Approximately 1.6 million US adults used methamphetamine each year from 2015 to 2018, many of whom had co-occurring substance use or mental illness. Higher rates of methamphetamine use were concentrated in non-urban areas, which raises concerns due to limited substance use treatment availability in outside of urban areas. Stimulant use is associated with increased risk of HIV transmission, and lower rates of viral suppression among HIV positive men who have sex with men (MSM) due to lower rates of engagement in HIV care. Successful behavioral health interventions to improve engagement in HIV care and viral suppression have often been limited to urban centers and confined to treatment settings, but mobile health (mHealth) technologies offer the opportunity to extend reach and efficacy of these interventions.
Drs. Adam Carrico, Keith Horvath, and Sabina Hirshfield recently received R01 funding from the National Institute on Drug Abuse (NIDA) to conduct a randomized clinical trial of an mHealth intervention to improve HIV treatment engagement and viral suppression among MSM who use stimulants. Dr. Carrico is a Professor of Public Health Sciences and Psychology and Director of the Division of Prevention Science and Community Health at the University of Miami Miller School of Medicine. His research largely focuses on the implications of substance use on HIV transmission and disease progression. Dr. Horvath is an Associate Professor in the Department of Psychology and San Diego State University. His primary research interests are the development and testing of mHealth interventions for sexual and gender minorities. Dr. Hirshfield is a Principal Research Scientist at SUNY Downstate Health Sciences University, where she conducts video- and message-based eHealth interventions with populations at-risk for, or living with, HIV. Her research includes home collection of dried blood spots for lab-based viral load testing. Together, the study team plans to evaluate the efficacy of the Supporting Treatment Adherence for Resilience and Thriving (START) mHealth intervention in improving and maintaining viral load suppression among MSM who use stimulants. The START intervention includes individual sessions and medication self-monitoring.
With input from the CHERISH Consultation Service, the START study team was able to include an economic evaluation for the mHealth intervention in his research plan. CHERISH Methodology Core Co-director Kathryn McCollister provided input for the grant application on how to best capture intervention costs and potential economic benefits of the START intervention. Dr. McCollister will also serve as a co-investigator to lead the economic evaluation for the intervention. Dr. Carrico reported that he was very satisfied with the consultation and would recommend the service to other investigators. “Dr. McCollister’s input strengthened our application and we look forward to collaborating on this important and timely project that will provide valuable information on both the effectiveness and cost of this mHealth intervention,” said Dr. Carrico.
The incidence of neonatal abstinence syndrome (NAS), also known as neonatal withdrawal syndrome, increased nationally from 3.4 per 1000 hospital births in 2009 to 5.8 in 2012. Recent estimates of NAS cost $1.5 billion dollars with the majority of the financial burden falling to state Medicaid programs. However, pregnancy offers a unique opportunity for women with opioid use disorder (OUD) to engage with the healthcare system and potentially initiate treatment for OUD.
Dr. Ashish Premkumar recently published a cost-effectiveness analysis comparing methadone, buprenorphine or detoxification with buprenorphine taper for management of OUD among pregnant women in Obstetrics and Gynecology. Dr. Premkumar, an obstetrician and gynecologist in the Division of Maternal-Fetal Medicine in the Feinberg School of Medicine at Northwestern University, used the CHERISH Consultation Service to assist him in conducting this cost-effectiveness analysis. During the consultation with CHERISH Research Affiliate Dr. Joshua Barocas at Boston Medical Center, Dr. Premkumar obtained assistance in identifying resources and cost estimates to inform the model. The cost estimates from the literature review provided ranges for sensitivity analyses that identified key determinants of cost-effectiveness outcomes.
The study found that buprenorphine was the preferred strategy for OUD treatment during pregnancy, but the findings were sensitive to the costs of methadone and detoxification. The detoxification strategy had the highest rate of relapse and had three times more individuals switching to methadone due to repeated relapse or overdose than the buprenorphine strategy. Although detoxification resulted in fewer cases of NAS and fewer admissions to the neonatal intensive care unit, the higher costs of OUD relapse and methadone maintenance following relapse offset the cost savings associated with fewer NAS cases.
Hospital-based consultation services that link inpatients with opioid use disorders to treatment offer a unique opportunity to narrow the treatment gap that results in only a minority of individuals with opioid use disorders receiving evidence-based treatment. Dr. Jennifer McNeely recently received R01 funding from the National Institute on Drug Abuse (NIDA) to study the Consult for Addiction Treatment and Care in Hospitals (CATCH) model implemented by NYC Health and Hospitals. NYC Health and Hospitals is the largest municipal hospital system in the US, providing inpatient, outpatient and home based services to over one million people across 70+ locations in NYC.
Dr. McNeely, an Associate Professor in the Department of Population Health and the Department of Medicine at NYU, used the CHERISH Methodology Consultation Service in preparing her grant application. Her research largely focuses on the implications of substance use for individuals and health systems, and access to substance use treatment. Dr. McNeely plans to evaluate the effectiveness of the CATCH model in increasing access to opioid use treatment and treatment retention. With input from CHERISH, Dr. McNeely was able to include an analysis of incremental costs or savings to Health and Hospitals associated with linkage to treatment for opioid use disorders in her research plan.
During her consultation with the CHERISH Methodology Core, CHERISH Director Bruce Schackman provided input on how to best capture program costs and potential economic benefits of the CATCH intervention compared to treatment as usual. Dr. McNeely reported that the Methodology Consultation was “very responsive to the needs of the project and the grant deadline, and extremely helpful. Overall, having CHERISH involved has been a very positive experience for me, and a real asset for the proposed study.”
Between 1999 and 2015, the annual sales of opioid analgesics in the US quadrupled to about $8 billion dollars. In an effort to address over-prescribing of opioid analgesics, Dr. Marcus Bachhuber recently received a career development award (K-award) from the National Institute on Drug Abuse (NIDA) to implement a default opioid prescribing system in the electronic health record that will nudge providers to prescribe fewer opioid pills. Dr. Bachhuber used the CHERISH Methodology Consultation Service to assist him in developing his K-award application.
Dr. Bachhuber is a primary care provider and Assistant Professor in the Department of Medicine at Albert Einstein College of Medicine in the substance use disorder field. His research focuses on health system and policy approaches to reducing harms from opioids. As part of his K award, Dr. Bachhuber is interested in evaluating whether a new default dose system for opioids would affect the subsequent healthcare utilization and associated costs for clients receiving fewer opioids. Previous studies have shown that changing default settings in the electronic health records system can affect prescribing behaviors such as substituting generic medications for those with brand names. Dr. Bachhuber seeks to apply this mechanism to test whether changing the default number of pills for opioid prescriptions can affect prescribing behavior and lower costs of opioid analgesics without a significant increase in patient healthcare utilization.
During his consultation with the CHERISH Methodology Core, Dr. Bachhuber worked with CHERISH Director Bruce Schackman, PhD over a series of phone calls to develop the economic analysis elements of his proposal and identify relevant potential mentors. Dr. Schackman then introduced Dr. Bachhuber to Sean Murphy, PhD, Director of the Consultation Service, who provided additional expert input. Dr. Bacchuber said he “really enjoyed working with Dr. Schackman and Dr. Murphy. They were extremely generous with their time and helped make the grant application much more impactful and innovative.” With the benefit of this consultation, Dr. Bachhuber received the K-award that will further his career goal of becoming an independent investigator. Dr. Bachhuber has since joined CHERISH as a Research Affiliate, and recently published an article with Dr. Murphy, CHERISH investigator Dr. Dan Polsky and fellow Research Affiliate Dr. Brendan Saloner describing the physician time burden and costs associated with querying state prescription drug monitoring programs.
Dr. Bulat Idrisov is a National Institute on Drug Abuse (NIDA) International Program INVEST Drug Abuse Research Fellow under the mentorship of Dr. Jeffrey Samet, CHERISH HCV/HIV co-director. Dr. Idrisov completed his medical training in pediatrics and internal medicine in Russia and received a Fulbright Scholarship to complete his Master of Science in Global Health Policy and Management at Brandies University in the Heller School where he focused on international health systems and healthcare policy. His current research is centered on HIV, substance use and healthcare systems. He recently published an article entitled “Implementation of methadone therapy for opioid use disorder in Russia- a modeled cost-effectiveness analysis” in the Journal of Substance Abuse Treatment, Prevention, and Policy with the help of CHERISH Consultation Director Dr. Sean Murphy.
Although his paper had been reviewed favorably, Dr. Idrisov worked with Dr. Murphy on how best to respond to the reviewers’ comments and strengthen the analysis. Upon completion of the consultation, Dr. Murphy agreed to come on board as a co-author. Dr. Murphy explained that “Dr. Idrisov’s article was very interesting and helped me explore substance use treatment from an international perspective. My previous work had been in the context of the United States and I enjoyed learning about the health system in Russia.” Under Dr. Murphy’s guidance, Dr. Idrisov reframed his analysis to focus on DALYs as the primary outcome and include tuberculosis as a comorbid condition, in addition to HIV. Dr. Idrisov commented that “I enjoyed working with Dr. Murphy; he is a talented researcher and a very pleasant person. Overall, I would recommend the CHERISH consultation service and hope to continue working with the CHERISH organization in the future.”
Dr. Alysse Wurcel is an infectious disease specialist and faculty member at Tufts University School of Medicine with a focus in HIV and hepatitis C (HCV) infection whose research interests closely align with her clinical work. Dr. Wurcel’s research is focused on the treatment of HCV in people who inject drugs (PWID), people in the criminal justice system and people living with HIV. While in the process of developing an application for an NIH-funded Center for AIDS Research Pilot Project grant, her mentor and CHERISH Investigator Dr. Benjamin Linas referred her to the CHERISH Methodology Consultation Service.
Dr. Wurcel’s pilot grant proposed to examine the costs of hospitalizations for inmates with HCV. The prevalence of HCV in prisons and jails is much higher than in the general population (about 20-30% depending on state, versus the average U.S. prevalence of about 1- 2%.) Prisons and jails have limited budgets that often do not allow for expensive new medications. Yet as a clinician, Dr. Wurcel has seen many inmates hospitalized several times for expensive complications of cirrhosis as a result of untreated HCV. She proposed to calculate the costs of hospitalizations for inmates with HCV and compare those costs to inmates without HCV. She also proposed to examine the costs of hospitalizations of inmates who are co-infected with HIV compared to inmates who are infected with HCV alone. To measure costs she proposed to use available data on diagnosis-related groups (DRGs) based in patient medical records.
Dr. Wurcel had not used health economics in any previous studies. Through her consultation with the CHERISH Methodology Core, she learned how to express her ideas in health economics language – for example, the differences between “costs” and “charges.” Her consultant also sent her articles explaining the development of the DRG unit and how to use DRG data in the proposed analysis. To make the most of the consultation, Dr. Wurcel recommends contacting the consultation service early in the grant writing process and with clear questions to guide the conversation. Although she has yet to apply the tools learned in the consultation in her project, she recommends the service to other researchers and hopes to get more comfortable using health economic methods as she executes the study analysis.
With the benefit of this consultation, Dr. Wurcel has now received the Center for AIDS Research Pilot Project grant. She and Dr. Linas have hired a research analyst and have begun working in the database. They have already found new research questions that need to be explored and she hopes the next steps for this research will include successful K-level grant funding and a partnership with the Massachusetts Department of Corrections to strategize on how to get more inmates treated for HCV.