Literature Collection

BACKGROUND: Unhealthy alcohol use (UAU) is common in primary care populations and can significantly impact mental health. Screening for UAU within primary care is increasingly used for point-in-time identification of UAU, but it is less clear whether changes in alcohol screening scores effectively capture changes in alcohol-related risk. METHODS: This retrospective cohort study used data from adult primary care patients in a Northwest US health system who had completed two AUDIT-C screens 11-24 months apart (T1, T2). Scores were grouped into five categories from no use to very high-risk UAU. Generalized estimating equation models tested whether changes in AUDIT-C categories from T1 to T2 were associated with changes in risk for nonaddiction mental health acute care utilization (emergency department or hospital admission) over 1 year after T1 and T2. RESULTS: Of 165,101 patients (61% female; mean age 55), mental health acute care utilization risks were 0.9% after T1 and 0.8% after T2. Compared to those with stable drinking (T1 utilization 0.8%, T2 0.8%), mental health acute care utilization risk decreased for patients with a one-level decrease (T1 1.1%, T2 0.9%, p < 0.01) or greater than or equal to two-level decrease (T1 2.5%, T2 1.4%, p < 0.001). Increases in AUDIT-C categories were not associated with increased risk of mental health acute care utilization. CONCLUSIONS: Changes in AUDIT-C score categories over time, particularly decreases, may reflect real changes in an important risk of UAU. Changes in alcohol screening scores may offer clinicians, health systems, and researchers meaningful information about changes in health risk.

OBJECTIVE: The authors report a secondary analysis from a large, multisite, pragmatic trial focused on increasing the degree of behavioral health and primary care service integration. In this analysis, the authors tested for an association between patients' reports of their clinicians' clinical empathy and the patients' self-reported physical and mental health status. METHODS: At two time points across 24 months, 3929 adult patients with chronic medical and behavioral conditions completed the Consultation and Relational Empathy (CARE) measure and the Patient-Reported Outcomes Measurement Information System (PROMIS-29) survey. The CARE was divided into 4 empathy ranges from lowest (median 31) to highest (median 50). While controlling for 49 practice and patient characteristics, the authors tested for an association between empathy range and self-reported physical and mental health (PROMIS). RESULTS: In adjusted analyses, moving from the lowest to the highest empathy range increased PROMIS (range 20-66) mental health by 2.4-3.0 points and physical health by 1.9-3.2 points. All the models were highly significant. These associations were not explained by any of the 49 measured confounders. CONCLUSION: The self-reported health status of primary care patients with multiple chronic conditions is positively correlated with the patient's experience of their clinician's empathy. It is unclear if empathic care is responsible for better outcomes, if better health engenders higher reports of empathy, or if both are caused by a third, unmeasured factor. This finding adds to the evidence that empathic care is associated with improved patient-centered health outcomes. PRACTICE IMPLICATIONS: Providing primary care services that patients experience as high in empathy is a promising strategy for improving physical and mental health.

This article examines the relationship between federal regulations, state scope-of-practice regulations on nurse practitioners (NPs), and buprenorphine prescribing patterns using pharmacy claims data from Optum's deidentified Clinformatics Data Mart between January 2015 and September 2018. The county-level proportion of patients filling prescriptions written by NPs was low even after the 2016 Comprehensive Addiction and Recovery Act (CARA), 2.7% in states that did not require physician oversight of NPs, and 1.1% in states that did. While analyses in rural counties showed higher rates of buprenorphine prescriptions written by NPs, rates were still considerably low: 3.7% in states with less restrictive regulations and 1.1% in other states. These results indicate that less restrictive scope-of-practice regulations are associated with greater NP prescribing following CARA. The small magnitude of the changes indicates that federal attempts to expand treatment access through CARA have been limited.

BACKGROUND: Prescription-type opioid use disorder (POUD) is often accompanied by comorbid anxiety, yet the impact of anxiety on retention in opioid agonist therapy (OAT) is unclear. Therefore, this study investigated whether baseline anxiety severity affects retention in OAT and whether this effect differs by OAT type (methadone maintenance therapy (MMT) vs. buprenorphine/naloxone (BNX)). METHODS: This secondary analysis used data from a pan-Canadian randomized trial comparing flexible take-home dosing BNX and standard supervised MMT for 24 weeks. The study included 268 adults with POUD. Baseline anxiety was assessed using the Beck Anxiety Inventory (BAI), with BAI ≥ 16 indicating moderate-to-severe anxiety. The primary outcomes were retention in assigned and any OAT at week 24. In addition, the impact of anxiety severity on retention was examined, and assigned OAT was considered an effect modifier. RESULTS: Of the participants, 176 (65%) reported moderate-to-severe baseline anxiety. In adjusted analyses, there was no significant difference in retention between those with BAI ≥ 16 and those with BAI < 16 assigned (29% vs. 28%; odds ratio (OR) = 2.03, 95% confidence interval (CI) = 0.94-4.40; P = 0.07) or any OAT (35% vs. 34%; OR = 1.57, 95% CI = 0.77-3.21; P = 0.21). In addition, there was no significant effect modification by OAT type for retention in assigned (P = 0.41) or any OAT (P = 0.71). In adjusted analyses, greater retention in treatment was associated with BNX (vs. MMT), male gender identity (vs. female, transgender, or other), enrolment in the Quebec study site (vs. other sites), and absence of a positive urine drug screen for stimulants at baseline. CONCLUSIONS: Baseline anxiety severity did not significantly impact retention in OAT for adults with POUD, and there was no significant effect modification by OAT type. However, the overall retention rates were low, highlighting the need to develop new strategies to minimize the risk of attrition from treatment. CLINICAL TRIAL REGISTRATION: This study was registered in ClinicalTrials.gov (NCT03033732).