Painful Places: Medicare Fails Homebound Patients With Substance Abuse Disorders

There is extensive literature on the significance of substance use, misuse, and abuse among the elderly in the United States. A literature review indicates a paucity of information on the nature, significance, or impacts of the lack of substance use and abuse coverage in Medicare home health. This article presents background on the topic and an initial, exploratory study to address the literature gap, based on interviews of a convenience sample of 48 home care social workers between January 2013 and May 2015 in the New York City metropolitan area. Results indicate social workers believe substance use and abuse occurs frequently among Medicare home health patients; substance use and abuse is not assessed and treated professionally in Medicare home health; the lack of coverage in Medicare home health results in exacerbation of existing patient physical and mental health conditions, which, in turn, worsen substance use and abuse conditions; the homebound requirement and lack of coverage of transportation and personal care assistants limits home care patients ability to obtain outpatient substance use and abuse treatment; and lack of home-based assessment and treatment contributes to increased home care readmissions, re-hospitalizations, and increased caregiver burden.

CONSUMO DE SUSTANCIAS EN TRASTORNO DEL ESPECTRO AUTISTA: ¿SÍNTOMA O COMORBILIDAD?

Descripción del caso Varón de 24 años diagnosticado de Trastorno del Especto Autista en la adolescencia que inicia consumo de sustancias con 15 años. En el momento actual se encuentra independizado realizando estudios superiores. Su único soporte social es su pareja. Ingresa por amenazas autolíticas ante la imposibilidad de consumir tóxicos. Intervención El paciente presenta, desde el inicio de su seguimiento, una evolución tórpida derivada principalmente del consumo y de las conductas de búsqueda de sustancias psicoactivas. A los 15 años inicia el uso de tóxicos con cannabis y dextrometorfano, a los 17 años ya consumía semanalmente heroína y cocaína fumadas, dicho consumo se ha mantenido hasta la actualidad. Presenta múltiples ingresos por intentos autolíticos. Ha tenido conflictos legales llegando incluso a cumplir condenas de privación de libertad. El patrón de consumo es rígido, asociado a un interés restringido por el uso de sustancias y la experimentación de estados alterados de conciencia. Al explorar sus intereses el paciente cita las sustancias psicoactivas, la lingüística y la política china. Resultados y conclusiones: Las características clínicas más llamativas del Trastorno de Espectro Autista son la dificultad en la interacción social así como los intereses restringidos y las conductas repetitivas y esterotipadas. Suscita dudas sobre qué papel tiene el consumo de tóxicos en este caso, como síntoma (intereses restringidos que condicionan la actividad diaria), también se puede entender como una comorbilidad que ensombrece el pronóstico y evolución. Bibliografia 1. Kunreuther E. Autism Spectrum Disorder and Substance Use Disorder. Child and Adolescent Psychiatric Clinics of North America. Elsevier BV; 2020Jul;29(3):467–81. Available from: https://doi.org/10.1016/j.chc.2020.03.002 2. Ressel M, Thompson B, Poulin M-H, Normand CL, Fisher MH, Couture G, et al. Systematic review of risk and protective factors associated with substance use and abuse in individuals with autism spectrum disorders. Autism. SAGE Publications; 2020May;24(4):899–918. Available from: https://doi.org/10.1177/1362361320910963

Latent Health Risk Classes Associated with Poor Physical and Mental Outcomes in Workers with COPD from Central Appalachian U.S. States

Adults who work in the Central Appalachian region of the United States (U.S.) are disproportionately affected by Chronic Obstructive Pulmonary Disease (COPD). While there is a socio-demographic profile of adults with COPD who are at increased risk for physical and mental distress, the risk factors that uniquely affect the health-related quality of life (HRQoL) of Central Appalachian workers with COPD are unknown. Therefore, we conducted a latent class analysis of 2016 and 2017 Behavioral Risk Factor Surveillance System data from 1326 currently employed adults with COPD living in four U.S. states (KY, NC, TN, and WV) within the Central Appalachian Region. Drawing from the social ecological model, we identified associations between theoretically informed risk indicators—comorbid health conditions, substance use and abuse, and limited access to healthcare—on three HRQoL variables, including infrequent (0–13 days) or frequent (≥14 days) physical distress, mental distress, and limited activity due to poor health over the past 30 days. Workers at high risk for comorbid conditions reported more frequent physical distress, mental distress, and activity limitations as compared to those at low risk. Workers reporting difficulty accessing healthcare were no more likely to report physical or mental distress when compared to workers with adequate access to healthcare; however, those with limited healthcare access did report more frequent activity limitation due to poor health. Interestingly, workers with COPD at high risk for substance use and abuse were no more likely to report poor HRQoL outcomes compared to those at low risk. Our findings have important implications for addressing indicators of poor health among Central Appalachian workers with COPD, especially those living with multiple comorbidities.

Systematic review of risk and protective factors associated with substance use and abuse in individuals with autism spectrum disorders

A systematic review of autism spectrum disorder and substance use and abuse was conducted based on the Preferred Reporting Items for Systematic Review and Meta-Analysis protocol guidelines (an internationally recognized standardized methodological framework for conducting systematic review). The objectives of the review were to update and extend findings reported by Arnevik and Helverschou’s review of the autism spectrum disorder and substance use literature by (1) evaluating study quality via the Mixed-Methods Appraisal Tool; (2) examining autism spectrum disorder and substance abuse diagnostic measures; (3) reporting on the prevalence of co-occurring autism spectrum disorder and substance abuse; and (4) identifying risk, protective, and positive treatment factors. Twenty-six studies on substance use and abuse in autism spectrum disorder were identified through a search of MEDLINE, PsycINFO and Google Scholar. Average study quality score was 75.4%. Prevalence rates of substance abuse among samples with autism spectrum disorder ranged from 1.3% to 36%, but due to variability in sample characteristics and diagnostic measures, a general prevalence rate could not be established. Risk and protective factors, recognized in the general population, such as familial substance abuse and comorbid externalizing disorders, and factors, which may be more likely to occur in individuals with autism spectrum disorder compared to the general population, such as few social resources (i.e. sense of social belonging, breadth of social support networks, and level of social capital) and low sensation-seeking, were identified. One intervention study was identified; however, methodological limitations preclude any conclusion regarding positive treatment factors at this time. More research, using standardized measures and comparable samples, is needed to understand risk and protective factors and to determine the prevalence of co-occurring substance abuse and autism spectrum disorder. Lay Abstract Symptoms characteristic of autism spectrum disorder were initially believed to protect individuals with autism spectrum disorder from developing substance abuse. However, recent studies suggest that up to 36% of individuals with autism spectrum disorder may have a co-occurring issue with substance abuse. In addition, substance abuse may worsen the difficulties with daily functioning some individuals with autism spectrum disorder experience. It is important to understand occurrence rates, and risk, protective and positive treatment factors of co-occurring autism spectrum disorder and substance abuse in order to promote the best possible support for this special population. This review aimed to find and synthesize evidence regarding risk, protective and treatment factors, and determine a general prevalence rate of co-occurring autism spectrum disorder and substance abuse from all studies on substance use and abuse in individuals with autism spectrum disorder. The review also aimed to assess study quality and identify a diagnostic measure for substance abuse in individuals with autism spectrum disorder. Twenty-six studies on substance use and abuse in autism spectrum disorder were included in the review. The rates of substance abuse among those with autism spectrum disorder identified by included studies ranged from 1.3% to 36%, but due to large differences in study methods, a general prevalence rate could not be determined. Risk and protective factors, recognized in the general population, such as familial substance abuse and co-occurring mental health issues, and factors which may be more likely to occur in individuals with autism spectrum disorder, such as limited social resources and low sensation-seeking, were identified. No diagnostic measures specific to individuals with autism spectrum disorder and substance abuse were identified. This review identified only one exploratory study on an adapted intervention for co-occurring autism spectrum disorder and substance abuse. However, there were many methodological challenges in this study that limit the conclusions that can be drawn from the data. More research, using consistent methods, is needed to understand risk and protective factors and to determine the prevalence of substance abuse among individuals with autism spectrum disorder. The potential for co-occurring autism spectrum disorder and substance abuse should be considered by professional working in both autism spectrum disorder and substance abuse services, as finding suggests substance abuse is possible among individuals with autism spectrum disorder and may occur more frequently than previously believed. In addition, autism spectrum disorder and substance abuse service providers should be sensitive to specific risk and protective factors identified by the review that may impact substance abuse course and outcomes.