Literature Collection

BACKGROUND: Irritability, a common behavioral problem for school-aged children, is often first assessed by primary care providers, who manage about a third of mental health conditions in children. Until recent changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM), irritability was often associated with mood disorders, which may have led to increases in bipolar disorder diagnosis and prescription of mood stabilizing medication. OBJECTIVE: Our aim was to explore differences between the approaches psychiatric and primary care providers use to assess irritability. METHODS: A single trained interviewer conducted detailed interviews and collected demographic data from a homogeneous group of physicians that saturated with a sample size of 17 pediatric, family medicine, and psychiatric providers who evaluate and treat school-aged children. Qualitative and quantitative data were collected and analyzed. RESULTS: In general, primary care providers chose to refer children with irritability to mental health specialists when medication management became complex, while the psychiatric providers chose behavior modification and parent education strategies rather than medications. The psychiatric group had a significantly higher caseload mix, prior experience with irritability, and more confidence in their assessment capabilities. There was lack of continuing medical education about irritability in all groups. CONCLUSION: This preliminary study highlights the importance of collaboration between primary care and subspecialties to promote accurate assessment and subsequent treatment of school-aged children with irritability, who can represent a safety concern for self and others. More research is needed to establish an efficient method of assessing and managing irritability in primary care and better utilization of specialists.

BACKGROUND: Integrated care addresses the fragmentation of patient health services and potentially improves the experience of care, reduces healthcare costs, and improves health outcomes. This study assessed the improvements in mental health and physical health outcomes among patients living with mental health challenges and treated in an integrated care setting. METHODS: The longitudinal retrospective cohort study evaluated anxiety (GAD-7), depression (PHQ-9), systolic blood pressure, and glycated hemoglobin levels from baseline to the next three assessments recorded from October 1, 2018, to December 31, 2023. RESULTS: At baseline, 239 participants responded to mental health outcome measures, 344 to systolic blood pressure, and 164 to glycated hemoglobin level. The Generalized Estimating Equations analysis showed an improvement in GAD-7 (-1.28 [95% CI, -1.71 to -0.85]) and PHQ-9 (-1.37 [95% CI, -1.73 to -0.92]) scores in successive assessments. The physical health outcomes (Systolic blood pressure (-0.004 [95% CI, -1.34 to 1.35]) and glycated hemoglobin (0.04 [95% CI, -0.07 to 0.15])) remained stable. CONCLUSION: This study demonstrates that patients with mental health challenges treated in integrated care experience improvements in depression and anxiety symptoms, with stable physical health outcomes.

IMPORTANCE: A central tenet of harm reduction and prevention of opioid overdose deaths is the distribution and use of naloxone. Patient-centered methods that investigate naloxone acquisition and carrying can guide opioid overdose education and naloxone distribution efforts. OBJECTIVE: To assess patients' self-reported naloxone acquisition and carrying after an emergency department (ED) encounter using automated text messaging. DESIGN, SETTING, AND PARTICIPANTS: This cohort study investigated self-reported patient behaviors involving naloxone after ED discharge in a large, urban academic health system in Philadelphia, Pennsylvania. Adult patients who were prescribed or dispensed naloxone and who had a mobile phone number listed in the electronic health record provided informed consent after ED discharge, and data were collected prospectively using text messaging from October 10, 2020, to March 19, 2021. Patients who did not respond to the survey or who opted out were excluded. EXPOSURE: Automated text message-based survey after ED discharge for patients who were prescribed or dispensed naloxone. MAIN OUTCOMES AND MEASURES: The primary outcome was patient-reported naloxone acquisition, carrying, and use. Descriptive statistics were used to summarize patient demographic characteristics. RESULTS: Of 205 eligible patients, 41 (20.0%) completed the survey; of those patients, the mean (SD) age was 39.5 (13.7) years, and 21 (51.2%) were women. Fifteen (36.6%) had a personal history of being given naloxone after an overdose. As indicated by the ED record, 27 participants (65.9%) had naloxone dispensed in the ED, and 36 (87.8%) self-reported acquiring naloxone during or after their ED visit. Twenty-four participants (58.5%) were not carrying naloxone in the week before their ED visit. Twenty participants (48.8%) were carrying naloxone after the ED visit, and 27 (65.9%) reported planning to continue carrying naloxone in the future. Of the 24 individuals (58.5%) not carrying naloxone before their ED encounter, 13 (54.2%) reported planning to continue carrying naloxone in the future. CONCLUSIONS AND RELEVANCE: In this cohort study of adult patients dispensed or prescribed naloxone from the ED, most reported acquiring naloxone on or after discharge. The ED remains a key point of access to naloxone for individuals at high risk of opioid use and overdose, and text messaging could be a method to engage and motivate patient-reported behaviors in enhancing naloxone acquisition and carrying.

IMPORTANCE: Racial and ethnic disparities persist across key health and substance use treatment outcomes for mothers and infants. The use of medications, such as methadone or buprenorphine, for the treatment of opioid use disorder (OUD) has been associated with improvements in the outcomes of mothers and infants; however, only half of all pregnant women with OUD receive these medications. The extent to which maternal race or ethnicity is associated with the use of medication to treat OUD, the duration of the use of medication to treat OUD, and the type of medication used to treat OUD during pregnancy are unknown. OBJECTIVE: To examine the extent to which maternal race and ethnicity is associated with the use of medications for the treatment of OUD in the year before delivery among pregnant women with OUD. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used a linked population-level statewide data set of pregnant women with OUD who delivered a live infant in Massachusetts between October 1, 2011, and December 31, 2015. Of 274 234 total deliveries identified, 5247 deliveries among women with indicators of having OUD were included in the analysis. Maternal race and ethnicity were defined as white non-Hispanic, black non-Hispanic, or Hispanic based on self-reported data on birth certificates. MAIN OUTCOMES AND MEASURES: Main outcomes were the receipt of any medication for OUD, the consistency of the use of medication (at least 6 continuous months of use before delivery, inconsistent use, or no use) for the treatment of OUD, and the type of medication (methadone or buprenorphine) used to treat OUD. Multivariable models were adjusted for maternal sociodemographic characteristics, comorbidities, and any significant interactions between the covariates and race and ethnicity. RESULTS: The sample included 5247 pregnant women with OUD who delivered a live infant in Massachusetts during the study period. The mean (SD) maternal age at delivery was 28.7 (5.0) years; 4551 women (86.7%) were white non-Hispanic, 462 women (8.8%) were Hispanic, and 234 women (4.5%) were black non-Hispanic. A total of 3181 white non-Hispanic women (69.9%) received any type of medication for the treatment of OUD in the year before delivery compared with 228 Hispanic women (49.4%) and 108 black non-Hispanic women (46.2%). Compared with white non-Hispanic women, black non-Hispanic and Hispanic women had a substantially lower likelihood (adjusted odds ratio [aOR], 0.37; 95% CI, 0.28-0.49 and aOR, 0.42; 95% CI, 0.35-0.52, respectively) of receiving any medication for the treatment of OUD. Stratification by maternal age identified greater disparities among younger women. Black non-Hispanic and Hispanic women also had a lower likelihood (aOR, 0.24; 95% CI, 0.17-0.35 and aOR, 0.34; 95% CI, 0.27-0.44, respectively) of consistent use of medication for the treatment of OUD compared with white non-Hispanic women. With respect to the type of medication used to treat OUD, black non-Hispanic and Hispanic women had a lower likelihood (aOR, 0.60; 95% CI, 0.40-0.90 and aOR, 0.77; 95% CI, 0.58-1.01, respectively) than white non-Hispanic women of receiving buprenorphine treatment compared with methadone treatment. CONCLUSIONS AND RELEVANCE: This study found racial and ethnic disparities in the use of medications to treat OUD during pregnancy, with black non-Hispanic and Hispanic women significantly less likely to use medications consistently or at all compared with white non-Hispanic women. Further investigation of patient, clinician, treatment program, and system-level factors associated with these findings is warranted.

OBJECTIVE:  Individual patient-level measures of adverse social determinants of health are associated with neonatal opioid withdrawal syndrome (NOWS), but the relative impact of community-level adverse social determinants of health remains to be defined. We examined the association between community-level social vulnerability and NOWS among pregnant individuals receiving buprenorphine for opioid use disorder. STUDY DESIGN:  We conducted a secondary analysis of an established cohort of pregnant individuals and their infants participating in a multidisciplinary prenatal/addiction care program from 2013 to 2021. Addresses were geocoded using ArcGIS and linked at the census tract to the Centers for Disease Control and Prevention 2018 Social Vulnerability Index (SVI), incorporating 15 census variables. The primary exposure was the SVI as a composite measure of community-level social vulnerability, and secondarily, individual scores for four thematic domains (socioeconomic status, household composition and disability, minority status and language, and housing type and transportation). The primary outcome was a clinical diagnosis of NOWS defined as withdrawal requiring pharmacological treatment following buprenorphine exposure. RESULTS:  Among 703 pregnant individuals receiving buprenorphine, 39.8% (280/703) of infants were diagnosed with NOWS. Among our patinets, those who were nulliparous, had post-traumatic stress disorder, a term birth (≥ 37 weeks) and had a male infant were more likely to have an infant diagnosed with NOWS. Individuals with and without an infant diagnosed with NOWS had similarly high community-level social vulnerability per composite SVI scores (mean [standard deviation]: 0.6 [0.4-0.7] vs. 0.6 [0.4-0.7], p = 0.2]. In adjusted analyses, SVI, as a composite measure as well as the four domains, was not associated with NOWS diagnosis. CONCLUSION:  Among pregnant persons receiving buprenorphine enrolled in a multidisciplinary prenatal and addition care program, while individual risk factors that measure adverse social determinants of health were associated with an NOWS diagnosis in the infant, community-level social vulnerability as measured by the SVI was not associated with the outcome. KEY POINTS: · Community-level SVI was not associated with neonatal opioid use disorder.. · Certain individual risk factors were identified as being associated with NOWS.. · Homogeneity of composite SVI scores may have led to lack of significant findings..