Nonmedical prescription drug use among US young adults by educational attainment

Purpose: Little is known about nonmedical use of prescription drugs among non-college-attending young adults in the United States. Methods: Data were drawn from 36,781 young adults (ages 18–22 years) from the 2008–2010 National Survey on Drug Use and Health public use files. The adjusted main effects for current educational attainment, along with its interaction with gender and race/ethnicity, were considered. Results: Compared to those attending college, non-college-attending young adults with at least and less than a HS degree had a higher prevalence of past-year nonmedical use of prescription opioids [NMUPO 13.1 and 13.2 %, respectively, vs. 11.3 %, adjusted odds ratios (aORs) 1.21 (1.11–1.33) and 1.25 (1.12–1.40)], yet lower prevalence of prescription stimulant use. Among users, regardless of drug type, non-college-attending youth were more likely to have past-year disorder secondary to use [e.g., NMUPO 17.4 and 19.1 %, respectively, vs. 11.7 %, aORs 1.55 (1.22–1.98) and 1.75 (1.35–2.28)]. Educational attainment interacted with gender and race: (1) among nonmedical users of prescription opioids, females who completed high school but were not enrolled in college had a significantly greater risk of opioid disorder (compared to female college students) than the same comparison for men; and (2) the risk for nonmedical use of prescription opioids was negligible across educational attainment groups for Hispanics, which was significantly different than the increased risk shown for non-Hispanic whites. Conclusions: There is a need for young adult prevention and intervention programs to target nonmedical prescription drug use beyond college campuses

Measuring the Long-Term Effects of Neighborhood Alcohol Outlet Density and Alcoholics Anonymous on Alcohol Relapse Using Longitudinal Targeted Maximum Likelihood Estimation

BackgroundAlcohol continues to adversely affect the lives of Americans, particularly individuals suffering from addiction. The majority of treated alcoholics relapse to alcohol abuse or dependence. Between 66% and 80% of adults relapse in the six months after an episode of community- or hospital-based drug or alcohol treatment and 40% will re-enter treatment. Thus, the aftercare and follow-up plan have potential to affect long-term treatment success. Research that tracks treatment outcomes for alcohol addiction has shown that while a variety of treatment interventions are effective, the progress clients make in treatment is frequently undermined if they are surrounded by or reside in an environment that triggers relapse. Although individual-level risk factors for alcoholism have been well-established they do not fully explain variability in recovery suggesting that environmental and social factors need to be explored. Neighborhood alcohol outlet density (AOD) and Alcoholics Anonymous (AA) affiliation are two environmental and social factors that show promise for intervention on a moderate time scale. Despite the contributions of research on how one’s living and social environment can affect alcohol use, very little is known about the impact of AOD and AA on recovery over time. To date, there are no studies examining the effect of AOD on relapse among alcoholics in recovery. Similarly, in spite of a vast body of literature on AA, few studies have examined the effectiveness of long-term affiliation with AA on relapse. Moreover, no studies have utilized parameters based on a causal inference framework to examine the potential impacts of these factors on relapse and recovery. MethodsUsing a 7-year prospective cohort study of alcoholics in recovery, the purpose of this dissertation was to estimate the effects of AOD and AA on relapse (past 30-day abstinence), applying improved analysis techniques. The most widespread statistical method in studies of AOD and AA associations with drinking rely on conventional regression. This approach does not appropriately adjust for time-dependent confounding, and the modeling assumptions may not always be met. An alternative approach is to estimate parameters motivated by the causal inference literature, which can be interpreted as estimates of the outcome under hypothetical interventions to the exposure of interest. In this framework, a key step is careful consideration of the assumptions necessary to interpret the parameter as a causal effect. The current work is stronger than past work with respect to some of the assumptions. In the first chapter, I estimate the longitudinal impact of AOD on abstinence using a parameter motivated by the causal inference literature. In the second chapter, I again examine the longitudinal impact of AOD on abstinence with a focus on specific types of alcohol outlets. In the third chapter, I examine the longitudinal impact of AA participation on abstinence. For all study questions, I use data-adaptive estimation (SuperLearning) combined with a recently released R package, Longitudinal Targeted Maximum Likelihood Estimation (ltmle), an estimation method that encourages an explicit process for specifying and estimating target parameters to address causal questions that specifically incorporate time-dependent confounders. SignificanceThis work will contribute to epidemiologic research in several ways. First, we hope to begin to fill the gap in the literature on the association between neighborhood AOD and drinking among alcoholics in recovery. Second, we aim to determine whether specific alcohol outlet types confer distinct drinking risks among alcoholics in recovery. Third, we hope to contribute to the limited literature examining the long-term impact of AA on alcohol recovery. Moreover, this work represents the first application of ltmle to the field of alcohol epidemiology. We hope to demonstrate how it can provide a powerful way of estimating parameters with direct public health relevance using observational data. Extensions of this research can help to improve understanding of how environmental and social contexts contribute to alcohol recovery, and identify ways to optimize future interventions in this area. Conceptually, this work will contribute to efforts aimed at promoting recovery by examining to what extent AOD exposure and AA participation are associated with drinking among alcoholics over time, two areas that warrant further research. Understanding the interrelationships between neighborhood context, social network, and subsequent alcohol use is critical to better understand alcohol relapse and recovery

Discordance between Treatment Guideline Recommendations and Real-World Practice in a Group of Large Integrated Delivery Networks for Venous Thromboembolism (VTE) Patients: A Closer Look at VTE Patients with Cancer

Background: For patients with VTE, current American Society of Hematology (ASH) guideline panel suggests using direct oral anticoagulants (DOACs) over vitamin K antagonists (VKAs) where VKAs are required to be bridged with a parenteral anticoagulant (PAC). For patients with VTE and cancer, current guidelines recommend DOACs over low molecular weight heparin (LMWH) and LMWH over unfractionated heparin (heparin) for the initial treatment of VTE. Limited evidence is available about the patterns of anticoagulant treatment for VTE in routine clinical practice of large healthcare delivery networks in the United States (US) and whether the VTE treatments are aligned with current guidelines. This study aimed to assess real-world anticoagulant treatment patterns among VTE patients using harmonized electronic health record (EHR) data from four Integrated Delivery Networks (IDNs) in the US. Methods: This was a retrospective, longitudinal, multicenter, cohort study using harmonized EHR data from both inpatient and outpatient settings. The study population included adult patients prescribed DOACs, warfarin, and/or PAC therapy as inpatient or outpatient treatment within ≤30 days of VTE diagnosis, between June 2015 through May 2018. Data from the four IDNs was pooled to describe demographic characteristics and treatment patterns among VTE patients overall and by subgroups. Results: A total of 10,527 patients who were treated with OACs after VTE diagnosis were included for analysis. The mean (SD) age was 61.9 (5.98) years, with 46.1% aged 65 or older. More than half (53.2%) were female, and White patients comprised the majority (74.4%), followed by African American patients (22.8%). Obese and morbidly obese patients comprised 39.1% and 16.1% of patients, respectively. Among all VTE patients, warfarin-only (n=3545; 33.7%) was the most commonly used OAC treatment, followed by warfarin + PAC (n=3128; 29.7%), rivaroxaban-only (n=1357; 12.9%), rivaroxaban + PAC (n=853; 8.1%), apixaban + PAC (n=839; 8.0%), apixaban-only (n=762; 7.2%), and Other OAC (n=357; 3.4%) (Table 1). When stratifying VTE patients by age, gender, race and BMI, some variations in OAC treatment were observed. Among both older (≥65 years) and younger (\u3c65 years) patients, warfarin-only was most commonly used, then warfarin + PAC. Warfarin-only was more commonly used among obese (36.3%) and morbidly obese (40.4%) patients than non-obese (29.8%) patients. OAC treatment patterns were generally comparable among men and women. Among White patients, approximately equal proportions of patients received warfarin + PAC (31.9%) and warfarin-only (31.0%). However, among African-American patients, a higher proportion of patients used warfarin-only (40.9%) vs. warfarin + PAC (24.5%). Patterns of anticoagulant treatments including OACs and/or parental anticoagulants among VTE patients with cancer were further analyzed (Figure 1). Among VTE patients with cancer (n=3657), heparin had the highest use (26.7%), then enoxaparin (22.7%); approximately the same proportion of cancer patients received warfarin-only (16.0%) and warfarin + PAC (16.9%). Of DOACs, rivaroxaban-only was the most commonly used treatment (4.9%), then apixaban + PAC (3.5%), and lastly, rivaroxaban + PAC (3.4%) among cancer patients. Conclusion: Current VTE treatment guidelines recommend warfarin to be bridged with PAC, however, warfarin-only therapy remained the most used treatment option followed by warfarin + PAC. While rivaroxaban and apixaban are not required to be bridged with PAC, such practices were observed for a large proportion of apixaban- and rivaroxaban-treated VTE patients. VTE treatment among patients with cancer was not completely aligned with current guidelines, as heparin was more commonly used than LMWH (enoxaparin). Our findings suggest greater efforts are needed to improve anticoagulant treatment practices among VTE patients