Medical-Legal Partnership Effects on Mental Health, Health Care Use, and Quality of Life in Primary Care: A Randomized Clinical Trial

PURPOSE

To determine whether an immediate referral to a medical-legal partnership (MLP), compared with a 6-month waitlist control, improved mental health, health care use, and quality of life.

METHODS

This trial randomly assigned individuals to an immediate referral or a wait-list control. The MLP involved a collaboration between the primary care clinic and a legal services organization. The primary outcome was stress (6 months) as measured by the Perceived Stress Scale (PSS). Secondary measures included the Center for Epidemiologic Studies Depression Scale; Generalized Anxiety Disorder scale (GAD-7); Patient-Reported Outcomes Measurement Information System (PROMIS); and emergency department (ED), urgent care, and hospital visits. Assessments were at baseline and 3-, 6-, and 9-month follow-ups. Bayesian statistical inference and a 75% posterior probability threshold were used to identify noteworthy differences.

RESULTS

Immediate referral was associated with lower PSS scores and higher GAD-7 scores. PROMIS scores were higher for the immediate referral group with respect to several subdomains. At 6 months, the immediate referral group demonstrated 21% fewer ED visits and 75.6% more hospital visits.

CONCLUSION

Immediate referral to the MLP was associated with lower stress and a lower rate of ED visits but higher anxiety and a higher rate of hospital visits.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03805126.

Effect of a Medical-Legal Partnership on Mental Health and Utilization: A Randomized Controlled Trial in Primary Care

Context: Family physicians lack resources to effectively intervene on health-harming legal needs (HHLNs), despite growing calls to address social determinants of health. One promising model is the medical-legal partnership (MLP), which embeds legal screening and referral in clinics, but more evidence is needed prior to broader implementation. Objective: To examine whether an MLP reduces stress, depression, and medical overutilization. Study design: Randomized controlled trial. Setting: Urban, primary care clinic in Houston. Population studied: Low-income individuals, aged 18 or older, who are English or Spanish speaking with positive screens for HHLNs. Intervention: Randomization to an MLP referral or 6-month waitlist. Outcome measures: The primary outcome was perceived stress at 6 months (Perceived Stress Scale (PSS); 0-40 range). Secondary outcomes were depression (Center for Epidemiologic Studies Depression Scale (CES-D); 0-60 range), anxiety (Generalized Anxiety Disorder scale (GAD-7); 0-21 range) and self-reported emergency department, urgent care, and hospital visits. Assessments occurred at 3, 6, and 9 months. Analysis: Generalized linear modeling was used to fit each outcome at 6-months as a function of MLP group, controlling for baseline. Bayesian statistical inference with weakly informative priors and a 75% posterior probability (PP) threshold was used to identify noteworthy differences. Results: One hundred sixty individuals were randomized to intervention (80) and control (80) groups. Analyses did not find meaningful group differences for emergency department visits, urgent care visits, or CES-D. Being in the intervention group was associated with lower PSS scores (18.8 vs. 19.9; PP = 75%) but higher hospitalizations (0.4 vs. 0.3; PP = 78%) and GAD-7 scores (10.3 vs. 6.7; PP=90%). Conclusion: Findings in this trial of an MLP referral were mixed. At 6 months, participants who received an MLP referral appeared to be less stressed but also reported higher anxiety and more hospitalizations.

Experiences of Parents with Opioid Use Disorder during Their Attempts to Seek Treatment: A Qualitative Analysis

In the U.S., 12.3% of children live with at least one parent who has a substance use disorder. Prior research has shown that men are more likely to seek treatment than women and that the barriers are different; however, there is limited research focusing specifically on opioid use disorder (OUD). We sought to understand the barriers and motivators for parents with OUD. We conducted a qualitative study by interviewing parents with OUD who were part of an outpatient treatment program. Interviews followed a semi-structured format with questions on access to and motivation for treatment. The interviews were recorded and transcribed using OpenAI software. Transcripts were coded by two separate reviewers and then analyzed for themes using Atlas.ti. We interviewed 14 individuals; 3 were men, and 3 of the women identified as LGBTQ+. The participants ranged in age from 27 to 54 years old. All participants had a least one child. Gender differences existed. Mothers reported experiencing more barriers-notably, a lack of childcare, shame, and guilt-while fathers reported higher levels of support from family. Both mothers and fathers identified their children as a motivation for recovery, albeit in differing ways. Mothers and fathers with OUD experience different barriers to treatment and also rely on different resources. Prior efforts to increase access to treatment for parents have focused on physical barriers; however, our research supports the need for expanded treatment services for families and efforts to address the stigma of substance abuse disorder, but more efforts are also needed to address stigma.

The Impact of COVID-19 on Opioid-Related Overdose Deaths in Texas

Prior to the COVID-19 pandemic, the United States was facing an epidemic of opioid overdose deaths, clouding accurate inferences about the impact of the pandemic at the population level. We sought to determine the existence of increases in the trends of opioid-related overdose (ORO) deaths in the Greater Houston metropolitan area from January 2015 through December 2021, and to describe the social vulnerability present in the geographic location of these deaths. We merged records from the county medical examiner's office with social vulnerability indexes (SVIs) for the region and present geospatial locations of the aggregated ORO deaths. Time series analyses were conducted to determine trends in the deaths, with a specific focus on the years 2019 to 2021. A total of 2660 deaths were included in the study and the mean (standard deviation, SD) age at death was 41.04 (13.60) years. Heroin and fentanyl were the most frequent opioids detected, present in 1153 (43.35%) and 1023 (38.46%) ORO deaths. We found that ORO deaths increased during the years 2019 to 2021 (p-value ≤ 0.001) when compared with 2015. Compared to the year 2019, ORO deaths increased for the years 2020 and 2021 (p-value ≤ 0.001). The geographic locations of ORO deaths were not associated with differences in the SVI. The COVID-19 pandemic had an impact on increasing ORO deaths in the metropolitan Houston area; however, identifying the determinants to guide targeted interventions in the areas of greatest need may require other factors, in addition to community-level social vulnerability parameters.

The Impact of Pediatric Opioid-Related Visits on U.S. Emergency Departments

Background: While there is significant research exploring adults’ use of opioids, there has been minimal focus on the opioid impact within emergency departments for the pediatric population. Methods: We examined data from the Agency for Healthcare Research, the National Emergency Department Sample (NEDS), and death data from the Centers for Disease Control and Prevention. Sociodemographic and financial variables were analyzed for encounters during 2014–2017 for patients under age 18, matching diagnoses codes for opioid-related overdose or opioid use disorder. Results: During this period, 59,658 children presented to an ED for any diagnoses involving opioids. The majority (68.5%) of visits were related to overdoses (poisoning), with a mean age of 11.3 years and a majority female (53%). There was a curvilinear relationship between age and encounters, with teens representing the majority of visits, followed by infants. The highest volume was seen in the Southern U.S., with over 58% more opioid visits than the next highest region (Midwest). Charges exceeded USD 157 million, representing 2% of total ED costs, with Medicaid responsible for 54% of the total. Conclusions: With increases in substance use among children, there is a growing need for pediatric emergency physicians to recognize, refer, and initiate treatments.

Machine Learning for Predicting Risk of Early Dropout in a Recovery Program for Opioid Use Disorder

Background: An increase in opioid use has led to an opioid crisis during the last decade, leading to declarations of a public health emergency. In response to this call, the Houston Emergency Opioid Engagement System (HEROES) was established and created an emergency access pathway into long-term recovery for individuals with an opioid use disorder. A major contributor to the success of the program is retention of the enrolled individuals in the program. Methods: We have identified an increase in dropout from the program after 90 and 120 days. Based on more than 700 program participants, we developed a machine learning approach to predict the individualized risk for dropping out of the program. Results: Our model achieved sensitivity of 0.81 and specificity of 0.65 for dropout at 90 days and improved the performance to sensitivity of 0.86 and specificity of 0.66 for 120 days. Additionally, we identified individual risk factors for dropout, including previous overdose and relapse and improvement in reported quality of life. Conclusions: Our informatics approach provides insight into an area where programs may allocate additional resources in order to retain high-risk individuals and increase the chances of success in recovery.

Sociodemographic and Clinical Characteristics Associated with Improvements in Quality of Life for Participants with Opioid Use Disorder

Background: The Houston Emergency Opioid Engagement System was established to create an access pathway into long-term recovery for individuals with opioid use disorder. The program determines effectiveness across multiple dimensions, one of which is by measuring the participant’s reported quality of life (QoL) at the beginning of the program and at successive intervals. Methods: A visual analog scale was used to measure the change in QoL among participants after joining the program. We then identified sociodemographic and clinical characteristics associated with changes in QoL. Results: 71% of the participants (n = 494) experienced an increase in their QoL scores, with an average improvement of 15.8 ± 29 points out of a hundred. We identified 10 factors associated with a significant change in QoL. Participants who relapsed during treatment experienced minor increases in QoL, and participants who attended professional counseling experienced the largest increases in QoL compared with those who did not. Conclusions: Insight into significant factors associated with increases in QoL may inform programs on areas of focus. The inclusion of counseling and other services that address factors such as psychological distress were found to increase participants’ QoL and success in recovery.

Patterns and risk factors of opioid-suspected EMS overdose in Houston metropolitan area, 2015-2019: A Bayesian spatiotemporal analysis

BACKGROUND

Opioid-related overdose deaths are the top accidental cause of death in the United States, and development of regional strategies to address this epidemic should begin with a better understanding of where and when overdoses are occurring.

METHODS AND FINDINGS

In this study, we relied on emergency medical services data to investigate the geographical and temporal patterns in opioid-suspected overdose incidents in one of the largest and most ethnically diverse metropolitan areas (Houston Texas). Using a cross sectional design and Bayesian spatiotemporal models, we identified zip code areas with excessive opioid-suspected incidents, and assessed how the incidence risks were associated with zip code level socioeconomic characteristics. Our analysis suggested that opioid-suspected overdose incidents were particularly high in multiple zip codes, primarily south and central within the city. Zip codes with high percentage of renters had higher overdose relative risk (RR = 1.03; 95% CI: [1.01, 1.04]), while crowded housing and larger proportion of white citizens had lower relative risks (RR = 0.9; 95% CI: [0.84, 0.96], RR = 0.97, 95% CI: [0.95, 0.99], respectively).

CONCLUSIONS

Our analysis illustrated the utility of Bayesian spatiotemporal models in assisting the development of targeted community strategies for local prevention and harm reduction efforts.

Prevalence of Mental Health Disorders among Individuals Enrolled in an Emergency Response Program for Treatment of Opioid Use Disorder

Background

Psychiatric co-occurring disorders among individuals with opioid use disorder has primarily focused on epidemiological surveys of patients in continuous or long-term treatment, yet little is known about the socio-economically vulnerable who are non-treatment seeking prior to an emergency response.

Methods

We retrospectively analyzed data from patients who had enrolled in a study involving home outreach to patients referred from police, emergency medical services (EMS), or hospital emergency departments following an emergency response. The sample is largely socio-economically vulnerable with high rates of unemployment and uninsured. Eligible consenting patients received an intervention consisting of medication (buprenorphine), behavioral counseling, and peer support. Participants completed semi-structured, psychological instruments to assess current and prior history for both substance use and mental health disorders. We used descriptive statistics to evaluate rates of co-occurring mental health comorbidity.

Results

Among 102 patients (average age = 36.5 years old), approximately 61 (59.8%) reported a prior mental health diagnosis, with 31 (30.3%) currently on medications for their diagnoses. Mood and anxiety disorders were most frequently recorded. Just over half (51%) had received any prior treatment for their substance use. Of those with dual disorders, 67.2% had experienced prior suicidal thoughts, and 63.7% reported polysubstance use of 5 or more substances.

Conclusion

Co-occurring psychiatric disorders, and specifically mood and anxiety disorders, appear to be prevalent in vulnerable populations at an increased rate. Mental health assessments should routinely be performed in the emergency setting and in early stages of treatment.

The Post Hurricane Harvey Respiratory Protection Training Program

OBJECTIVES

This study evaluated the effectiveness of an outreach program which included safety training and the distribution of personal protection kits in the Houston area in the aftermath of Hurricane Harvey.

METHODS

Outreach: 71 volunteers conducted training sessions at 19 different sites and distributed a total of 1187 kits. Follow-up study: We conducted telephonic interviews to collect data on respiratory symptoms and obtain perceptions of the quality of the safety training provided among 83 participants.

RESULTS

Participants reported an increase in airway symptoms four weeks after Hurricane Harvey. Outreach efforts were felt to be effective by a majority of participants.

CONCLUSION

Future studies may adopt some of the best practices from our training efforts in terms of utilizing a combination of verbal demonstrations and written training guidelines on proper respirator usage.

Using virtual reality to study food cravings

Food cravings (FCs) are associated with overeating and obesity and are triggered by environmental cues. The study of FCs is challenged by difficulty replicating the natural environment in a laboratory. Virtual reality (VR) could be used to deliver naturalistic cues in a laboratory. The purpose of this study was to investigate whether food related cues delivered by VR could induce greater FCs than neutral VR cues, photographic food cues, or real food. Sixty normal weight non-dieting women were recruited; and, to prevent a floor effect, half were primed with a monotonous diet (MD). Experimental procedures involved delivering neutral cues via VR and food related cues via VR, photographs, and real food in counterbalanced order while measuring subjective (self-report) and objective (salivation) FCs. FCs produced by VR were marginally greater than a neutral cue, not significantly different from picture cues, and significantly less than real food. The modest effects may have been due to quality of the VR system and/or measures of FC (i.e., self-report and salivation). FC threshold among non-dieting normal weight women was lowered with the use of a MD condition. Weight loss programs with monotonous diets may inadvertently increase FCs making diet compliance more difficult.