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Martin CE. Commentary on Cochran et al.: Meeting people where they are in addictions research. Addiction 2024; 119:557-558. [PMID: 38183349 PMCID: PMC10872413 DOI: 10.1111/add.16418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 11/29/2023] [Indexed: 01/08/2024]
Abstract
In addiction treatment, it’s important to ‘meet people where they are’. However, in research, we commonly ask participants to meet us where we are in the interventions we develop. Cochran et al. report on a patient navigation intervention for pregnant and postpartum people with opioid use disorder. Their study illustrates a delicate balance reached between the research need to maximize scientific rigor and the clinical need to ‘meet people where they are’.
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Affiliation(s)
- Caitlin E Martin
- Department of Obstetrics and Gynecology, Institute for Drug and Alcohol Studies, Virginia Commonwealth University, Richmond, Virginia, USA
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Cesare N, Lines LM, Chandler R, Gibson EB, Vickers-Smith R, Jackson R, Bazzi AR, Goddard-Eckrich D, Sabounchi N, Chisolm DJ, Vandergrift N, Oga E. Development and validation of a community-level social determinants of health index for drug overdose deaths in the HEALing Communities Study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 157:209186. [PMID: 37866438 DOI: 10.1016/j.josat.2023.209186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 09/11/2023] [Accepted: 10/10/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Social determinants of health (SDoH), such as socioeconomic status, education level, and food insecurity, are believed to influence the opioid crisis. While global SDoH indices such as the CDC's Social Vulnerability Index (SVI) and Area Deprivation Index (ADI) combine the explanatory power of multiple social factors for understanding health outcomes, they may be less applicable to the specific challenges of opioid misuse and associated outcomes. This study develops a novel index tailored to opioid misuse outcomes, tests the efficacy of this index in predicting drug overdose deaths across contexts, and compares the explanatory power of this index to other SDoH indices. METHODS Focusing on four HEALing Communities Study (HCS) states (Kentucky, Massachusetts, New York and Ohio; encompassing 4269 ZIP codes), we identified multilevel SDoH potentially associated with opioid misuse and aggregated publicly available data for each measure. We then leveraged a random forest model to develop a composite measure that predicts age-adjusted drug overdose mortality rates based on SDoH. We used this composite measure to understand HCS and non-HCS communities in terms of overdose risk across areas of varying racial composition. Finally, we compared variance in drug overdose deaths explained by this index to variance explained by the SVI and ADI. RESULTS Our composite measure included 28 SDoH measures and explained approximately 89 % percent of variance in age-adjusted drug overdose mortality across HCS states. Health care measures, including emergency department visits and primary care provider availability, were top predictors within the index. Index accuracy was robust within and outside of HCS communities and states. This measure identified high levels of overdose mortality risk in segregated communities. CONCLUSIONS Existing SDoH indices fail to explain much variation in area-level overdose mortality rates. Having tailored composite indices can help us to identify places in which residents are at highest risk based on their composite contexts. A comprehensive index can also help to develop effective community interventions for programs such as HCS by considering the context in which people live.
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Affiliation(s)
- Nina Cesare
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, 85 East Newton Street Suite 906, Boston, MA, USA.
| | - Lisa M Lines
- RTI International, 3040 East Cornwallis Road, PI Box 12194, Research Triangle Park, NC, USA.
| | - Redonna Chandler
- National Institute on Drug Abuse, C/O NIH Mail Center 3WFN 16071 Industrial Dr, Gaithersburg, MD, USA.
| | - Erin B Gibson
- Boston Medical Center, 850 Harrison Ave., Boston, MA, USA.
| | | | - Rebecca Jackson
- Ohio State University Medical Center, 410 West Ave, Columbus, OH, USA.
| | - Angela R Bazzi
- University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92161, USA.
| | | | - Nasim Sabounchi
- CUNY Graduate School of Public Health & Health Policy, 55 W 125th St., New York, NY, USA.
| | - Deena J Chisolm
- Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH, USA.
| | - Nathan Vandergrift
- RTI International, 3040 East Cornwallis Road, PI Box 12194, Research Triangle Park, NC, USA.
| | - Emmanuel Oga
- RTI International, 3040 East Cornwallis Road, PI Box 12194, Research Triangle Park, NC, USA.
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Xu KY, Huang V, Williams AR, Martin CE, Bazazi AR, Grucza RA. Co-occurring psychiatric disorders and disparities in buprenorphine utilization in opioid use disorder: An analysis of insurance claims. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 9:100195. [PMID: 38023343 PMCID: PMC10630609 DOI: 10.1016/j.dadr.2023.100195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/18/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023]
Abstract
Background As the overdose crisis continues in the U.S. and Canada, opioid use disorder (OUD) treatment outcomes for people with co-occurring psychiatric disorders are not well characterized. Our objective was to examine the influence of co-occurring psychiatric disorders on buprenorphine initiation and discontinuation. Methods This retrospective cohort study used multi-state administrative claims data in the U.S. to evaluate rates of buprenorphine initiation (relative to psychosocial treatment without medication) in a cohort of 236,198 people with OUD entering treatment, both with and without co-occurring psychiatric disorders, grouping by psychiatric disorder subtype (mood, psychotic, and anxiety-and-related disorders). Among people initiating buprenorphine, we assessed the influence of co-occurring psychiatric disorders on buprenorphine retention. We used multivariable Poisson regression to estimate buprenorphine initiation and Cox regression to estimate time to discontinuation, adjusting for all 3 classes of co-occurring disorders simultaneously and adjusting for baseline demographic and clinical characteristics. Results Buprenorphine initiation occurred in 29.3 % of those with co-occurring anxiety-and-related disorders, compared to 25.9 % and 17.5 % in people with mood and psychotic disorders. Mood (adjusted-risk-ratio[aRR] = 0.82[95 % CI = 0.82-0.83]) and psychotic disorders (aRR = 0.95[0.94-0.96]) were associated with decreased initiation (versus psychosocial treatment), in contrast to greater initiation in the anxiety disorders cohort (aRR = 1.06[1.05-1.06]). We observed an increase in buprenorphine discontinuation associated with mood (adjusted-hazard-ratio[aHR] = 1.20[1.17-1.24]) and anxiety disorders (aHR = 1.12[1.09-1.14]), in contrast to no association between psychotic disorders and buprenorphine discontinuation. Conclusions We observed underutilization of buprenorphine among people with co-occurring mood and psychotic disorders, as well as high buprenorphine discontinuation across anxiety, mood, and psychotic disorders.
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Affiliation(s)
- Kevin Y Xu
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Vivien Huang
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Arthur Robin Williams
- Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York, New York, USA
- Division of Substance Use Disorders, New York State Psychiatric Institute, New York, New York, USA
| | - Caitlin E Martin
- Department of Obstetrics and Gynecology and the VCU Institute for Drug and Alcohol Studies, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Alexander R. Bazazi
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Richard A. Grucza
- Department of Family and Community Medicine, St. Louis University, St. Louis, Missouri, USA
- Department of Health and Clinical Outcomes Research, St. Louis University, St Louis, Missouri, USA
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Martin CE, Britton E, Shadowen H, Johnson J, Sabo R, Cunningham P. Postpartum medication for opioid use disorder outcomes associated with prenatal treatment and neighborhood-level social determinants. Am J Obstet Gynecol MFM 2023; 5:101173. [PMID: 37783277 PMCID: PMC10727449 DOI: 10.1016/j.ajogmf.2023.101173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/07/2023] [Accepted: 09/24/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Opioid use disorder is a leading cause of death through the year postpartum. OBJECTIVE This study aimed to identify the association of neighborhood-level social determinants of health and prenatal opioid use disorder treatment receipt with the outcomes of medication treatment for opioid use disorder through the year postpartum among a cohort of birthing people. STUDY DESIGN This was a population-based retrospective cohort study that used state Medicaid claims and enrollment data for the 1690 individuals who delivered a live infant between July 1, 2016 and December 31, 2020 and received medication for opioid use disorder at delivery. The primary exposure was the state Health Opportunity Index, a composite measure of social determinants of health linked at the census-tract level. Secondary exposures included comprehensiveness of opioid use disorder treatment and duration of medication treatment for opioid use disorder received prenatally. Outcomes included the duration and continuity of postpartum medication treatment for opioid use disorder, operationalized as the time from delivery to the discontinuation of medication treatment for opioid use disorder, and percentage of days covered by medication treatment for opioid use disorder within the 12 months after delivery, respectively. RESULTS Within the study sample, 711 deliveries were to birthing people in the lowest state Health Opportunity Index tercile (indicating high burden of negative social determinants of health), 647 in the middle state Health Opportunity Index tercile, and 332 in the highest state Health Opportunity Index tercile. Using stepwise multivariable regression (Cox proportional hazards and negative binomial models) guided by a socioecological framework, prenatal receipt of more comprehensive opioid use disorder treatment and/or longer duration of prenatal medication treatment for opioid use disorder was associated with improved 1-year postpartum opioid use disorder treatment outcomes (duration and continuity of medication treatment for opioid use disorder). When the state Health Opportunity Index was added to the models, these significant associations remained stable, with the state Health Opportunity Index not demonstrating an association with the outcomes (duration hazard ratio, 1.39; 95% confidence interval, 0.551-3.512; continuity relative risk, 1.024; 95% confidence interval, 0.323-3.247). CONCLUSION Targeted efforts at expanding access to and quality of evidence-based opioid use disorder treatments for reproductive-age people across the life course should be prioritized within the spectrum of work aimed at eradicating disparities in pregnancy-related mortality.
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Affiliation(s)
- Caitlin E Martin
- Department of Obstetrics and Gynecology, School of Medicine, Institute for Drug and Alcohol Studies, Virginia Commonwealth University, Richmond, VA (Dr Martin).
| | - Erin Britton
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA (Dr Britton, Ms Shadowen, and Dr Cunningham)
| | - Hannah Shadowen
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA (Dr Britton, Ms Shadowen, and Dr Cunningham)
| | - Jasmine Johnson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN (Dr Johnson)
| | - Roy Sabo
- Department of Biostatistics, School of Medicine, Virginia Commonwealth University, Richmond, VA (Dr Sabo)
| | - Peter Cunningham
- Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond, VA (Dr Britton, Ms Shadowen, and Dr Cunningham)
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Cook RR, Jaworski EN, Hoffman KA, Waddell EN, Myers R, Korthuis PT, Vergara-Rodriguez P. Treatment Initiation, Substance Use Trajectories, and the Social Determinants of Health in Persons Living With HIV Seeking Medication for Opioid Use Disorder. Subst Abus 2023; 44:301-312. [PMID: 37842910 PMCID: PMC10830143 DOI: 10.1177/08897077231200745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
BACKGROUND People living with HIV and opioid use disorder (OUD) are disproportionally affected by adverse socio-structural exposures negatively affecting health, which have shown inconsistent associations with uptake of medications for OUD (MOUD). This study aimed to determine whether social determinants of health (SDOH) were associated with MOUD uptake and trajectories of substance use in a clinical trial of people seeking treatment. METHODS Data are from a 2018 to 2019 randomized trial comparing the effectiveness of different MOUD to achieve viral suppression among people living with HIV and OUD. SDOH were defined by variables mapping to Healthy People 2030 domains: education (Education Access and Quality), income (Economic Stability), homelessness (Neighborhood and Built Environment), criminal justice involvement (Social and Community Context), and recent SUD care (Health Care Access and Quality). Associations between SDOH and MOUD initiation were assessed with Cox proportional hazards models, and SDOH and substance use over time with generalized estimating equation models. RESULTS Participants (N = 114) averaged 47 years old, 63% were male, 56% were Black, and 12% Hispanic. Participants reported an average of 2.3 out of 5 positive SDOH indicators (SD = 1.2). Stable housing was the most commonly reported SDOH (61%), followed by no recent criminal justice involvement (59%), having a high-school level education or greater (56%), income stability (45%), and recent SUD care (13%). Each additional favorable SDOH was associated with a 25% increase in the likelihood of MOUD initiation during the study period [adjusted HR = 1.25, 95% CI = (1.01, 1.55), P = .044]. Positive SDOH were also associated with a decrease in the odds of baseline opioid use and a greater reduction in opioid use during subsequent weeks of the study (P < .001 for a joint test of baseline and slope differences). CONCLUSIONS Positive social determinants of health, in aggregate, may increase the likelihood of MOUD treatment initiation among people living with HIV and OUD.
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Affiliation(s)
- Ryan R. Cook
- Department of Medicine, Section of Addiction Medicine, Oregon Health and Science University, Portland
| | - Erin N. Jaworski
- Center for Dissemination and Implementation Science, Department of Medicine, University of Illinois-Chicago, Chicago, IL
| | - Kim A. Hoffman
- Oregon Health and Science University-Portland State University School of Public Health, Portland
| | - Elizabeth N Waddell
- Oregon Health and Science University-Portland State University School of Public Health, Portland
| | - Renae Myers
- Department of Medicine, Section of Addiction Medicine, Oregon Health and Science University, Portland
| | - P. Todd Korthuis
- Department of Medicine, Section of Addiction Medicine, Oregon Health and Science University, Portland
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Martin CE, Patel H, Dzierewski JM, Moeller FG, Bierut LJ, Grucza RA, Xu KY. Benzodiazepine, Z-drug, and sleep medication prescriptions in male and female people with opioid use disorder on buprenorphine and comorbid insomnia: an analysis of multistate insurance claims. Sleep 2023; 46:zsad083. [PMID: 36970994 PMCID: PMC10262036 DOI: 10.1093/sleep/zsad083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/19/2023] [Indexed: 03/29/2023] Open
Abstract
STUDY OBJECTIVES In adult populations, women are more likely than men to be prescribed benzodiazepines. However, such disparities have not been investigated in people with opioid use disorder (OUD) and insomnia receiving buprenorphine, a population with particularly high sedative/hypnotic receipt. This retrospective cohort study used administrative claims data from Merative MarketScan Commercial and MultiState Medicaid Databases (2006-2016) to investigate sex differences in the receipt of insomnia medication prescriptions among patients in OUD treatment with buprenorphine. METHODS We included people aged 12-64 years with diagnoses of insomnia and OUD-initiating buprenorphine during the study timeframe. The predictor variable was sex (female versus male). The primary outcome was receipt of insomnia medication prescription within 60 days of buprenorphine start, encompassing benzodiazepines, Z-drugs, or non-sedative/hypnotic insomnia medications (e.g. hydroxyzine, trazodone, and mirtazapine). Associations between sex and benzodiazepine, Z-drug, and other insomnia medication prescription receipt were estimated using Poisson regression models. RESULTS Our sample included 9510 individuals (female n = 4637; male n = 4873) initiating buprenorphine for OUD who also had insomnia, of whom 6569 (69.1%) received benzodiazepines, 3891 (40.9%) Z-drugs, and 8441 (88.8%) non-sedative/hypnotic medications. Poisson regression models, adjusting for sex differences in psychiatric comorbidities, found female sex to be associated with a slightly increased likelihood of prescription receipt: benzodiazepines (risk ratio [RR], RR = 1.17 [1.11-1.23]), Z-drugs (RR = 1.26 [1.18-1.34]), and non-sedative/hypnotic insomnia medication (RR = 1.07, [1.02-1.12]). CONCLUSIONS Sleep medications are commonly being prescribed to individuals with insomnia in OUD treatment with buprenorphine, with sex-based disparities indicating a higher prescribing impact among female than male OUD treatment patients.
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Affiliation(s)
- Caitlin E Martin
- Department of Obstetrics and Gynecology and VCU Institute for Drug and Alcohol Studies, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Hetal Patel
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | | | - F. Gerard Moeller
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, Richmond, VA, USA
| | - Laura J Bierut
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
- Alvin J Siteman Cancer Center, Barnes Jewish Hospital, St. Louis, MO, USA
| | - Richard A Grucza
- Departments of Family and Community Medicine and Health and Outcomes Research, St. Louis University, St. Louis, MO, USA
| | - Kevin Y Xu
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
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Mayer S, Boyd J, Fairbairn N, Chapman J, Brohman I, Jenkins E, McNeil R. Women's experiences in injectable opioid agonist treatment programs in Vancouver, Canada. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 117:104054. [PMID: 37192557 DOI: 10.1016/j.drugpo.2023.104054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/18/2023] [Accepted: 04/30/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Injectable opioid agonist treatment (iOAT) has recently been expanded in some geographical contexts in Canada as part of a response to the escalating overdose crisis. Complex gendered dynamics, including power differentials, violence, and social norms, shape the overdose crisis and drug treatment programs which can adversely impact women's experiences. This qualitative study examines how social (e.g., gender, income, housing) and structural factors (e.g., program policies) impact women's experiences of iOAT. METHODS Qualitative interviews were completed with 16 women enrolled in four iOAT programs in Vancouver, Canada. Approximately 50 hours of ethnographic observations were conducted. Interview transcripts and ethnographic fieldnotes were analyzed using a critical feminist lens by applying the concepts of embodiment, relationality, and social control to understand women's engagement and self-reported treatment outcomes. RESULTS Initial iOAT engagement was a relational process, including initiating treatment with a partner and engaging with iOAT to (re)build personal relationships. Relationships with iOAT providers, including flexibility and support with medication administration, were important to women, providing an affirming embodied experience and a greater sense of agency. However, program operations (e.g., mandated daily attendance, program crowding) incompatible with women's needs (e.g., employment) could undermine these positive experiences. Women's reported outcomes highlight a tension between achieving more agency and the constraints of intensive and stigmatized treatment. CONCLUSION This study highlights how iOAT is both a source of care and control for women from a relational and embodied perspective. Findings underscore the need for gender-attentive and flexible drug treatment services to meet the varied needs of women and the importance of providing relational care for women accessing iOAT.
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Affiliation(s)
- Samara Mayer
- British Columbia Centre on Substance Use, 717 East Hastings St. Vancouver, BC V6Z 2A9, Canada; Interdisciplinary Studies Graduate Program, University of British Columbia, 170-6371 Crescent Road, Vancouver, BC V6T 1Z2, Canada
| | - Jade Boyd
- British Columbia Centre on Substance Use, 717 East Hastings St. Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street. Vancouver, BC V6Z 1Y6, Canada
| | - Nadia Fairbairn
- British Columbia Centre on Substance Use, 717 East Hastings St. Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street. Vancouver, BC V6Z 1Y6, Canada
| | - Jules Chapman
- British Columbia Centre on Substance Use, 717 East Hastings St. Vancouver, BC V6Z 2A9, Canada
| | - Isabella Brohman
- British Columbia Centre on Substance Use, 717 East Hastings St. Vancouver, BC V6Z 2A9, Canada
| | - Emily Jenkins
- School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall. Vancouver, BC V6T 2B5, Canada
| | - Ryan McNeil
- British Columbia Centre on Substance Use, 717 East Hastings St. Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street. Vancouver, BC V6Z 1Y6, Canada; Internal Medicine, Yale School of Medicine, New Haven, 06510, United States; Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, 06510, United States; Department of Anthropology, Yale University, New Haven, 06510, United States.
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