Laurel A. Copeland Ph.D.

Salas, J., J. F. Scherrer, B. K. Ahmedani, L. A. Copeland, K. K. Bucholz, M. D. Sullivan, T. Burroughs, F. D. Schneider and P. J. Lustman (2017). “Gender and the association between long-term prescription opioid use and new onset depression.” J Pain: 1-33.

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Women have a higher prevalence of chronic non-cancer pain conditions and report more severe pain, yet, it is not known if the association between long term opioid analgesic use (OAU) and risk of a new depression episode (NDE) differs by gender. We analyzed patient data from the Veterans Health Administration (VHA; 2000 to 2012; n=70,997) and a large private-sector health care organization (2003 to 2012; n=22,981) to determine whether long-term OAU and risk of NDE differed by gender. Patients were free of depression and OAU for two years prior to baseline. OAU duration was defined as 1-30, 31-90 and >90 days, and NDE was defined by ICD-9 codes. Gender-stratified Cox proportional hazard models estimated hazard ratios. Propensity scores and subsequent inverse probability of treatment weighting controlled for confounding. In the VHA, >90 compared to 1-30 day OAU was more strongly associated with NDE among females than males (female: HR=1.79; 95%CI:1.45-2.22 vs. male HR=1.25; 95%CI:1.16-1.34, p=0.002). In private sector patients, there was no gender difference in the association between >90 day OAU and NDE (female HR=1.97; 95%CI:1.64-2.37 vs. male HR=1.99; 95%CI:1.44-2.74). Risk of NDE following long-term OAU is similar in men and women in private-sector patients but may differ for VHA patients. Future prospective studies are needed to identify mechanisms for the association between longer OAU and NDE. PERSPECTIVE: Existing research is mixed regarding gender differences in outcomes following long-term prescription opioid use. This study found both genders have increased risk of a new depression episode following >90 day opioid use. Women and men may benefit from closer monitoring of mood associated with chronic opioid use.

Hollis, R. H., L. A. Graham, J. S. Richman, M. S. Morris, H. J. Mull, T. S. Wahl, E. Burns, L. A. Copeland, G. L. Telford, A. K. Rosen, K. F. Itani, J. Whittle, T. H. Wagner and M. T. Hawn (2017). “Hospital readmissions after surgery: How important are hospital and specialty factors?” J Am Coll Surg 224(4): 515-523.

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BACKGROUND: Hospital readmission rates after surgery can represent an overall hospital effect or a combination of specialty and patient effects. We hypothesized that hospital readmission rates for procedures within specialties were more strongly correlated than rates across specialties within the same hospital. STUDY DESIGN: For general, orthopaedic, and vascular specialties at Veterans Affairs hospitals during 2008 to 2014, 30-day risk-adjusted readmission rates were estimated for 6 high-volume procedures and each specialty. Relationships were assessed using the Pearson correlation coefficient. RESULTS: At 84 hospitals, 64,724 orthopaedic, 24,963 general, and 10,399 vascular inpatient procedures were performed; mean readmission rates were 6.3%, 13.6%, and 16.4%, respectively. There was no correlation between specialty-specific adjusted hospital readmission rates: general and orthopaedic (r = 0.21; p = 0.06), general and vascular (r = 0.15; p = 0.19), and vascular and orthopaedic surgery (r = 0.07; p = 0.55). Within specialties, we found modest correlations between knee and hip arthroplasty readmission rates (r = 0.39; p < 0.01) and colectomy and ventral hernia repair (r = 0.24; p = 0.03), but not between lower-extremity bypass and endovascular aortic repair (r = 0.13; p = 0.26). Overall, controlling for patient-level factors, 1.9% of the variation in readmissions was attributable to specialty-level factors; only 0.6% was attributable to hospital-level factors. CONCLUSIONS: Hospital readmission rates for orthopaedic, vascular, and general surgery were not correlated between specialties; within each of the 3 specialties, modest correlations were found between 2 procedures within 2 of these specialties. These findings suggest that hospital surgical readmission rates are primarily explained by patient- and procedure-specific factors and less by broader specialty and/or hospital effects.

Scherrer, J. F., J. Salas, F. D. Schneider, K. K. Bucholz, M. D. Sullivan, L. A. Copeland, B. K. Ahmedani, T. Burroughs and P. J. Lustman (2017). “Characteristics of new depression diagnoses in patients with and without prior chronic opioid use.” J Affect Disord 210: 125-129.

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Chronic use (>90 Days) of opioid analgesics significantly increases the risk of development of new depression episodes (NDE). It is unclear whether depression that develops in this manner is similar to or different from NDE in persons not exposed to opioid analgesic use (OAU). METHODS: VA patients were classified into two groups, those who did not receive an opioid and developed depression (non-OAU+NDE, n=4314) and those that had >90 days OAU and developed NDE (OAU+NDE, n=444). OAU+NDE patients were compared to non-OAU+NDE in terms of depression severity (PHQ-9 scores), incidence of PTSD, other anxiety disorders and substance use disorders after NDE, receipt of acute phase antidepressant treatment, dual antidepressant treatment, mood stabilizers and atypical antipsychotics. Prior to computing bivariate analysis, the prevalence of pain conditions and average maximum pain scores were equalized between the two groups using propensity scores and inverse probability of treatment weighting. RESULTS: Controlling for pain, OAU+NDE patients had more depression symptoms (p=.012), more incident PTSD (p=.04) and opioid abuse/dependence and were more likely to receive 12 weeks of antidepressant treatment (p<.0001). Last, non-OAU+NDE were more likely to have incident diagnoses for any other anxiety disorder (p=.014). CONCLUSIONS: Within the limitations of electronic medical record data, results indicate OAU+NDE patients have more depression symptoms, greater treatment adherence and different comorbid psychiatric conditions compared to non-OAU+NDE, independent of pain. Overall OAU related depression is as severe as non-OAU related depression and repeated depression screening in chronic opioid therapy may be warranted for pain patients, regardless of pain severity.

Scherrer, J. F., J. Salas, F. D. Schneider, K. K. Bucholz, M. D. Sullivan, L. A. Copeland, B. K. Ahmedani, T. Burroughs and P. J. Lustman (2016). “Characteristics of new depression diagnoses in patients with and without prior chronic opioid use.” J Affect Disord 210: 125-129.

Full text of this article.

Chronic use (>90 Days) of opioid analgesics significantly increases the risk of development of new depression episodes (NDE). It is unclear whether depression that develops in this manner is similar to or different from NDE in persons not exposed to opioid analgesic use (OAU). METHODS: VA patients were classified into two groups, those who did not receive an opioid and developed depression (non-OAU+NDE, n=4314) and those that had >90 days OAU and developed NDE (OAU+NDE, n=444). OAU+NDE patients were compared to non-OAU+NDE in terms of depression severity (PHQ-9 scores), incidence of PTSD, other anxiety disorders and substance use disorders after NDE, receipt of acute phase antidepressant treatment, dual antidepressant treatment, mood stabilizers and atypical antipsychotics. Prior to computing bivariate analysis, the prevalence of pain conditions and average maximum pain scores were equalized between the two groups using propensity scores and inverse probability of treatment weighting. RESULTS: Controlling for pain, OAU+NDE patients had more depression symptoms (p=.012), more incident PTSD (p=.04) and opioid abuse/dependence and were more likely to receive 12 weeks of antidepressant treatment (p<.0001). Last, non-OAU+NDE were more likely to have incident diagnoses for any other anxiety disorder (p=.014). CONCLUSIONS: Within the limitations of electronic medical record data, results indicate OAU+NDE patients have more depression symptoms, greater treatment adherence and different comorbid psychiatric conditions compared to non-OAU+NDE, independent of pain. Overall OAU related depression is as severe as non-OAU related depression and repeated depression screening in chronic opioid therapy may be warranted for pain patients, regardless of pain severity.

Henry, C., C. Boethel, L. A. Copeland, S. Ghamande, A. C. Arroliga and H. D. White (2017). “Clinical utility of testing for legionella pneumonia in central texas.” Ann Am Thorac Soc 14(1): 65-69.

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RATIONALE: Legionella pneumophila is an uncommon cause of community-acquired pneumonia in the south central region of the United States, and regular testing may not be cost effective in areas of low incidence. OBJECTIVES: To evaluate the incidence of Legionella in central Texas and to determine the cost effectiveness of Legionella urinary antigen testing. METHODS: We performed a single-center retrospective cohort study of patients admitted with pneumonia between January 2001 and December 2013. Patients were identified by Binax Legionella urinary antigen and International Classification of Disease, Ninth Revision codes. Demographic characteristics and clinical history of the confirmed Legionella pneumonia cases were obtained by chart review. Descriptive statistics were used to describe patient characteristics. MEASUREMENTS AND MAIN RESULTS: Over 12 years, 5,807 patients with 11,377 admissions for pneumonia were tested for Legionella urinary antigen. A positive Legionella urinary antigen was found in 17 patients. Cumulative incidence during the study period was 0.23%. Among the Legionella-positive patients, intensive care unit admission and median length of stay were 58.8% and 8.5 days, respectively. Most patients (64.7%) met American Thoracic Society criteria for severe pneumonia. All patients empirically received either a macrolide or fluoroquinolone covering Legionella. There were two in-hospital and three total 90-day deaths in those with a positive urinary antigen. The estimated cost of screening this population with Legionella urinary antigen was $214,438 over 13 years. CONCLUSIONS: This study reveals the low incidence of Legionella pneumonia in central Texas. Use of guideline-concordant antibiotic treatment provides coverage for Legionella. We speculate that testing in a low-prevalence area would not influence outcomes or be cost effective.