Ajay Manhapra - Academia.edu (original) (raw)

Papers by Ajay Manhapra

Journal of Dual Diagnosis, Oct 1, 2023

Authorea (Authorea), Oct 1, 2023

Journal of the American College of Cardiology, Mar 1, 2004

The Journals of Gerontology, Apr 25, 2023

Impact statement: Using nationally representative data, this is the first study to examine patter... more Impact statement: Using nationally representative data, this is the first study to examine patterns of opioid and non-pharmacological treatments for chronic pain in older adults before and during Covid-19 pandemic.

Drug and Alcohol Dependence

BACKGROUND Substance use disorder (SUD) is a major risk factor for homelessness, but the specific... more BACKGROUND Substance use disorder (SUD) is a major risk factor for homelessness, but the specific association of opioid use disorder (OUD) and homelessness in the context of their shared risk factors has not been the focus of prior studies. We used national data from the United States Veterans Health Administration (VHA) to examine the association of OUD and homelessness in the context of shared risk factors. METHODS In this cross-sectional analysis of veterans who received VHA care during Fiscal Year 2012 (N = 5,450,078), we compared the prevalence of OUD and other sociodemographic, and clinical factors among homeless and non-homeless veterans. We estimated the odds ratio for homelessness associated with OUD alone, and after adjusting for other factors through multivariate logistic regression. RESULTS Homeless veterans had substantially higher prevalence of OUD than other VHA patients (7.7 % Vs 0.6 %) and OUD was associated with 13 times higher unadjusted odds of homelessness (Odds Ratio [OR] 13.36, 95 % CI 13.09-13.62), which decreased with adjustment for sociodemographic factors (black race, mean income and age), other SUD, medical, and psychiatric diagnoses (final OR 1.57, 95 % CI 1.53-1.61). Other SUDs (alcohol, cannabis, cocaine, and hallucinogens) showed similar or slightly higher odds of homelessness as OUD in the final model. CONCLUSIONS OUD was strongly associated with homelessness among US veterans although this association was largely but not entirely attenuated by shared sociodemographic and co-morbid risk factors including several other SUDs. Treatment of homeless veterans with OUD should address socio-economic vulnerabilities and other co-morbidities in addition to treatments for OUD.

Current Treatment Options in Oncology

Long-term opioid therapy (LTOT) for chronic cancer and non-cancer pain is commonly ineffective in... more Long-term opioid therapy (LTOT) for chronic cancer and non-cancer pain is commonly ineffective in providing its stated goal of improving function through good control of pain. Opioid tapering (slow dose reduction and/or discontinuation), the logical solution, also appears to be ineffective among many patients on LTOT as it often leads to even worse pain control and function, leaving the patients and providers managing LTOT in a clinical conundrum with little treatment choices. Complex persistent opioid dependence (CPOD) was recently offered as a heuristic to explain this clinical conundrum exemplified by the ineffectiveness of both LTOT and opioid tapering. This manuscript provides a detailed description of the neurobehavioral underpinnings of CPOD, explaining how long-term opioid use can lead to more pain even while experiencing relief with each opioid dose. CPOD is characterized by the allostatic opponent mechanisms of neuroadaptations related to the progression of opioid dependence and tolerance involving nociceptive/anti-nociceptive brain systems causing opioid-induced hyperalgesia and reward/anti-reward systems causing hyperkatefia or suffering that induces pain experience through the cognitive/emotional component of pain mechanisms. “Opioid Induced Chronic Pain syndrome” (OICP) is offered as an alternate clinical diagnostic term instead of CPOD that has several limitations as a diagnosis term including poor patient acceptance due to stigma towards addiction and clinical confounding with opioid use disorder, a related but separate clinical entity. OICP with LTOT is conceptualized as a recoverable iatrogenic problem that can be managed by pain providers. Broad guidance on management of OICP is also provided.

Drug and Alcohol Dependence, 2022

BACKGROUND Although substance use disorder (SUD) is frequently complicated by pain, the prevalenc... more BACKGROUND Although substance use disorder (SUD) is frequently complicated by pain, the prevalence and correlates of persistent pain and dysfunction following SUD remission have not been studied. METHODS Using a cross-sectional sample of United States (US) adults with SUD identified in the National Epidemiologic Survey on Alcohol and Related Conditions Wave III, we evaluated the prevalence of moderate/severe pain interference (PI) in subgroups with current and remitted SUD and the independent association of SUD remission and PI with self-reported psychosocial and physical function (Mental Health Composite Score [MCS] and Physical Function Score [PFS] from the Short Form 12). RESULTS A fifth (20.6%; 7.6 million) of estimated 36.7 million US adults with past year SUD and a slightly higher proportion (25.6%; 9.6 million) of 37.4 million with SUD remission reported PI. MCS and PFS showed independent negative associations with PI among adults with both past year SUD and SUD remission. MCS had a positive independent association with SUD remission, but a stronger negative association with PI. While PFS had no statistically significant association with SUD remission, it had a strong negative association with PI. Analysis of interaction between SUD remission and PI revealed that SUD remission had no effect on the association of PI and MCS but had significant moderating influence on the association between PI and PFS. CONCLUSIONS Moderate to severe pain interference continues to be a significant problem among a sizable population achieving SUD remission potentially impeding recovery, and deserves focused clinical attention both active SUD and its remission.

Cardiovascular risk factor prevalence among men in a

Treating Opioid Addiction, 2019

While the United States experienced a surge in morbidity and mortality associated with opioid pre... more While the United States experienced a surge in morbidity and mortality associated with opioid prescriptions after the year 2000, the country has since 2011 been mired in a growing crisis of overdose and addiction in which illicit opioids play a central role. The drastic increase in persons with prescription opioid use, misuse, and opioid use disorder prompted myriad public health and clinical interventions to curtail opioid-related harms. These approaches can be classified into three main categories: (1) curtailing opioid prescribing, (2) monitoring opioid prescribing, and (3) myriad public policies and initiatives to mitigate and treat opioid use, misuse, and opioid use disorder. Since many persons with opioid use disorder started with potentially prescribed opioids, efforts to curtail and control opioid prescriptions emerged as a primary policy response to address opioid-related morbidity and mortality in the United States. Central to these efforts were the landmark “CDC Guideline...

AIDS and Behavior, 2021

Although opioid agonist therapy (OAT) is associated with positive health outcomes, including impr... more Although opioid agonist therapy (OAT) is associated with positive health outcomes, including improved HIV management, long-term retention in OAT remains low among patients with opioid use disorder (OUD). Using data from the Veterans Aging Cohort Study (VACS), we identify variables independently associated with OAT retention overall and by HIV status. Among 7,334 patients with OUD, 13.7% initiated OAT, and 27.8% were retained 12-months later. Likelihood of initiation and retention did not vary by HIV status. Variables associated with improved likelihood of retention included receiving buprenorphine (relative to methadone), receiving both buprenorphine and methadone at some point over the 12-month period, or diagnosis of HCV. History of homelessness was associated with a lower likelihood of retention. Predictors of retention were largely distinct between patients with HIV and patients without HIV. Findings highlight the need for clinical, systems, and research initiatives to better understand and improve OAT retention.

Journal of Nervous & Mental Disease, 2021

Abstract Mental health (MH) research among veterans receiving services from the Veterans Health A... more Abstract Mental health (MH) research among veterans receiving services from the Veterans Health Administration (VHA) is extensive and growing and informs many clinical practice guidelines. We used nationally representative survey data to examine the generalizability of this extensive body of research by comparing sociodemographic and clinical characteristics of male veteran veterans health service (VHS) users (n = 491) with veteran non-VHS users (n = 840) and nonveteran (n = 6300) MH service users. VHS users were older, more often reported Black race, and less likely to have private or Medicaid insurance, but had similar prevalence of psychiatric or substance use disorder diagnoses but with a greater prevalence of posttraumatic stress disorder (PTSD). VHS users reported higher rates of medical diagnoses, pain interference, and poorer physical and MH status. These results suggest that VHA MH research may be reasonably generalizable to US mental health service users with caveats regarding age, PTSD diagnosis, pain, and racial distribution.

Journal of Psychiatric Research, 2021

Post-traumatic stress disorder (PTSD) is an often disabling mental disorder whose management typi... more Post-traumatic stress disorder (PTSD) is an often disabling mental disorder whose management typically focuses on reducing PTSD symptoms. Chronic pain and other comorbidities that commonly accompany PTSD symptoms may also be independently associated with disability. Using data from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions, we examined the independent association of PTSD symptom severity, pain interference, non-PTSD psychiatric and substance use disorders (SUD), and medical illnesses with each of four domains of function: mental health-related quality of life and physical functioning assessed with the Mental Health Composite Score (MCS) and Physical Function Score (PFS) of the Short Form-12; perceived social support from the Interpersonal Support and Evaluation List-12 (ISEL-12); and self-reported past year employment. Among 1779 individuals representing 11 million U.S. adults who met the Diagnostic and Statistical Manual-5 (DSM-5) criteria for Past Year PTSD, the MCS (41.2; SD 12.5), PFS (44.8; SD 13.2) and ISEL-12 (33.6; SD 7.2) indicated substantial disability when compared to population norms, and only 63.6% were employed. Multiple regression showed the MCS had a modest negative association with PTSD symptoms, pain interference, psychiatric multimorbidity and medical comorbidity although not with SUD. PFS and employment had significant negative associations with pain interference and medical comorbidity. ISEL-12 had a weak negative association with PTSD symptoms and non-PTSD psychiatric comorbidity. Common comorbidities thus significantly influence disability associated with PTSD, often more strongly than PTSD symptoms. PTSD treatment may require integrative multimorbidity management beyond a focus on PTSD symptoms.

Mayo Clinic Proceedings, 2020

Long-term opioid therapy has the potential for serious adverse outcomes and is often used in a vu... more Long-term opioid therapy has the potential for serious adverse outcomes and is often used in a vulnerable population. Because adverse effects or failure to maintain benefits is common with longterm use, opioid taper or discontinuation may be indicated in certain patients. Concerns about the adverse individual and population effects of opioids have led to numerous strategies aimed at reductions in prescribing. Although opioid reduction efforts have had generally beneficial effects, there have been unintended consequences. Abrupt reduction or discontinuation has been associated with harms that include serious withdrawal symptoms, psychological distress, self-medicating with illicit substances, uncontrolled pain, and suicide. Key questions remain about when and how to safely reduce or discontinue opioids in different patient populations. Thus, health care professionals who reduce or discontinue long-term opioid therapy require a clear understanding of the associated benefits and risks as well as guidance on the best practices for safe and effective opioid reduction. An interdisciplinary panel of pain clinicians and one patient advocate formulated recommendations on tapering methods and ongoing pain management in primary care with emphasis on patient-centered, integrated, comprehensive treatment models employing a biopsychosocial perspective.

Drug and Alcohol Dependence, 2019

Background: Opioid use disorder (OUD) is prevalent among people with HIV (PWH). Opioid agonist th... more Background: Opioid use disorder (OUD) is prevalent among people with HIV (PWH). Opioid agonist therapy (OAT) is the most effective treatment for OUD and is associated with improved health outcomes, but is often not initiated. To inform clinical practices and policies, we identified factors predictive of OAT initiation among patients with and without HIV. Methods: In this longitudinal, cohort study, we identified 19,698 new clinical encounters of OUD occurring between 2000 and 2012 in the Veterans Aging Cohort Study (VACS), a national observational cohort of PWH and matched uninfected controls. Mixed effects models examined factors predictive of initiation of any OAT within 30-days of a new OUD clinical encounter. We used a five-month break-in-care to ensure the identified OUD clinical encounter constituted a new opportunity for treatment. Results: 4.9% of both PWH and uninfected patients initiated any OAT within 30 days of a new OUD clinical encounter. In adjusted models, participants with a psychiatric diagnosis (adjusted odds ration [aOR] = 0.54, 95% confidence interval [CI] 0.47-0.62), PWH (aOR=0.79, 95% CI 0.68-0.92), and rural residence (aOR=0.56, 95% CI 0.39-0.78) had a lower likelihood of any OAT initiation, while African-American patients (aOR=1.60, 95% CI 1.34-1.92), those with an alcohol related diagnosis (aOR=1.76, 95% CI 1.48-2.08), diagnosis year 2005-2008 relative to 2000-2004 (aOR=1.24, 95% CI 1.05-1.45), and patients with HCV (aOR=1.50, 95% CI 1.27-1.77) had a greater likelihood of initiating any OAT within 30 days. Predictive factors were similar in the total sample and PWH only models. Conclusions: PWH were less likely to receive timely OAT initiation than demographically similar uninfected patients. Given the known health benefits of such treatment, the low rate of OAT initiation warrants focused efforts in both PWH and uninfected populations.

JAMA Internal Medicine, 2019

Biological Psychiatry, 2018