Addiction Medicine

Poverty and Excess Length of Hospital Stay in Neonatal Opioid Withdrawal Syndrome Objectives: To study the impact of sociodemographic factors on length of stay (LOS) for infants with neonatal opioid withdrawal syndrome (NOWS) secondary to fetal opioid exposure. Methods: In this retrospective cohort study, we included term infants with NOWS, excluding those with other significant medical issues. Comprehensive clinical and sociodemographic data were collected. Multivariate regression modeling was used to identify factors which contributed to excess LOS, which was defined as the number of days beyond the standard monitoring and/or treatment protocol. Results: In all, 129 infants were identified; mean gestational age of 37.9 ± 1.3 weeks and mean body weight of 2880 ± 496 g. Among them, 68% of infants were exposed to opioids; 27% were exposed to methadone; and 67% required pharmacologic treatment. The degree of poverty was assessed using the Area Deprivation Index (ADI) based on the mother's address at the time of birth. Median LOS for treated infants was 23 days versus 8 days for those who did not need pharmacologic treatment. The median excess LOS was 4 days (range 0–24). Excess hospital days were strongly correlated with degree of deprivation in the mother's community (r = 0.55, P < 0.01). ADI remained a strong predictor of excess LOS, even when controlling for pharmacologic treatment, placement in state's custody, race, and gestational age at birth. Conclusions: These results suggest poverty is associated with excess LOS and that early allocation of resources for at-risk families may help to reduce overall length of hospital stay. Send correspondence to: Zachary A. Vesoulis, MD, Department of Pediatrics, Washington University School of Medicine, 1 Children's Place, St. Louis, MO 63110. E-mail: vesoulis_z@kids.wustl.edu. Received 10 January, 2019 Accepted 11 March, 2019 Funding: This work was supported by the following grants: Washington University Institute of Clinical and Translational Sciences KL2 Training Program (NIH/NCATS KL2 TR000450); the Barnes-Jewish Hospital Foundation and the Washington University Institute of Clinical and Translational Sciences Clinical and Translational Funding Program (NIH/NCATS UL1 TR000448). The authors report no conflicts of interest. © 2019 American Society of Addiction Medicine

How Might Maternal Poverty Impact the Course of Neonatal Opioid Withdrawal Syndrome? Neonatal Opioid Withdrawal Syndrome (NOWS) is an increasing problem in the midst of the current opioid epidemic, frequently associated with pharmacologic treatment and prolonged hospitalizations. NOWS is a highly variable condition with many clinical and genetic variables contributing to the clinical course. Social variables such as maternal poverty remain understudied. In this commentary, we review one of the first studies of the association between maternal poverty and infant hospital length of stay in infants with NOWS. This has important implications for designing population level interventions to improve NOWS outcomes. Send correspondence to Elisha M. Wachman, MD, Boston Medical Center, 771 Albany Street, Dowling 4103, Boston, MA 02118. E-mail: Elisha.Wachman@bmc.org Received 26 March, 2019 Accepted 31 March, 2019 Financial disclosures: No funding was provided for this manuscript. Dr Wachman has no conflicts of interest to disclose. © 2019 American Society of Addiction Medicine

The Role of Hospitalists in Treating Opioid Use Disorder No abstract available

The Role of Hospitalists in Treating Opioid Use Disorder No abstract available

Exploring the Effects of Vitamin D Supplementation on Cognitive Functions and Mental Health Status in Subjects Under Methadone Maintenance Treatment Objectives: Vitamin D deficiency may be linked to several mental complications including cognitive deficits, depression, and anxiety in patients under methadone maintenance treatment (MMT). This study was designed to explore the effect of vitamin D supplementation on cognitive functions and mental health parameters in subjects under MMT. Methods: This randomized, double-blinded, placebo-controlled clinical trial was carried out among 64 patients under MMT. Participants were randomly allocated to receive either 50,000 IU vitamin D supplements (n = 32) or placebo (n = 32) every 2 weeks for 24 weeks. Cognitive functions and mental health parameters were taken at baseline and posttreatment to evaluate relevant variables. Results: After the 24-week intervention, compared with the placebo, serum 25(OH) vitamin D levels significantly increased in participants who received vitamin D supplements (β 14.50; 95% confidence interval [CI], 13.17–15.83; P < 0.001). In addition, compared with the placebo, subjects who received vitamin D had a significant reduction in Iowa Gambling Task (β −6.25; 95% CI, −8.60 to −3.90; P < 0.001), and significant increases in Verbal Fluency Test (β 2.82; 95% CI, 0.78–4.86; P = 0.007), Immediate Logic Memory (β 1. 32; 95% CI, 0.27–2.37; P = 0.01), Reverse Digit Span (β 2.06; 95% CI, 1.18–2.94; P < 0.001) and visual working memory (β 0.75; 95% CI, 0.33–1.16; P = 0.001). Also, vitamin D supplementation significantly improved BDI (β −2.76; 95% CI, −3.97 to −1.55; P < 0.001) compared with the placebo. When we applied Bonferroni correction, LM-Immediate (P = 0.07) became nonsignificant, and other mental health parameters did not alter. Conclusions: Overall, taking 50,000 IU vitamin D supplements every 2 weeks for 24 weeks by patients under MMT had beneficial effects on cognitive functions and some mental health parameters. Further studies are needed to confirm our findings. Send correspondence to Zatollah Asemi, PhD, Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran. E-mail: asemi_r@yahoo.com Received 8 May, 2018 Accepted 9 May, 2019 The authors report no conflicts of interest. Clinical trial registration number: www.irct.ir: IRCT2017101133079N4. © 2019 American Society of Addiction Medicine

Editor's note: Congratulations to the 2019 Author and Reviewer Award Winners No abstract available

Prenatal Practice Staff Perceptions of Three Substance Use Screening Tools for Pregnant Women Objective: There is a need to identify an acceptable and comprehensive substance use screening tool for pregnant women in the United States. This qualitative study sought to better understand prenatal practice staff perceptions of three existing substance use screening tools for use among pregnant women in an outpatient practice setting. Methods: Eight focus groups with 40 total participants were conducted with clinical and administrative staff of 2 diverse Maryland prenatal practices to determine the acceptability and usability of 3 substance use screening tools (4P's Plus, NIDA-Modified Alcohol, Smoking and Substance Involvement Screening Test, and the Substance Use Risk Profile-Pregnancy scale). The focus groups were digitally recorded, transcribed, coded, and analyzed using thematic analysis. Results: Participant perceptions of screening tools were dependent upon screening tool length, tone, comprehensiveness, subjectivity, time frame of questions, and scoring and clinician instructions. Most participants preferred the 4P's Plus screening tool because it is brief, comprehensive, easy for the patient to understand, and excludes judgmental language and subjective questions. Conclusions: These results provide valuable insight into the specific needs and preferences of prenatal practice staff as it relates to prenatal substance use screening and provides evidence that the 4P's Plus may be a preferred screening tool for standardized use in prenatal care. Send correspondence to Victoria H. Coleman-Cowger, PhD, The Emmes Company, LLC, 401N. Washington Street, Suite 700, Rockville, MD 20850. E-mail: vcolemancowger@emmes.com Received 7 December, 2018 Accepted 18 March, 2019 Funding: Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number R01DA041328. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Health Resources and Services Administration. The authors report no conflicts of interest. © 2019 American Society of Addiction Medicine

Job Satisfaction Among Methadone Maintenance Treatment Clinic Service Providers in Jiangsu, China: A Cross-sectional Survey Objective: Service providers' job satisfaction is critical to the stability of the work force and thereby the effectiveness of methadone maintenance treatment (MMT) programs. This study aimed to explore MMT clinic service providers' job satisfaction and associated factors in Jiangsu, China. Methods: This secondary study used baseline data of a randomized interventional trial implemented in Jiangsu, China. A survey was conducted among 76 MMT service providers using the computer-assisted self-interview (CASI) method. Job satisfaction responses were assessed via a 30-item scale, with a higher score indicating a higher level of job satisfaction. Perceived institutional support and perceived stigma due to working with drug users were measured using a 9-item scale. Correlation and multiple linear regression analyses were performed to identify factors associated with job satisfaction. Results: Correlation analyses found a significant association between job satisfaction and having professional experience in the prevention and control of HIV, other sexually transmitted infections, or other infectious diseases (P = 0.046). Multiple regression analyses revealed that working at MMT clinics affiliated with Center for Disease Control and Prevention sites was associated with a lower level of job satisfaction (P = 0.014), and perception of greater institutional support (P = 0.001) was associated with a higher level of job satisfaction. Conclusion: Job satisfaction among MMT clinic service providers was moderate in our study. Our findings suggest that institutional support for providers should be improved, and that acquisition of additional expertise should be encouraged. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 Send correspondence to Zunyou Wu, PhD National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Beijing 102206, China. E-mail: wuzy@263.net, wuzunyou@chinaaids.cn Received 25 April, 2018 Revised 11 November, 2018 Accepted 5 December, 2018 The authors declare no conflicts of interest. © 2019 American Society of Addiction Medicine

The Association Between Antenatal Maternal Self-reported Substance Use, Maternal Characteristics, and Obstetrical Variables Background: Substance use disorders during pregnancy are a concern both to the public and medical community, because the negative consequences can be detrimental to both mother and the fetus. The accurate identification of prenatal drug exposure is necessary to determine appropriate medical and psychosocial intervention, and to identify risk factors that may affect outcomes for the mother and her newborn. The prevalence of prenatal drug exposure is very difficult to estimate because of flaws in all methods of identification. Objective: The study is designed to identify risk factors and demographic variables that contribute to nondisclosure of illicit and nonillicit substance use. In addition, this study aims to determine if nondisclosure leads to adverse neonatal outcomes. Study design: Newborns delivered with a positive meconium or urine toxicology, and/or known maternal exposure to illicit and nonillicit substances, were identified. Maternal records were reviewed for disclosure of substance use during pregnancy at admission for delivery along with other medical and demographic variables. Women with antenatal prescription drug use that may alter toxicology screens were excluded from analysis. Pediatric records were also reviewed to obtain neonatal variables. Results: One hundred sixty-eight newborns were identified as having prenatal exposure to an illicit or nonillicit substance over the 4-year period. Eighty-six per cent (145/168) of women tested positive or their newborn tested positive for at least 1 illicit substance, and 49% (82/168) tested positive for multiple illicit substances. Fifty-four per cent (91/168) of women did not disclose using at least one illicit drug for which she or her newborn tested positive. With regards to maternal characteristics, there was no statistically significant difference between age (P = 0.958), parity (P = 0.300), or race (P = 0.531), and disclosure or failure to disclose about illicit drug use. However, patients who did not report prenatal illicit drug use (33/82 = 40%) were less likely (P = 0.049) to receive complete prenatal care (defined as 3 or more visits) compared with those who acknowledged their substance use (40/70 = 57%). Conclusion: Substance use disorders during pregnancy are an often underestimated cause of maternal, fetal, and neonatal complications. Limited studies have examined the relationship between maternal characteristics and associated illicit or nonillicit drug use. The absence of correlation between maternal demographics and disclosure of illicit substance use demonstrates the fact that all antepartum patients are at risk for these behaviors. Furthermore, the fact that women who did not disclose their illicit drug use were less likely to seek complete prenatal care reflects the need for physicians to provide a destigmatized healthcare environment, encouraging pregnant women to disclose their substance use so they can be provided with appropriate counseling and treatment. Send correspondence to Alexandra Berra, MD, 6651 Main Street, Houston, TX 77030. E-mail: aberraeras@gmail.com Received 10 May, 2018 Accepted 5 December, 2018 Central Association of Obstetricians and Gynecologists, 84th Annual Meeting, Scottsdale, Arizona, October 18–21, 2017. The authors have nothing to disclose. © 2019 American Society of Addiction Medicine

Pain Anxiety as a Mechanism Linking Pain Severity and Opioid Misuse and Disability Among Individuals With Chronic Pain Objective: Chronic pain affects a significant number of individuals in the United States and is associated with several negative health-related outcomes, including possibility of opioid misuse and disability. The identification of factors associated with both opioid misuse and disability is of critical public health importance, and significant research suggests that pain severity has been shown to be associated with both. Pain-related anxiety has been uniquely associated with both opioid misuse and disability, yet little research has examined pain-related anxiety as a potential mechanism linking pain severity with opioid misuse and disability. Method: Therefore, the current study examined whether pain-related anxiety explains, in part, the relationship between pain severity, opioid misuse, and disability among 396 adults with chronic pain (55.8% female, Mage 36.61, SD 11.40). Results: Cross-sectional analyses indicated that pain-related anxiety significantly mediated the relationship between pain severity, opioid misuse outcomes, and psychosocial disability, but not physical disability. Conclusions: These results build upon the literature indicating the importance of pain-related anxiety in those with chronic pain by suggesting this construct may account, in part, for the relation of pain intensity to opioid misuse and psychosocial disability. Future research should longitudinally examine these associations. Send correspondence and reprint requests to: Kevin E. Vowles, PhD, Department of Psychology, University of New Mexico, MSC03-2220 Logan Hall, Albuquerque, NM 87131-0001. E-mail: k.e.vowles@gmail.com. Received 9 December, 2018 Accepted 11 March, 2019 The authors declare no conflicts of interest. © 2019 American Society of Addiction Medicine

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