Literature Collection

Pain remains a major unmet health need. Rising opioid prescribing has not reduced population pain and has directly contributed to increased morbidity and mortality. Opioid use disorder (OUD) and pain frequently coexist. Many people with OUD experience acute and chronic pain and a substantial proportion of patients prescribed opioids develop OUD. We have contributed to this problem. In this Position Paper, we defend the idea that we must urgently redefine pain medicine as a frontline discipline in opioid use disorder prevention and recovery. Pain management must be reframed as part of the solution for people with or at risk of OUD. Core principles include: early identification of OUD and psychiatric comorbidity, routine incorporation of trauma-informed, stigma-reducing communication and shared decision-making; continuation of opioid agonist therapy during acute care; use of tailored multimodal, opioid-sparing analgesia; and perioperative planning with addiction and primary care follow-up. At a system level, we recommend multidisciplinary opioid stewardship, clear limits on opioid indication, dose and duration, diversion-mitigation strategies and policy changes such as reduced pack sizes and limiting indications for prolonged-released opioids. Research priorities include qualitative studies of lived experience, inclusion of patient-reported outcomes in trials and big-data analyses of prescribing to identify targets for intervention. Integrating clinical best practice, stigma-aware care and system reforms can reduce harm while ensuring equitable, effective pain relief for people with pain and those with or at risk of OUD. SIGNIFICANCE: This position paper synthesises clinical, psychosocial and system-level strategies to manage pain in people with or at risk of OUD. It emphasises our unique responsibility by learning from failures, and constructively sees the future. Treatment continuity, trauma-informed and stigma-reducing communication, integrated care, interdisciplinary coordination and opioid stewardship policies are no longer optional. These recommendations aim to reduce harms, improve pain and mental-health outcomes and guide clinicians and policymakers toward better and more equitable care.

IMPORTANCE: Care management benefits community-dwelling patients with dementia, but studies include few patients with moderate to severe dementia or from racial and ethnic minority populations, lack palliative care, and seldom reduce health care utilization. OBJECTIVE: To determine whether integrated dementia palliative care reduces dementia symptoms, caregiver depression and distress, and emergency department (ED) visits and hospitalizations compared with usual care in moderate to severe dementia. DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial of community-dwelling patients with moderate to severe dementia and their caregivers enrolled from March 2019 to December 2020 from 2 sites in central Indiana (2-year follow-up completed on January 7, 2023). Electronic health record screening identified patients with dementia; caregivers confirmed eligibility, including dementia stage. INTERVENTION: The intervention consisted of monthly calls from a trained nurse or social worker and evidence-based protocols to help caregivers manage patients' neuropsychiatric symptoms, caregiver distress, and palliative care issues (eg, advance care planning, symptoms, and hospice) (n = 99). Usual care caregivers received written dementia resource information and patients received care from usual clinicians (n = 102). MAIN OUTCOMES AND MEASURES: The primary outcome was Neuropsychiatric Inventory Questionnaire (NPI-Q) severity score (scores range from 0-36, with higher scores indicating worse patient symptoms). Secondary outcomes included Symptom Management in End-of-Life Dementia scores, caregiver depression (Patient Health Questionnaire-8) scores, caregiver distress (NPI-Q distress) scores, and combined ED and hospitalization events. Outcomes were assessed quarterly for 24 months or until patient death. RESULTS: A total of 201 dyads were enrolled (patients were 67.7% female; 43.3% African American; mean [SD] age, 83.6 [7.9] years); 3 dyads withdrew and 83 patients died over the course of the study, with at least 90% of eligible dyads in both groups completing each of the quarterly assessments. For the dementia palliative care vs usual care groups, mean NPI-Q severity scores were 9.92 vs 9.41 at baseline and 9.15 vs 9.39 at 24 months, respectively (between-group difference at 24 months, -0.24 [95% CI, -2.33 to 1.84]). There was no significant difference in the rate of change in NPI-Q severity from baseline between groups over time (P = .87 for the group and time interaction). There were no significant differences in the secondary outcomes, except that there were fewer combined ED and hospitalization events in the dementia palliative care group (mean events/patient, 1.06 in dementia palliative care vs 2.37 in usual care; between-group difference, -1.31 [95% CI, -1.93 to -0.69]; relative risk, 0.45 [95% CI, 0.31 to 0.65]). CONCLUSIONS AND RELEVANCE: Among community-dwelling patients with moderate to severe dementia and their caregivers, dementia palliative care, compared with usual care, did not significantly improve patients' neuropsychiatric symptoms through 24 months. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03773757.

Buprenorphine is a highly effective treatment for opioid use disorder and a critical tool for addressing the worsening U.S. overdose crisis. However, multiple barriers to treatment - including stringent federal regulations - have historically made this medication hard to reach for many who need it. In 2020, under the COVID-19 Public Health Emergency, federal regulators substantially changed access to buprenorphine by allowing prescribers to initiate patients on buprenorphine via telehealth without first evaluating them in person. As the Public Health Emergency is set to expire in May of 2023, Congress and federal agencies can leverage extensive evidence from studies conducted during the wake of the pandemic to make evidencebased decisions on the regulation of buprenorphine going forward. To aid policy makers, this review synthesizes and interprets peer-reviewed research on the effect of buprenorphine flexibilities on uptake and implementation of telehealth, and its impact on OUD patient and prescriber experiences, access to treatment and health outcomes. Overall, our review finds that many prescribers and patients took advantage of telehealth, including the audio-only option, with a wide range of benefits and few downsides. As a result, federal regulators-including agencies and Congress-should continue non-restricted use of telehealth for buprenorphine initiation.

Buprenorphine is a highly effective treatment for opioid use disorder (OUD) and a critical tool for addressing the worsening US overdose crisis. However, multiple barriers to treatment-including stringent federal regulations-have historically made this medication hard to reach for many who need it. In 2020, under the COVID-19 public health emergency, federal regulators substantially changed access to buprenorphine by allowing prescribers to initiate patients on buprenorphine via telehealth without first evaluating them in person. As the public health emergency has been set to expire in May of 2023, Congress and federal agencies can leverage extensive evidence from studies conducted during the wake of the pandemic to make evidence-based decisions on the regulation of buprenorphine going forward. To aid policy makers, this narrative review synthesizes and interprets peer-reviewed research on the effect of buprenorphine flexibilities on the uptake and implementation of telehealth, and its impact on OUD patient and prescriber experiences, access to treatment, and health outcomes. Overall, our review finds that many prescribers and patients took advantage of telehealth, including the audio-only option, with a wide range of benefits and few downsides. As a result, federal regulators-including agencies and Congress-should continue nonrestricted use of telehealth for buprenorphine initiation.

Patients with extensive hospitalization experience present challenges for mental healthcare by disrupting continuity of care across service systems. This study explores how mental healthcare services address the needs of these patients, focusing on service gaps between hospitalization and community services. By examining the underlying reasons for their reliance on hospitals, the study offers insights into the lived experiences of this marginalized group. The study aims to provide knowledge that can enhance treatment and care for patients with severe mental disorders. Using a narrative explanatory design, we interviewed 14 patients with extensive hospitalization experience. A holistic-content analysis revealed shortcomings in community services that contributed to frequent hospitalizations. These inconsistencies contributed to paternalistic treatment and collaboration issues, misaligning services with patients' needs. Patients were frequently labeled as "difficult" and placed at inappropriate levels of care, sometimes resorting to extreme measures to access the care they required. The study highlights paradoxes and contradictions between goals, policies, and service provision in mental healthcare. Patients were caught between two extremes entrenched in a struggle with services, either to gain access to support or to break free from service constraints. We argue that better access to institution-based treatment and care could provide benefits to these patients and help bridge service gap. Establishing long-term, well-staffed residential facilities would not only relieve hospitals of the burden of frequent readmissions but also enhance service integration. This would provide a much-needed middle ground, ensuring that patients receive the appropriate level of care while preventing unnecessary hospitalization.

OBJECTIVE: To examine the effects of PlayReadVIP, a pediatric primary care intervention promoting early relational health, on child behaviors. STUDY DESIGN: A factorial randomized controlled trial enrolled mother-child dyads postpartum. PlayReadVIP was delivered in 2 phases: birth to 3 years (PlayReadVIP 0-3) and 3-5 years (PlayReadVIP 3-5). At enrollment, dyads were assigned to PlayReadVIP 0-3 or control. At age 3, dyads were rerandomized to PlayReadVIP 3-5 or control. Analyses included dyads with a second randomization and complete data on the mediators and child outcomes. In PlayReadVIP, dyads attended one-on-one sessions with a parent coach, in which they received child development information, learning materials, and real-time, strengths-based feedback on brief video recordings of parent-child interactions. Cognitive stimulation and harsh discipline were reported by mothers. Child behaviors were assessed using the Behavior Assessment System for Children, Second Edition. RESULTS: A total of 143 dyads, primarily immigrant, Latino/Hispanic, and low-socioeconomic status, comprised the analytic sample. Mothers in PlayReadVIP vs control had higher cognitive stimulation at 54 months, which resulted in reduced problem behaviors (aggression and attention problems) and better social skills in their children in second grade. No significant indirect effects through harsh discipline were found. CONCLUSIONS: PlayReadVIP leads to sustained but small improvements in child behaviors by enhancing maternal cognitive stimulation, emphasizing the potential of early intervention in pediatric primary care for promoting child mental health in disadvantaged populations.