Concurrent Paper Session B

Emergency Admissions and the Prescribing of Buprenorphine, Methadone, and Psychotropic Medications in People with Sickle Cell Disease: An Analysis of National Insurance Claims

Summary
Chronic opioid medications are necessary and well tolerated in patients with sickle cell disease (SCD) for the treatment of vaso-occlusive pain crises. However, amid the endemic of structural racism and drug related poisonings in the US, people with SCD with physiologic opioid dependence or tolerance face tremendous stigmatization and barriers to the comprehensive management of acute and chronic pain. Real-world data is lacking on adverse health outcomes such as emergency admissions for drug related poisoning events in people with SCD and physiologic opioid dependence or tolerance. To address this gap in research, our study uses national administrative claims in the US to quantify the burden of acute iatrogenic events (i.e., respiratory depression requiring naloxone reversal) in a cohort of people with SCD and physiologic opioid dependence or tolerance or opioid use disorder. We also calculated the prevalence of opioid and CNS acting prescriptions in people with SCD and physiologic opioid dependence or tolerance or opioid use disorder. Overall, our data show a high rate of emergency or acute care utilization (>60%) and a significant burden of psychiatric comorbidity in a cohort of people with SCD and physiologic opioid dependence or tolerance. The prescribing of potentially safer opioids, such as buprenorphine, was uncommon (less than 5%) in the cohort. Further research is urgently needed to optimize opioid treatment strategies, combat stigma, and improve the comprehensive management of pain and co-occurring disorders in the SCD population.

Methods
In this retrospective cohort study of people with physiologic opioid dependence/tolerance or opioid use disorder (OUD), we analyzed ten years (1/2006-12/2016) of data from the Merative™ MarketScan® Commercial and Multi-State Medicaid Databases. The predictor variable was SCD (versus a comparator group of people with chronic pain), with diagnoses identified using ICD-9/10 codes. The outcome variable was emergency admissions or hospitalization for non-fatal iatrogenic events (i.e., respiratory depression requiring naloxone reversal, toxic-metabolic encephalopathy related to psychotropic medications) and prescriptions for opioids and other CNS-acting medications, identified via procedure codes and linked pharmacy records respectively. We used multivariable Poisson regression models, adjusting for sociodemographic and clinical characteristics, to assess the relationship between SCD and prescriptions for CNS-acting 2 2023 AAAP Annual Meeting and Scientific Symposium medications.

Results
Our overall cohort consisted of 34,319 people with physiologic opioid/dependence or OUD, including 306 with SCD and 34,013 with non-SCD chronic pain. In the SCD cohort, the median age was 31.4 years, and 82% were enrolled in Medicaid. More than 1/3 of the SCD cohort had a co-occurring mood or anxiety disorder; prescriptions for CNS-acting medications were common (27.9% antidepressants; 18.4% benzodiazepines or z-drugs; 10.3% gabapentin; 10.1% antipsychotics).Compared to the non-SCD chronic pain cohort, the SCD cohort had more hospitalizations or emergency admissions for iatrogenic events (62% vs 34.9%, p<.001). The SCD cohort had a lower prevalence of buprenorphine prescriptions (4.9% vs 30.7%, aRR=0.18[0.11-0.30]) and a higher prevalence of methadone (65% vs 7.1%, aRR=7.57[6.51-8.81]) and non-methadone/non-buprenorphine opioid prescriptions (66.3% vs 20.2%, aRR=3.65[3.16-4.21]).

Conclusion
We observed an elevated rate of emergency admission and/or hospitalization for adverse iatrogenic events , as well as a significant burden of psychiatric comorbidity in a cohort of people with SCD and physiologic opioid dependence or tolerance or opioid use disorder. The prescribing of potentially safer opioids, such as buprenorphine, was uncommon in the cohort. Further research is urgently needed to optimize opioid treatment strategies, combat stigma, and improve the comprehensive management of pain and co-occurring disorders in the SCD population.

Scientific Significance
This study illustrates a high rate of emergency admission and/or hospitalization for adverse iatrogenic events in people with SCD and physiologic opioid dependence or tolerance or opioid use disorder. The prescribing of potentially safer opioids such as buprenorphine was uncommon, which may represent a pivot point for future intervention.

Learning Objectives

Understand the burden of acute care utilization for iatrogenic adverse events in people with sickle cell disease (SCD) and physiologic opioid tolerance/dependence or opioid use disorder.
Describe the burden of psychiatric comorbidity and CNS-acting medication receipt in people with sickle cell disease and physiologic opioid tolerance/dependence or opioid use disorder.
Recognize that potentially safer opioids such as buprenorphine are uncommonly prescribed in people with sickle cell disease and physiologic opioid tolerance/dependence or opioid use disorder.

Keywords

Co-Occuring Disorders
Opioid Dependence
Buprenorphine
Chronic Pain
Sickle Cell Disease

Presenter
Kevin Xu, MD, MPH

I am a physician-scientist at Wash U, where I completed psychiatry residency on the NIMH R25 research track, joined the faculty as a pharmacoepidemiologist in the TranSTAR NIDA T32 program (June 2022-June 2023), and recently received a NIDA K12 award (beginning July 2023). My research uses administrative claims to test how clinical trial findings generalize to the real world, especially in populations underrepresented in substance use disorders research. I have a particular interest in addiction treatment gaps in pregnancy and the rational deprescribing and prescribing of controlled substances. My work has been published in journals such as the American Journal of Psychiatry, Obstetrics & Gynecology, and multiple JAMA network publications.

Co-Authors: Shiyuan Anabeth Liu, Tashalee R. Brown, Lewei (Allison) Lin, Allison King, Richard A. Grucza

Prescription Psychostimulant Use in Pregnant People with Opioid Use Disorder: An Analysis of Treatment Initiation, Retention, and Acute Substance Use Disorder-Related Admissions

Summary
The United States (U.S.) has experienced significant increases in the number of pregnant people with opioid use disorder (OUD). Yet, less than 50% receive medications such as buprenorphine and methadone to treat their OUD. In non-pregnant populations, data has shown that psychostimulant treatment of underlying attention deficit hyperactivity disorder (ADHD) may decrease the burden of substance use disorder (SUD)-related acute care utilization, boost outpatient SUD treatment engagement, and improve buprenorphine retention.

Methods
We examined 3,247 pregnant people with OUD (ages 16-49 years) in the Merative™ MarketScan® Databases (2006-2016) who were initiating buprenorphine, methadone, or psychosocial treatment without MOUD. The Merative™ databases include comprehensive longitudinal clinical, enrollment, and pharmacy data for all clinical encounters and filled prescriptions in the U.S.. Pregnancy status and mental health diagnoses were identified using ICD-9/10 codes. Prescription psychostimulants (amphetamine salts, methylphenidate, lisdexamfetamine) were identified using linked pharmacy records. We used multivariable poisson regression to estimate the association of prescription psychostimulant receipt with buprenorphine and methadone initiation rates, cox regression models to estimate treatment discontinuation, and a recurrent-event, within-person case-crossover approach to evaluate risk of substance use disorder (SUD)-related emergency admission and/or hospitalization.

Results
5% (n=168) of pregnant people with OUD received prescription psychostimulants to treat ADHD. Compared to peers not receiving psychostimulants, the psychostimulant cohort had higher rates (adjusted-relative-risk[aRR]=1.81[1.50-2.18]) of buprenorphine initiation but lower methadone initiation (aRR=0.39[0.19-0.78]). As so few patients receiving psychostimulants 3 2023 AAAP Annual Meeting and Scientific Symposium initiated treatment on methadone, analyses were underpowered to evaluate methadone retention. Among people taking psychostimulants who initiated buprenorphine, psychostimulant receipt conferred a 100+ day median increase in buprenorphine retention length; 180-day retention was 55.5%, compared to 41.7% for peers not taking psychostimulants (p=.0001), which was robust in multivariable cox models showing lower buprenorphine discontinuation associated with psychostimulants (adjusted-hazard-ratio=0.77[0.67-0.88]). Person-days defined by psychostimulant fills were associated with fewer SUD-related admissions compared to days without fills (odds-ratio=0.56[0.44-0.72]).

Conclusion
The receipt of psychostimulants is uncommon among people initiating methadone for the treatment of OUD, compared to peers initiating buprenorphine, raising concern for the undertreatment of co-occurring ADHD in methadone clinics. In addition, our data shows that use of psychostimulants in pregnancy is associated with improved buprenorphine retention, thus increasing the protective effect of buprenorphine against SUD-related admissions, while having protective effects of their own with regards to decreased burden of SUD-related emergency admissions.

Scientific Significance
Psychostimulant receipt for the treatment of ADHD was more prevalent in pregnant people receiving buprenorphine than peers in methadone clinics.People who continued prescription psychostimulants such as methylphenidate and mixed amphetamine salts during pregnancy exhibited improved buprenorphine treatment retention as well as decreased SUD-related emergency room admissions and hospitalizations. These findings highlight important potential benefits of pharmacologically treating ADHD with stimulants in pregnant people with concomitant OUD and ADHD. Future studies are warranted to clarify pregnancy and neonatal outcomes when treating this specific population to further inform share decision-making.

Learning Objectives

Understand how pregnant people receiving buprenorphine and methadone differ with regards to their likelihood of receiving psychostimulants for the treatment of ADHD.
Describe the association between psychostimulant receipt and retention in OUD treatment.
Recognize that psychostimulant receipt (for the treatment of ADHD) does not translate into increased risk of emergency admission/hospitalization for drug-related poisonings in pregnant people with OUD.

Keywords

Pregnancy
ADHD
Opioid Use Disorder
Psychostimulants
Buprenorphone

Presenter
Kevin Xu, MD, MPH

I am a physician-scientist at Wash U, where I completed psychiatry residency on the NIMH R25 research track, joined the faculty as a pharmacoepidemiologist in the TranSTAR NIDA T32 program (June 2022-June 2023), and recently received a NIDA K12 award (beginning July 2023). My research uses administrative claims to test how clinical trial findings generalize to the real world, especially in populations underrepresented in substance use disorders research. I have a particular interest in addiction treatment gaps in pregnancy and the rational deprescribing and prescribing of controlled substances. My work has been published in journals such as the American Journal of Psychiatry, Obstetrics & Gynecology, and multiple JAMA network publications.

Co-Authors: Tiffani Berkel, Caitlin Martin, Hendree Jones, Ebony Carter, Jeannie Kelly, Frances Levin, Carrie Mintz, Richard Grucza

Semi-Structured Manualized Treatment Program (SSMTP) for Substance Use Disorders Among Patients in a Canadian Forensic Psychiatric Program

Summary
This paper will highlight how semi-structured manualized treatment programs (SSMTPs) based on motivational enhancement and cognitive behavioral models may increase recognition and degree of steps taken toward substance use cessation and abstinence in forensic populations with concurrent disorders. This provides a point-of-care perspective to inform future assessments and treatment, which is important given substance abuse is disproportionately prevalent among individuals in the criminal justice system and is linked with criminal behaviour. Co-existing substance use disorders with major mental disorders in forensic patients can complicate diagnosis, treatment, and rehabilitation for community re-integration. Psychosocial therapy is integral for substance use treatments but can be limited in ensuring abstinence and may lack efficacy if not well-designed to target patient risk factors and resources.

Methods
A single-centered, retrospective review of pre- and post-treatment data of forensic adult patients who underwent the SSMTP (a multi-levelled comprehensive substance abuse treatment program for individuals with concurrent disorders found UST or NCR). These individuals were either admitted to inpatient units or resided in the community as outpatients. The program was based on principles of motivational enhancement to increase engagement and cognitive behavioral models to assist with positive social and coping skill development. Participants’ readiness for change was assessed pre- and post-treatment using the Stage of Change Readiness and Treatment Eagerness 3 2023 AAAP Annual Meeting and Scientific Symposium Scale across domains of recognition, ambivalence, and taking steps, comparing performance with paired t-tests with p-value ≤ .05. Sociodemographic and clinical characteristics were analyzed with descriptive statistics, including frequencies, percentages, and mean (standard deviation).

Results
For participants using alcohol, there was no significant change noted from pre-treatment (M=17.1) to post-treatment (M=18.9), p=.091, in recognition of alcohol causing problems or in steps taken for positive change (M=28.4 to M=30.8), p=.127. However, ambivalence increased significantly (M=10.0 to M=11.4), p=.025. For participants using cannabis, cocaine, and tobacco, there were significant increases in recognition and taking steps, without any significant change in ambivalence. Cannabis recognition increased from M=21.2 to M=23.6, p=.024, and taking steps increased from M=33.1 to M=35.5, p=.008. Cocaine recognition increased from M=24.4 to M=26.7, p=.05, and taking steps increased from M=34.5 to M=37.4, p=.011. Tobacco recognition increased from M=19.0 to M=21.3, p=.022, and taking steps increased from M=32.6 to M=34.7, p=.021.

Conclusion
This study suggests that semi-structured manualized treatment programs may increase the level of recognition and degree of steps taken toward substance use cessation and abstinence in forensic populations with concurrent disorders, especially as it pertains to cannabis, cocaine, and tobacco use. Recommendations would be for the implementation of similar intervention programs in forensic populations to improve overall rehabilitation, progression through the forensic system, and limiting the risk to public safety. Future studies may build upon this study and inform further recommendations via the conduction of randomized control trials at multiple centers with greater sample sizes, broader clinical diagnoses, other substances of abuse, larger female samples, administration of treatment programs in multiple languages, and monitoring participant satisfaction and relapse rates post-treatment.

Scientific Significance
The management of substance use disorders remains a major issue for recovery, mitigation of risk, and good overall outcomes in the forensic psychiatric system. In this study, the semi-structured manualized treatment program increased recognition of substance use’s impact on individuals’ lives and enacted positive change. With these positive and significant changes regarding the use of various substances, we have added validation to possible benefits derived from further implementation of programs that use motivational enhancement and CBT techniques, education on substance use and dependency, the development of coping skills, and the identification of resources for support to work toward and maintain abstinence. Future approaches promoting combined pharmaco-psychotherapy for optimal treatment of substance use in individuals within the forensic psychiatry setting will likely improve overall outcomes.

Learning Objectives

Learners will be provided with an overview on the prevalence of substance abuse in individuals with concurrent disorders involved in the criminal justice system to inform their practice and recognize unmet patient needs related to substance use.
Learners will understand the beneficial effects of talk-based treatment in the form of a semi-structured manualized treatment program (SSMTP) on the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) scores among forensic psychiatry patients with concurrent disorders to highlight the value of its implementation in concurrent disorder care.
We will discuss lessons learned from implementing an SSMTP and the factors associated with good outcomes so that learners can consider the feasibility of implementing similar interventions while accounting for important contextual factors in their addiction care environment.

Keywords

Addiction
Substance Use Disorders
Concurrent Disorders
Forensic Populations
Psychosocial Intervention

Presenter
Kyle Fediuk, MD

Dr. Kyle Jonathan Fediuk, MD, HBSc, completed medical school at the Northern Ontario School of Medicine (NOSM) in his hometown of Thunder Bay, Ontario, Canada. Currently, he is in his second year of General Psychiatry Residency at McMaster University and St. Joseph’s Healthcare Hamilton (SJHH) in Hamilton, Ontario, Canada. Having trained and worked in a variety of settings across 3 different continents, in rural communities, Indigenous reserves, and larger urban centers, Dr. Fediuk has a breadth of experience that underlies his passion for addiction care and psychiatry. In the challenging milieu of Addiction Psychiatry, themes of harm reduction and public education have been important aspects of his work within the community. Dr. Fediuk’s clinical passions in Addiction Psychiatry, acute care, and Forensic Psychiatry have combined with his interest in translational research to optimize treatment programs that will lead to better health outcomes and satisfaction for patients. With his current team at McMaster University and SJHH, he hopes to bring insight into addiction care in forensic psychiatry patients with concurrent disorders, and how lessons learned in their work may translate into the care provided by other AAAP members and ultimately improve the well-being of our communities.

Co-Authors: Peter Sheridan, Christina Oliveira-Picado, John Bradford, Gary Chaimoqitz, Andrew Olagunji

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