Mental health disorders and long-term opioid use among adolescents and young adults with chronic pain

PurposeThe purpose of this study was to examine the association between mental health disorders and subsequent risk for long-term opioid use among adolescents and young adults presenting with common chronic pain complaints (back pain, neck pain, headache, and arthritis/joint pain).MethodsUsing claims data from January 1, 2001 to June 30, 2008, we conducted a longitudinal analysis of opioid use patterns among 13–24-year-old subjects presenting with a new episode of chronic pain. Long-term opioid use was defined as receiving >90 days of opioids within a 6-month period with no gap of >30 days in use of opioids in the 18 months after the first qualifying pain diagnosis. Mental health disorders were identified from claims in the 6 months before the first qualifying pain diagnosis.ResultsFifty-nine thousand seventy-seven youth met criteria for a new episode of chronic pain. Among these youth, 321 (.5%) met criteria for long-term opioid use, and 16,172 (27.4%) had some opioid use. After controlling for demographic and clinical factors, youth with preexisting mental health diagnoses had a 2.4-fold increased risk of subsequently receiving long-term opioids versus no opioids (odds ratio = 2.36, 95% confidence interval = 1.73–3.23) and a 1.8-fold increased likelihood of receiving long-term opioids versus some opioids (odds ratio = 1.83, 95% confidence interval = 1.34–2.50).ConclusionsMental health disorders are associated with increased risk for long-term opioid use among adolescents and emerging young adults. Further study is warranted to examine risks and benefits of long-term opioid use in this population.     

A Business Case for Quality Improvement in Addiction Treatment: Evidence from the NIATx Collaborative

The Network for the Improvement of Addiction Treatment (NIATx) promotes treatment access and retention through a customer-focused quality improvement model. This paper explores the issue of the “business case” for quality improvement in addiction treatment from the provider’s perspective. The business case model developed in this paper is based on case examples of early NIATx participants coupled with a review of the literature. Process inefficiencies indicated by long waiting times, high no-show rates, and low continuation rates cause underutilization of capacity and prevent optimal financial performance. By adopting customer-focused practices aimed at removing barriers to treatment access and retention, providers may be able to improve financial performance, increase staff retention, and gain long-term strategic advantage.     

New models for large prospective studies: is there a better way?

Large prospective cohort studies are critical for identifying etiologic factors for disease, but they require substantial long-term research investment. Such studies can be conducted as multisite consortia of academic medical centers, combinations of smaller ongoing studies, or a single large site such as a dominant regional health-care provider. Still another strategy relies upon centralized conduct of most or all aspects, recruiting through multiple temporary assessment centers. This is the approach used by a large-scale national resource in the United Kingdom known as the "UK Biobank," which completed recruitment/examination of 503,000 participants between 2007 and 2010 within budget and ahead of schedule. A key lesson from UK Biobank and similar studies is that large studies are not simply small studies made large but, rather, require fundamentally different approaches in which "process" expertise is as important as scientific rigor. Embedding recruitment in a structure that facilitates outcome determination, utilizing comprehensive and flexible information technology, automating biospecimen processing, ensuring broad consent, and establishing essentially autonomous leadership with appropriate oversight are all critical to success. Whether and how these approaches may be transportable to the United States remain to be explored, but their success in studies such as UK Biobank makes a compelling case for such explorations to begin.     

Fermentable carbohydrate restriction reduces luminal bifidobacteria and gastrointestinal symptoms in patients with irritable bowel syndrome

Preliminary studies indicate that dietary restriction of fermentable short-chain carbohydrates improves symptoms in irritable bowel syndrome (IBS). Prebiotic fructo-oligosaccharides and galacto-oligosaccharides stimulate colonic bifidobacteria. However, the effect of restricting fermentable short-chain carbohydrates on the gastrointestinal (GI) microbiota has never been examined. This randomized controlled trial aimed to investigate the effects of fermentable carbohydrate restriction on luminal microbiota, SCFA, and GI symptoms in patients with IBS. Patients with IBS were randomized to the intervention diet or habitual diet for 4 wk. The incidence and severity of symptoms and stool output were recorded for 7 d at baseline and follow-up. A stool sample was collected and analyzed for bacterial groups using fluorescent in situ hybridization. Of 41 patients randomized, 6 were withdrawn. At follow-up, there was lower intake of total short-chain fermentable carbohydrates in the intervention group compared with controls (P = 0.001). The total luminal bacteria at follow-up did not differ between groups; however, there were lower concentrations (P < 0.001) and proportions (P < 0.001) of bifidobacteria in the intervention group compared with controls when adjusted for baseline. In the intention-to-treat analysis, more patients in the intervention group reported adequate control of symptoms (13/19, 68%) compared with controls (5/22, 23%; P = 0.005). This randomized controlled trial demonstrated a reduction in concentration and proportion of luminal bifidobacteria after 4 wk of fermentable carbohydrate restriction. Although the intervention was effective in managing IBS symptoms, the implications of its effect on the GI microbiota are still to be determined.     

The Development and Psychometric Properties of the Humanitarian Emergency Settings Perceived Needs (HESPER) Scale

Objectives. We developed the Humanitarian Emergency Settings Perceived Needs (HESPER) Scale, a valid and reliable scale to rapidly assess perceived needs of populations in humanitarian settings in low- and middle-income countries.Methods. We generated items through a literature review; reduced the number of items on the basis of a survey with humanitarian experts; pilot-tested the scale in Gaza, Jordan, Sudan, and the United Kingdom; and field-tested it in Haiti, Jordan, and Nepal.Results. During field-testing, intraclass correlation coefficients (absolute agreement) for the total number of unmet needs were 0.998 in Jordan, 0.986 in Haiti, and 0.995 in Nepal (interrater reliability), and 0.961 in Jordan and 0.773 in Nepal (test–retest reliability). Cohen’s κ for the 26 individual HESPER items ranged between 0.66 and 1.0 (interrater reliability) and between 0.07 and 1.0 (test–retest reliability) across sites. Most HESPER items correlated as predicted with related questions of the World Health Organization Quality of Life-100 (WHOQOL-100), and participants found items comprehensive and relevant, suggesting criterion (concurrent) validity and content validity.Conclusions. The HESPER Scale rapidly provides valid and reliable population-based data on perceived needs in humanitarian settings.Needs assessments in humanitarian settings (i.e., places in which a large part of the population is at risk of dying or experiencing immense suffering) are vital in enabling effective and efficient emergency relief. However, current needs assessments are often far from ideal; indeed, in 2009, heads of 26 large humanitarian donor agencies signed a letter to the United Nations asking for an improvement in the area of needs assessment (J. Isbister, G. Weinberger, J.-P. Loir, et al., unpublished letter, 2009).There have also been repeated recommendations for increased participation of affected populations in humanitarian assessment.1–6 People’s participation in assessment is seen as a right and as essential for optimizing resource allocation, program design, and population empowerment.6 It increases the likelihood that interventions are based on needs as expressed by the affected population. The international humanitarian community’s focus on participation is exemplified by the fact that the recently revised, influential Sphere Handbook (5,6) on standards for humanitarian aid emphasizes the involvement of affected people.Participation is recommended throughout the assessment, design, monitoring, and evaluation program cycle.1,3–5 Additionally, in a recent ranking exercise for research priorities in the area of mental health and psychosocial support, 3 of the 10 most highly prioritized research questions in humanitarian settings included the participation of affected populations; the identification of affected populations’ stressors was ranked as top priority.7 Related to this is the notion of accountability within the international humanitarian response, including that humanitarian action should be accountable to affected populations.4Within this framework of increased participation and accountability, it has been recommended that the assessment of perceived needs be used to inform project design, monitoring, and evaluation,1–5,8,9 and perceived needs are considered a key determinant of psychosocial well-being.1,8,10 Perceived needs are defined here as needs expressed by members of the affected population themselves. They are thus problem areas for which people would likely want help. In the humanitarian field, perceived needs are still assessed mostly through rapid participatory assessments in the early phase of a crisis; these assessments tend to involve gaining qualitative data from selected stakeholders through focus groups or key respondent interviews.11 Although certainly valuable, such assessments cannot provide a population-level picture. Most population-based quantitative assessments are of “objective” indicators, such as mortality rates, malnutrition rates, or livelihood data.12–14 These indicators are often defined by outsiders (i.e., nonmembers of the affected population) and do not quantify the prevalence and distribution of needs as perceived by members of the population themselves.With a few exceptions,15–17 assessment tools in the humanitarian field tend to have unknown psychometric properties (i.e., indices of validity and reliability). Without published psychometric properties, it is unknown to what extent assessment tools are fit for purpose.To address these gaps, we developed a method and instrument to rapidly and quantitatively assess perceived needs in emergency-affected populations—the Humanitarian Emergency Settings Perceived Needs (HESPER) Scale.18 We describe the development and psychometric properties of the scale.     

Experience of place for young adults under 65 years with complex disabilities moving into purpose-built residential care

The aim of this research was to examine first-person accounts of the significance of place for young adults (aged between 18 and 65 years of age) with complex disabilities moving into purpose-built residential care accommodation. Interviews with residents, family members and staff working at the accommodation site considered the impact of the physical, care and social environment on the experience of place. Five elements of experience were identified, including (a) freedom and self-expression, (b) designed for disability (c) flexible and responsive care environment, (d) establishing relationships and (e) defining spaces. Findings confirmed the need for a ‘value added approach’ to housing and support for young adults with complex disability. A value added approach extends the importance of place beyond the physical context for people with complex conditions and incorporates essential symbolic and relational concepts of value – being of value (for family members), having value (for residents) and giving value (for staff). The framework of the therapeutic landscape is applied within the context of supported residential care and the factors that promote a healing environment are examined.