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Jones BLH, Geier M, Neuhaus J, Coffin PO, Snyder HR, Soran CS, Knight KR, Suen LW. Withdrawal during outpatient low dose buprenorphine initiation in people who use fentanyl: a retrospective cohort study. Harm Reduct J 2024; 21:80. [PMID: 38594721 PMCID: PMC11005253 DOI: 10.1186/s12954-024-00998-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/02/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Buprenorphine is an effective treatment for opioid use disorder (OUD); however, buprenorphine initiation can be complicated by withdrawal symptoms including precipitated withdrawal. There has been increasing interest in using low dose initiation (LDI) strategies to reduce this withdrawal risk. As there are limited data on withdrawal symptoms during LDI, we characterize withdrawal symptoms in people with daily fentanyl use who underwent initiation using these strategies as outpatients. METHODS We conducted a retrospective chart review of patients with OUD using daily fentanyl who were prescribed 7-day or 4-day LDI at 2 substance use disorder treatment clinics in San Francisco. Two addiction medicine experts assessed extracted chart documentation for withdrawal severity and precipitated withdrawal, defined as acute worsening of withdrawal symptoms immediately after taking buprenorphine. A third expert adjudicated disagreements. Data were analyzed using descriptive statistics. RESULTS There were 175 initiations in 126 patients. The mean age was 37 (SD 10 years). 71% were men, 26% women, and 2% non-binary. 21% identified as Black, 16% Latine, and 52% white. 60% were unstably housed and 75% had Medicaid insurance. Substance co-use included 74% who used amphetamines, 29% cocaine, 22% benzodiazepines, and 19% alcohol. Follow up was available for 118 (67%) initiations. There was deviation from protocol instructions in 22% of these initiations with follow up. 31% had any withdrawal, including 21% with mild symptoms, 8% moderate and 2% severe. Precipitated withdrawal occurred in 10 cases, or 8% of initiations with follow up. Of these, 7 had deviation from protocol instructions; thus, there were 3 cases with follow up (3%) in which precipitated withdrawal occurred without protocol deviation. CONCLUSIONS Withdrawal was relatively common in our cohort but was mostly mild, and precipitated withdrawal was rare. Deviation from instructions, structural barriers, and varying fentanyl use characteristics may contribute to withdrawal. Clinicians should counsel patients who use fentanyl that mild withdrawal symptoms are likely during LDI, and there is still a low risk for precipitated withdrawal. Future studies should compare withdrawal across initiation types, seek ways to support patients in initiating buprenorphine, and qualitatively elicit patients' withdrawal experiences.
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Affiliation(s)
- Benjamin L H Jones
- Medical Student Center, UCSF School of Medicine, 533 Parnassus Avenue, S-245, San Francisco, CA, 94143, USA.
| | - Michelle Geier
- San Francisco Department of Public Health, 101 Grove Street, San Francisco, CA, 94102, USA
| | - John Neuhaus
- Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th Street, 2nd Floor, San Francisco, CA, 94158, USA
| | - Phillip O Coffin
- San Francisco Department of Public Health, 101 Grove Street, San Francisco, CA, 94102, USA
- Department of Medicine, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Hannah R Snyder
- Department of Family and Community Medicine, University of California San Francisco, 995 Potrero Avenue, San Francisco, CA, 94110, USA
| | - Christine S Soran
- Division of General Internal Medicine, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
- Division of Substance Abuse and Addiction Medicine, San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
| | - Kelly R Knight
- Department of Humanities and Social Sciences, University of California San Francisco, 490 Illinois Street, 7th Floor, San Francisco, CA, 94143, USA
| | - Leslie W Suen
- Department of Medicine, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143, USA
- Division of General Internal Medicine, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
- Division of Substance Abuse and Addiction Medicine, San Francisco General Hospital, University of California San Francisco, 1001 Potrero Avenue, San Francisco, CA, 94110, USA
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Abstract
Seagrasses are remarkable plants that have adapted to live in a marine environment. They form extensive meadows found globally that bioengineer their local environments and preserve the coastal seascape. With the increasing realization of the planetary emergency that we face, there is growing interest in using seagrasses as a nature-based solution for greenhouse gas mitigation. However, seagrass sensitivity to stressors is acute, and in many places, the risk of loss and degradation persists. If the ecological state of seagrasses remains compromised, then their ability to contribute to nature-based solutions for the climate emergency and biodiversity crisis remains in doubt. We examine the major ecological role that seagrasses play and how rethinking their conservation is critical to understanding their part in fighting our planetary emergency.
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Affiliation(s)
- Richard K F Unsworth
- Seagrass Ecosystem Research Group, Faculty of Science and Engineering, Swansea University, Singleton Park, Swansea SA2 8PP, Wales, UK.,Project Seagrass, The Yard, Bridgend Industrial Estate, Bridgend CF31 3EB, Wales, UK
| | - Leanne C Cullen-Unsworth
- Seagrass Ecosystem Research Group, Faculty of Science and Engineering, Swansea University, Singleton Park, Swansea SA2 8PP, Wales, UK.,Project Seagrass, The Yard, Bridgend Industrial Estate, Bridgend CF31 3EB, Wales, UK
| | - Benjamin L H Jones
- Project Seagrass, The Yard, Bridgend Industrial Estate, Bridgend CF31 3EB, Wales, UK.,Department of Ecology, Environment and Plant Sciences, Stockholm University, SE-106 91 Stockholm, Sweden
| | - Richard J Lilley
- Project Seagrass, The Yard, Bridgend Industrial Estate, Bridgend CF31 3EB, Wales, UK
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Abstract
Purpose of Review In this review, we examine the intersection of the HIV and COVID-19 epidemics with focus on COVID-19-related health outcomes and risk factors for SARS-CoV-2 among people living with HIV (PLWH). Recent Findings Evidence to date do not suggest a higher incidence of SARS-CoV-2 infection among PLWH compared to the general population, although—once exposed—PLWH are at greater risk of severe COVID-19 outcomes. Key risk factors for severe COVID-19 include non-HIV comorbidities known to be associated with severe disease, as well as HIV-specific risk factors such as low CD4 + T-cell count, unsuppressed viral load, and tuberculosis co-infection. The disproportionate impact of the SARS-CoV-2 pandemic among Black, Latinx, and Native American/Alaskan Native PLWH could worsen pre-existing disparities in health outcomes among PLWH. Data on SARS-CoV-2 vaccine protection among PLWH needs additional study, although some studies suggest decreased humoral responses among those with low CD4 + T-cell counts, while there is a signal of increased vaccine breakthrough rates among PLWH in two large observational cohorts. Data on post-acute sequelae of SARS-CoV-2 (PASC) among PLWH is also limited. Summary PLWH do not have a higher susceptibility to SARS-CoV-2, but once exposed, they are at higher risk of severe COVID-19 outcomes. Additional resources will need to be dedicated to the development of interventions to improve health outcomes and address disparities among PLWH impacted by the COVID-19 pandemic.
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Affiliation(s)
- Matthew A Spinelli
- Division of HIV, ID, and Global Medicine, University of California, San Francisco, CA, 94110, USA
| | - Benjamin L H Jones
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Monica Gandhi
- Division of HIV, ID, and Global Medicine, University of California, San Francisco, CA, 94110, USA.
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Hall WJ, Jones BLH, Witkemper KD, Collins TL, Rodgers GK. State Policy on School-based Sex Education: A Content Analysis Focused on Sexual Behaviors, Relationships, and Identities. Am J Health Behav 2019; 43:506-519. [PMID: 31046882 DOI: 10.5993/ajhb.43.3.6] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objectives: Adolescents in the United States face crucial sexual health behavior issues, including consequences of sexually transmitted infections and diseases, pregnancy, and sexual violence. Lesbian, gay, bisexual, and transgender youth are disproportionately affected by these issues. State policies about sex education in K-12 schools shape what is taught to students about sexual health. In this study, we analyzed the content of school-based sex education policies of all 50 states and focuses on sexual behaviors, relationships, and identities. Methods: Policies analyzed include state statutes, state board of education policies, and state department of education or public instruction curriculum standards. Data were analyzed using content analysis. Results: Most state policies emphasized abstinence from sexual behavior and did not require education about contraceptive and barrier methods. Few policies required detailed information about contraceptive and barrier methods to prevent pregnancy and sexually transmitted infections. Around half of states addressed relationship issues (ie, healthy relationships, sexual decision-making, and sexual violence); however, few states required content on communication about sexual consent. Eight state policies explicitly stigmatized homosexuality. Conversely, 12 states were inclusive of diverse sexual orientations and 7 states were inclusive of diverse gender identities. Conclusion: Sex education policies should be evidence-based and inclusive of sexual diversity.
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