A neuroeconomic signature of opioid craving: How fluctuations in craving bias drug-related and nondrug-related value

How does craving bias decisions to pursue drugs over other valuable, and healthier, alternatives in addiction? To address this question, we measured the in-the-moment economic decisions of people with opioid use disorder as they experienced craving, shortly after receiving their scheduled opioid maintenance medication and ~24 h later. We found that higher cravers had higher drug-related valuation, and that moments of higher craving within-person also led to higher drug-related valuation. When experiencing increased opioid craving, participants were willing to pay more for personalized consumer items and foods more closely related to their drug use, but not for alternative “nondrug-related” but equally desirable options. This selective increase in value with craving was greater when the drug-related options were offered in higher quantities and was separable from the effects of other fluctuating psychological states like negative mood. These findings suggest that craving narrows and focuses economic motivation toward the object of craving by selectively and multiplicatively amplifying perceived value along a “drug relatedness” dimension.

Time-to-first exacerbation, adherence, and medical costs among US patients receiving umeclidinium/vilanterol or tiotropium as initial maintenance therapy for chronic obstructive pulmonary disease: a retrospective cohort study

Background Adherence to chronic obstructive pulmonary disease (COPD) maintenance medication is important for managing symptoms and exacerbation risk, and is associated with reduced mortality, hospitalizations, and costs. This study compared on-treatment exacerbations, medical costs, and medication adherence in patients with COPD initiating treatment with umeclidinium/vilanterol (UMEC/VI) or tiotropium (TIO). Methods This retrospective matched cohort study selected patients from Optum’s de-identified Clinformatics Data Mart database who initiated maintenance treatment with UMEC/VI or TIO between 01/01/2014 and 12/31/2017 (index date defined as the first dispensing). Eligible patients were ≥ 40 years of age and had ≥ 12 months continuous health plan coverage pre- and post-index; ≥ 1 medical claim for COPD pre-index or on the index date; no moderate/severe COPD-related exacerbations on the index date; no asthma diagnosis pre- or post-index; no maintenance medication fills containing inhaled corticosteroids, long-acting β2-agonists, or long-acting muscarinic antagonists pre-index or on the index date; and no fills for both UMEC/VI and TIO on the index date. Outcomes included time-to-first (Kaplan–Meier analysis) and rates of on-treatment COPD-related moderate/severe exacerbations, medication adherence (proportion of days covered [PDC] and proportion of adherent patients [PDC ≥ 0.8]), and COPD-related medical costs per patient per month (PPPM). Propensity score matching was used to adjust for potential confounders. Results Each cohort included 3929 matched patients. Kaplan–Meier rates of on-treatment COPD-related exacerbations were similar between cohorts (hazard ratio at 12 months; overall: 0.93, moderate: 0.92, severe: 1.07; all p > 0.05). UMEC/VI versus TIO initiators had significantly higher adherence (mean PDC: 0.44 vs 0.37; p < 0.001; proportion with PDC ≥ 0.8: 22.0% vs 16.4%; p< 0.001) and significantly lower mean on-treatment COPD-related total medical costs ($867 vs $1095 PPPM; p = 0.028), driven by lower outpatient visit costs. Conclusions These findings provide valuable information for physicians considering UMEC/VI or TIO as initial maintenance therapy options for patients with COPD.

The effectiveness of a pharmacy-based eHealth intervention promoting correct use of medication in patients with asthma and COPD: Results from a non-randomized pre-post study (Preprint)

BACKGROUND Asthma and chronic obstructive pulmonary disease (COPD) affect millions of people worldwide. Whilst medication can control and improve disease symptoms, incorrect use of medication is a common problem. eHealth intervention ‘SARA’ aims to improve participants’ correct use of inhalation medication by providing information, as well as as-needed tailored follow-up support by a pharmacist. OBJECTIVE The primary aim of this study was to investigate the effect of SARA on exacerbation rates in participants with asthma and COPD. Secondary aims were to investigate its effects in terms of adherence to maintenance medication and antimycotic treatment. METHODS In this non-randomized pre-post study, medication dispensing data of 382 Dutch community pharmacies were included. Exacerbation rates were assessed with dispensed oral corticosteroids short courses. Medication adherence was assessed by calculating the proportion of days covered (PDC) from dispensed inhalation maintenance medication, wherefore a distinction was made between new and chronic users. Antimycotic treatment was investigated from dispensed oral antimycotics in participants who were also dispensed inhaled corticosteroids (ICS). Outcomes were assessed one year before and one year after implementation of SARA and compared between SARA participants and control participants. More specifically, for exacerbation rates and medication adherence, a difference score was calculated (year after SARA minus year before SARA), and subsequently compared between the study groups with independent samples t-tests. For antimycotics, the relative number of participants who were dispensed antimycotics was calculated and subsequently analyzed with a mixed-effects logistic regression RESULTS The study population comprised 9,452 participants, of whom 2,400 were SARA participants. The mean age of the population was about 61, and approximately two-third was female. The results showed an increase in mean exacerbation rates over time for both study groups; 0.05 increase in SARA and 0.15 in controls. However this increase in exacerbations was significantly lower in the SARA condition (t9450= 3.10, 95% CI= 0.04 – 0.16, P= .002, Cohen d = 0.06). Chronic users of inhalation medication showed an increase in medication adherence over time in both study groups (6.73 in SARA and 4.48 control participants respectively); yet, this increase was significantly higher for SARA participants (t5886= -2.74, 95% CI= -3.86 – -0.84, P=.01, Cohen d = -0.07). In new users of inhalation medication, results showed no significant difference in medication adherence between SARA and controls in the year after implementation of SARA (t1434= -1.85, 95% CI= -5.60 – 0.16, P=.06, Cohen d = -0.10). In ICS-users, no significant differences between the study groups were found over time in terms of the proportion of participants who were dispensed antimycotics (t5654= 0.29, 95% CI= -0.40 - 0.54, P=.76, Cohen d = 0.00). CONCLUSIONS This study provides preliminary evidence that eHealth intervention SARA might have the potential to decrease exacerbation rates and improve medication adherence.

P649 Ulcerative Colitis Narrative Japanese survey: Identifying gaps between patient and healthcare professional perspectives on communication and disease management to optimise patient care

Background The Ulcerative Colitis (UC) Narrative is a global initiative examining perspectives on multiple aspects of UC via 2 related surveys (1 patient [pt]-based and 1 healthcare professional [HCP]-based), with the aim of improving understanding of the impact of UC and identifying gaps in optimal care. We present survey responses from pts and HCPs in Japan, a subanalysis of the global UC Narrative. Methods Surveys were conducted by The Harris Poll between Nov 2017 and Jan 2018. Pts (≥18 years of age) met the following criteria: had a diagnosis of UC (confirmed by endoscopy), had not had a colectomy, had taken prescription UC medication beyond 5-aminosalicylates, and had visited a gastroenterologist/internist in the previous year. HCPs were required to see ≥5 pts with UC per month, and ≥10% of their current pts had to be taking a biologic for their UC. Self-reported treatment history was used as a proxy for disease severity, and &gt;80% of pt respondents were required to have moderate to severe UC. Results 210 pts and 151 HCPs in Japan responded. The mean age of pts with UC was 44.3 (standard deviation 11.6; median 44) years, and 73% were male. Most (85%) pts were satisfied with their communication with their HCP. HCPs slightly underestimated pt satisfaction, believing that, on average, 71% of their pts were satisfied. However, most pts (65%) and HCPs (82%) wished for more discussion about goals for managing or treating UC. Most (83%) pts said they were honest with their HCP when discussing their experiences with UC, although almost half (45%) said they regretted not telling their HCP more; most (75%) HCPs felt that their pts were being honest with them. Over half (55%) of pts said they were hesitant to tell their HCP if they did not take their medication exactly as prescribed; however, most (79%) HCPs believed that &gt;50% of their pts adhered to treatment. HCPs underestimated the importance of toileting accidents to pts (28% vs 54%), and overestimated the importance of mucosal healing (59% vs 29%) (Figure 1). Some pts had misconceptions about treatment: only 69% knew that it was not OK to stop taking UC medications once they felt better, only 76% knew that it was not OK to keep using steroids as a long-term maintenance medication, and only 60% knew that it was possible for their body to stop responding to biologics (Figure 2). Most (71%) HCPs believed that pt advocacy organisations are important, but only recommended them to 26% of pts; only 38% of pts had interacted with one. Conclusion There was a high level of concordance in responses between pts in Japan and their HCPs; however, this survey revealed several gaps between pt and HCP perspectives. Consequently, the importance of pt-HCP communication in treat-to-target strategies remains.

DOP44 Long term outcomes of patients with untreated IBD - A population-based analysis from the epi-IIRN

Background Therapy in IBD is recommended in order to treat or prevent complications. In this nationwide study we aimed to assess the incidence of patients with IBD who were not receiving maintenance treatment after diagnosis and the duration of non-treatment. Methods This study was performed on data from four Health Maintenance Organizations (HMOs), covering 98% of the Israeli population. We included all patients with IBD diagnosed from 2005 to 2019. Non-treatment was defined as lack of drug prescription of maintenance medication for at least six months from diagnosis. Sustainability was defined as lack of maintenance medications and without IBD-related surgeries. Cox regression model was used to explore estimated predictors of sustainability. Results A total of 30,168 patients were diagnosed with IBD in Israel since 2005 (16,936 [56%] Crohn’s disease [CD] and 13,231 [44%] ulcerative colitis [UC]). A total of 5,448 (32%) patients with CD were untreated, compared to 5,158 (39%) with UC (OR 1.35 [95%CI 1.3–1.4]; p&lt;0.001). Non-treatment was more likely in adult compared to pediatric-onset (34% vs 21%, respectively, p&lt;0.001 in CD; and 41%% vs 22%, respectively, in UC; p&lt;0.001) (Figure 1). Sustainability rate in CD was 72%, 46%, 36% and 28% after one, two, five and ten years from diagnosis, while in UC the corresponding rates were 59%, 39%, 24% and 16%. In CD, sustainability was associated with older age at diagnosis (HR 0.996 [95%CI 0.994–0.998]) and no induction therapy (HR 0.7 [95%CI 0.6–0.9] compared to steroids). In UC, sustainability was associated only with female sex (HR 0.9 [95%CI 0.88–0.98]). Conclusion Most patients with IBD eventually require maintenance therapy. Lack of maintenance treatment is more common in UC. Nevertheless, a third of patients with CD and one quarter with UC who had no medical treatment at six months from diagnosis remained untreated for five years, especially in older patients with CD and those who did not require induction therapy, suggesting milder disease.

COVID-19 pharmacy student perceptions: pharmacists' impact during the COVID-19 pandemic

Pharmacists around the world are playing an active role in educating the public about COVID-19. First-year pharmacy students taking a healthcare course at Temple University in Philadelphia were asked to write papers based on the nature of a pharmacist’s contributions during the pandemic. 90% of the essays outlined the importance of community pharmacists, as they are the most accessible healthcare professional, providing immediate social interaction and drug expertise. They help minimize the need for hospital visits, limiting their time in public, therefore reducing their risk of becoming infected. For the pharmacies that have a drive-thru window, over-the-counter medications and other necessities can be sold to decrease the likelihood of transmission. Many students also proposed the opportunity for more leniency in prescribing power. Unless pharmacists are within a collaborative practice agreement, they cannot prescribe even maintenance medication. Due to the pandemic, it has become increasingly hard to reach the doctor or see them in person, as most offices have switched to telehealth. Clinical pharmacists operating out of hospitals have the opportunity to oversee proposed treatment options or experimental drugs, such as remdesivir. Retail pharmacies are emerging as key resources in this pandemic, and it is i

Successful Long-Term Control of the Syndrome of Episodic Angioedema With Eosinophilia (Gleich Syndrome) With Low-Dose Imatinib Mesylate and Prednisone

The syndrome of episodic angioedema with eosinophilia, first reported over 40 years ago, is a hypereosinophilic disorder that, uniquely, is not associated with end-organ pathology. However, patients develop a constellation of symptoms that include angioedema, urticaria, fatigue, and fever. Episodes are accompanied by massive hypereosinophilia and weight gain. Type II serum cytokine levels (IL-5, IL-13, IL-9, and IL-10) show cyclic variations peaking at or just prior to the peak of eosinophilia and an abnormal Th2 cell phenotype has been reported. Attacks may occur with predictable regularity and have been described in both adults and children. Glucocorticoid therapy reliably reverses symptoms with accompanying diuresis, defervesce, and normalization of the eosinophil count. In this report, a patient who had the syndrome of episodic angioedema with eosinophilia exceeding 20 years is reported. He has had no end-organ damage to date. Testing for the CHIC2 deletion, a surrogate for the FIP1L1-PDGFRA fusion, was negative. Use of imatinib mesylate, initially as a steroid-sparing agent, and subsequently as a maintenance medication, plus low-dose prednisone has provided long-term control of hypereosinophilia and all clinical manifestations.

Management of Pregnant Inflammatory Bowel Disease Patients During the COVID-19 Pandemic

The rapid emergence of the novel coronavirus [SARS-CoV2] and the coronavirus disease 2019 [COVID-19] has caused significant global morbidity and mortality. This is particularly concerning for vulnerable groups such as pregnant women with inflammatory bowel disease [IBD]. Care for pregnant IBD patients in itself is a complex issue because of the delicate balance between controlling maternal IBD as well as promoting the health of the unborn child. This often requires continued immunosuppressive maintenance medication or the introduction of new IBD medication during pregnancy. The current global COVID-19 pandemic creates an additional challenge in the management of pregnant IBD patients. In this paper we aimed to answer relevant questions that can be encountered in daily clinical practice when caring for pregnant women with IBD during the current COVID-19 pandemic. Podcast This article has an associated podcast which can be accessed at https://academic.oup.com/ecco-jcc/pages/podcast