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Nordeck CD, Kelly SM, Schwartz RP, Mitchell SG, Welsh C, O'Grady KE, Gryczynski J. Hospital admissions among patients with Comorbid Substance Use disorders: a secondary analysis of predictors from the NavSTAR Trial. Addict Sci Clin Pract 2024; 19:33. [PMID: 38678216 PMCID: PMC11056040 DOI: 10.1186/s13722-024-00463-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 04/09/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Individuals with substance use disorders (SUDs) frequently use acute hospital services. The Navigation Services to Avoid Rehospitalization (NavSTAR) trial found that a patient navigation intervention for hospitalized patients with comorbid SUDs reduced subsequent inpatient admissions compared to treatment-as-usual (TAU). METHODS This secondary analysis extends previous findings from the NavSTAR trial by examining whether selected patient characteristics independently predicted hospital service utilization and moderated the effect of the NavSTAR intervention. Participants were 400 medical/surgical hospital patients with comorbid SUDs. We analyzed 30- and 90-day inpatient readmissions (one or more readmissions) and cumulative incidence of inpatient admissions through 12 months using multivariable logistic and negative binomial regression, respectively. RESULTS Consistent with primary findings and controlling for patient factors, NavSTAR participants were less likely than TAU participants to be readmitted within 30 (P = 0.001) and 90 (P = 0.03) days and had fewer total readmissions over 12 months (P = 0.008). Hospitalization in the previous year (P < 0.001) was associated with cumulative readmissions over 12 months, whereas Medicaid insurance (P = 0.03) and index diagnoses of infection (P = 0.001) and injuries, poisonings, or procedural complications (P = 0.004) were associated with fewer readmissions. None of the selected covariates moderated the effect of the NavSTAR intervention. CONCLUSIONS Previous findings showed that patient navigation could reduce repeat hospital admissions among patients with comorbid SUDs. Several patient factors were independently associated with readmission. Future research should investigate risk factors for hospital readmission among patients with comorbid SUDs to optimize interventions. TRIAL REGISTRATION NIH ClinicalTrials.gov NCT02599818, Registered November 9, 2015 https://classic. CLINICALTRIALS gov/ct2/show/NCT02599818 .
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Affiliation(s)
- Courtney D Nordeck
- Friends Research Institute, 1040 Park Avenue #103, Baltimore, MD, USA, 21201.
| | - Sharon M Kelly
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert P Schwartz
- Friends Research Institute, 1040 Park Avenue #103, Baltimore, MD, USA, 21201
| | - Shannon G Mitchell
- Friends Research Institute, 1040 Park Avenue #103, Baltimore, MD, USA, 21201
| | | | | | - Jan Gryczynski
- Friends Research Institute, 1040 Park Avenue #103, Baltimore, MD, USA, 21201
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Martinez NG, Truong AQ, Nordeck CD, Agus D, Genberg BL, Buresh ME. "I want to stay here": Patient and staff perspectives on transitioning from a low-threshold buprenorphine program to clinic-based care. Drug Alcohol Depend 2024; 257:111130. [PMID: 38452408 DOI: 10.1016/j.drugalcdep.2024.111130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/09/2024] [Accepted: 02/11/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND The Project Connections At Re-Entry (PCARE) Van is a low-threshold buprenorphine program operating outside the Baltimore City Detention Center. Like other low-threshold programs, PCARE seeks to engage a vulnerable population in care, stabilize patients, then transition patients to longer-term care; however, <10% of patients transition to clinic-based buprenorphine treatment. Our goal was to better understand these low transition rates and center patient perspectives in discussion of broader low-threshold program design. METHODS From December 2022 to June 2023, semi-structured interviews were conducted with 20 former and current PCARE patients and 6 staff members. We used deductive and inductive coding followed by thematic content analysis to identify themes around treatment experiences and care preferences. RESULTS There were strong preferences among current and former patients for continuing buprenorphine treatment at the PCARE Van. Several themes emerged from the data that explained patient preferences, including both advantages to continuing care at the van (preference for continuity, feeling respected by the program's structure and philosophy) and disadvantages to transitioning to a clinic (perceived harms associated with rigid or punitive care models). Staff noted limited program capacity, and patients expressed that if needed, they would transition to a clinic for altruistic reasons. Staff expressed varied perspectives on low-threshold care, emphasizing both larger systems factors, as well as beliefs about individual patient responsibility. CONCLUSIONS While many low-threshold care settings are designed as transitional bridge models, this research highlights patient preference for long-term care at low-threshold programs and supports efforts to adapt low-threshold models to be sustainable as longitudinal care.
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Affiliation(s)
- Noelle G Martinez
- Division of Addiction Medicine, Johns Hopkins University School of Medicine, Mason F. Lord Building East Tower 2nd Floor, 5200 Eastern Avenue, Baltimore, MD 21224, USA.
| | - Ashley Q Truong
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Courtney D Nordeck
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD 21201, USA
| | - Deborah Agus
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA; Behavioral Health Leadership Institute, 2601N. Howard Street, Baltimore, MD 21218, USA
| | - Becky L Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Megan E Buresh
- Division of Addiction Medicine, Johns Hopkins University School of Medicine, Mason F. Lord Building East Tower 2nd Floor, 5200 Eastern Avenue, Baltimore, MD 21224, USA
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Nordeck CD, Sharma A, Terplan M, Dusek K, Gilliams E, Gryczynski J. Opioid Use Disorder Treatment Linkage at Strategic Touchpoints Using Buprenorphine (OUTLAST-B): Rationale, Design, and Evolution of a Randomized Controlled Trial. J Psychiatr Brain Sci 2023; 8:e230010. [PMID: 38456042 PMCID: PMC10919199 DOI: 10.20900/jpbs.20230010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Background Despite the effectiveness and growing availability of treatment for opioid use disorder (OUD) with buprenorphine, many people with OUD do not access treatment services. This article describes the rationale, methodological design, evolution, and progress of an ongoing clinical trial of treatment linkage strategies for people with untreated OUD. Methods The study, titled Opioid Use Disorder Treatment Linkage at Strategic Touchpoints using Buprenorphine (OUTLAST-B), uses "strategic touchpoints", initially sexual health clinics and subsequently broadened to other service venues and participant social networks, for recruitment and screening. Adults with untreated OUD (target N = 360) are randomized to one of the three arms: Usual Care (UC, enhanced with overdose education and naloxone distribution), Patient Navigation (PN), or Patient Navigation with an immediate short-term bridge prescription for buprenorphine (PN + BUP). In the PN and PN + BUP arms, the Patient Navigator works with participants for 2 months to facilitate treatment entry and early retention, resolve barriers (e.g., ID cards, transportation), and provide motivational support. Results The primary outcome is OUD treatment entry within 30 days of enrollment. Participants are assessed at baseline and followed at 3- and 6-months post-enrollment on measures of healthcare utilization, substance use, and general functioning. Challenges and recruitment adaptations pursuant to the COVID-19 pandemic are discussed. Conclusions This study could provide insights on how to reach people with untreated OUD and link them to care through non-traditional routes. Trial Registration The study is registered at ClinicalTrials.gov (NCT04991974).
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Affiliation(s)
| | - Anjalee Sharma
- Friends Research Institute, Baltimore, MD 21201, USA
- Behavioral Pharmacology Research Unit, Johns Hopkins School of Medicine, Baltimore, MD 21224, USA
| | | | - Kristi Dusek
- Friends Research Institute, Baltimore, MD 21201, USA
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Alexander K, Nordeck CD, Rosecrans A, Harris R, Collins A, Gryczynski J. The effect of a non-congregate, integrated care shelter on health: A qualitative study. Public Health Nurs 2023. [PMID: 37102455 DOI: 10.1111/phn.13197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 03/22/2023] [Accepted: 04/09/2023] [Indexed: 04/28/2023]
Abstract
OBJECTIVE To describe the experiences of unstably housed, medically vulnerable residents living at the Haven, a novel, non-congregate integrated care shelter operating in a historic hotel during the COVID-19 pandemic. DESIGN A qualitative descriptive design. SAMPLE/MEASUREMENT Semi-structured qualitative interviews were conducted in February and March 2022 with a purposive sample of 20 residents living in the integrated care shelter. Data were analyzed in May and June 2022 using the thematic analysis methods described by Braun and Clarke. RESULTS Six women and 14 men, ages 23-71 (M = 50, SD = 14), were interviewed. Lengths of stay at the time of the interview ranged from 74 to 536 days (M = 311 days). Medical co-morbidities and substance use details were collected at baseline. Three themes were identified: (1) Autonomy, (2) supportive environments, and (3) stability and the need for permanent housing. Participants characterized the integrated care, non-congregate model as having multiple advantages over traditional shelter systems. Participants emphasized the role of nurses and case managers in providing a respectful, caring environment in the integrated shelter model. CONCLUSION Participants described acute physical and mental health needs which were largely met by the innovative integrated shelter care model. The effect of homelessness and housing insecurity on health is well documented, but few solutions exist that promote autonomy. Participants in this qualitative study emphasized the benefits of living in a non-congregate integrated care shelter and the services which promoted their self-management of chronic diseases. PATIENT OR PUBLIC CONTRIBUTION Patients were the participants in the study, but were not involved in the design, analysis of interpretation of the data, or preparation of the manuscript. Due to this project's small scope, we could not involve patients or the public after the study concluded data collection.
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Affiliation(s)
| | | | | | - Robert Harris
- Baltimore City Health Department, Baltimore, Maryland
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Orme S, Zarkin GA, Dunlap LJ, Nordeck CD, Schwartz RP, Mitchell SG, Welsh C, O’Grady KE, Gryczynski J. Cost and Cost Savings of Navigation Services to Avoid Rehospitalization for a Comorbid Substance Use Disorder Population. Med Care 2022; 60:631-635. [PMID: 35687900 PMCID: PMC9382857 DOI: 10.1097/mlr.0000000000001743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A randomized clinical trial found that patient navigation for hospital patients with comorbid substance use disorders (SUDs) reduced emergency department (ED) and inpatient hospital utilization compared with treatment-as-usual. OBJECTIVE To compare the cost and calculate any cost savings from the Navigation Services to Avoid Rehospitalization (NavSTAR) intervention over treatment-as-usual. RESEARCH DESIGN This study calculates activity-based costs from the health care providers and uses a net benefits approach to calculate the cost savings generated from NavSTAR. NavSTAR provided patient navigation focused on engagement in SUD treatment, starting before hospital discharge and continuing for up to 3 months postdischarge. SUBJECTS Adult hospitalized medical/surgical patients with comorbid SUD for opioids, cocaine, and/or alcohol. COST MEASURES Cost of the 3-month NavSTAR patient navigation intervention and the cost of all inpatient days and ED visits over a 12-month period. RESULTS OF BASE CASE ANALYSIS NavSTAR generated $17,780 per participant in cost savings. Ninety-seven percent of bootstrapped samples generated positive cost savings, and our sensitivity analyses did not change our results. LIMITATIONS Participants were recruited at one hospital in Baltimore, MD through the hospital's addiction consultation service. Findings may not generalize to the broader population. Outpatient health care cost data was not available through administrative records. CONCLUSION Our findings show that patient navigation interventions should be considered by payors and policy makers to reduce the high hospital costs associated with comorbid SUD patients.
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Affiliation(s)
- Stephen Orme
- RTI International, 3040 East Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709
| | - Gary A. Zarkin
- RTI International, 3040 East Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709
| | - Laura J. Dunlap
- RTI International, 3040 East Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709
| | | | - Robert P. Schwartz
- Friends Research Institute, 1040 Park Avenue Suite 103. Baltimore, MD 21201
| | | | - Christopher Welsh
- University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201
| | - Kevin E. O’Grady
- Department of Psychology, University of Maryland, College Park, 4094 Campus Drive, College Park, MD 20742
| | - Jan Gryczynski
- Friends Research Institute, 1040 Park Avenue Suite 103. Baltimore, MD 21201
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6
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Sharma A, Mitchell SG, Nordeck CD, Schwartz RP, Dusek K, O'Grady KE, Gryczynski J. Sexually Transmitted Infection Testing After Brief Intervention for Risk Behaviors in School-Based Health Centers. J Adolesc Health 2022; 70:577-583. [PMID: 35078735 DOI: 10.1016/j.jadohealth.2021.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 11/03/2021] [Accepted: 11/05/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE The initiation and escalation of substance use and sex behaviors is prevalent during adolescence. School-based health centers (SBHCs) are well-equipped to provide interventions for risky behaviors and offer sexually transmitted infection (STI) testing services. This study examined receipt of STI testing following brief intervention (BI) among sexually active adolescents. METHODS This is a secondary analysis of data from a randomized trial comparing computer versus nurse practitioner-delivered BI approaches among adolescents (ages 14-18) with risky alcohol and/or cannabis use at two SBHCs within two urban high schools. Associations were examined among receipt of STI testing and participant characteristics, BI format, site, and frequency of substance use/sexual behaviors. RESULTS Among sexually active participants (N = 254), 64.2% received STI testing at their SBHC within 6 months of receiving a BI. Participants receiving nurse practitioner-delivered BI had higher odds of getting STI testing than participants receiving computer-delivered BI (adjusted odds ratio 2.51, 95% confidence interval 1.41-4.47, p = .002). Other variables associated with STI testing in multivariable logistic regression included female sex (p = .001), being in a serious relationship (p = .018), and SBHC site (p < .001). Frequency of substance use and sexual risk behaviors were not independently associated with receipt of STI testing services. CONCLUSION Sexually active adolescents who received in-person BI from a nurse practitioner were more likely to get STI testing than adolescents who received BI via computer. Nurse practitioners working in SBHCs can successfully engage adolescents in additional sexual health services subsequent to BI for risky behaviors.
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Affiliation(s)
| | | | - Courtney D Nordeck
- Friends Research Institute, Baltimore, Maryland; Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | | | - Kevin E O'Grady
- Department of Psychology, University of Maryland, College Park, Maryland
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Nordeck CD, Riehm KE, Smail EJ, Holingue C, Kane JC, Johnson RM, Veldhuis CB, Kalb LG, Stuart EA, Kreuter F, Thrul J. Changes in drinking days among United States adults during the COVID-19 pandemic. Addiction 2022; 117:331-340. [PMID: 34159674 PMCID: PMC8441933 DOI: 10.1111/add.15622] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/30/2020] [Accepted: 06/09/2021] [Indexed: 12/11/2022]
Abstract
AIMS To examine changes in drinking behavior among United States (US) adults between March 10 and July 21, 2020, a critical period during the COVID-19 pandemic. DESIGN Longitudinal, internet-based panel survey. SETTING The Understanding America Study (UAS), a nationally representative panel of US adults age 18 or older. PARTICIPANTS A total of 4298 US adults who reported alcohol use. MEASUREMENTS Changes in number of reported drinking days from March 11, 2020 through July 21, 2020 in the overall sample and stratified by sex, age, race/ethnicity, household structure, poverty status, and census region. FINDINGS Compared with March 11, the number of drinking days per week was significantly higher on April 1 by an average of 0.36 days (95% CI = 0.30, 0.43), on May 1 by an average of 0.55 days (95% CI = 0.47, 0.63), on June 1 by an average of 0.41 days (95% CI = 0.33, 0.49), and on July 1 by an average of 0.39 days (95% CI = 0.31, 0.48). Males, White participants, and older adults reported sustained increases in drinking days, whereas female participants and individuals living under the federal poverty line had attenuated drinking days in the latter part of the study period. CONCLUSIONS Between March and mid-July 2020, adults in the United States reported increases in the number of drinking days, with sustained increases observed among males, White participants, and older adults.
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Affiliation(s)
- Courtney D. Nordeck
- Department of Mental Health, Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMDUSA
| | - Kira E. Riehm
- Department of Mental Health, Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMDUSA
| | - Emily J. Smail
- Department of Mental Health, Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMDUSA
| | - Calliope Holingue
- Department of Mental Health, Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMDUSA
- Department of Neuropsychology, Kennedy Krieger InstituteJohns Hopkins UniversityBaltimoreMDUSA
| | - Jeremy C. Kane
- Department of Epidemiology, Mailman School of Public HealthColumbia UniversityNew YorkNYUSA
| | - Renee M. Johnson
- Department of Mental Health, Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMDUSA
| | | | - Luther G. Kalb
- Department of Mental Health, Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMDUSA
- Department of Neuropsychology, Kennedy Krieger InstituteJohns Hopkins UniversityBaltimoreMDUSA
| | - Elizabeth A. Stuart
- Department of Mental Health, Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMDUSA
| | - Frauke Kreuter
- Joint Program in Survey MethodologyUniversity of MarylandMDUSA
- Department of StatisticsLudwig Maximilian University of MunichMunichGermany
- Statistical Methods GroupInstitute for Employment ResearchNurembergGermany
| | - Johannes Thrul
- Department of Mental Health, Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreMDUSA
- Centre for Alcohol Policy ResearchLa Trobe UniversityBundooraVICAustralia
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Brenneke SG, Nordeck CD, Riehm KE, Schmid I, Tormohlen KN, Smail EJ, Johnson RM, Kalb LG, Stuart EA, Thrul J. Trends in cannabis use among U.S. adults amid the COVID-19 pandemic. Int J Drug Policy 2022; 100:103517. [PMID: 34894469 PMCID: PMC8653409 DOI: 10.1016/j.drugpo.2021.103517] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/18/2021] [Accepted: 10/20/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The COVID-19 pandemic has had an impact on mental health and alcohol use in the US, however there is little research on its impacts on cannabis use. Considering the role of cannabis as a coping strategy or self-medicating behavior, there is a need to understand how individuals who use cannabis have adapted their use amid the pandemic. Therefore, this study examined changes in self-reported cannabis use among US adults in the context of COVID-19 pandemic by (1) describing trends of use during the first 8 months of the pandemic among adults who used cannabis in this period; and (2) characterizing trends of use within sociodemographic subgroups and by state cannabis policy status. METHODS The sample consisted of 1,761 US adults who used cannabis at least once during the 8-month study period from the nationally representative Understanding America Study. Linear mixed-effect models were used to model changes in the number of days of past-week cannabis use across 16 waves from March 10, 2020, to November 11, 2020. RESULTS Compared to early March, the number of days cannabis was used per week was significantly higher at the start of April (β=0.11, 95% CI=0.03, 0.18) and May (β=0.21,95% CI=0.05, 0.36). In subsequent months (June - November), the number of days of cannabis use attenuated to levels comparable to March. Trends of cannabis use across the study period generally did not differ across sociodemographic characteristics and state cannabis policy status. CONCLUSION Though increases in use were marginal among many groups, the evolving pandemic and the growing concern for the mental health of segments of the U.S. population warrant close monitoring of coping behaviors, including substance use.
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Affiliation(s)
- Savannah G Brenneke
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624N Broadway, Baltimore, MD 21205, USA.
| | - Courtney D Nordeck
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624N Broadway, Baltimore, MD 21205, USA
| | - Kira E Riehm
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624N Broadway, Baltimore, MD 21205, USA
| | - Ian Schmid
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624N Broadway, Baltimore, MD 21205, USA
| | - Kayla N Tormohlen
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, 624N Broadway, Baltimore, MD 21205, USA
| | - Emily J Smail
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624N Broadway, Baltimore, MD 21205, USA
| | - Renee M Johnson
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624N Broadway, Baltimore, MD 21205, USA
| | - Luther G Kalb
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624N Broadway, Baltimore, MD 21205, USA; Department of Neuropsychology, Kennedy Krieger Institute, Johns Hopkins University, 1750 E Fairmount Ave, Baltimore, MD 21231, USA
| | - Elizabeth A Stuart
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624N Broadway, Baltimore, MD 21205, USA
| | - Johannes Thrul
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624N Broadway, Baltimore, MD 21205, USA; Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, USA; Centre for Alcohol Policy Research, La Trobe University, Melbourne, Australia
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Mitchell SG, Nordeck CD, Lertch E, Ross TE, Welsh C, Schwartz RP, Gryczynski J. Patients with substance use disorders receiving continued care in skilled nursing facilities following hospitalization. Subst Abus 2022; 43:848-854. [PMID: 35179452 PMCID: PMC9793431 DOI: 10.1080/08897077.2021.2007512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: As hospitals in the US face pressures to reduce lengths of stay, healthcare systems are increasingly utilizing skilled nursing facilities (SNFs) to continue treating patients stable enough to leave the hospital, but not to return home. Substance use disorder (SUD) can complicate care of patients transferred to SNFs. The objective of this paper is to understand SNF experiences for this population of patients with comorbid SUD transferred to SNFs and examine care experiences in these facilities. Methods: This secondary mixed-methods analysis focuses on SNF experiences from a clinical trial of patient navigation services for medically-hospitalized adults with comorbid opioid, cocaine, and/or alcohol use disorder. This study compared baseline assessments and medical record review for participants (N = 400) with vs. without SNF transfer, and analyzed semi-structured qualitative interviews with a subsample of 15 participants purposively selected based on their transfer to a SNF. Results: Over 1 in 4 participants had a planned discharged to a SNF (26.8% sub-acute, 3.3% acute). Compared to participants with other types of discharge, participants discharged to a SNF had longer initial hospitalizations (4.9 vs. 11.8 days, p < 0.001), and were more likely to be White (38.6 vs. 50.8%; p = 0.02), female (38.9 vs. 52.5%; p = 0.01), have opioid use disorder (75.7 vs. 85.0%, p = 0.03), and be hospitalized for infection (43.6 vs. 58.3%; p = 0.007), and less likely to have worked prior to hospitalization (24.3 vs. 12.5%; p = 0.006). Qualitative narratives identified several themes from the SNF experience, including opioid analgesic dosing issues, challenges to the use of opioid agonist treatment of OUD, illicit opioid dealing/use, and limited access to addiction recovery support services during and following the SNF stay. Conclusions: SNFs are a common disposition for patients in need of subacute services following hospitalization but may be ill-equipped to properly manage patients in need of new or continuing SUD treatment.
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Affiliation(s)
| | - Courtney D. Nordeck
- Friends Research Institute, Inc., Baltimore, MD,Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | | | - Christopher Welsh
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD
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Gryczynski J, Nordeck CD, Welsh C, Mitchell SG, O'Grady KE, Schwartz RP. Preventing Hospital Readmission for Patients With Comorbid Substance Use Disorder : A Randomized Trial. Ann Intern Med 2021; 174:899-909. [PMID: 33819055 DOI: 10.7326/m20-5475] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Hospitalized patients with comorbid substance use disorders (SUDs) are at high risk for poor outcomes, including readmission and emergency department (ED) use. OBJECTIVE To determine whether patient navigation services reduce hospital readmissions. DESIGN Randomized controlled trial comparing Navigation Services to Avoid Rehospitalization (NavSTAR) versus treatment as usual (TAU). (ClinicalTrials.gov: NCT02599818). SETTING Urban academic hospital in Baltimore, Maryland, with an SUD consultation service. PARTICIPANTS 400 hospitalized adults with comorbid SUD (opioid, cocaine, or alcohol). INTERVENTION NavSTAR used proactive case management, advocacy, service linkage, and motivational support to resolve internal and external barriers to care and address SUD, medical, and basic needs for 3 months after discharge. MEASUREMENTS Data on inpatient readmissions (primary outcome) and ED visits for 12 months were obtained for all participants via the regional health information exchange. Entry into SUD treatment, substance use, and related outcomes were assessed at 3-, 6-, and 12-month follow-up. RESULTS Participants had high levels of acute care use: 69% had an inpatient readmission and 79% visited the ED over the 12-month observation period. Event rates per 1000 person-days were 6.05 (NavSTAR) versus 8.13 (TAU) for inpatient admissions (hazard ratio, 0.74 [95% CI, 0.58 to 0.96]; P = 0.020) and 17.66 (NavSTAR) versus 27.85 (TAU) for ED visits (hazard ratio, 0.66 [CI, 0.49 to 0.89]; P = 0.006). Participants in the NavSTAR group were less likely to have an inpatient readmission within 30 days than those receiving TAU (15.5% vs. 30.0%; P < 0.001) and were more likely to enter community SUD treatment after discharge (P = 0.014; treatment entry within 3 months, 50.3% NavSTAR vs. 35.3% TAU). LIMITATION Single-site trial, which limits generalizability. CONCLUSION Patient navigation reduced inpatient readmissions and ED visits in this clinically challenging sample of hospitalized patients with comorbid SUDs. PRIMARY FUNDING SOURCE National Institute on Drug Abuse.
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Affiliation(s)
- Jan Gryczynski
- Friends Research Institute, Baltimore, Maryland (J.G., C.D.N., S.G.M., R.P.S.)
| | - Courtney D Nordeck
- Friends Research Institute, Baltimore, Maryland (J.G., C.D.N., S.G.M., R.P.S.)
| | - Christopher Welsh
- University of Maryland School of Medicine, Baltimore, Maryland (C.W.)
| | - Shannon G Mitchell
- Friends Research Institute, Baltimore, Maryland (J.G., C.D.N., S.G.M., R.P.S.)
| | | | - Robert P Schwartz
- Friends Research Institute, Baltimore, Maryland (J.G., C.D.N., S.G.M., R.P.S.)
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Gryczynski J, Nordeck CD, Martin RD, Welsh C, Schwartz RP, Mitchell SG, Jaffe JH. Leveraging health information exchange for clinical research: Extreme underreporting of hospital service utilization among patients with substance use disorders. Drug Alcohol Depend 2020; 212:107992. [PMID: 32388492 PMCID: PMC7299087 DOI: 10.1016/j.drugalcdep.2020.107992] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 03/22/2020] [Accepted: 03/24/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Substance use disorders are associated with inefficient and fragmented use of healthcare services. The Chesapeake Regional Information System for Our Patients, Inc. (CRISP) is a Health Information Exchange (HIE) linking disparate systems of care in the mid-Atlantic region. METHODS This article describes applications of HIE for tracking hospital service utilization in substance use disorder clinical and services research, drawing upon data from one of the first studies approved to access the CRISP HIE. Participants were 200 medical/surgical inpatients with comorbid opioid, cocaine, and/or alcohol use disorder (45.5 % female; 56.5 % black; 77.5 % opioid use disorder; 42.0 % homeless). This study compared HIE-identified hospital service utilization with conventional methods of participant self-report during in-person research follow-ups (3-, 6-, and 12-months post-discharge) and electronic health record (EHR) review from the hospital system of the index admission. RESULTS This sample exhibited high levels of hospital utilization, which would have been underestimated using conventional methods. Relying exclusively on self-report in the 12-month observation period would have identified only 33.8 % of 429 inpatient hospitalizations and 9.0 % of 1,287 ED visits, due to both loss-to-follow-up and failure to report events. Even combining self-report with single-system EHR review identified only 66.2 % of inpatient hospitalizations and 59.8 % of ED visits. CONCLUSIONS CRISP HIE data were superior to conventional methods for ascertaining hospital service utilization in this sample of patients exhibiting high-volume and fragmented care. The use of HIE holds implications for improving rigor, safety, and efficiency in research studies.
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Affiliation(s)
- Jan Gryczynski
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD 21201, USA.
| | - Courtney D. Nordeck
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD, USA 21201
| | - Ross D. Martin
- Chesapeake Regional Information System for Our Patients, Inc., 7160 Columbia Gateway Drive, Suite 100, Columbia, MD, USA 21046
| | - Christopher Welsh
- University of Maryland School of Medicine, 655 W. Baltimore St.,Baltimore, MD, USA 21201
| | - Robert P. Schwartz
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD, USA 21201
| | | | - Jerome H. Jaffe
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD, USA 21201
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Nordeck CD, Gryczynski J, O’Grady KE, Polak K, Svikis DS, McNeely J, Wu LT, Schwartz RP. Comparison of timeline follow-back self-report and oral fluid testing to detect substance use in adult primary care patients. Drug Alcohol Depend 2020; 209:107939. [PMID: 32114329 PMCID: PMC7360056 DOI: 10.1016/j.drugalcdep.2020.107939] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 01/09/2020] [Accepted: 02/19/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Timeline Follow-back (TLFB) interviews using self-report are often used to assess substance use. Oral fluid testing (OFT) offers an objective measure of substance use. There are limited data on the agreement between TLFB and OFT. METHODS In this secondary analysis from a multisite study in five primary care sites, self-reported TLFB and OFT data collected under confidential conditions were compared to assess concordance (N=1799). OFT samples were analyzed for marijuana, heroin, cocaine, and non-medical use of prescription opioids. Demographic differences in discordance relative to TLFB and OFT concordant results for marijuana, the only substance with an adequate sample size in this analysis, were examined using multinomial logistic regression. RESULTS Overall concordance rates between TLFB and OFT were 94.9 % or higher for each substance, driven by large subgroups with no use. Among participants with discordant use, marijuana was the only substance with lower detection on OFT than self-report (27.6 % OFT-positive only vs 32.2 % TLFB-positive only), whereas cocaine (65.6 % vs 8.6 %), prescription opioids (90.4 % vs 6.0 %), and heroin (40.7 % vs 26.0 %) all had higher detection via OFT than TLFB. Participants who reported marijuana use but had a negative OFT were more likely to be younger, Hispanic, and White compared to those with TLFB and OFT concordant positive results. CONCLUSIONS TLFB and OFT show disparate detection of different substances. Researchers should consider the implications of using either self-report or oral fluid testing in isolation, depending on the substance and collection setting. Triangulating multiple sources of information may improve detection of drug use.
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Affiliation(s)
| | | | | | | | | | | | - Li-Tzy Wu
- Duke University School of Medicine, Durham, NC, USA
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Nordeck CD, Welsh C, Schwartz RP, Mitchell SG, Cohen A, O’Grady KE, Gryczynski J. Rehospitalization and substance use disorder (SUD) treatment entry among patients seen by a hospital SUD consultation-liaison service. Drug Alcohol Depend 2018; 186. [PMID: 29529456 PMCID: PMC5922267 DOI: 10.1016/j.drugalcdep.2017.12.043] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Substance use disorders (SUD) are associated with non-adherence to medical care and high utilization of hospital services. This study characterized patterns and correlates of rehospitalization among patients seen by a hospital-based SUD consultation-liaison (CL) team. METHODS This study was a retrospective medical record review of patients in a large urban academic hospital who received SUD consultation and were diagnosed with opioid, cocaine, and/or alcohol use disorder (N = 267). Data were collected on patient characteristics, substance-specific SUD diagnoses (opioids, cocaine, and alcohol), opioid agonist treatment (OAT) with methadone or buprenorphine (treatment status at admission; in-hospital initiation of OAT), and rehospitalization through 180 days post-discharge. Associations with rehospitalization were examined using bivariate tests of independence and multivariate logistic regression, with patient background and medical characteristics, substance-specific SUD diagnoses, and OAT status (at admission and in-hospital initiation) as predictors. RESULTS Rehospitalization rates were higher among patients with current opioid (38% vs. 24%; p < .05) and cocaine use disorders (39% vs. 26%; p < .05) compared to patients without these diagnoses. In multivariate logistic regression analysis, the number of medical comorbidities [Adjusted Odds Ratio (AOR) = 1.2; p < .01] and opioid use disorder (AOR = 2.4, p < .05) were independently associated with rehospitalization. CONCLUSIONS In this sample of hospital patients receiving SUD CL services, the risk of rehospitalization differed by type of SUD diagnosis. In-hospital initiation of OAT is promising for facilitating treatment linkage post-discharge, but this small study did not show differences in rehospitalization based on OAT initiation. These findings could inform services for hospital patients with comorbid SUDs.
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Affiliation(s)
- Courtney D. Nordeck
- Friends Research Institute, 1040 Park Avenue, Suite 103. Baltimore, MD 21201, USA
| | - Christopher Welsh
- Department of Psychiatry, Division of Alcohol and Drug Abuse, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD 21201, USA
| | - Robert P. Schwartz
- Friends Research Institute, 1040 Park Avenue, Suite 103. Baltimore, MD 21201, USA
| | | | - Art Cohen
- Department of Psychiatry, Division of Alcohol and Drug Abuse, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD 21201, USA
| | - Kevin E. O’Grady
- Department of Psychology, University of Maryland, 4094 Campus Drive, College Park, MD 20742, USA
| | - Jan Gryczynski
- Friends Research Institute, 1040 Park Avenue, Suite 103. Baltimore, MD 21201, USA.
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Gryczynski J, Schwartz RP, Fishman MJ, Nordeck CD, Grant J, Nidich S, Rothenberg S, O'Grady KE. Integration of Transcendental Meditation® (TM) into alcohol use disorder (AUD) treatment. J Subst Abuse Treat 2018; 87:23-30. [DOI: 10.1016/j.jsat.2018.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 01/10/2018] [Accepted: 01/12/2018] [Indexed: 01/22/2023]
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Gryczynski J, McNeely J, Wu LT, Subramaniam GA, Svikis DS, Cathers LA, Sharma G, King J, Jelstrom E, Nordeck CD, Sharma A, Mitchell SG, O'Grady KE, Schwartz RP. Validation of the TAPS-1: A Four-Item Screening Tool to Identify Unhealthy Substance Use in Primary Care. J Gen Intern Med 2017; 32:990-996. [PMID: 28550609 PMCID: PMC5570743 DOI: 10.1007/s11606-017-4079-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 03/16/2017] [Accepted: 04/28/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Tobacco, Alcohol, Prescription Medication, and Other Substance use (TAPS) tool is a combined two-part screening and brief assessment developed for adult primary care patients. The tool's first-stage screening component (TAPS-1) consists of four items asking about past 12-month use for four substance categories, with response options of never, less than monthly, monthly, weekly, and daily or almost daily. OBJECTIVE To validate the TAPS-1 in primary care patients. DESIGN Participants completed the TAPS tool in self- and interviewer-administered formats, in random order. In this secondary analysis, the TAPS-1 was evaluated against DSM-5 substance use disorder (SUD) criteria to determine optimal cut-points for identifying unhealthy substance use at three severity levels (problem use, mild SUD, and moderate-to-severe SUD). PARTICIPANTS Two thousand adult patients at five primary care sites. MAIN MEASURES DSM-5 SUD criteria were determined via the modified Composite International Diagnostic Interview. Oral fluid was used as a biomarker of recent drug use. KEY RESULTS Optimal frequency-of-use cut-points on the self-administered TAPS-1 for identifying SUDs were ≥ monthly use for tobacco and alcohol (sensitivity = 0.92 and 0.71, specificity = 0.80 and 0.85, AUC = 0.86 and 0.78, respectively) and any reported use for illicit drugs and prescription medication misuse (sensitivity = 0.93 and 0.89, specificity = 0.85 and 0.91, AUC = 0.89 and 0.90, respectively). The performance of the interviewer-administered format was similar. When administered first, the self-administered format yielded higher disclosure rates for past 12-month alcohol use, illicit drug use, and prescription medication misuse. Frequency of use alone did not provide sufficient information to discriminate between gradations of substance use problem severity. Among those who denied drug use on the TAPS-1, less than 4% had a drug-positive biomarker. CONCLUSIONS The TAPS-1 can identify unhealthy substance use in primary care patients with a high level of accuracy, and may have utility in primary care for rapid triage.
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Affiliation(s)
- Jan Gryczynski
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD, 21201, USA.
| | | | - Li-Tzy Wu
- Duke University School of Medicine, Durham, NC, USA
| | - Geetha A Subramaniam
- Center for Clinical Trials Network, National Institute on Drug Abuse, North Bethesda, MD, USA
| | | | | | | | | | | | - Courtney D Nordeck
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD, 21201, USA
| | - Anjalee Sharma
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD, 21201, USA
| | - Shannon G Mitchell
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD, 21201, USA
| | | | - Robert P Schwartz
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD, 21201, USA
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Schwartz RP, McNeely J, Wu LT, Sharma G, Wahle A, Cushing C, Nordeck CD, Sharma A, O'Grady KE, Gryczynski J, Mitchell SG, Ali RL, Marsden J, Subramaniam GA. Identifying substance misuse in primary care: TAPS Tool compared to the WHO ASSIST. J Subst Abuse Treat 2017; 76:69-76. [PMID: 28159441 DOI: 10.1016/j.jsat.2017.01.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 01/25/2017] [Accepted: 01/25/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND There is a need for screening and brief assessment instruments to identify primary care patients with substance use problems. This study's aim was to examine the performance of a two-step screening and brief assessment instrument, the TAPS Tool, compared to the WHO ASSIST. METHODS Two thousand adult primary care patients recruited from five primary care clinics in four Eastern US states completed the TAPS Tool followed by the ASSIST. The ability of the TAPS Tool to identify moderate- and high-risk use scores on the ASSIST was examined using sensitivity and specificity analyses. RESULTS The interviewer and self-administered computer tablet versions of the TAPS Tool generated similar results. The interviewer-administered version (at cut-off of 2), had acceptable sensitivity and specificity for high-risk tobacco (0.90 and 0.77) and alcohol (0.87 and 0.80) use. For illicit drugs, sensitivities were >0.82 and specificities >0.92. The TAPS (at a cut-off of 1) had good sensitivity and specificity for moderate-risk tobacco use (0.83 and 0.97) and alcohol (0.83 and 0.74). Among illicit drugs, sensitivity was acceptable for moderate-risk of marijuana (0.71), while it was low for all other illicit drugs and non-medical use of prescription medications. Specificities were 0.97 or higher for all illicit drugs and prescription medications. CONCLUSIONS The TAPS Tool identified adult primary care patients with high-risk ASSIST scores for all substances as well moderate-risk users of tobacco, alcohol, and marijuana, although it did not perform well in identifying patients with moderate-risk use of other drugs or non-medical use of prescription medications. The advantages of the TAPS Tool over the ASSIST are its more limited number of items and focus solely on substance use in the past 3months.
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Affiliation(s)
- R P Schwartz
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD 21201, USA.
| | - J McNeely
- New York University School of Medicine, Department of Population Health, 550 First Avenue, VZ30 6th floor, New York, NY 10016, USA.
| | - L T Wu
- Duke University, Department of Psychiatry and Behavioral Sciences and Department of Medicine, Duke University Medical Center, Durham, NC, USA.
| | - G Sharma
- Emmes Corporation, 401 North Washington Street, Suite 700, Rockville, MD 20850, USA.
| | - A Wahle
- Emmes Corporation, 401 North Washington Street, Suite 700, Rockville, MD 20850, USA
| | - C Cushing
- National Institute on Drug Abuse, 6001 Executive Boulevard, Rockville, MD 20852, USA
| | - C D Nordeck
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD 21201, USA
| | - A Sharma
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD 21201, USA
| | - K E O'Grady
- University of Maryland, College Park, Department of Psychology, 4094 Campus Dr., College Park, MD 20742, USA
| | - J Gryczynski
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD 21201, USA
| | - S G Mitchell
- Friends Research Institute, 1040 Park Avenue, Suite 103, Baltimore, MD 21201, USA
| | - R L Ali
- University of Adelaide, Department of Pharmacology, Frome Road, Level 5, Medical School North Bldg, The University of Adelaide, Adelaide, SA 5005, Australia.
| | - J Marsden
- Addictions Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Addiction Sciences Building, 4 Windsor Walk, Denmark Hill, SE5 8BB London, United Kingdom.
| | - G A Subramaniam
- National Institute on Drug Abuse, 6001 Executive Boulevard, Rockville, MD 20852, USA.
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