellevue Hospital Center, 562 First Avenue, 21st Floor, New York, NY 10016, USA.

The current state of emergency child and adolescent psychiatry includes common historical challenges to safe and effective care as well as recent innovations in multiple settings that increase the quality of that care. These include (1) enhancements within pediatric emergency departments (EDs), (2) specialized and dedicated child psychiatry emergency programs that are hospital based, (3) telepsychiatry programs that spread access to child psychiatric evaluation and treatment planning, and (4) community-based mobile programs diverting youth from EDs. Together, these highlight the work in North America over the past 5 years to improve the care of youth in psychiatric crisis.
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http://dx.doi.org/10.1016/j.chc.2018.02.001DOI Listing
July 2018

Risk of Heroin Dependence in Newly Incident Heroin Users.

JAMA Psychiatry 2018 08;75(8):863-864

Department of Epidemiology and Biostatistics, Michigan State University, East Lansing.

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http://dx.doi.org/10.1001/jamapsychiatry.2018.1214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6584277PMC
August 2018

Network-Based Research on Rural Opioid Use: an Overview of Methods and Lessons Learned.

Curr HIV/AIDS Rep 2018 04;15(2):113-119

Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, KY, USA.

Purpose Of Review: The purpose of this paper is to provide a thorough overview of methods used for recruitment, network data collection, and network data management in a network-based study of rural people who use drugs (PWUD) and to offer methodological recommendations for future research on rural drug use.

Recent Findings: The Social Networks among Appalachian People (SNAP) study recruited a cohort of 503 rural PWUD via respondent-driven sampling (RDS) and has retained more than 80% of eligible participants over 7-9 years. SNAP has yielded important methodological insights, including that (1) RDS referral was non-random and disproportionately involved kin and (2) interviewer-administered questionnaires were successful in eliciting accurate name and age information about network members. The SNAP experience suggests that RDS was a successful recruitment strategy for rural PWUD and questionnaires administered by community-based interviewers in the context of a Certificate of Confidentiality could elicit detailed data on PWUD risk networks.
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http://dx.doi.org/10.1007/s11904-018-0391-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5884725PMC
April 2018

Friendly Faces: Characteristics of Children and Adolescents With Repeat Visits to a Specialized Child Psychiatric Emergency Program.

Pediatr Emerg Care 2021 Jan;37(1):4-10

Statistical Research Consultants, LLC, Schaumburg, IL.

Objectives: Pediatric mental health emergency department (ED) visits continue to rise with 19% to 62% of youth presenting to the ED ultimately returning for a mental health-related complaint. To better understand the needs of children returning to the ED, this study examines the clinical, demographic, and environmental factors associated with revisits to a dedicated child psychiatric ED.

Methods: Clinical factors, home environment, and mental health service utilization of 885 children presenting to a dedicated child psychiatric ED over a 1-year period were abstracted by retrospective chart review. Bivariate analyses comparing demographic and clinical characteristics for children with and without revisits and a multivariable logistic regression were performed.

Results: Of the children presenting to the ED, 186 (21.0%) had at least 1 revisit in the subsequent 180 days. Thirty-one percent of initial visits presented as urgent, 55% presented as emergent. Children presenting with more severe symptoms at their initial visit were more likely to return within 6 months. Female gender, suicidal and disruptive behavioral symptomatology, and a diagnosis of oppositional defiant disorder were associated with repeat visits. Children with mental health system involvement were more likely to have revisits than those who were "treatment naive."

Conclusions: Revisits to the ED are driven by both clinical factors, including severity and psychosocial complexity, and barriers to accessing services. Addressing the problem of return ED visits will require the development of a robust mental health service system that is accessible to children and families of all socioeconomic levels.
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http://dx.doi.org/10.1097/PEC.0000000000001428DOI Listing
January 2021

A qualitative analysis of gabapentin misuse and diversion among people who use drugs in Appalachian Kentucky.

Psychol Addict Behav 2018 02 14;32(1):115-121. Epub 2017 Dec 14.

Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky College of Medicine.

Gabapentin, an anticonvulsant and analgesic for postherpetic neuralgia, has been thought to have no abuse potential despite numerous published reports to the contrary. Gabapentin has been linked with impaired driving and opioid use, highlighting the need to more fully understand its risk profile. Thirty-three individuals reporting recent nonmedical use of gabapentin were recruited from two ongoing longitudinal studies of drug users in Appalachian Kentucky to participate in focus groups. Four sessions were held (two in the community and two in jail settings), during which participants responded to questions regarding their personal experiences with gabapentin misuse. Focus group participants were similar to other gabapentin users in the larger cohort studies with respect to demographics and drug use behaviors. Overall, the sample reported having initiated gabapentin more than 10 years earlier after having it prescribed for a legitimate, though generally off-label, medical indication (e.g., pain, anxiety, opioid detoxification). Participants reported use of gabapentin in combination with buprenorphine, other opioids, cocaine, and caffeine to produce sought-after central nervous system effects (e.g., muscle relaxation, pain reduction, sleep induction, feeling drunk, and feeling "high"). Focus group responses highlighted the low cost of gabapentin for the purpose of getting high and noted increasing popularity in the community, particularly over the last 2 years. Gabapentin was a prominent drug of abuse in two cohorts of the primarily opioid-using individuals. Providers should be aware of gabapentin's abuse potential, and a reexamination of the need for scheduling is warranted. (PsycINFO Database Record
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http://dx.doi.org/10.1037/adb0000337DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5805633PMC
February 2018

Drug Use and Incarceration among Rural Appalachian Women: Findings From a Jail Sample.

Subst Use Misuse 2018 05 21;53(6):931-941. Epub 2017 Nov 21.

d Department of Behavioral Science, Center on Drug and Alcohol Research , University of Kentucky , Lexington , Kentucky , USA.

Background/objective: The purpose of this paper is to examine drug use and incarceration history among rural Appalachian women.

Methods: This study involved random selection, screening, and interviews with rural women from local jails in Appalachia.

Results: Of the women randomly selected and screened, 97% met criteria for substance use intervention. Significant factors associated with incarceration history included age, education, custody status, and mental health. A significant interaction was observed between male sex partners and drug use on incarceration history.

Conclusions: Study findings suggest that the drug/crime relationship among rural Appalachian women is associated with their high-risk home environment, partner relationships, and mental health. Specifically, in addition to drug use, factors such as family and child relationships, anxiety, victimization, and relationships with partners should also be considered in the trajectory of criminal careers among rural Appalachian women.
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http://dx.doi.org/10.1080/10826084.2017.1385631DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6121714PMC
May 2018

African American women and sexually transmitted infections: The contextual influence of unbalanced sex ratios and individual risk behaviors.

J Drug Issues 2017 Oct 12;47(4):543-561. Epub 2016 Nov 12.

Department of Behavioral Science, Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA.

This study uses data from 564 African American women to examine the correlates of lifetime prevalence of a sexually transmitted infection (STI). Specifically, we test the effects of perceptions about the availability of African American males, five partner characteristics, and drug history. At the bivariate-level, women with an STI diagnosis were significantly more likely to have dated a man who was married, older, had sex with another man, involved in concurrent partnerships, and had been incarcerated. About half of the participants stated it was difficult to find an eligible African American male and attributed the limited pool of same-race partners to drug trafficking, a lack of monogamy, and high rates of incarceration. Multivariate analyses revealed having dated a man who had concurrent sexual partnerships or had been incarcerated, as well as drug use during sex were positively associated with ever having an STI. Individual and contextual implications are addressed.
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http://dx.doi.org/10.1177/0022042616678610DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5624720PMC
October 2017

Physicians' Decision-making When Implementing Buprenorphine With New Patients: Conjoint Analyses of Data From a Cohort of Current Prescribers.

J Addict Med 2018 Jan/Feb;12(1):31-39

Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, Lexington, KY (HKK, MRL, SLW, JRH); and Department of Behavioral Science, University of Kentucky, Lexington, KY (JLS).

Objectives: Few studies have considered how providers make decisions to prescribe buprenorphine to new patients with opioid use disorder. This study examined the relative importance of patients' clinical, financial, and social characteristics on physicians' decision-making related to willingness to prescribe buprenorphine to new patients and the number of weeks of medication that they are willing to initially prescribe after induction.

Methods: A national sample of 1174 current prescribers was surveyed. Respondents rated willingness to prescribe on a 0 to 10 scale and indicated the number of weeks of medication (ranging from none to >4 weeks) for 20 hypothetical patients. Conjoint analysis estimated relative importance scores and part-worth utilities for these 2 outcome ratings.

Results: The mean rating for willingness to prescribe was 5.52 (SD 2.47), indicating a moderate willingness to implement buprenorphine treatment. The mean prescription length was 2.06 (SD 1.34), which corresponds to 1 week of medication. For both ratings, the largest importance scores were for other risky substance use, method of payment, and spousal involvement in treatment. Illicit benzodiazepine use, having Medicaid insurance to pay for the office visit, and having an opioid-using spouse were negatively associated with these outcome ratings, whereas a history of no risky alcohol or benzodiazepine use, cash payment, and having an abstinent spouse were positively associated with both ratings.

Conclusions: Reticence to prescribe to individuals using an illicit benzodiazepine and individuals with a drug-using spouse aligns with practice guidelines. However, reluctance to prescribe to patients with Medicaid may hamper efforts to expand access to treatment.
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http://dx.doi.org/10.1097/ADM.0000000000000360DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5786469PMC
April 2019