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Aims: This study, supported by the CTN Ohio Valley Node, aimed to identify substance use disorder (SUD) patterns and their association with T2DM health outcomes among patients with type 2 diabetes and hypertension.

Methods: Researchers used latent class analysis on electronic health records from the MetroHealth System (Cleveland, Ohio) to obtain the target SUD groups: i) only tobacco (TUD), ii) tobacco and alcohol (TAUD), and iii) tobacco, alcohol, and at least one more substance (PSUD). A matching program with Mahalanobis distance within propensity score calipers created the matched control groups: no SUD (NSUD) for TUD and TUD for the other two SUD groups. The numbers of participants for the target-control groups were 8009 (TUD), 1672 (TAUD), and 642 (PSUD).

Results: TUD was significantly associated with T2DM complications. Compared to TUD, the TAUD group showed a significantly higher likelihood for all-cause mortality (adjusted odds ratio (aOR) = 1.46) but not for any of the T2DM complications. Compared to TUD, the PSUD group experienced a significantly higher risk for cerebrovascular accident (CVA) (aOR = 2.19), diabetic neuropathy (aOR = 1.76), myocardial infarction (MI) (aOR = 1.76), and all-cause mortality (aOR = 1.66).

Conclusions: The findings of increased risk associated with PSUDs may provide insights for better management of patients with T2DM and hypertension co-occurrence.

Patients with a substance use disorder (SUD) often present with co-occurring chronic conditions in primary care. Despite the high co-occurrence of chronic medical conditions and SUD, little is known about whether chronic condition outcomes or related service utilization in primary care varies between patients with versus without documented SUDs. This study examined whether having a SUD influenced the use of primary care services and common chronic condition outcomes for patients with diabetes, hypertension, and obesity.

A longitudinal cohort observational study examined electronic health record data from 21 primary care clinics in Washington and Idaho to examine differences in service utilization and clinical outcomes for diabetes, hypertension, and obesity in patients with and without a documented SUD diagnosis. Differences between patients with and without documented SUD diagnoses were compared over a three-year window for clinical outcome measures, including hemoglobin A1c, systolic and diastolic blood pressure, and body mass index, as well as service outcome measures, including number of encounters with primary care and co-located behavioral health providers, and orders for prescription opioids. Adult patients (N = 10,175) diagnosed with diabetes, hypertension, or obesity before the end of 2014, and who had =2 visits across a three-year window including at least one visit in 2014 (baseline) and at least one visit occurring 12 months or longer after the 2014 visit (follow-up) were examined.

Patients with SUD diagnoses and co-occurring chronic conditions were seen by providers more frequently than patients without SUD diagnoses (p’s < 0.05), and patients with SUD diagnoses were more likely to be prescribed opioid medications. Chronic condition outcomes were no different for patients with versus without SUD diagnoses.

Conclusions: Despite the higher visit rates to providers in primary care, a majority of patients with SUD diagnoses and chronic medical conditions in primary care did not get seen by co-located behavioral health providers, who can potentially provide and support evidence informed care for both SUD and chronic conditions. Patients with chronic medical conditions also were more likely to get prescribed opioids if they had an SUD diagnosis. Care pathway innovations for SUDs that include greater utilization of evidence-informed co-treatment of SUDs and chronic conditions within primary care settings may be necessary for improving care overall for patients with comorbid SUDs and chronic conditions.

The following files have been made publicly available by the authors:

• Overview of SAS Matching Programs Developed by the NIDA CTN Ohio Valley Node (.pdf)
• Greedy matching data file (.zip file containing .sas file)
• Optimal matching data file (.zip file containing .sas file)

Substance use disorder (SUD) screening has been recommended for general medical healthcare settings, but remains underutilized. An alternative to universal SUD screening would be screening in patients with medical conditions significantly exacerbated by SUD. This value-based approach may be particularly useful for patients with multiple chronic health conditions, who account for the majority of healthcare spending and who interface frequently with the healthcare system, affording greater opportunity for screening and treatment coordination.

This study evaluated whether SUD is associated with type 2 diabetes mellitus (T2DM) complications in patients with co-occurring T2DM and hypertension, a patient group selected due to the prevalence, cost, and morbidity and mortality associated with this combination of health issues.

This analysis used a limited data set obtained through IBM Watson Health Explorys, a platform integrating data from electronic health records. Matched controls were defined for each of five SUDs: tobacco use disorder (TUD), opioid use disorder (OUD), cocaine use disorder, cannabis use disorder (DUC) and alcohol use disorder (AUD) using Mahalanobis distance within propensity score calipers. All patients were seen in the Metro Health System (Cleveland, OH, USA), and had diagnosis codes for T2DM and hypertension.

Outcome was diagnosis (yes/no) of four T2DM complications (cerebrovascular accident, diabetic neuropathy, diabetic renal disease, myocardial infarction) and all-cause mortality. Logistic regressions revealed that SUD was significantly associated with greater risk of:

• cerebrovascular accident (TUD odds ratio (OR) = 1.79, OUD-OR = 1.94, cocaine use disorder OR = 2.67),
• diabetic neuropathy (TUD-adjusted OR (aOR) = 1.47, cocaine use
  disorder-aOR = 1.35, AUD-aOR = 1.27],
• diabetic renal disease (TUD-aOR = 1.25, OUD-OR = 1.34),
• myocardial infarction, (TUD-OR = 1.96, OUD-OR = 2.01,
• cocaine use disorder (TUD-aOR = 2.68, CUD-OR = 2.48, AUD-OR = 1.42), and
• mortality (TUD-OR = 1.15, cocaine use disorder-OR = 1.61, CUD-OR = 1.49, AUD-OR = 1.35).

Conclusions: Among patients in Ohio with both type 2 diabetes mellitus (T2DM) and hypertension, those with substance use disorders appear to have greater risk for T2DM complications and all-cause mortality. Future research to replicate this finding and to delineate the potential mechanisms by which SUD may impact T2DM-related outcomes seems warranted.

This is the Results Article for CTN-0057-Ot.

The majority of the U.S. health care resources are utilized by a small population characterized as high-risk, high-need persons with complex care needs (e.g., adults with multiple chronic conditions). Substance use disorders (SUDs) and mental health disorders (MHDs) are a driver of poor health and additional healthcare costs, but they are understudied among high-need patients. This study examined the prevalence and correlates of SUDs and MHDs among adults with high-risk diabetes, who are patients at the top 10% risk score for developing poor outcomes (hospital admission or death). A risk algorithm developed from Duke University Health System electronic health record (EHR) data was used to identify patients with high-risk diabetes for targeting home-based primary care. The EHR data of the 263 patients with high-risk diabetes were analyzed to understand patterns of SUDs and MHDs to inform care-coordinating efforts

Results found that both SUDs and MHDs were prevalent:

• Any SUD: 48.3%; Alcohol: 12.5%; Tobacco: 38.8%; Drug: 23.2%
• Any MHD: 74.9%; Mood: 53.2%; Sleep: 37.3%; Anxiety: 32.7%; Schizophrenia/Psychotics/Delusional: 14.8%; Dementia/Delirium/Amnestic/Cognitive: 14.4%; Adjustment: 9.1%

Overall, 81% of the same had SUD or MHD. Elevated odds of SUD were noted among men (tobacco, alcohol) and those who were never married (alcohol, cannabis). African American race (vs. other race/ethnicity) was associated with lower odds of anxiety disorders.

Conclusions: This study is the first to document a comprehensive pattern of SUD and MHD prevalence among adults with high-risk diabetes. While data are limited to one large academic health system, they provide clinical evidence revealing that 82% of patients with high-risk diabetes had SUD and/or MHD record in their EHRs, highlighting a need for developing service models to optimize high-risk care.

Related protocols: CTN-0057-Ot

The Affordable Care Act encourages healthcare systems to integrate behavioral and medical healthcare, as well as to employ electronic health records (EHRs) for health information exchange and quality improvement. Pragmatic research paradigms that employ EHRs in research are needed to produce clinical evidence in real-world medical settings for informing learning healthcare systems. Adults with comorbid diabetes and substance use disorders (SUDs) tend to use costly inpatient treatments; however, there is a lack of empirical data on implementing behavioral healthcare to reduce health risk in adults with high-risk diabetes. Given the complexity of high-risk patients’ medical problems and the cost of conducting randomized trials, a feasibility project is warranted to guide practical study designs.

This paper describes the study design for such a project, a new study in the NIDA Clinical Trials Network (CTN-0057) aimed at exploring the feasibility of implementing substance use Screening, Brief Intervention, and Referral to Treatment (SBIRT) among adults with high-risk type 2 diabetes mellitus (T2DM) within a home-based primary care setting. The study includes the development of an integrated EHR datamart to identify eligible patients and collect diabetes healthcare data, and the use of a geographic health information system to understand the social context in patients’ communities. Analysis will examine recruitment, proportion of patients receiving brief intervention and/or referrals, substance use, SUD treatment use, diabetes outcomes, and retention. By capitalizing on an existing T2DM project that uses home-based primary care, this study’s results will provide timely clinical information to inform the designs and implementation of future SBIRT studies among adults with multiple medical conditions.

Related protocols: CTN-0057-Ot

Comorbid diabetes and substance use diagnoses (SUD) represent a hazardous combination, both in terms of healthcare cost and morbidity. To date, there is limited information about the association of SUD and related mental disorders with type 2 diabetes mellitus (T2DM). This study examined the associations between T2DM and multiple psychiatric diagnosis categories, with a focus on SUD and related psychiatric comorbidities among adults with T2DM. Electronic health record (EHR) data on 170,853 unique adults aged 18 or older from the EHR warehouse of a large academic healthcare system were analyzed. Logistic regression analyses were conducted to estimate the strength of an association for comorbidities.

Overall, 9% of adults (n=16,243) had T2DM. Blacks, Hispanics, Asians, and Native Americans had greater odds of having T2DM than whites. All 10 psychiatric diagnosis categories were more prevalent among adults with T2DM than among those without T2DM. Prevalent diagnoses among adults with T2DM were mood (21.22%), SUD (17.02%: tobacco 13.24%, alcohol 4%, drugs 4.22%), and anxiety diagnoses (13.98%). Among adults with T2DM, SUD was positively associated with mood, anxiety, personality, somatic, and schizophrenia diagnoses.

Conclusions: This study examined a large diverse sample of individuals and found clinical evidence of SUD and psychiatric comorbidities among adults with T2DM. These results highlight the need to identify feasible collaborative care models for adults with T2DM and SUD related psychiatric comorbidities, particularly in primary care settings, that will improve behavioral health and reduce health risk.

Related protocols: CTN-0057-Ot