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Background Opioid use disorder (OUD) is a serious health condition that is effectively treated with buprenorphine. However, only a minority of people with OUD are able to access buprenorphine. Many access points for buprenorphine have high barriers for initiation and retention. Health care and drug treatment systems have not been able to provide services to all—let alone the majority—who need it, and many with OUD report extreme challenges starting and staying on buprenorphine in those care settings. We describe the design and protocol for a study of a rapid access buprenorphine program model in six Washington State communities at existing sites serving people who are unhoused and/or using syringe services programs. This study aimed to test the effectiveness of a Community-Based Medication-First Program model. Methods We are conducting a hybrid effectiveness-implementation study of a rapid access buprenorphine model of care staffed by prescribers, nurse care managers, and care navigators. The Community-Based Medication-First model of care was designed as a 6-month, induction-stabilization-transition model to be delivered between 2019 and 2022. Effectiveness outcomes will be tested by comparing the intervention group with a comparison group derived from state records of people who had OUD. Construction of the comparison group will align characteristics such as geography, demographics, historical rates of arrests, OUD medication, and health care utilization, using restriction and propensity score techniques. Outcomes will include arrests, emergency and inpatient health care utilization, and mortality rates. Descriptive statistics for buprenorphine utilization patterns during the intervention period will be documented with the prescription drug monitoring program. Discussion Results of this study will help determine the effectiveness of the intervention. Given the serious population-level and individual-level impacts of OUD, it is essential that services be readily available to all people with OUD, including those who cannot readily access care due to their circumstances, capacity, preferences, and related systems barriers.

Objective: Disproportionate occupational injury rates for Latinos are well documented, but there is limited information about whether disparity is increasing over time. This study describes trends in the burden of work-related traumatic injuries sustained by Latinos in Washington State. Methods: Washington State Trauma Registry data from 1998 to 2008 were used to model annual change in the odds that a work-related traumatic injury was sustained by a Latino, controlling for demographics, injury-related factors, and Latino representation in the underlying labor force. Results: We found a 5% mean annual increase in the odds that a comparable work-related traumatic injury was sustained by a Latino (P = 0.007). Falls in industrial/mine/quarry locations were the strongest contributor to increasing disparity. Conclusions: Latinos bear an increasingly disproportionate burden of occupational injuries and are less likely to have health insurance coverage aside from workers' compensation.

Background Patient enrollment levels at Veterans Health Administration (VHA) facilities change based on Veteran demand for care, potentially affecting demands on staff. Effects on burnout in the primary care workforce associated with increases or decreases in enrollment are unknown. Objective Estimate associations between patient enrollment and burnout. Design In this serial cross-sectional study, VHA patient enrollment and workforce data from 2014 to 2018 were linked to burnout estimates for 138 VHA facilities. The VHA’s annual All Employee Survey provided burnout estimates. Participants A total of 82,421 responses to the 2014–2018 All Employee Surveys by primary care providers (PCPs), including physicians, nurse practitioners, and physician assistants; nurses; clinical associates; and administrative clerks were included. Respondents identified as patient-aligned care team members. Main Measures Independent variables were (1) the ratio of enrollment to PCPs at VHA facilities and (2) the year-over-year change in enrollment per PCP. Burnout was measured as the annual proportion of staff at VHA facilities who reported emotional exhaustion and/or depersonalization. Each primary care role was analyzed independently. Key Results Overall enrollment decreased from 1553 enrollees per PCP in 2014 to 1442 enrollees per PCP in 2018 across VHA facilities. Forty-three facilities experienced increased enrollment (mean of 1524 enrollees/PCP in 2014 to 1668 in 2018) and 95 facilities experienced decreased enrollment (mean of 1566 enrollees/PCP in 2014 to 1339 in 2018). Burnout decreased for all primary care roles. PCP burnout was highest, decreasing from a facility-level mean of 51.7% in 2014 to 43.8% in 2018. Enrollment was not significantly associated with burnout for any role except nurses, for whom a 1% year-over-year increase in enrollment was associated with a 0.2 percentage point increase in burnout (95% CI: 0.1 to 0.3). Conclusions Studies assessing changes in organizational-level predictors are rare in burnout research. Patient enrollment predicted burnout only among nurses in primary care.

Purpose The purpose of this study was to descriptively quantify experiences of injured workers with permanent impairment during their first year of work reintegration. Methods A representative survey was conducted to characterize health, disability, pain, employment, reinjury, and economic outcomes for 598 workers with permanent impairment who had returned to work during the year after workers’ compensation claim closure. Survey responses were summarized by degree of whole body impairment (< 10% vs. ≥ 10%). Results Injured workers who had returned to work reported that permanent impairment made it difficult to get a job (47%) and to keep their job (58%). A year after claim closure, 66% reported moderate to very severe pain; 40% reported pain interference with work. About 13% reported new work injuries; over half thought permanent impairment increased their reinjury risk. Asked to compare current to pre-injury work status, workers with a higher degree of impairment more frequently reported working fewer hours (OR 1.60; 95% CI 1.06, 2.42), earning less (OR 1.56; 95% CI 1.04, 2.36), and being at higher risk of losing their current job due to their impairment (OR 1.66; 95% CI 1.01, 2.71). Conclusions Injured workers with permanent impairment face long-term challenges related to health limitations, chronic pain, work reintegration, and economic impacts. Workers with a higher degree of impairment more frequently reported several economic and job security challenges. Developing workplace and workers’ compensation-based interventions that reduce return-to-work interruption and reinjury for workers with permanent impairment should be prioritized as an important public health and societal goal.

OBJECTIVE:To estimate associations between early high-risk opioid prescribing practices and long-term work-related disability. METHODS:Washington State Fund injured workers with at least one opioid prescription filled within 6 weeks after injury (2002 to 2013) were included (N = 83,150). Associations between early high-risk opioid prescribing (longer duration, higher dosage, concurrent sedatives), and time lost from work, total permanent disability, and a surrogate measure for Social Security disability benefits were tested. Measures of early hospitalization, body part, and nature of injury were included to address confounding by indication concerns, along with sensitivity analyses controlling for injury severity. RESULTS:In adjusted logistic models, early high-risk opioid prescribing was associated with roughly three times the odds of each outcome. CONCLUSION:Exposure to high-risk opioid prescribing within 90 days of injury was significantly and substantially associated with long-term temporary and permanent disability.

To estimate associations between early high-risk opioid prescribing practices and long-term work-related disability. Washington State Fund injured workers with at least one opioid prescription filled within 6 weeks after injury (2002 to 2013) were included (N = 83,150). Associations between early high-risk opioid prescribing (longer duration, higher dosage, concurrent sedatives), and time lost from work, total permanent disability, and a surrogate measure for Social Security disability benefits were tested. Measures of early hospitalization, body part, and nature of injury were included to address confounding by indication concerns, along with sensitivity analyses controlling for injury severity. In adjusted logistic models, early high-risk opioid prescribing was associated with roughly three times the odds of each outcome. Exposure to high-risk opioid prescribing within 90 days of injury was significantly and substantially associated with long-term temporary and permanent disability.

Electronic health record (EHR) inbox notifications can be burdensome for primary care providers (PCPs), potentially contributing to burnout. We estimated the association between changes in the quantities of EHR inbox notifications and PCP burnout. In this observational study, we tested the association between the percent change in daily inbox notification volumes and PCP burnout after an initiative to reduce low-value notifications at the Veterans Health Administration (VHA). The VHA initiative resulted in increases and decreases in notification volumes for PCPs. For each facility, the proportion of PCPs reporting burnout was estimated using VHA All Employee Survey responses before and after the initiative in 2016 and 2018, respectively. Survey responses were aggregated for 6459 PCPs (physicians, nurse practitioners, and physician assistants) at 138 VHA facilities. Fixed effects regression models estimated the association of small and large increases and small and large decreases in notifications on burnout. Daily inbox notifications per PCP decreased by a mean (SD) of 5.9% (30.1%) across study facilities, from a mean (SD) of 128 (52) notifications to 114 (44) notifications after the initiative. Fifty-one percent of facilities experienced reductions in notifications, 30% experienced no change, and 20% experienced increased notifications. PCP burnout was not significantly associated with any level of increase or decrease in notifications. Changes in notification volumes alone did not predict PCP burnout. Future research to reduce burnout might still address EHR notification volumes, but as part of a broader set of strategies that consider the other stressors that PCPs experience.

ObjectiveHigh-risk opioid prescribing practices in workers’ compensation (WC) settings are associated with excess opioid-related morbidity, longer work disability and higher costs. This study characterises the burden of prescription opioid-related hospitalisations among injured workers.MethodsHospital discharge data for eight states (Arizona, Colorado, Michigan, New Jersey, New York, South Carolina, Utah and Washington) were obtained from the State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. We calculated 5-year (2010–2014) average annual rates of prescription opioid overdose/adverse effect (AE) hospitalisations. Injured workers were identified using payer (WC) and external cause codes.ResultsState-level average annual prescription opioid overdose/AE hospitalisation rates ranged from 0.3 to 1.2 per 100 000 employed workers. Rates for workers aged ≥65 years old were two to six times the overall rates. Among those hospitalised with prescription opioid overdose/AEs, injured workers were more likely than other inpatients to have a low back disorder diagnosis, and less likely to have an opioid dependence/abuse or cancer diagnosis, or a fatal outcome. Averaged across states, WC was the primary expected payer for <1% of prescription opioid overdose/AE hospitalisations vs 6% of injury hospitalisations.ConclusionsPopulation-based estimates of prescription opioid morbidity are almost nonexistent for injured workers; this study begins to fill that gap. Rates for injured workers increased markedly with age but were low relative to inpatients overall. Research is needed to assess whether WC as payer adequately identifies work-related opioid morbidity for surveillance purposes, and to further quantify the burden of prescription opioid-related morbidity.

BackgroundOpioid overdose is a major and increasing cause of injury and death. There is an urgent need for interventions to reduce overdose events among high-risk persons.MethodsAdults at elevated risk for opioid overdose involving heroin or pharmaceutical opioids who had been cared for in an emergency department (ED) were randomised to overdose education combined with a brief behavioural intervention and take-home naloxone or usual care. Outcomes included: (1) time to first opioid overdose-related event resulting in medical attention or death using competing risks survival analysis; and (2) ED visit and hospitalisation rates, using negative binomial regression and adjusting for time at risk.ResultsDuring the follow-up period, 24% of the 241 participants had at least one overdose event, 85% had one or more ED visits and 55% had at least one hospitalisation, with no significant differences between intervention and comparison groups. The instantaneous risk of an overdose event was not significantly lower for the intervention group (sub-HR: 0.83; 95% CI 0.49 to 1.40).DiscussionThese null findings may be due in part to the severity of the population in terms of housing insecurity (70% impermanently housed), drug use, unemployment and acute healthcare issues. Given the high overdose and healthcare utilisation rates, more intensive interventions, such as direct referral and provision of housing and opioid agonist treatment medications, may be necessary to have a substantial impact on opioid overdoses for this high-acuity population in acute care settings.Trial registration numberNCT0178830; Results.