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Jordan AE, Bachhuber MA, Tuazon E, Jimenez C, Lincourt P, Hussain S, Rubinfeld J, Cunningham CO. Methadone dosing at New York State opioid treatment programs following initial revisions to federal regulations. Drug Alcohol Depend 2024; 258:111283. [PMID: 38581920 PMCID: PMC11088491 DOI: 10.1016/j.drugalcdep.2024.111283] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 03/28/2024] [Accepted: 03/28/2024] [Indexed: 04/08/2024]
Abstract
INTRODUCTION In March 2020, a temporary federal regulatory exemption for opioid treatment programs (OTPs) was issued, allowing for a greater number of take-home methadone doses than was previously permitted. In the same month, to address financial sustainability, New York State (NYS) Medicaid also transitioned to a bundle reimbursement methodology for OTPs. We examined methadone dosing schedules in NYS before and after these regulatory and financing changes. METHODS We conducted a retrospective cohort study using NYS OTP patient data from two sources: the client data system for a baseline period (February 2020) and survey data collected after regulatory and financing changes (May 2020 to August 2021, 64 weekly surveys). We compared methadone dosing schedules over time using chi-square tests and Poisson regression. RESULT At baseline, data were available for 78% (n=77/99) of OTPs including 90.9% (n=26,225/28,839) of their enrolled patients. During the survey period, 99 OTPs completed 93.1% (n=5901/6336) of weekly surveys, with a mean statewide weekly patient census of 38,904 (SD=1214.5). Between February and May 2020, daily dosing significantly decreased from 55.4% to 16.3% of patients (-39.1 percentage points [95%CI: -39.8 to -38.4]), although it significantly increased subsequently (3.33%/4-weeks [95%CI: 3.28, 3.39]). In addition, weekly-to-monthly dosing significantly increased from 26.9% to 54.5% of patients (27.6 percentage points [95%CI: 26.9, 28.4]), although it significantly decreased subsequently (-1.19%/4-weeks [95%CI: -1.23, -1.15]). DISCUSSION Despite large initial changes, we found a trend toward gradual return to more restrictive dosing schedules. OTPs need further support in leveraging new opportunities to improve methadone treatment and outcomes.
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Affiliation(s)
- Ashly E Jordan
- New York State Office of Addiction Services and Supports, Albany, NY, USA.
| | - Marcus A Bachhuber
- New York State Office of Addiction Services and Supports, Albany, NY, USA
| | - Ellenie Tuazon
- New York City Department of Health and Mental Hygiene, Queens, NY, USA
| | - Christian Jimenez
- New York City Department of Health and Mental Hygiene, Queens, NY, USA
| | - Pat Lincourt
- New York State Office of Addiction Services and Supports, Albany, NY, USA
| | - Shazia Hussain
- New York State Office of Addiction Services and Supports, Albany, NY, USA
| | - Jason Rubinfeld
- New York State Office of Addiction Services and Supports, Albany, NY, USA
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Ackerman M, Holmes CS, Antigua JR, Riback LR, Zhang C, Walker JG, Vickerman P, Travers A, Linder M, Day R, Fox AD, Cunningham CO, Akiyama MJ. Mitigation through on-site testing & education among formerly incarcerated individuals against Covid-19 - The MOSAIC study: Design and rationale. Contemp Clin Trials 2024; 136:107406. [PMID: 38097063 PMCID: PMC11055630 DOI: 10.1016/j.cct.2023.107406] [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: 08/31/2023] [Revised: 11/29/2023] [Accepted: 12/02/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Many of the largest COVID-19 outbreaks in the United States have occurred at carceral facilities. Criminal legal system (CLS)-involved individuals typically face structural barriers accessing medical care post-release. Improving COVID-19 testing and education for CLS-involved individuals could improve health outcomes for this vulnerable population and the communities to which they return. Community-based organizations (CBO) and community health workers (CHWs) fill care gaps by connecting CLS-involved individuals with essential re-entry services. The MOSAIC study will: 1) test an onsite CHW-led SARS-CoV-2 testing and education intervention in a reentry CBO and 2) model the cost-effectiveness of this intervention compared to standard care. METHODS We will recruit 250 CLS-involved individuals who have left incarceration in the prior 90 days. Participants will be randomized to receive onsite Point-of-Care testing and education (O-PoC) or Standard of Care (SoC). Over one year, participants will complete quarterly questionnaires and biweekly short surveys through a mobile application, and be tested for SARS-CoV-2 quarterly, either at the CBO (O-PoC) or an offsite community testing site (SoC). O-PoC will also receive COVID-19 mitigation counseling and education from the CHW. Our primary outcome is the proportion of SARS-CoV-2 tests performed with results received by participants. Secondary outcomes include adherence to mitigation behaviors and cost-effectiveness of the intervention. DISCUSSION The MOSAIC study will offer insight into cost effective strategies for SARS-CoV-2 testing and education for CLS-involved individuals. The study will also contribute to the growing literature on CHW's role in health education, supportive counseling, and building trust between patients and healthcare organizations.
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Affiliation(s)
- Maxwell Ackerman
- Albert Einstein College of Medicine, Montefiore Medical Center, Morris Park Ave, Bronx, NY 10467, United States of America
| | - Connor S Holmes
- Albert Einstein College of Medicine, Montefiore Medical Center, Morris Park Ave, Bronx, NY 10467, United States of America
| | - Jordy Rojas Antigua
- Albert Einstein College of Medicine, Montefiore Medical Center, Morris Park Ave, Bronx, NY 10467, United States of America
| | - Lindsey R Riback
- Albert Einstein College of Medicine, Montefiore Medical Center, Morris Park Ave, Bronx, NY 10467, United States of America
| | - Chenshu Zhang
- Albert Einstein College of Medicine, Montefiore Medical Center, Morris Park Ave, Bronx, NY 10467, United States of America
| | - Josephine G Walker
- Bristol Medical School, Population Health Sciences, University of Bristol, Queens Road, Bristol BS8 1QU, UK
| | - Peter Vickerman
- Bristol Medical School, Population Health Sciences, University of Bristol, Queens Road, Bristol BS8 1QU, UK
| | - Ann Travers
- The Fortune Society, 2976 Northern Blvd, Long Island City, NY 11101, United States of America
| | - Micaela Linder
- The Fortune Society, 2976 Northern Blvd, Long Island City, NY 11101, United States of America
| | - Ronald Day
- The Fortune Society, 2976 Northern Blvd, Long Island City, NY 11101, United States of America
| | - Aaron D Fox
- Albert Einstein College of Medicine, Montefiore Medical Center, Morris Park Ave, Bronx, NY 10467, United States of America
| | - Chinazo O Cunningham
- Albert Einstein College of Medicine, Montefiore Medical Center, Morris Park Ave, Bronx, NY 10467, United States of America
| | - Matthew J Akiyama
- Albert Einstein College of Medicine, Montefiore Medical Center, Morris Park Ave, Bronx, NY 10467, United States of America.
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Wartko PD, Bobb JF, Boudreau DM, Matthews AG, McCormack J, Lee AK, Qiu H, Yu O, Hyun N, Idu AE, Campbell CI, Saxon AJ, Liu DS, Altschuler A, Samet JH, Labelle CT, Zare-Mehrjerdi M, Stotts AL, Braciszewski JM, Murphy MT, Dryden D, Arnsten JH, Cunningham CO, Horigian VE, Szapocznik J, Glass JE, Caldeiro RM, Phillips RC, Shea M, Bart G, Schwartz RP, McNeely J, Liebschutz JM, Tsui JI, Merrill JO, Lapham GT, Addis M, Bradley KA, Ghiroli MM, Hamilton LK, Hu Y, LaHue JS, Loree AM, Murphy SM, Northrup TF, Shmueli-Blumberg D, Silva AJ, Weinstein ZM, Wong MT, Burganowski RP. Nurse Care Management for Opioid Use Disorder Treatment: The PROUD Cluster Randomized Clinical Trial. JAMA Intern Med 2023; 183:1343-1354. [PMID: 37902748 PMCID: PMC10616772 DOI: 10.1001/jamainternmed.2023.5701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/01/2023] [Indexed: 10/31/2023]
Abstract
Importance Few primary care (PC) practices treat patients with medications for opioid use disorder (OUD) despite availability of effective treatments. Objective To assess whether implementation of the Massachusetts model of nurse care management for OUD in PC increases OUD treatment with buprenorphine or extended-release injectable naltrexone and secondarily decreases acute care utilization. Design, Setting, and Participants The Primary Care Opioid Use Disorders Treatment (PROUD) trial was a mixed-methods, implementation-effectiveness cluster randomized clinical trial conducted in 6 diverse health systems across 5 US states (New York, Florida, Michigan, Texas, and Washington). Two PC clinics in each system were randomized to intervention or usual care (UC) stratified by system (5 systems were notified on February 28, 2018, and 1 system with delayed data use agreement on August 31, 2018). Data were obtained from electronic health records and insurance claims. An implementation monitoring team collected qualitative data. Primary care patients were included if they were 16 to 90 years old and visited a participating clinic from up to 3 years before a system's randomization date through 2 years after. Intervention The PROUD intervention included 3 components: (1) salary for a full-time OUD nurse care manager; (2) training and technical assistance for nurse care managers; and (3) 3 or more PC clinicians agreeing to prescribe buprenorphine. Main Outcomes and Measures The primary outcome was a clinic-level measure of patient-years of OUD treatment (buprenorphine or extended-release injectable naltrexone) per 10 000 PC patients during the 2 years postrandomization (follow-up). The secondary outcome, among patients with OUD prerandomization, was a patient-level measure of the number of days of acute care utilization during follow-up. Results During the baseline period, a total of 130 623 patients were seen in intervention clinics (mean [SD] age, 48.6 [17.7] years; 59.7% female), and 159 459 patients were seen in UC clinics (mean [SD] age, 47.2 [17.5] years; 63.0% female). Intervention clinics provided 8.2 (95% CI, 5.4-∞) more patient-years of OUD treatment per 10 000 PC patients compared with UC clinics (P = .002). Most of the benefit accrued in 2 health systems and in patients new to clinics (5.8 [95% CI, 1.3-∞] more patient-years) or newly treated for OUD postrandomization (8.3 [95% CI, 4.3-∞] more patient-years). Qualitative data indicated that keys to successful implementation included broad commitment to treat OUD in PC from system leaders and PC teams, full financial coverage for OUD treatment, and straightforward pathways for patients to access nurse care managers. Acute care utilization did not differ between intervention and UC clinics (relative rate, 1.16; 95% CI, 0.47-2.92; P = .70). Conclusions and Relevance The PROUD cluster randomized clinical trial intervention meaningfully increased PC OUD treatment, albeit unevenly across health systems; however, it did not decrease acute care utilization among patients with OUD. Trial Registration ClinicalTrials.gov Identifier: NCT03407638.
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Affiliation(s)
- Paige D Wartko
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Jennifer F Bobb
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Biostatistics, School of Public Health, University of Washington, Seattle
| | - Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute, Seattle
- Now with Genentech Inc, South San Francisco, California
| | | | | | - Amy K Lee
- Kaiser Permanente Washington Health Research Institute, Seattle
- Now with Kaiser Permanente Washington, Renton
| | - Hongxiang Qiu
- Kaiser Permanente Washington Health Research Institute, Seattle
- Now with Department of Epidemiology and Biostatistics, Michigan State University, East Lansing
| | - Onchee Yu
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Noorie Hyun
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Abisola E Idu
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Cynthia I Campbell
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
| | - Andrew J Saxon
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, Seattle, Washington
| | - David S Liu
- National Institute on Drug Abuse Center for Clinical Trials Network, North Bethesda, Maryland
| | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Jeffrey H Samet
- Boston University Schools of Medicine and Public Health, Boston Medical Center, Boston, Massachusetts
| | - Colleen T Labelle
- Boston University Schools of Medicine and Public Health, Boston Medical Center, Boston, Massachusetts
| | - Mohammad Zare-Mehrjerdi
- Department of Family and Community Medicine, UTHealth Houston McGovern Medical School, Houston, Texas
| | - Angela L Stotts
- Department of Family and Community Medicine, UTHealth Houston McGovern Medical School, Houston, Texas
| | - Jordan M Braciszewski
- Center for Health Policy and Health Services Research, Henry Ford Health, Detroit, Michigan
| | | | - Douglas Dryden
- MultiCare Health System, Tacoma, Washington
- Now with Mosaic Medical, Bend, Oregon
| | - Julia H Arnsten
- Montefiore Medical Center, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
| | - Chinazo O Cunningham
- Albert Einstein College of Medicine, Bronx, New York
- Now with New York State Office of Addiction Services and Supports, New York
| | - Viviana E Horigian
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, Florida
| | - José Szapocznik
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, Florida
| | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Ryan M Caldeiro
- Mental Health and Wellness Department, Kaiser Permanente Washington, Renton
| | | | - Mary Shea
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Gavin Bart
- Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota
- University of Minnesota Medical School, Minneapolis
| | | | - Jennifer McNeely
- Department of Population Health, Grossman School of Medicine, New York University, New York
| | - Jane M Liebschutz
- Center for Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Judith I Tsui
- Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle
| | - Joseph O Merrill
- Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle
| | - Gwen T Lapham
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle
| | - Megan Addis
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Katharine A Bradley
- Kaiser Permanente Washington Health Research Institute, Seattle
- Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle
- Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, California
| | - Megan M Ghiroli
- Montefiore Medical Center, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
| | - Leah K Hamilton
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Yong Hu
- Center for Health Policy and Health Services Research, Henry Ford Health, Detroit, Michigan
| | | | - Amy M Loree
- Center for Health Policy and Health Services Research, Henry Ford Health, Detroit, Michigan
| | - Sean M Murphy
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | - Thomas F Northrup
- Department of Family and Community Medicine, UTHealth Houston McGovern Medical School, Houston, Texas
| | | | | | - Zoe M Weinstein
- Boston University Schools of Medicine and Public Health, Boston Medical Center, Boston, Massachusetts
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Rosen H, Cunningham CO. Time to End Racial Disparities in Buprenorphine Access. Am J Public Health 2023; 113:1083-1085. [PMID: 37590915 PMCID: PMC10484128 DOI: 10.2105/ajph.2023.307388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Affiliation(s)
- Henry Rosen
- Henry Rosen is the Chief of Staff at the New York State Office of Addiction Services and Supports, New York, NY. Chinazo O. Cunningham is the Commissioner of the New York State Office of Addiction Services and Supports and is a clinical professor of medicine at the Albert Einstein College of Medicine, New York, NY
| | - Chinazo O Cunningham
- Henry Rosen is the Chief of Staff at the New York State Office of Addiction Services and Supports, New York, NY. Chinazo O. Cunningham is the Commissioner of the New York State Office of Addiction Services and Supports and is a clinical professor of medicine at the Albert Einstein College of Medicine, New York, NY
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Zolotov Y, Lomba J, Ghiroli M, Masyukova M, Arnsten JH, Starrels JL, Ross J, Cunningham CO, Slawek DE. "It doesn't make any sense to even try": the disruptive impact of COVID-19's first wave on people with chronic pain using medical cannabis in New York. J Cannabis Res 2023; 5:10. [PMID: 36978185 PMCID: PMC10049907 DOI: 10.1186/s42238-023-00180-1] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 03/17/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic disrupted health care but it is unknown how it impacted the lives of people using medical cannabis for chronic pain. OBJECTIVE To understand the experiences of individuals from the Bronx, NY, who had chronic pain and were certified to use medical cannabis during the first wave of the COVID-19 pandemic. METHODS We conducted 1:1 semi-structured qualitative telephone interviews from March through May 2020 with a convenience sample of 14 individuals enrolled in a longitudinal cohort study. We purposively recruited participants with both frequent and infrequent patterns of cannabis use. Interviews addressed the impact of the COVID-19 pandemic on daily life, symptoms, medical cannabis purchase, and use. We conducted a thematic analysis, with a codebook approach, to identify and describe prominent themes. RESULTS Participants' median age was 49 years, nine were female, four were Hispanic, four were non-Hispanic White, and four were non-Hispanic Black. We identified three themes: (1) disrupted access to health services, (2) disrupted access to medical cannabis due to the pandemic, and (3) mixed impact of chronic pain on social isolation and mental health. Due to increased barriers to health care in general and to medical cannabis specifically, participants reduced medical cannabis use, stopped use, or substituted medical cannabis with unregulated cannabis. Living with chronic pain both prepared participants for the pandemic and made the pandemic more difficult. CONCLUSION The COVID-19 pandemic amplified pre-existing challenges and barriers to care, including to medical cannabis, among people with chronic pain. Understanding pandemic-era barriers may inform policies in ongoing and future public health emergencies.
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Affiliation(s)
- Yuval Zolotov
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 3300 Kossuth Ave, Bronx, NY, 10467, USA.
| | - Jacinta Lomba
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 3300 Kossuth Ave, Bronx, NY, 10467, USA
| | - Megan Ghiroli
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 3300 Kossuth Ave, Bronx, NY, 10467, USA
| | - Mariya Masyukova
- Department of Family and Social Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Julia H Arnsten
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 3300 Kossuth Ave, Bronx, NY, 10467, USA
| | - Joanna L Starrels
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 3300 Kossuth Ave, Bronx, NY, 10467, USA
| | - Jonathan Ross
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 3300 Kossuth Ave, Bronx, NY, 10467, USA
| | - Chinazo O Cunningham
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 3300 Kossuth Ave, Bronx, NY, 10467, USA
| | - Deepika E Slawek
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 3300 Kossuth Ave, Bronx, NY, 10467, USA
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Zhang C, Slawek DE, Ross J, Zolotov Y, Castillo F, Levin FR, Sohler NL, Minami H, Cunningham CO, Starrels JL, Arnsten JH. Factors Associated with Medical Cannabis Use After Certification: A Three-Month Longitudinal Study. Cannabis Cannabinoid Res 2023. [PMID: 36961410 DOI: 10.1089/can.2022.0248] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
Background: Over the past decade, there has been increased utilization of medical cannabis (MC) in the United States. Few studies have described sociodemographic and clinical factors associated with MC use after certification and more specifically, factors associated with use of MC products with different cannabinoid profiles. Methods: We conducted a longitudinal cohort study of adults (N=225) with chronic or severe pain on opioids who were newly certified for MC in New York State and enrolled in the study between November 2018 and January 2022. We collected data over participants' first 3 months in the study, from web-based assessment of MC use every 2 weeks (unit of analysis). We used generalized estimating equation models to examine associations of sociodemographic and clinical factors with (1) MC use (vs. no MC use) and (2) use of MC products with different cannabinoid profiles. Results: On average, 29% of the participants used predominantly high delta-9-tetrahydrocannabinol (THC) MC products within the first 3 months of follow-up, 30% used other MC products, and 41% did not use MC products. Non-Hispanic White race, pain at multiple sites, and past 30-day sedative use were associated with a higher likelihood of MC use (vs. no MC use). Current tobacco use, unregulated cannabis use, and enrollment in the study during the COVID-19 pandemic were associated with a lower likelihood of MC use (vs. no MC use). Among participants reporting MC use, female gender and older age were associated with a lower likelihood of using predominantly high-THC MC products (vs. other MC products). Conclusion: White individuals were more likely to use MC after certification, which may be owing to access and cost issues. The findings that sedative use was associated with greater MC use, but tobacco and unregulated cannabis were associated with less MC use, may imply synergism and substitution that warrant further research. From the policy perspective, additional measures are needed to ensure equitable availability of and access to MC. Health practitioners should check patients' history and current use of sedative, tobacco, and unregulated cannabis before providing an MC recommendation and counsel patients on safe cannabis use. clinicaltrials.gov (NCT03268551).
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Affiliation(s)
- Chenshu Zhang
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
- Department of Medicine, Einstein College of Medicine, New York, New York, USA
| | - Deepika E Slawek
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
- Department of Medicine, Einstein College of Medicine, New York, New York, USA
| | - Jonathan Ross
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
- Department of Medicine, Einstein College of Medicine, New York, New York, USA
| | - Yuval Zolotov
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
- Department of Medicine, Einstein College of Medicine, New York, New York, USA
| | - Felipe Castillo
- Division on Substance Use Disorders, NY State Psychiatric Institute, New York, New York, USA
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
| | - Frances R Levin
- Division on Substance Use Disorders, NY State Psychiatric Institute, New York, New York, USA
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
| | - Nancy L Sohler
- Department of Community Health and Social Medicine, City University of New York, New York, New York, USA
| | - Haruka Minami
- Department of Psychology, Fordham University, Bronx, New York, USA
| | | | - Joanna L Starrels
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
- Department of Medicine, Einstein College of Medicine, New York, New York, USA
| | - Julia H Arnsten
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
- Department of Medicine, Einstein College of Medicine, New York, New York, USA
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Cunningham CO, Starrels JL. Guideline Promoting Buprenorphine for Treatment of Chronic Pain: Transformative Yet Underdeveloped. Ann Intern Med 2023; 176:419-420. [PMID: 36780656 DOI: 10.7326/m23-0229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Affiliation(s)
- Chinazo O Cunningham
- New York State Office of Addiction Services and Supports, New York, and Albert Einstein College of Medicine, Bronx, New York
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Buonora MJ, Hanna DB, Zhang C, Bachhuber MA, Moir LH, Salvi PS, Cunningham CO, Starrels JL. U.S. state policies on opioid prescribing during the peak of the prescription opioid crisis: Associations with opioid overdose mortality. Int J Drug Policy 2022; 110:103888. [PMID: 36270085 PMCID: PMC9742344 DOI: 10.1016/j.drugpo.2022.103888] [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: 06/30/2022] [Revised: 10/09/2022] [Accepted: 10/10/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND In response to the opioid overdose crisis in the United States, many states implemented policies to guide opioid prescribing, but their impact on overdose mortality (prescription and non-prescription) remains poorly understood. We examined the impact of U.S. state opioid-prescribing policies on opioid overdose mortality following implementation. METHODS We calculated opioid overdose mortality rates from 1999-2016 by U.S. state using the CDC WONDER database, overall and separately for overdose deaths from prescription and non-prescription opioids. For each state, policies active on 1/1/2014 were reviewed for the presence and strength of six provisions recommending judicious opioid prescribing practices; "strong" provisions used the words "should," "shall," or "must". Interrupted time series (ITS) tested the association of each strong provision with overdose mortality, overall and separately for prescription and non-prescription opioids, in the two years following implementation. Sensitivity analyses compared between states, used time-lagged analyses, and excluded synthetic opioids from non-prescription opioid deaths. RESULTS All six provisions had consistent direction of effect in ITS and sensitivity analyses. Strong provisions for prescriber training and limits on opioid dose reduced the slope of overall and prescription opioid overdose mortality in both ITS and sensitivity analyses. Reduced non-prescription opioid overdose mortality was only associated with strong provision for prescriber training. Some provisions had a negative impact. In ITS, strong provision for prescriber response to misuse increased the slope of non-prescription opioid overdose mortality. Strong provision for mandatory prescription drug monitoring program use had no relationship with overdose mortality in ITS and was associated with increased overall, prescription and non-prescription opioid overdose mortality in between-state sensitivity analysis. CONCLUSION Opioid prescribing policies in U.S. states at the peak of the prescription opioid epidemic had modest mortality benefit, and did not reduce non-prescription opioid overdose mortality. A strong provision for prescriber training was the only provision associated with reduced prescription and non-prescription opioid overdose mortality. These findings can inform future efforts addressing prescription drug epidemics.
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Affiliation(s)
- Michele J Buonora
- Division of General Internal Medicine, Albert Einstein College of Medicine & Montefiore Medical Center, Bronx, NY, USA; National Clinician Scholars Program, Yale University School of Medicine, New Haven, CT, USA; Departments of Medicine, Veterans Affairs Connecticut Healthcare System & Yale University School of Medicine, West Haven, CT, USA.
| | - David B Hanna
- Department of Epidemiology and Public Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Chenshu Zhang
- Division of General Internal Medicine, Albert Einstein College of Medicine & Montefiore Medical Center, Bronx, NY, USA
| | - Marcus A Bachhuber
- Division of General Internal Medicine, Albert Einstein College of Medicine & Montefiore Medical Center, Bronx, NY, USA; Department of Medicine, Section of Community and Population Medicine, Louisiana State University Health Sciences Center-New Orleans School of Medicine, New Orleans, LA, USA
| | - Lorlette H Moir
- Division of General Internal Medicine, Albert Einstein College of Medicine & Montefiore Medical Center, Bronx, NY, USA; Infectious Disease Prevention, Investigation & Care Services Section, Bureau of Infectious Disease Control, Division of Public Health Services, New Hampshire Department of Health & Human Services, NH, USA
| | - Pooja S Salvi
- Division of General Internal Medicine, Albert Einstein College of Medicine & Montefiore Medical Center, Bronx, NY, USA
| | - Chinazo O Cunningham
- Division of General Internal Medicine, Albert Einstein College of Medicine & Montefiore Medical Center, Bronx, NY, USA
| | - Joanna L Starrels
- Division of General Internal Medicine, Albert Einstein College of Medicine & Montefiore Medical Center, Bronx, NY, USA
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9
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Abstract
Appropriate clinical management of opioid withdrawal is a crucial bridge to long-term treatment for opioid use disorder (OUD), because it is a high-risk time for potential opioid overdose and relapse. We provide a narrative review of evidence-based opioid withdrawal management strategies applicable to a variety of treatment settings and geographies. The goals of opioid withdrawal management include relieving suffering associated with withdrawal, providing appropriate diagnosis and screening, engaging patients in initiation of OUD treatment, and using harm reduction strategies, all guided by a patient-centered approach to care. In addition, we discuss complex cases, relapse prevention strategies, and new developments in opioid withdrawal management.
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Affiliation(s)
| | - Tiffany Y Lu
- Albert Einstein College of Medicine/Montefiore Health System, Department of Medicine, Bronx, NY, USA
| | - Melissa B Weimer
- Yale School of Medicine and Public Health, New Haven, CT, USA.,Yale School of Public Health, New Haven, CT, USA
| | - Melissa R Stein
- Albert Einstein College of Medicine/Montefiore Health System, Department of Medicine, Bronx, NY, USA
| | - Chinazo O Cunningham
- Albert Einstein College of Medicine/Montefiore Health System, Department of Medicine, Bronx, NY, USA
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10
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Bachhuber MA, Nash D, Southern WN, Heo M, Berger M, Schepis M, Sugarman OK, Cunningham CO. Reducing Opioid Analgesic Prescribing in Dentistry Through Prescribing Defaults: A Cluster-Randomized Controlled Trial. Pain Med 2022; 24:1-10. [PMID: 35792881 PMCID: PMC9825153 DOI: 10.1093/pm/pnac106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 06/22/2022] [Accepted: 06/29/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine the effect of a uniform, reduced, default dispense quantity for new opioid analgesic prescriptions on the quantity of opioids prescribed in dentistry practices. METHODS We conducted a cluster-randomized controlled trial within a health system in the Bronx, NY, USA. We randomly assigned three dentistry sites to a 10-tablet default, a 5-tablet default, or no change (control). The primary outcome was the quantity of opioid analgesics prescribed in the new prescription. Secondary outcomes were opioid analgesic reorders and health service utilization within 30 days after the new prescription. We analyzed outcomes from 6 months before implementation through 18 months after implementation. RESULTS Overall, 6,309 patients received a new prescription. Compared with the control site, patients at the 10-tablet-default site had a significantly larger change in prescriptions for 10 tablets or fewer (38.7 percentage points; confidence interval [CI]: 11.5 to 66.0), lower number of tablets prescribed (-3.3 tablets; CI: -5.9 to -0.7), and lower morphine milligram equivalents (MME) prescribed (-14.1 MME; CI: -27.8 to -0.4), which persisted in the 30 days after the new prescription despite a higher percentage of reorders (3.3 percentage points; CI: 0.2 to 6.4). Compared with the control site, patients at the 5-tablet-default site did not have a significant difference in any outcomes except for a significantly higher percentage of reorders (2.6 percentage points; CI: 0.2 to 4.9). CONCLUSIONS Our findings further support the efficacy of strategies that lower default dispense quantities, although they indicate that caution is warranted in the selection of the default. TRIAL REGISTRATION ClinicalTrials.org ID: NCT03030469.
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Affiliation(s)
- Marcus A Bachhuber
- Correspondence to: Marcus A. Bachhuber, MD, MSHP, Section of Community and Population Medicine, Department of Medicine, Louisiana State University Health Sciences Center-New Orleans, 533 Bolivar St., 5th Fl, New Orleans, LA 70112, USA. Tel: (504) 568-5700; Fax: (504) 568-5701; E-mail:
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York (CUNY), New York, New York,Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, City University of New York (CUNY), New York, New York
| | - William N Southern
- Division of Hospital Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Moonseong Heo
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York,This author is now with the Department of Public Health Sciences, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, South Carolina, New Orleans, Louisiana, USA
| | - Matthew Berger
- Montefiore Information Technology, Montefiore Medical Center, Bronx, New York
| | - Mark Schepis
- Montefiore Information Technology, Montefiore Medical Center, Bronx, New York
| | - Olivia K Sugarman
- Section of Community and Population Medicine, Department of Medicine, Louisiana State University Health Sciences Center-New Orleans, New Orleans, Louisiana, USA
| | - Chinazo O Cunningham
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
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11
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Cunningham CO, Zhang C, Hollins M, Wang M, Singh-Tan S, Joudrey PJ. Availability of medical cannabis services by racial, social, and geographic characteristics of neighborhoods in New York: a cross-sectional study. BMC Public Health 2022; 22:671. [PMID: 35387635 PMCID: PMC8988426 DOI: 10.1186/s12889-022-13076-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 02/16/2022] [Indexed: 11/21/2022] Open
Abstract
Background Within the United States (US), because racial/ethnic disparities in cannabis arrests continue, and cannabis legalization is expanding, understanding disparities in availability of legal cannabis services is important. Few studies report mixed findings regarding disparities in availability of legal cannabis services; none examined New York. We examined disparities in availability of medical cannabis services in New York. We hypothesized that New York census tracts with few Black or Hispanic residents, high incomes, high education levels, and greater urbanicity would have more medical cannabis services. Methods In this cross-sectional study, we used data from the 2018 US Census Bureau 5-year American Community Survey and New York Medical Marijuana Program. Main exposures were census tract characteristics, including urban–rural classification, percentage of Black and Hispanic residents, percentage of residents with bachelor’s degrees or higher, and median household income. Main outcomes were presence of at least one medical cannabis certifying provider and dispensary in each census tract. To compare census tracts’ characteristics with (vs. without) certifying providers and dispensaries, we used chi-square tests and t-tests. To examine characteristics independently associated with (vs. without) certifying providers, we used multivariable logistic regression. Results Of 4858 New York census tracts, 1073 (22.1%) had medical cannabis certifying providers and 37 (0.8%) had dispensaries. Compared to urban census tracts, suburban census tracts were 62% less likely to have at least one certifying provider (aOR = 0.38; 95% CI = 0.25–0.57). For every 10% increase in the proportion of Black residents, a census tract was 5% less likely to have at least one certifying provider (aOR = 0.95; 95% CI = 0.92–0.99). For every 10% increase in the proportion of residents with bachelor’s degrees or higher, a census tract was 30% more likely to have at least one certifying provider (aOR = 1.30; 95% CI = 1.21–1.38). Census tracts with (vs. without) dispensaries were more likely to have a higher percentage of residents with bachelor’s degrees or higher (43.7% vs. 34.1%, p < 0.005). Conclusions In New York, medical cannabis services are least available in neighborhoods with Black residents and most available in urban neighborhoods with highly educated residents. Benefits of legal cannabis must be shared by communities disproportionately harmed by illegal cannabis.
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Affiliation(s)
- Chinazo O Cunningham
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, 10461, USA.
| | - Chenshu Zhang
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, 10461, USA
| | - Maegan Hollins
- Northwestern University, 633 Clark St, Evanston, IL, 60208, USA
| | - Melinda Wang
- Yale School of Medicine, 333 Cedar St, New Haven, CT, 06510, USA
| | - Sumeet Singh-Tan
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, 10461, USA
| | - Paul J Joudrey
- Yale School of Medicine, 333 Cedar St, New Haven, CT, 06510, USA
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12
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Miodownik H, Curtis SA, Ogu UO, Bradford C, Starrels JL, Cunningham CO, Arnsten JH, Choi J, Eisenberg R, Minniti CP. Frequent health care utilisation and avascular necrosis are associated with cannabis use in adults with sickle cell disease. Br J Haematol 2022; 196:e41-e44. [PMID: 34661288 PMCID: PMC9838730 DOI: 10.1111/bjh.17901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 09/30/2021] [Accepted: 10/02/2021] [Indexed: 01/18/2023]
Affiliation(s)
| | - Susanna A. Curtis
- Montefiore Health Systems, Albert Einstein College of Medicine, Division of Hematology, Bronx, NY, USA
| | - Ugochi Olivia Ogu
- Montefiore Health Systems, Albert Einstein College of Medicine, Division of Hematology, Bronx, NY, USA,Center for Sickle Cell Disease, University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - Joanna L. Starrels
- Division of General Internal Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Chinazo O. Cunningham
- Division of General Internal Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Julia H. Arnsten
- Division of General Internal Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jaeun Choi
- Albert Einstein College of Medicine, Department of Epidemiology and Population Health, Bronx, NY, USA
| | - Ruth Eisenberg
- Albert Einstein College of Medicine, Department of Epidemiology and Population Health, Bronx, NY, USA
| | - Caterina P. Minniti
- Montefiore Health Systems, Albert Einstein College of Medicine, Division of Hematology, Bronx, NY, USA
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13
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Ross J, Yamada J, Slawek D, Starrels JL, Cunningham CO, Arnsten JH. Increasing Access to Safe Medical Cannabis: Establishment of a Medical Cannabis Program in a Safety-Net Academic Medical Center. NEJM Catal Innov Care Deliv 2022; 3:10.1056/cat.21.0373. [PMID: 36172004 PMCID: PMC9512136 DOI: 10.1056/cat.21.0373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Despite numerous challenges, Montefiore Medical Center in New York City implemented a program aimed at providing comprehensive, evidence-based medical cannabis certifications to patients, including those who have been historically disenfranchised, and shares insights from five years of operation.
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Affiliation(s)
- Jonathan Ross
- Assistant Professor of Medicine, Montefiore Health System, Division of General Internal Medicine, Bronx, New York, USA,Assistant Professor of Medicine, Albert Einstein College of Medicine, Division of General Internal Medicine, Bronx, New York, USA
| | - Jaclyn Yamada
- Resident, Northwell Health, New Hyde Park, New York, USA,Former medical student, Albert Einstein College of Medicine, Division of General Internal Medicine, Bronx, New York, USA
| | - Deepika Slawek
- Assistant Professor of Medicine, Montefiore Health System, Division of General Internal Medicine, Bronx, New York, USA,Assistant Professor of Medicine, Albert Einstein College of Medicine, Division of General Internal Medicine, Bronx, New York, USA
| | - Joanna L. Starrels
- Associate Professor of Medicine, Montefiore Health System, Division of General Internal Medicine, Bronx, New York, USA,Associate Professor of Medicine, Albert Einstein College of Medicine, Division of General Internal Medicine, Bronx, New York, USA
| | - Chinazo O. Cunningham
- Professor of Medicine, Family and Social Medicine, and Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Division of General Internal Medicine, Bronx, New York, USA
| | - Julia H. Arnsten
- Professor of Medicine, Epidemiology & Population Health, and Psychiatry and Behavioral Sciences, Montefiore Health System, Division of General Internal Medicine, Bronx, New York, USA,Professor of Medicine, Epidemiology & Population Health, and Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Division of General Internal Medicine, Bronx, New York, USA
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14
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Perez-Correa A, Abbas B, Riback L, Ghiroli M, Norton B, Murphy S, Jakubowski A, Hayes BT, Cunningham CO, Fox AD. Onsite buprenorphine inductions at harm reduction agencies to increase treatment engagement and reduce HIV risk: Design and rationale. Contemp Clin Trials 2022; 114:106674. [PMID: 34990854 PMCID: PMC10123766 DOI: 10.1016/j.cct.2021.106674] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 12/28/2021] [Accepted: 12/28/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite dramatic increases in opioid use disorder (OUD) and overdose deaths, the U.S. has been unable to consistently deliver OUD treatment to those who need it. Syringe services programs (SSPs) can engage an out-of-treatment population of people with OUD that has elevated overdose risk. Buprenorphine treatment is safe and effective, and US regulations allow for prescribing from diverse locations, including SSPs. This study's objective is to test buprenorphine treatment initiation at SSPs. We hypothesize that offering onsite buprenorphine treatment initiation will improve OUD treatment engagement without reducing buprenorphine treatment effectiveness or safety. METHODS We will recruit 250 out-of-treatment SSP participants with OUD in a large urban area. Participants will be randomized to onsite buprenorphine treatment initiation or enhanced referral. Over 2 weeks, participants in the onsite treatment arm will see a buprenorphine provider twice at the SSP, receive weekly medication packs, and then their care will be transferred to a community health center for treatment continuation. In the control arm, within one week, participants will receive an appointment at the same community health center as in the intervention arm for buprenorphine initiation and continuation. Participants will be assessed with urine drug tests, questionnaires, and medical record review. The primary outcome will be engagement in buprenorphine treatment at 30 days. Secondary outcomes include buprenorphine diversion, opioid-free urine drug tests, and intervention cost-effectiveness. DISCUSSION Our study will contribute to the growing literature on SSPs as a conduit to OUD treatment. SSPs hold promise to deliver needed care to people with OUD.
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Affiliation(s)
- Andres Perez-Correa
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY 10461, United States of America.
| | - Bilal Abbas
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY 10461, United States of America
| | - Lindsey Riback
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY 10461, United States of America
| | - Megan Ghiroli
- Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, United States of America
| | - Brianna Norton
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY 10461, United States of America; Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, United States of America
| | - Sean Murphy
- Weill Cornell Medicine, Department of Population Health Sciences, 425 East 61st Street, Suite 301, New York, NY 10065-8722, United States of America
| | - Andrea Jakubowski
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY 10461, United States of America; Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, United States of America
| | - Benjamin T Hayes
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY 10461, United States of America; Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, United States of America
| | - Chinazo O Cunningham
- NYC Department of Health and Mental Hygiene, 42-09 28th Street, CN 2, Long Island City, NY 11101-4132, United States of America
| | - Aaron D Fox
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY 10461, United States of America; Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, United States of America
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15
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Abstract
Cannabis use in the United States is growing at an unprecedented pace. Most states in the United States have legalized medical cannabis use, and many have legalized nonmedical cannabis use. In this setting, health care professionals will increasingly see more patients who have questions about cannabis use, its utility for medical conditions, and the risks of its use. This narrative review provides an overview of the background, pharmacology, therapeutic use, and potential complications of cannabis.
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Affiliation(s)
- Deepika E Slawek
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA.
| | - Susanna A Curtis
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA. https://twitter.com/DrSusieC2
| | - Julia H Arnsten
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA. https://twitter.com/DrArnsten
| | - Chinazo O Cunningham
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA. https://twitter.com/DrChinazo
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16
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Ross J, Slawek DE, Zhang C, Starrels JL, Levin FR, Sohler NL, Minami H, Arnsten JH, Cunningham CO. First-Year Trajectories of Medical Cannabis Use Among Adults Taking Opioids for Chronic Pain: An Observational Cohort Study. Pain Med 2021; 22:3080-3088. [PMID: 34411246 DOI: 10.1093/pm/pnab257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/30/2021] [Accepted: 08/12/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To describe first-year trajectories of medical cannabis use and identify characteristics associated with patterns of use in a cohort of adults using opioids for chronic pain. DESIGN Latent class trajectory analysis of a prospective cohort study using data on the 14-day frequency of medical cannabis use. SETTING A large academic medical center and four medical cannabis dispensaries in the New York City metropolitan area. SUBJECTS Adults with chronic pain using opioids and newly certified for medical cannabis in New York between 2018 and 2020. METHODS Using latent class trajectory analysis, we identified clusters of participants based on the 14-day frequency of medical cannabis use. We used logistic regression to determine factors associated with cluster membership, including sociodemographic characteristics, pain, substance use, and mental health symptoms. RESULTS Among 99 participants, the mean age was 53 years; 62% were women, and 52% were White. We identified three clusters of medical cannabis use: infrequent use (n = 30, mean use = 1.5 days/14-day period), occasional use (n = 28, mean = 5.7 days/14-day period), and frequent use (n = 41, mean = 12.1 days/14-day period). Within clusters, use patterns did not vary significantly over 52 weeks. Differences were observed in two sociodemographic variables: Frequent (vs infrequent) use was associated with non-Hispanic White race/ethnicity (adjusted odds ratio 4.54, 95% confidence interval 1.49-14.29), while occasional (vs infrequent) use was associated with employment (adjusted odds ratio 13.84, 95% confidence interval 1.21-158.74). CONCLUSIONS Three clusters of medical cannabis use patterns emerged and were stable over time. Results suggest that structural factors related to race/ethnicity and employment may be major drivers of medical cannabis use, even among adults certified for its use.
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Affiliation(s)
- Jonathan Ross
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
| | - Deepika E Slawek
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
| | - Chenshu Zhang
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
| | - Joanna L Starrels
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
| | - Frances R Levin
- Division on Substance Use Disorders, NY State Psychiatric Institute, New York, New York, USA.,Department of Psychiatry, Columbia University Irving Medical Center, New York, USA
| | - Nancy L Sohler
- Department of Community Health and Social Medicine, City University of New York, New York, New York, USA
| | - Haruka Minami
- Department of Psychology, Fordham University, Bronx, New York, USA
| | - Julia H Arnsten
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
| | - Chinazo O Cunningham
- Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, New York, USA
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17
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Slawek DE, Syed M, Cunningham CO, Zhang C, Ross J, Herman M, Sohler N, Minami H, Levin FR, Arnsten JH, Starrels JL. Pain catastrophizing and mental health phenotypes in adults with refractory chronic pain: A latent class analysis. J Psychiatr Res 2021; 145:102-110. [PMID: 34890916 PMCID: PMC9160202 DOI: 10.1016/j.jpsychires.2021.12.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 11/22/2021] [Accepted: 12/01/2021] [Indexed: 01/12/2023]
Abstract
Chronic pain, pain catastrophizing, and mental health disorders such as anxiety or depression frequently occur together and are challenging to treat. To help understand the relationship between these conditions, we sought to identify distinct phenotypes associated with worse pain and function. In a cohort of people with chronic pain on opioids seeking medical cannabis in New York, we conducted latent class analysis to identify clusters of participants based on pain catastrophizing and mental health symptoms of depression, anxiety, post-traumatic stress disorder (PTSD) and attention deficit/hyperactivity disorder (ADHD). We then compared clusters with respect to sociodemographic and clinical characteristics using descriptive statistics. Among 185 participants, we identified four discrete groups: low pain catastrophizing and low mental health symptoms (49% of participants), low pain catastrophizing and ADHD-predominant mental health symptoms (11%), high pain catastrophizing and anxiety-predominant mental health symptoms (11%), and high pain catastrophizing and high mental health symptoms (30%). The group with high pain catastrophizing and high mental health symptoms had the worst pain intensity and interference, disability, insomnia, and quality of life, compared to the two groups with lower pain catastrophizing, though not all differences were statistically significant. Our findings highlight the importance of identifying and addressing pain catastrophizing in patients with comorbid chronic pain and mental health symptoms.
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Affiliation(s)
- Deepika E Slawek
- Division of General Internal Medicine, Montefiore Health System, Bronx, NY, USA.
| | - Madiha Syed
- Department of Psychiatry and Behavioral Sciences, Montefiore Health System, Bronx, NY, USA
| | | | - Chenshu Zhang
- Division of General Internal Medicine, Montefiore Health System, Bronx, NY, USA
| | - Jonathan Ross
- Division of General Internal Medicine, Montefiore Health System, Bronx, NY, USA
| | - Merrill Herman
- Department of Psychiatry and Behavioral Sciences, Montefiore Health System, Bronx, NY, USA
| | - Nancy Sohler
- School of Medicine, City University of New York, New York, NY, USA
| | - Haruka Minami
- Psychology Department, Fordham University, Bronx, NY, USA
| | - Frances R Levin
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
| | - Julia H Arnsten
- Division of General Internal Medicine, Montefiore Health System, Bronx, NY, USA
| | - Joanna L Starrels
- Division of General Internal Medicine, Montefiore Health System, Bronx, NY, USA
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18
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Cunningham CO, Khalid L, Deng Y, Torres-Lockhart K, Masyukova M, Thomas S, Zhang C, Lu T. A comparison of office-based buprenorphine treatment outcomes in Bronx community clinics before versus during the COVID-19 pandemic. J Subst Abuse Treat 2021; 135:108641. [PMID: 34863608 PMCID: PMC8550890 DOI: 10.1016/j.jsat.2021.108641] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/03/2021] [Accepted: 10/04/2021] [Indexed: 01/01/2023]
Abstract
Introduction In 2020, the US and New York City experienced unprecedented deaths due to the COVID-19 pandemic and drug overdoses. Policy changes reduced burdensome regulations for medication treatment for opioid use disorder (OUD). Despite these policy changes, few studies examined buprenorphine treatment outcomes during the pandemic. We compared treatment outcomes among Bronx patients referred to office-based buprenorphine treatment before versus during the pandemic. Methods In a retrospective cohort study, we compared patients referred to buprenorphine treatment in a Bronx community clinic before (March–August 2019) versus during (March–August 2020) the pandemic. We describe changes to buprenorphine treatment during the pandemic, including telehealth and prioritizing harm reduction. Using data from medical records and program logs, main outcomes included steps of the OUD treatment cascade of care—initial visit scheduled and completed, treatment initiated, and retained in treatment at 90 days. Using chi square and t-tests, we examined differences in patient characteristics and OUD treatment cascade steps before versus during the pandemic. Results Before and during the pandemic, 72 and 35 patients were referred to buprenorphine treatment, respectively. Patients' mean age was 46 years, most were male (67.3%) or Hispanic (52.3%), and few had private insurance (19.6%). Patients referred during (vs. before) the pandemic were more likely to have private insurance (31.4% vs. 13.9%, p < 0.05) and be referred from acute care settings (37.1% vs. 19.4%, p < 0.05). No significant differences in OUD cascade of care outcomes existed between those referred during versus before the pandemic. However, among patients who initiated buprenorphine treatment, those referred during (vs. before) the pandemic were more likely to be retained in treatment at 90 days (68.0% vs. 42.9%, p < 0.05). Conclusions Despite the COVID-19 pandemic's unprecedented devastation to the Bronx, along with worsening drug overdose deaths, OUD cascade of care outcomes were similar among patients referred to buprenorphine treatment before versus during the pandemic. Among patients who initiated buprenorphine treatment, treatment retention was better during (versus before) the pandemic. During a public health emergency, incorporating telehealth and prioritizing harm reduction are key strategies to maintain optimal OUD treatment outcomes.
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Affiliation(s)
- Chinazo O Cunningham
- Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY, United States of America.
| | - Laila Khalid
- Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Yuting Deng
- Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Kristine Torres-Lockhart
- Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Mariya Masyukova
- Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Shenell Thomas
- Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Chenshu Zhang
- Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY, United States of America
| | - Tiffany Lu
- Montefiore Medical Center & Albert Einstein College of Medicine, Bronx, NY, United States of America
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19
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Scott TM, Arnsten J, Olsen JP, Arias F, Cunningham CO, Rivera Mindt M. Neurocognitive, psychiatric, and substance use characteristics in a diverse sample of persons with OUD who are starting methadone or buprenorphine/naloxone in opioid treatment programs. Addict Sci Clin Pract 2021; 16:64. [PMID: 34689841 PMCID: PMC8543954 DOI: 10.1186/s13722-021-00272-4] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 10/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Medications for opioid use disorder such as opioid agonist treatment (OAT, including methadone, buprenorphine) are the gold standard intervention for opioid use disorder (OUD). Persons with OUD have high rates of neurocognitive impairment and psychiatric and substance use disorders, but few studies have examined these characteristics in diverse patients initiating OAT in opioid treatment programs (OTPs). Additionally, in these individuals, poor neurocognitive functioning and psychiatric/other substance use disorders are associated with poor OUD treatment outcomes. Given rapid changes in the opioid epidemic, we sought to replicate findings from our pilot study by examining these characteristics in a large diverse sample of persons with OUD starting OTP-based OAT. METHODS Ninety-seven adults with OUD (M age = 42.2 years [SD = 10.3]; M education = 11.4 years [SD = 2.3]; 27% female; 22% non-Hispanic white) were enrolled in a randomized longitudinal trial evaluating methadone versus buprenorphine/naloxone on neurocognitive functioning. All participants completed a comprehensive neurocognitive, psychiatric, and substance use evaluation within one week of initiating OAT. RESULTS Most of the sample met criteria for learning (79%) or memory (69%) impairment. Half exhibited symptoms of current depression, and comorbid substance use was highly prevalent. Lifetime cannabis and cocaine use disorders were associated with better neurocognitive functioning, while depression was associated with worse neurocognitive functioning. CONCLUSIONS Learning and memory impairment are highly prevalent in persons with OUD starting treatment with either methadone or buprenorphine/naloxone in OTPs. Depression and comorbid substance use are prevalent among these individuals, but neither impact learning or memory. However, depression is associated with neurocognitive impairment in other domains. These findings might allow clinicians to help persons with OUD starting OAT to develop compensatory strategies for learning and memory, while providing adjunctive treatment for depression. Trial Registration NCT, NCT01733693. Registered November 4, 2012, https://clinicaltrials.gov/ct2/show/NCT01733693 .
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Affiliation(s)
- Travis M Scott
- VA Palo Alto Health Care System Sierra Pacific Mental Illness Research Education Clinical Center, 3801 Miranda Ave, Palo Alto, CA, 94304, USA. .,Department of Psychiatry and Behavioral Sciences, Stanford School of Medicine, Stanford, CA, USA.
| | - Julia Arnsten
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - James Patrick Olsen
- Department of Neurology, North Shore University Hospital, Manhasset, NY, USA
| | - Franchesca Arias
- The Aging Brain Center, Hebrew SeniorLife, Boston, MA, USA.,Department of Cognitive Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Chinazo O Cunningham
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Monica Rivera Mindt
- Department of Psychology and Latin America and Latino Studies Institute, Fordham University, New York, NY, USA.,Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Mindt MR, Coulehan K, Aghvinian M, Scott TM, Olsen JP, Cunningham CO, Arias F, Arnsten JH. Underrepresentation of diverse populations and clinical characterization in opioid agonist treatment research: A systematic review of the neurocognitive effects of buprenorphine and methadone treatment. J Subst Abuse Treat 2021; 135:108644. [PMID: 34857427 DOI: 10.1016/j.jsat.2021.108644] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 08/27/2021] [Accepted: 10/05/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The relative neurocognitive effects of the two most common opioid agonist treatments (OAT; buprenorphine and methadone) for opioid use disorder (OUD) are poorly understood. The aim of this systematic review is to examine the neurocognitive effects of OAT (buprenorphine and methadone) and the clinical and sociodemographic characteristics of study samples. METHODS The research team queried PubMed, PsycINFO and Cochrane Reviews for articles (01/1980-01/2020) with terms related to neurocognitive testing in adults (age ≥ 18) prescribed OAT. The team extracted neurocognitive data and grouped them by domain (e.g., executive functioning, learning/memory), and assessed study quality. RESULTS The search retrieved 2341 abstracts, the team reviewed 278 full articles, and 32 met inclusion criteria. Of these, 31 were observational designs and one was an experimental design. Healthy controls performed better across neurocognitive domains than OAT-treated persons (buprenorphine or methadone). Compared to those with active OUD, OAT-treated persons had better neurocognition in various domains. However, in seven studies comparing buprenorphine- and methadone-treated persons, buprenorphine was associated with better neurocognition than was methadone, with moderate to large effect sizes in executive functioning, attention/working memory, and learning/memory. Additionally, OAT research underreports clinical characteristics and underrepresents Black and Latinx adults, as well as women. CONCLUSIONS Findings suggest that compared to active opioid use, both buprenorphine and methadone treatment are associated with better neurocognitive functioning, but buprenorphine is associated with better executive functioning, attention/working memory, and learning/memory. These findings should be interpreted with caution given widespread methodological heterogeneity, and limited representation of ethnoracially diverse adults and women. Rigorous longitudinal comparisons with more diverse, better characterized samples will help to inform treatment and policy recommendations for persons with OUD.
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Affiliation(s)
- Monica Rivera Mindt
- Fordham University, Department of Psychology, USA; Icahn School of Medicine at Mount Sinai, Department of Neurology, USA.
| | | | - Maral Aghvinian
- Fordham University, Department of Psychology, USA; Icahn School of Medicine at Mount Sinai, Department of Neurology, USA.
| | - Travis M Scott
- VA Palo Alto Health Care System, Sierra Pacific Mental Illness Research Education Clinical Center, USA; Stanford School of Medicine, Department of Psychiatry and Behavioral Sciences, USA.
| | | | - Chinazo O Cunningham
- Albert Einstein College of Medicine and Montefiore Medical Center, Department of Medicine, USA.
| | - Franchesca Arias
- The Aging Brain Center, Hebrew SeniorLife, USA; Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Cognitive Neurology, USA.
| | - Julia H Arnsten
- Albert Einstein College of Medicine and Montefiore Medical Center, Department of Medicine, USA.
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21
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Boudreau DM, Lapham G, Johnson EA, Bobb JF, Matthews AG, McCormack J, Liu D, Campbell CI, Rossom RC, Binswanger IA, Yarborough BJ, Arnsten JH, Cunningham CO, Glass JE, Murphy MT, Zare M, Hechter RC, Ahmedani B, Braciszewski JM, Horigian VE, Szapocznik J, Samet JH, Saxon AJ, Schwartz RP, Bradley KA. Documented opioid use disorder and its treatment in primary care patients across six U.S. health systems. J Subst Abuse Treat 2021; 112S:41-48. [PMID: 32220410 DOI: 10.1016/j.jsat.2020.02.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [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: 10/31/2019] [Revised: 02/05/2020] [Accepted: 02/08/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND The United States is in the middle of an opioid overdose epidemic, and experts are calling for improved detection of opioid use disorders (OUDs) and treatment with buprenorphine or extended release (XR) injectable naltrexone, which can be prescribed in general medical settings. To better understand the magnitude of opportunities for treatment among primary care (PC) patients, we estimated the prevalence of documented OUD and medication treatment of OUD among PC patients. METHODS This cross-sectional study included patients with ≥2 visits to PC clinics across 6 healthcare delivery systems who were ≥16 years of age during the study period (fiscal years 2014-2016). Diagnoses, prescriptions, and healthcare utilization were ascertained from electronic health records and insurance claims (5 systems that also offer health insurance). Documented OUDs were defined as ≥1 International Classification of Diseases code for OUDs (active or remission), and OUD treatment was defined as ≥1 prescription(s) for buprenorphine formulations indicated for OUD or naltrexone XR, during the 3-year study period. The prevalence of documented OUD and treatment (95% confidence intervals) across health systems were estimated, and characteristics of patients by treatment status were compared. Prevalence of OUD and OUD treatment were adjusted for age, gender, and race/ethnicity. Combined results were also adjusted for site. RESULT Among 1,403,327 eligible PC patients, 54-62% were female and mean age ranged from 46 to 51 years across health systems. The 3-year prevalence of documented OUD ranged from 0.7-1.4% across the health systems. Among patients with documented OUD, the prevalence of medication treatment (primarily buprenorphine) varied across health systems: 3%, 12%, 16%, 20%, 22%, and 36%. CONCLUSION The prevalence of documented OUD and OUD treatment among PC patients varied widely across health systems. The majority of PC patients with OUD did not have evidence of treatment with buprenorphine or naltrexone XR, highlighting opportunities for improved identification and treatment in medical settings. These results can inform initiatives aimed at improving treatment of OUD in PC. Future research should focus on why there is such variation and how much of the variation can be addressed by improving access to medication treatment.
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Affiliation(s)
- Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute, United States of America.
| | - Gwen Lapham
- Kaiser Permanente Washington Health Research Institute, United States of America
| | - Eric A Johnson
- Kaiser Permanente Washington Health Research Institute, United States of America
| | - Jennifer F Bobb
- Kaiser Permanente Washington Health Research Institute, United States of America
| | | | | | - David Liu
- National Institute on Drug Abuse Center for Clinical Trials Network, United States of America
| | - Cynthia I Campbell
- Kaiser Permanente Northern California Division of Research, United States of America
| | | | - Ingrid A Binswanger
- Kaiser Permanente Colorado Institute for Health Research and Colorado Permanente Medical Group, United States of America
| | - Bobbi Jo Yarborough
- Kaiser Permanente Northwest Center for Health Research, United States of America
| | | | | | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, United States of America
| | | | - Mohammad Zare
- University of Texas at Houston, United States of America
| | - Rulin C Hechter
- Kaiser Permanente Southern California Department of Research and Evaluation, United States of America
| | | | | | | | | | - Jeffrey H Samet
- Boston Medical Center, Boston University School of Medicine, United States of America
| | - Andrew J Saxon
- Veteran Affairs Puget Sound Health Care System, United States of America
| | | | - Katharine A Bradley
- Kaiser Permanente Washington Health Research Institute, United States of America
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Roy PJ, Price R, Choi S, Weinstein ZM, Bernstein E, Cunningham CO, Walley AY. Shorter outpatient wait-times for buprenorphine are associated with linkage to care post-hospital discharge. Drug Alcohol Depend 2021; 224:108703. [PMID: 33964730 PMCID: PMC8180499 DOI: 10.1016/j.drugalcdep.2021.108703] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/22/2021] [Accepted: 02/22/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Inpatient addiction consult services (ACS) lower barriers to accessing medications for opioid use disorder (MOUD), however not every patient recommended for MOUD links to outpatient care. We hypothesized that fewer days between discharge date and outpatient appointment date was associated with improved linkage to buprenorphine treatment among patients evaluated by an ACS. METHODS We extracted appointment and demographic data from electronic medical records and conducted retrospective chart review of adults diagnosed with opioid use disorder (OUD) evaluated by an ACS in Boston, MA between July 2015 and August 2017. These patients were initiated on or recommended buprenorphine treatment on discharge and provided follow-up appointment at our hospital post-discharge. Multivariable logistic regression assessed whether arrival to the appointment post-discharge was associated with shorter wait-times (0-1 vs. 2+ days). RESULTS In total, 142 patients were included. Among patients who had wait-times of 0-1 day, 63 % arrived to their appointment compared to wait-times of 2 or more days (42 %). There were no significant differences between groups based on age, gender, distance of residence from the hospital, insurance status, co-occurring alcohol use disorder diagnosis, or discharge with buprenorphine prescription. After adjusting for covariates, patients with 0-1 day of wait-time had 2.6 times the odds of arriving to their appointment [95 % CI 1.3-5.5] compared to patients who had 2+ days of wait-time. CONCLUSION For hospitalized patients with OUD evaluated for initiating MOUD, same- and next-day appointments are associated with increased odds of linkage to outpatient MOUD care post-discharge compared to waiting two or more days.
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Affiliation(s)
- Payel J Roy
- Department of Medicine, University of Pittsburgh School of Medicine, 200 Lothrop St, Pittsburgh, PA, 15213, USA.
| | - Ryan Price
- Department of Medicine, Boston University School of Medicine, 801 Massachusetts Ave, Boston, MA, 02118, USA
| | - Sugy Choi
- Department of Health Law, Policy, and Management, Boston University School of Public Health, 715 Albany St, Boston, MA, 02118, USA
| | - Zoe M Weinstein
- Department of Medicine, Boston University School of Medicine, 801 Massachusetts Ave, Boston, MA, 02118, USA
| | - Edward Bernstein
- Department of Community Health Sciences, Boston University School of Public Health, 715 Albany St, Boston, MA, 02118, USA; Department of Emergency Medicine, Boston University School of Medicine, 850 Harrison Ave, Boston, MA, 02118, USA
| | - Chinazo O Cunningham
- Department of Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| | - Alexander Y Walley
- Department of Medicine, Boston University School of Medicine, 801 Massachusetts Ave, Boston, MA, 02118, USA
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Buonora M, Perez HR, Stumph J, Allen R, Nahvi S, Cunningham CO, Merlin JS, Starrels JL. Medical Record Documentation About Opioid Tapering: Examining Benefit-to-Harm Framework and Patient Engagement. Pain Med 2021; 21:2574-2582. [PMID: 32142143 DOI: 10.1093/pm/pnz361] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Guidelines recommend that clinicians make decisions about opioid tapering for patients with chronic pain using a benefit-to-harm framework and engaging patients. Studies have not examined clinician documentation about opioid tapering using this framework. DESIGN AND SETTING Thematic and content analysis of clinician documentation about opioid tapering in patients' medical records in a large academic health system. METHODS Medical records were reviewed for patients aged 18 or older, without cancer, who were prescribed stable doses of long-term opioid therapy between 10/2015 and 10/2016 then experienced an opioid taper (dose reduction ≥30%) between 10/2016 and 10/2017. Inductive thematic analysis of clinician documentation within six months of taper initiation was conducted to understand rationale for taper, and deductive content analysis was conducted to determine the frequencies of a priori elements of a benefit-to-harm framework. RESULTS Thematic analysis of 39 patients' records revealed 1) documented rationale for tapering prominently cited potential harms of continuing opioids, rather than observed harms or lack of benefits; 2) patient engagement was variable and disagreement with tapering was prominent. Content analysis found no patients' records with explicit mention of benefit-to-harm assessments. Benefits of continuing opioids were mentioned in 56% of patients' records, observed harms were mentioned in 28%, and potential harms were mentioned in 90%. CONCLUSIONS In this study, documentation of opioid tapering focused on potential harms of continuing opioids, indicated variable patient engagement, and lacked a complete benefit-to-harm framework. Future initiatives should develop standardized ways of incorporating a benefit-to-harm framework and patient engagement into clinician decisions and documentation about opioid tapering.
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Affiliation(s)
- Michele Buonora
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
| | - Hector R Perez
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
| | - Jordan Stumph
- Department of Physical Medicine and Rehabilitation, New York-Presbyterian Columbia/Cornell, New York, New York
| | - Robert Allen
- Department of Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, New York
| | - Shadi Nahvi
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
| | - Chinazo O Cunningham
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
| | - Jessica S Merlin
- Center for Research on Healthcare, Divisions of General Internal Medicine and Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Joanna L Starrels
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York
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Tsui JI, Akosile MA, Lapham GT, Boudreau DM, Johnson EA, Bobb JF, Binswanger IA, Yarborough BJH, Glass JE, Rossom RC, Murphy MT, Cunningham CO, Arnsten JH, Thakral M, Saxon AJ, Merrill JO, Samet JH, Bart GB, Campbell CI, Loree AM, Silva A, Stotts AL, Ahmedani B, Braciszewski JM, Hechter RC, Northrup TF, Horigian VE, Bradley KA. Prevalence and Medication Treatment of Opioid Use Disorder Among Primary Care Patients with Hepatitis C and HIV. J Gen Intern Med 2021; 36:930-937. [PMID: 33569735 PMCID: PMC8041979 DOI: 10.1007/s11606-020-06389-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 12/03/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Hepatitis C and HIV are associated with opioid use disorders (OUD) and injection drug use. Medications for OUD can prevent the spread of HCV and HIV. OBJECTIVE To describe the prevalence of documented OUD, as well as receipt of office-based medication treatment, among primary care patients with HCV or HIV. DESIGN Retrospective observational cohort study using electronic health record and insurance data. PARTICIPANTS Adults ≥ 18 years with ≥ 2 visits to primary care during the study (2014-2016) at 6 healthcare systems across five states (CO, CA, OR, WA, and MN). MAIN MEASURES The primary outcome was the diagnosis of OUD; the secondary outcome was OUD treatment with buprenorphine or oral/injectable naltrexone. Prevalence of OUD and OUD treatment was calculated across four groups: HCV only; HIV only; HCV and HIV; and neither HCV nor HIV. In addition, adjusted odds ratios (AOR) of OUD treatment associated with HCV and HIV (separately) were estimated, adjusting for age, gender, race/ethnicity, and site. KEY RESULTS The sample included 1,368,604 persons, of whom 10,042 had HCV, 5821 HIV, and 422 both. The prevalence of diagnosed OUD varied across groups: 11.9% (95% CI: 11.3%, 12.5%) for those with HCV; 1.6% (1.3%, 2.0%) for those with HIV; 8.8% (6.2%, 11.9%) for those with both; and 0.92% (0.91%, 0.94%) among those with neither. Among those with diagnosed OUD, the prevalence of OUD medication treatment was 20.9%, 16.0%, 10.8%, and 22.3%, for those with HCV, HIV, both, and neither, respectively. HCV was not associated with OUD treatment (AOR = 1.03; 0.88, 1.21), whereas patients with HIV had a lower probability of OUD treatment (AOR = 0.43; 0.26, 0.72). CONCLUSIONS Among patients receiving primary care, those diagnosed with HCV and HIV were more likely to have documented OUD than those without. Patients with HIV were less likely to have documented medication treatment for OUD.
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Affiliation(s)
- Judith I Tsui
- University of Washington/Harborview Medical Center, Seattle, USA
| | - Mary A Akosile
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Gwen T Lapham
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Eric A Johnson
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Jennifer F Bobb
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Ingrid A Binswanger
- Kaiser Permanente Colorado, Colorado Permanente Medical Group, and the University of Colorado School of Medicine, Aurora, USA
| | | | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA
| | - Rebecca C Rossom
- HealthPartners Institute, University of Minnesota, Bloomington, USA
| | - Mark T Murphy
- MultiCare Institute for Research and Innovation, MultiCare Health System WA, Seattle, USA
| | - Chinazo O Cunningham
- Albert Einstein College of Medicine, Montefiore Medical Center, New York City, USA
| | - Julia H Arnsten
- Albert Einstein College of Medicine, Montefiore Medical Center, New York City, USA
| | - Manu Thakral
- College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, USA
| | - Andrew J Saxon
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System/University of Washington School of Medicine, Seattle, USA
| | - Joseph O Merrill
- University of Washington/Harborview Medical Center, Seattle, USA
| | | | - Gavin B Bart
- Hennepin Healthcare, University of Minnesota, Minneapolis, USA
| | - Cynthia I Campbell
- Division of Research, Kaiser Permanente Northern California, Oakland, USA
| | - Amy M Loree
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, USA
| | - Angela Silva
- MultiCare Institute for Research and Innovation, MultiCare Health System WA, Seattle, USA
| | - Angela L Stotts
- Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth), Houston, USA
| | - Brian Ahmedani
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, USA
| | - Jordan M Braciszewski
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, USA
- Department of Psychiatry, Henry Ford Health System, Detroit, USA
| | - Rulin C Hechter
- Department of Research and Evaluation, Kaiser Permanente Southern California, Oakland, USA
| | - Thomas F Northrup
- Department of Family and Community Medicine, McGovern Medical School, University of Texas Health Science Center at Houston (UTHealth), Houston, USA
| | - Viviana E Horigian
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Florida, USA
| | - Katharine A Bradley
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA.
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Bachhuber MA, Nash D, Southern WN, Heo M, Berger M, Schepis M, Thakral M, Cunningham CO. Effect of Changing Electronic Health Record Opioid Analgesic Dispense Quantity Defaults on the Quantity Prescribed: A Cluster Randomized Clinical Trial. JAMA Netw Open 2021; 4:e217481. [PMID: 33885773 PMCID: PMC8063068 DOI: 10.1001/jamanetworkopen.2021.7481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Interventions to improve judicious prescribing of opioid analgesics for acute pain are needed owing to the risks of diversion, misuse, and overdose. OBJECTIVE To assess the effect of modifying opioid analgesic prescribing defaults in the electronic health record (EHR) on prescribing and health service use. DESIGN, SETTING, AND PARTICIPANTS A cluster randomized clinical trial with 2 parallel arms was conducted between June 13, 2016, and June 13, 2018, in a large urban health care system comprising 32 primary care and 4 emergency department (ED) sites in the Bronx, New York. Data were analyzed using a difference-in-differences method from 6 months before implementation through 18 months after implementation. Data were analyzed from January 2019 to February 2020. INTERVENTIONS A default dispense quantity for new opioid analgesic prescriptions of 10 tablets (intervention) vs no change (control) in the EHR. MAIN OUTCOMES AND MEASURES The primary outcome was the quantity of opioid analgesics prescribed with the new default prescription. Secondary outcomes were opioid analgesic reorders and health service use within 30 days after the new prescription. Intention-to-treat analysis was conducted. RESULTS Overall, 21 331 patients received a new opioid analgesic prescription from 490 prescribers. Comparing the intervention and control arms, site, prescriber, and patient characteristics were similar. For the new prescription, compared with the control arm, patients in the intervention arm had significantly more prescriptions for 10 tablets or fewer (7.6 percentage points; 95% CI, 6.1-9.2 percentage points), a lower number of tablets prescribed (-2.1 tablets; 95% CI, -3.3 to -0.9 tablets), and lower morphine milligram equivalents (MME) prescribed (-14.6 MME; 95% CI, -22.6 to -6.6 MME). Within 30 days after the new prescription, significant differences remained in the number of tablets prescribed (-2.7 tablets; 95% CI, -4.8 to -0.6 tablets), but not MME (-15.8 MME; 95% CI, -33.8 to 2.2 MME). Within this 30-day period, there were no significant differences between the arms in health service use. CONCLUSIONS AND RELEVANCE In this study, implementation of a uniform reduced default dispense quantity of 10 tablets for opioid analgesic prescriptions led to a modest reduction in the quantity prescribed initially, without significantly increasing health service use. However, during 30 days after implementation, the influence on prescribing was mixed. Reducing EHR default dispense quantities for opioid analgesics is a feasible strategy that can be widely disseminated and may modestly reduce prescribing. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03003832.
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Affiliation(s)
- Marcus A. Bachhuber
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
- Now with Section of Community and Population Medicine, Louisiana State University Health Sciences Center–New Orleans
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York
- Graduate School of Public Health and Health Policy, Department of Epidemiology and Biostatistics, City University of New York, New York, New York
| | - William N. Southern
- Division of Hospital Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Moonseong Heo
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
- Now with College of Behavioral, Social and Health Sciences, Department of Public Health Sciences, Clemson University, Clemson, South Carolina
| | - Matthew Berger
- Montefiore Information Technology, Montefiore Medical Center, Bronx, New York
| | - Mark Schepis
- Montefiore Information Technology, Montefiore Medical Center, Bronx, New York
| | - Manu Thakral
- College of Nursing and Health Sciences, University of Massachusetts Boston, Boston
| | - Chinazo O. Cunningham
- Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
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Frost T, Deutsch S, Brown S, Lemien E, Cunningham CO, Fox AD. "We'll be able to take care of ourselves" - A qualitative study of client attitudes toward implementing buprenorphine treatment at syringe services programs. Subst Abus 2021; 42:983-989. [PMID: 33759722 PMCID: PMC10112278 DOI: 10.1080/08897077.2021.1901173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Syringe services programs (SSPs) complement substance use disorder treatment in providing services that improve the health of people who use drugs (PWUD). Buprenorphine treatment is an effective underutilized opioid use disorder treatment. Regulations allow buprenorphine prescribing from office-based settings, potentially including SSPs although few studies have examined this approach. Our objective was to assess the attitudes among PWUD toward the potential introduction of buprenorphine treatment in an SSP. Methods: In this qualitative study, we recruited 34 participants who were enrolled at a New York City-based SSP to participate in one of seven focus group sessions. The focus group facilitators prompted participants to share their thoughts in five domains: attitudes toward (1) medical clinics; (2) harm reduction in general; (3) SSP-based buprenorphine treatment; (4) potential challenges of SSP-based treatment; and (5) logistical considerations of an SSP-based buprenorphine treatment program. Four researchers analyzed focus group transcripts using thematic analysis. Results: Of the 34 participants, most were white (68%), over the age of 40 years old (56%), and had previously tried buprenorphine (89%). Common themes were: 1) The SSP is a supportive community for people who use drugs; 2) Participants felt less stigmatized at the SSP than in general medical settings; 3) Offering buprenorphine treatment could change the SSP's culture; and 4) SSP participants receiving buprenorphine may be tempted to divert their medication. Participants offered suggestions for a slow intentional introduction of buprenorphine treatment at the SSP including structured appointments, training medical providers in harm reduction, and program eligibility criteria. Conclusion: Overall, participants expressed enthusiasm for onsite buprenorphine treatment at SSPs. Research on SSP-based buprenorphine treatment should investigate standard buprenorphine treatment outcomes but also any effects on the program itself and medication diversion. Implementation should consider cultural and environmental aspects of the SSP and consult program staff and participants.
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Affiliation(s)
- Taeko Frost
- Washington Heights CORNER Project, New York, New York, USA
| | - Sarah Deutsch
- Washington Heights CORNER Project, New York, New York, USA
| | - Shoshana Brown
- Washington Heights CORNER Project, New York, New York, USA
| | - Ellen Lemien
- Washington Heights CORNER Project, New York, New York, USA
| | - Chinazo O Cunningham
- Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| | - Aaron D Fox
- Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
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Jaureguiberry-Bravo M, Kelschenbach J, Murphy A, Carvallo L, Hadas E, Tesfa L, Scott TM, Rivera-Mindt M, Cunningham CO, Arnsten JH, Volsky DJ, Berman JW. Treatment with buprenorphine prior to EcoHIV infection of mice prevents the development of neurocognitive impairment. J Leukoc Biol 2021; 109:675-681. [PMID: 32578908 PMCID: PMC8525325 DOI: 10.1002/jlb.5ab0420-531r] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 10/24/2019] [Revised: 04/24/2020] [Accepted: 05/14/2020] [Indexed: 11/06/2022] Open
Abstract
Approximately 15-40% of people living with HIV develop HIV-associated neurocognitive disorders, HAND, despite successful antiretroviral therapy. There are no therapies to treat these disorders. HIV enters the CNS early after infection, in part by transmigration of infected monocytes. Currently, there is a major opioid epidemic in the United States. Opioid use disorder in the context of HIV infection is important because studies show that opioids exacerbate HIV-mediated neuroinflammation that may contribute to more severe cognitive deficits. Buprenorphine is an opioid derivate commonly prescribed for opiate agonist treatment. We used the EcoHIV mouse model to study the effects of buprenorphine on cognitive impairment and to correlate these with monocyte migration into the CNS. We show that buprenorphine treatment prior to mouse EcoHIV infection prevents the development of cognitive impairment, in part, by decreased accumulation of monocytes in the brain. We propose that buprenorphine has a novel therapeutic benefit of limiting the development of neurocognitive impairment in HIV-infected opioid abusers as well as in nonabusers, in addition to decreasing the use of harmful opioids. Buprenorphine may also be used in combination with HIV prevention strategies such as pre-exposure prophylaxis because of its safety profile.
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Affiliation(s)
- Matias Jaureguiberry-Bravo
- Department of Pathology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, 10461, USA
| | - Jennifer Kelschenbach
- Department of Medicine/Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, 10029 USA
| | - Aniella Murphy
- Department of Pathology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, 10461, USA
| | - Loreto Carvallo
- Department of Medicine/Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, 10029 USA
| | - Eran Hadas
- Department of Medicine/Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, 10029 USA
| | - Lydia Tesfa
- Department of Microbiology and Immunology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, 10461, USA
| | - Travis M. Scott
- Department of Psychology, Fordham University, Bronx, NY 10458, USA
| | | | - Chinazo O. Cunningham
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, 10461, USA
| | - Julia H. Arnsten
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, 10461, USA
| | - David J. Volsky
- Department of Medicine/Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, 10029 USA
| | - Joan W. Berman
- Department of Pathology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, 10461, USA
- Department of Microbiology and Immunology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, 10461, USA
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Norton BL, Norton BL, Gutierrez NR, Cunningham CO, Litwin AH. 1062. HCV GET-UP: A Group Evaluation and Treatment Uptake Intervention Improves HCV Linkage to Care for PWID. Open Forum Infect Dis 2020. [PMCID: PMC7776556 DOI: 10.1093/ofid/ofaa439.1248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Though PWID represent the overwhelming majority of those living with HCV in the United States, most have not been treated. PWID often have reduced access to specialty care, as well as limited HCV knowledge, low perceived vulnerability to poor HCV-related health outcomes, poor self-efficacy, high levels of perceived stigma, and mistrust of healthcare providers. We therefore evaluated an primary care based HCV Group Evaluation and Treatment UPtake (HCV GET-UP) intervention to improve HCV medical evaluation and treatment uptake for HCV+ PWIDs. Figure 1 ![]()
Methods We enrolled 84 HCV+ PWID and randomize them 1:1 to a 4-week group evaluation intervention followed by individual treatment (intervention) versus onsite treatment alone (control). The group consisted of 4 weekly 1-hour sessions focused on HCV education, peer motivation, and health behavior change skills, along with an HCV medical evaluation. Both arms received HCV treatment according to national guidelines. Baseline questionnaires were performed via Audio Computer-Assisted Self-Interview (ACASI) technology. Clinical Data was extracted from the medical chart. Our primary outcomes were HCV linkage to care (HCV evaluation) and treatment uptake. Bivariate analyses were performed to evaluate HCV treatment outcomes between arms using chi square tests. Results Of the 76 participants that have currently completed the study (84 enrolled) 35% identified their race as black, 61% identified their ethnicity as Hispanic, 79% were male, and 25% of the participants were homeless. 87% had genotype 1, 28% were HIV+, and 20% had cirrhosis. Baseline urine tocixicologies were positive for cocaine in 38% of participants and 40% for heroin. Of those randomized to the group treatment arm vs individual arm 87% vs 62% were linked to care (p=0.012), 51% vs. 41% initiated treatment (p=.35), 41% vs. 35% completed treatment (p=0.6), and 33% vs. 27% (p=0.6) Conclusion HCV GET-UP, a primary-care based group evaluation and treatment uptake intervention significantly improved linkage to care for HCV+ PWID. Though this is encouraging, we must integrate other interventions to aid PWID as they move through the more proximal steps of the HCV cascade, for HCV cure still remains elusive for the majority of PWID enrolled. Disclosures Chinazo O. Cunningham, MD, MPH, General Electric Health (Other Financial or Material Support, My husband is currently employed by General Electric Health and receives stock and stock options.)Quest Diagnostics (Other Financial or Material Support, My husband was previously employed by Quest Diagnostics and received stocks and stock options.) Alain H. Litwin, MD, MPH, MS, Gilead (Advisor or Review Panel member)Merck (Advisor or Review Panel member)
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Affiliation(s)
| | | | | | | | - Alain H Litwin
- Greenville Health System/Clemson University, Columbia, South Carolina
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Abstract
Background Though people who inject drugs (PWID) represent the overwhelming majority of those living with HCV, most have not been treated. Many HCV+ PWID represent the most marginalized persons in society, often experiencing poverty and poor access to care. We set out to determine the social determinants of health (SDOH) among a population of HCV+ PWID and determine if poor SDOH were related to reduced HCV treatment uptake. Methods The HCV-GET UP study was a randomized controlled trial to assess the effectiveness of an HCV group evaluation intervention vs. individual HCV treatment among PWID within a primary care clinic in the Bronx, NY. HCV treatment was provided according to national guidelines.. Here, we include all patient characteristics and baseline social determinants of health (SDOH), obtained through questionnaires using Audio Computer-Assisted Self-Interview (ACASI) technology. We performed bivariate analyses between treatment initiation and the various factors of the SDOH using chi square tests. Results The majority of the 84 participants enrolled were black (35%) or Hispanic (60%) males (77%), aged 51 (SD11). The majority are on NY State Medicaid insurance (68%), indicating that their income is less than 138% of the Federal Poverty Level. 42% of participants report running out of money for basic needs on a daily or weekly basis, 69% receive food stamps, and 23% are homeless. Nearly half (45%) of participants have less than a high school education, 57% have ever been incarcerated, 48% report not having transportation to get to a medical appointment, and 25% do not trust doctors. A total of 57% of participants initiated HCV treatment, and no factors of SDOH were associated with treatment initiation. Conclusion We found that HCV+ PWID have extremely poor SDOH. Despite this, over half of participants initiated HCV treatment, indicating participants willingness to receive HCV treatment, and resilience in overcoming SDOH. Poor SDOH, such as homelessness, should not be a reason to delay HCV treatment in this population; however, we risk severely muting the health benefits of HCV cure in this population, if we do not address the underlying SDOH that will certainly lead to poor health outcomes, and early death. Disclosures Chinazo O. Cunningham, MD, MPH, General Electric Health (Other Financial or Material Support, My husband is currently employed by General Electric Health and receives stock and stock options.)Quest Diagnostics (Other Financial or Material Support, My husband was previously employed by Quest Diagnostics and received stocks and stock options.) Alain H. Litwin, MD, MPH, MS, Gilead (Advisor or Review Panel member)Merck (Advisor or Review Panel member)
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Affiliation(s)
| | | | | | - Alain H Litwin
- Greenville Health System/Clemson University, Columbia, South Carolina
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Cunningham CO, Starrels JL, Zhang C, Bachhuber MA, Sohler NL, Levin FR, Minami H, Slawek DE, Arnsten JH. Medical Marijuana and Opioids (MEMO) Study: protocol of a longitudinal cohort study to examine if medical cannabis reduces opioid use among adults with chronic pain. BMJ Open 2020; 10:e043400. [PMID: 33376181 PMCID: PMC7778768 DOI: 10.1136/bmjopen-2020-043400] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION In the USA, opioid analgesic use and overdoses have increased dramatically. One rapidly expanding strategy to manage chronic pain in the context of this epidemic is medical cannabis. Cannabis has analgesic effects, but it also has potential adverse effects. Further, its impact on opioid analgesic use is not well studied. Managing pain in people living with HIV is particularly challenging, given the high prevalence of opioid analgesic and cannabis use. This study's overarching goal is to understand how medical cannabis use affects opioid analgesic use, with attention to Δ9-tetrahydrocannabinol and cannabidiol content, HIV outcomes and adverse events. METHODS AND ANALYSES We are conducting a cohort study of 250 adults with and without HIV infection with (a) severe or chronic pain, (b) current opioid use and (c) who are newly certified for medical cannabis in New York. Over 18 months, we collect data via in-person visits every 3 months and web-based questionnaires every 2 weeks. Data sources include: questionnaires; medical, pharmacy and Prescription Monitoring Program records; urine and blood samples; and physical function tests. Using marginal structural models and comparisons within participants' 2-week time periods (unit of analysis), we will examine how medical cannabis use (primary exposure) affects (1) opioid analgesic use (primary outcome), (2) HIV outcomes (HIV viral load, CD4 count, antiretroviral adherence, HIV risk behaviours) and (3) adverse events (cannabis use disorder, illicit drug use, diversion, overdose/deaths, accidents/injuries, acute care utilisation). ETHICS AND DISSEMINATION This study is approved by the Montefiore Medical Center/Albert Einstein College of Medicine institutional review board. Findings will be disseminated through conferences, peer-reviewed publications and meetings with medical cannabis stakeholders. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT03268551); Pre-results.
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Affiliation(s)
- Chinazo O Cunningham
- Division of General Internal Medicine, Montefiore Health System, Bronx, New York, USA
| | - Joanna L Starrels
- Division of General Internal Medicine, Montefiore Health System, Bronx, New York, USA
| | - Chenshu Zhang
- Division of General Internal Medicine, Montefiore Health System, Bronx, New York, USA
| | - Marcus A Bachhuber
- Section of Community and Population Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| | - Nancy L Sohler
- School of Medicine, City University of New York, New York, New York, USA
| | - Frances R Levin
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
| | - Haruka Minami
- Psychology Department, Fordham University, Bronx, New York, USA
| | - Deepika E Slawek
- Division of General Internal Medicine, Montefiore Health System, Bronx, New York, USA
| | - Julia H Arnsten
- Division of General Internal Medicine, Montefiore Health System, Bronx, New York, USA
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Linas BP, Cunningham CO. Coronavirus Disease 2019 (COVID-19) Disparities: A Call for Equity in Health Outcomes and Clinical Research. Clin Infect Dis 2020; 73:e4139-e4140. [PMID: 33111148 PMCID: PMC7543378 DOI: 10.1093/cid/ciaa1460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 09/28/2020] [Indexed: 11/22/2022] Open
Affiliation(s)
- Benjamin P Linas
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, USA.,Schools of Medicine and Public Health, Boston University, Boston, Massachusetts, USA
| | - Chinazo O Cunningham
- Montefiore Health System, Bronx, New York, USA.,Albert Einstein College of Medicine, Bronx, New York, USA
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Buonora M, Perez HR, Heo M, Cunningham CO, Starrels JL. Race and Gender Are Associated with Opioid Dose Reduction Among Patients on Chronic Opioid Therapy. Pain Med 2020; 20:1519-1527. [PMID: 30032197 DOI: 10.1093/pm/pny137] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Among patients with chronic pain, risk of opioid use is elevated with high opioid dose or concurrent benzodiazepine use. This study examined whether these clinical factors, or sociodemographic factors of race and gender, are associated with opioid dose reduction. DESIGN AND SETTING A retrospective cohort study of outpatients prescribed chronic opioid therapy between 2007 and 2012 within a large, academic health care system in Bronx, New York, using electronic medical record data. Included patients were prescribed a stable dose of chronic opioid therapy over a one-year "baseline period" and did not have cancer. METHODS The primary outcome was opioid dose reduction (≥30% reduction from baseline) within two years. Multivariable logistic regression tested the associations of two clinical variables (baseline daily opioid dose and concurrent benzodiazepine prescription) and two sociodemographic variables (race/ethnicity and gender) with opioid dose reduction. RESULTS Of 1,097 patients, 463 (42.2%) had opioid dose reduction. High opioid dose (≥100 morphine-milligram equivalents [MME]) was associated with lower odds of opioid dose reduction compared with an opioid dose <100 MME (adjusted odds ratio [AOR] = 0.69, 95% confidence interval [CI] = 0.54-0.89). Concurrent benzodiazepine prescription was not associated with opioid dose reduction. Black (vs white) race and female (vs male) gender were associated with greater odds of opioid dose reduction (AOR = 1.82, 95% CI = 1.22-2.70; and AOR = 1.43, 95% CI = 1.11-1.83, respectively). CONCLUSIONS Black race and female gender were associated with greater odds of opioid dose reduction, whereas clinical factors of high opioid dose and concurrent benzodiazepine prescription were not. Efforts to reduce opioid dose should target patients based on clinical factors and address potential biases in clinical decision-making.
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Affiliation(s)
| | - Hector R Perez
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Moonseong Heo
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Chinazo O Cunningham
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
| | - Joanna L Starrels
- Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York
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Slawek DE, Arnsten J, Sohler N, Zhang C, Grossberg R, Stein M, Cunningham CO. Daily and near-daily cannabis use is associated with HIV viral load suppression in people living with HIV who use cocaine. AIDS Care 2020; 33:1350-1357. [PMID: 32748649 DOI: 10.1080/09540121.2020.1799922] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Disparities remain in HIV viral load (VL) suppression between people living with HIV (PLWH) who use cocaine and those who do not. It is not known how cannabis use affects VL suppression in PLWH who use cocaine. We evaluated the relationship between cannabis use and VL suppression among PLWH who use cocaine. We conducted a secondary data analysis of 119 baseline interviews from a randomized controlled trial in the Bronx, NY (6/2012 to 1/2017). Participants were adult PLWH prescribed antiretrovirals for ≥16 weeks, who endorsed imperfect antiretroviral adherence and used cocaine in the past 30-days. In bivariate and multivariable regression analyses, we examined how cannabis use, is associated with VL suppression among PLWH who use cocaine. Participants were a mean age of 50 years; most were male (64%) and non-Hispanic black (55%). Participants with VL suppression used cocaine less frequently than those with no VL suppression (p < 0.01); cannabis use was not significantly different. In regression analysis, compared with no use, daily/near-daily cannabis use was associated with VL suppression (aOR = 4.2, 95% CI: 1.1-16.6, p < 0.05). Less-frequent cannabis use was not associated with VL suppression. Further investigation is needed to understand how cannabis use impacts HIV outcomes among PLWH who use cocaine.
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Affiliation(s)
- Deepika E Slawek
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA.,Montefiore Medical Center, Bronx, NY, USA
| | - Julia Arnsten
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA.,Montefiore Medical Center, Bronx, NY, USA
| | - Nancy Sohler
- City University of New York School of Medicine, New York, NY, USA
| | | | - Robert Grossberg
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA.,Montefiore Medical Center, Bronx, NY, USA
| | - Melissa Stein
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA.,Montefiore Medical Center, Bronx, NY, USA
| | - Chinazo O Cunningham
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA.,Montefiore Medical Center, Bronx, NY, USA
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Incze MA, Slawek D, Cunningham CO. The Importance of Pediatric Safety in Tetrahydrocannabinol Education-Reply. JAMA Intern Med 2020; 180:1027. [PMID: 32421145 DOI: 10.1001/jamainternmed.2020.1394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Michael A Incze
- Division of General Internal Medicine, University of Utah, Salt Lake City
| | - Deepika Slawek
- Division of General Internal Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
| | - Chinazo O Cunningham
- Division of General Internal Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
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Abstract
Adapting to this new paradigm during this pandemic has been ever-changing and extraordinarily challenging, both personally and professionally.
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Affiliation(s)
- Chinazo O Cunningham
- Montefiore Health System and Albert Einstein College of Medicine, Bronx, New York (C.O.C., C.D., D.E.S.)
| | - Chanelle Diaz
- Montefiore Health System and Albert Einstein College of Medicine, Bronx, New York (C.O.C., C.D., D.E.S.)
| | - Deepika E Slawek
- Montefiore Health System and Albert Einstein College of Medicine, Bronx, New York (C.O.C., C.D., D.E.S.)
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Lapham G, Boudreau DM, Johnson EA, Bobb JF, Matthews AG, McCormack J, Liu D, Samet JH, Saxon AJ, Campbell CI, Glass JE, Rossom RC, Murphy MT, Binswanger IA, Yarborough BJH, Bradley KA, Ahmedani B, Amoroso PJ, Arnsten JH, Bart G, Braciszewski JM, Cunningham CO, Hechter RC, Horigian VE, Liebschutz JM, Loree AM, Matson TE, McNeely J, Merrill JO, Northrup TF, Schwartz RP, Stotts AL, Szapocznik J, Thakral M, Tsui JI, Zare M. Prevalence and treatment of opioid use disorders among primary care patients in six health systems. Drug Alcohol Depend 2020; 207:107732. [PMID: 31835068 PMCID: PMC7158756 DOI: 10.1016/j.drugalcdep.2019.107732] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 10/25/2019] [Accepted: 11/11/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND The U.S. experienced nearly 48,000 opioid overdose deaths in 2017. Treatment of opioid use disorder (OUD) with buprenorphine is a recommended part of primary care, yet little is known about current U.S. practices in this setting. This observational study reports the prevalence of documented OUD and OUD treatment with buprenorphine among primary care patients in six large health systems. METHODS Adults with ≥2 primary care visits during a three-year period (10/1/2013-9/30/2016) in six health systems were included. Data were obtained from electronic health record and claims data, with measures, assessed over the three-year period, including indicators for documented OUD from ICD 9 and 10 codes and OUD treatment with buprenorphine. The prevalence of OUD treatment was adjusted for age, gender, race/ethnicity, and health system. RESULTS Among 1,368,604 primary care patients, 13,942 (1.0 %) had documented OUD, and among these, 21.0 % had OUD treatment with buprenorphine. For those with documented OUD, the adjusted prevalence of OUD treatment with buprenorphine varied across demographic and clinical subgroups. OUD treatment was lower among patients who were older, women, Black/African American and Hispanic (compared to white), non-commercially insured, and those with non-cancer pain, mental health disorders, greater comorbidity, and more opioid prescriptions, emergency department visits or hospitalizations. CONCLUSIONS Among primary care patients in six health systems, one in five with an OUD were treated with buprenorphine, with disparities across demographic and clinical characteristics. Less buprenorphine treatment among those with greater acute care utilization highlights an opportunity for systems-level changes to increase OUD treatment.
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Affiliation(s)
- Gwen Lapham
- Kaiser Permanente Washington Health Research Institute, United States; University of Washington, Department of Health Services, United States.
| | - Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute.,University of Washington Department of Pharmacy
| | | | | | | | | | - David Liu
- National Institute on Drug Abuse Center for Clinical Trials Network
| | - Jeffrey H Samet
- Boston University & Boston Medical Center Department of Medicine, Division of General Internal Medicine
| | - Andrew J Saxon
- Veteran Affairs Puget Sound Health Care System Center of Excellence in Substance Abuse Treatment and Education.,University of Washington Department of Psychiatry and Behavioral Sciences
| | | | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute.,University of Washington Department of Psychiatry and Behavioral Sciences
| | | | - Mark T Murphy
- Multicare Health System MultiCare Tacoma Central Family Medicine
| | - Ingrid A Binswanger
- Kaiser Permanente Colorado Institute for Health Research.,Colorado Permanente Medical Group, Denver, Colorado
| | | | - Katharine A Bradley
- Kaiser Permanente Washington Health Research Institute.,University of Washington Department of Health Services.,University of Washington Department of Medicine
| | - Brian Ahmedani
- Henry Ford Health System Center for Health Policy & Health Services Research
| | - Paul J Amoroso
- Multicare Health System MultiCare Institute for Research and Innovation
| | - Julia H Arnsten
- Montefiore Medical Center Department of Medicine.,Montefiore Medical Center Division of General Internal Medicine.,Albert Einstein College of Medicine Department of Medicine, Division of General Internal Medicine
| | | | | | - Chinazo O Cunningham
- Montefiore Medical Center Department of Medicine.,Albert Einstein College of Medicine Department of Medicine, Division of General Internal Medicine
| | - Rulin C Hechter
- Kaiser Permanente Southern California Department of Research and Evaluation
| | - Viviana E Horigian
- University of Miami Miller School of Medicine, Department of Public Health Sciences
| | - Jane M Liebschutz
- University of Pittsburgh School of Medicine Division of General Internal Medicine, Center for Research on Health Care
| | - Amy M Loree
- Henry Ford Health System Center for Health Policy & Health Services Research
| | | | - Jennifer McNeely
- New York University School of Medicine, Department of Population Health and Department of Medicine, Division of General Internal Medicine and Clinical Innovation
| | | | - Thomas F Northrup
- McGovern Medical School at The University of Texas Health Science Center at Houston
| | | | - Angela L Stotts
- McGovern Medical School at The University of Texas Health Science Center at Houston
| | - José Szapocznik
- University of Miami Miller School of Medicine, Department of Public Health Sciences
| | - Manu Thakral
- University of Massachusetts Boston College of Nursing and Health Sciences, Boston, MA, USA
| | - Judith I Tsui
- University of Washington Division of General Internal Medicine
| | - Mohammad Zare
- McGovern Medical School at The University of Texas Health Science Center at Houston
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Smith LR, Mittal ML, Wagner K, Copenhaver MM, Cunningham CO, Earnshaw VA. Factor structure, internal reliability and construct validity of the Methadone Maintenance Treatment Stigma Mechanisms Scale (MMT-SMS). Addiction 2020; 115:354-367. [PMID: 31478272 PMCID: PMC7089617 DOI: 10.1111/add.14799] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 05/07/2019] [Accepted: 08/23/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Experience of stigma towards methadone maintenance treatment (MMT) may be a barrier to the use of this treatment by people with opioid use disorder. We evaluated the factor structure, internal reliability, construct and criterion validity of a theory-based stigma measure, the Methadone Maintenance Treatment Stigma Mechanisms Scale (MMT-SMS) and compared this with the Substance Use Stigma Mechanism Scale (SU-SMS). DESIGN Surveys at the beginning and end of a prospective study together with records of drug use and treatment attendance during that study. SETTING Community methadone clinic in the Northeastern USA. PARTICIPANTS Ninety-three participants who were receiving MMT; the average daily methadone dose was 84.8 mg/day (standard deviation = 28.39 mg/day). MEASUREMENTS The MMT-SMS uses a self-report questionnaire to assess three dimensions reflecting experiences of anticipated (nine items), enacted (nine items) and internalized stigma (seven items) specifically related to receiving MMT. Anticipated and enacted scales include three stigma source subscales (family, employers, health care workers; three items each). Responses are recorded on a five-point Likert-type scale, then averaged to produce the MMT-SMS scale/subscale scores. The SU-SMS is a self-report questionnaire to assess experiences of anticipated, enacted and internalized stigma regarding substance use history. Both scales were administered at the final parent study visit. Other measures included were assessed in the parent study and used to assess life-time and recent MMT (e.g. current MMT dose) and drug use experiences (e.g. past 30-day heroin injection). FINDINGS The MMT-SMS demonstrated good internal reliability (α = 0.806-0.952 for components). Confirmatory factor analysis supported the seven-factor scale structure, distinguishing between experiences of anticipated, enacted and internalized stigma, and anticipated and enacted stigma source subscales (family, employers, health care workers) [root mean square error of approximation (RMSEA) = 0.076, 90% confidence interval (CI) = 0.061-0.090, P-close = 0.003; confirmatory fit index (CFI) = 0.974; Tucker-Lewis index (TLI) = 0.971]. Construct validity helped to distinguish the MMT-SMS from established substance use stigma constructs. Criterion validity observed associations with substance use experiences while on MMT, likely to predict future MMT success. Internalized MMT stigma was uniquely associated with daily MMT dose. Regarding criterion validity: anticipated MMT and enacted substance use stigma were associated with past 30-day heroin injection, MMT stigma uniquely associated with opioid use behaviors while receiving MMT, and substance use stigma broadly associated with injection-related behaviors. CONCLUSIONS The Methadone Maintenance Treatment Stigma Mechanisms Scale appears to be a reliable measure of methadone maintenance treatment stigma with robust validity in a sample of people with opioid use disorders receiving methadone maintenance treatment.
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Affiliation(s)
- Laramie R. Smith
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, CA, United States
| | - Maria Luisa Mittal
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, CA, United States
| | - Karla Wagner
- School of Community Health Sciences, University of Nevada, Reno, Reno, NV
| | | | - Chinazo O. Cunningham
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, United States
| | - Valerie A. Earnshaw
- Department of Human Development and Family Sciences, University of Delaware, Newark, DE, United States
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Sohler N, Slawek D, Earnshaw V, Jost J, Lee A, Mancini J, Mompremier A, Cunningham CO. Drug use and HIV medication adherence in people living with HIV. Subst Abus 2020; 42:310-316. [PMID: 31951807 DOI: 10.1080/08897077.2019.1706695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Opioid and cocaine use epidemics continue to be substantial in the United States and intersect with the HIV epidemic. Antiretroviral medication (ARV) adherence is critical for optimum HIV outcomes. While previous research explored harm reduction strategies to prevent HIV spread for people who use drugs (PWUD), little is known about strategies used by PWUD living with HIV to maintain ARV adherence. Methods: We explored whether PWUD modify their drug use explicitly to maintain ARV adherence, and identified factors associated with this process. We conducted 23 semi-structured interviews. Data were analyzed using a modified framework analysis approach. Results: Participants had a mean age of 54 years and were predominantly male (70%) and non-Hispanic black (65%). Most described periods of being able to adhere to ARVs while still using drugs, difficulty adhering to ARVs while using drugs, and abstinence/near abstinence from drug use. In exploring factors that influenced changes in drug use and ARV adherence behaviors, we noted consistent acknowledgment of the roles of family, partners, or providers. Conclusions: PWUD living with HIV often modify their drug use to improve ARV adherence. Providers caring for this population might consider family or group education models to encourage harm reduction to improve outcomes.
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Affiliation(s)
- Nancy Sohler
- CUNY School of Medicine, City College of New York, New York, NY, USA
| | - Deepika Slawek
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Valerie Earnshaw
- Department of Human Development and Family Sciences, University of Delaware, Newark, DE, USA
| | - John Jost
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Alice Lee
- CUNY School of Medicine, City College of New York, New York, NY, USA
| | - John Mancini
- CUNY School of Medicine, City College of New York, New York, NY, USA
| | | | - Chinazo O Cunningham
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
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40
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Perez HR, Buonora M, Cunningham CO, Heo M, Starrels JL. Opioid Taper Is Associated with Subsequent Termination of Care: a Retrospective Cohort Study. J Gen Intern Med 2020; 35:36-42. [PMID: 31428983 PMCID: PMC6957663 DOI: 10.1007/s11606-019-05227-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 04/03/2019] [Accepted: 06/18/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Opioid tapering is increasingly utilized by providers to decrease risks of chronic opioid therapy, but it is unknown whether tapering is associated with termination of care. OBJECTIVE To determine whether patients taking chronic opioid therapy who experienced opioid tapers were at greater risk of subsequently terminating their care compared with those who were continued on their doses. DESIGN Retrospective cohort study of patients in a large, urban health system between 2008 and 2012 with 2 years of follow-up. PARTICIPANTS Adult patients prescribed a stable baseline dose of chronic opioid therapy of at least 25 morphine milligram equivalents per day during a baseline year. MAIN MEASURES An opioid taper during an exposure year, defined as a reduction in the average daily dose of at least 30% from the baseline dose in both of the two 6-month periods in the year following the baseline year. Opioid dose continuation was defined as any increase in dose, no change in dose, or any decrease up to 30% compared with baseline dose in the exposure year. The primary outcome was termination of care, defined as no outpatient encounters in the health system, in the year following the exposure year. KEY RESULTS Of 1624 patients on chronic opioid therapy, 207 (15.5%) experienced an opioid taper and 78 (4.8%) experienced termination of care. Compared with opioid dose continuation, opioid taper was significantly associated with termination of care (AOR 4.3 [95% CI 2.2-8.5]). CONCLUSIONS Opioid taper is associated with subsequent termination of care. These findings invite caution and demonstrate the need to fully understand the risks and benefits of opioid tapers.
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Affiliation(s)
- Hector R Perez
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Michele Buonora
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Moonseong Heo
- Department of Public Health Sciences, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, SC, USA
| | - Joanna L Starrels
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Edelman EJ, Moore BA, Calabrese SK, Berkenblit G, Cunningham CO, Ogbuagu O, Patel VV, Phillips KA, Tetrault JM, Shah M, Blackstock O. Preferences for implementation of HIV pre-exposure prophylaxis (PrEP): Results from a survey of primary care providers. Prev Med Rep 2019; 17:101012. [PMID: 31890474 PMCID: PMC6926349 DOI: 10.1016/j.pmedr.2019.101012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 08/15/2019] [Accepted: 10/20/2019] [Indexed: 12/11/2022] Open
Abstract
PrEP implementation in primary care has been slow. Primary care providers equally favor training all vs. having a PrEP specialist. Efforts to promote knowledge of clinical guidelines may enhance PrEP implementation.
Primary care physicians (PCPs) are critical for promoting HIV prevention by prescribing pre-exposure prophylaxis (PrEP). Yet, there are limited data regarding PCP’s preferred approaches for PrEP implementation. In 2015, we conducted an online survey of PCPs’ PrEP prescribing and implementation. Participants were general internists recruited from a national professional organization. We examined provider and practice characteristics and perceived implementation barriers and facilitators associated with preferred models for PrEP implementation. Among 240 participants, the majority (85%) favored integrating PrEP into primary care, either by training all providers (“all trained”) (42%) or having an onsite PrEP specialist (“on-site specialist”) (43%). Only 15% preferred referring patients out of the practice to a specialist (“refer out”). Compared to those who preferred to “refer out,” participants who preferred the “all trained” model were more likely to spend most of their time delivering direct patient care and to practice in the Northeast. Compared to participants who preferred the “refer out” or on-site specialist” models, PCPs preferring the all trained model were less likely to perceive lack of clinic PrEP guidelines/protocols as a barrier to PrEP. Most PCPs favored integrating PrEP into primary care by either training all providers or having an on-site specialist. Time devoted to clinical care and geography may influence preferences for PrEP implementation. Establishing clinic-specific PrEP protocols may promote on-site PrEP implementation. Future studies should focus on evaluating the effectiveness of different PrEP implementation models on PrEP delivery.
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Affiliation(s)
- E. Jennifer Edelman
- Yale, New Haven, CT, United States
- Corresponding author at: Yale University, School of Medicine and Public Health, 367 Cedar Street, E.S. Harkness Memorial Hall, Building A, Suite 401, New Haven, CT 06510 203.737.7115, United States.
| | | | - Sarah K. Calabrese
- Yale, New Haven, CT, United States
- George Washington University, Washington, DC, United States
| | | | - Chinazo O. Cunningham
- Albert Einstein College of Medicine, Montefiore Health System, Bronx, NY, United States
| | | | - Viraj V. Patel
- Albert Einstein College of Medicine, Montefiore Health System, Bronx, NY, United States
| | | | | | | | - Oni Blackstock
- Albert Einstein College of Medicine, Montefiore Health System, Bronx, NY, United States
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Ross J, Akiyama MJ, Slawek D, Stella J, Nichols K, Bekele M, Cunningham CO, Blackstock OJ. Undocumented African Immigrants' Experiences of HIV Testing and Linkage to Care. AIDS Patient Care STDS 2019; 33:336-341. [PMID: 31194578 DOI: 10.1089/apc.2019.0036] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
In the United States, undocumented African immigrants living with HIV enter care late, potentially leading to adverse individual and population health outcomes, yet little is known about the specific experiences of HIV diagnosis and linkage to care among this population. We conducted individual, semi-structured interviews with adults who were undocumented African immigrants living with HIV in New York City. Interviews explored perspectives regarding individual, social, institutional, and societal barriers and facilitators of HIV testing and linkage to care. Of 14 participants from 9 different African countries, 9 were women and the median age was 44 years (interquartile range: 42-50). Participants described fear of discovery by immigration authorities as a substantial barrier to HIV testing and linking to initial medical appointments. Actual and perceived structural barriers to both testing and care linkage included difficulty obtaining health insurance and a belief that undocumented immigrants are ineligible for any health services. Participants also expressed reluctance to be tested because of HIV-related stigma within the immigrant communities that they heavily relied on. After diagnosis, however, participants overwhelmingly described a positive role of health and social service providers in facilitating linkage to HIV care. Concerns about immigration status and HIV-related stigma are significant barriers to HIV testing and linkage to care among undocumented African immigrants. Multilevel efforts to reduce stigma and increase awareness of available services could enhance rates of HIV testing and care linkage in this population.
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Affiliation(s)
- Jonathan Ross
- Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Matthew J. Akiyama
- Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Deepika Slawek
- Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Jennifer Stella
- Division of Hospital Medicine, Zuckerberg San Francisco General/University of California, San Francisco, San Francisco, California
| | - Kim Nichols
- African Services Committee, New York, New York
| | | | - Chinazo O. Cunningham
- Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Oni J. Blackstock
- New York City Department of Health and Mental Hygiene, New York, New York
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Kladney M, Joudrey P, Cunningham CO, Bachhuber MA. Pharmacotherapy Prescribing to Patients with Concurrent Tobacco and Alcohol Use Disorder in a Large, Urban, Integrated Health System. J Gen Intern Med 2019; 34:804-805. [PMID: 30604121 PMCID: PMC6544704 DOI: 10.1007/s11606-018-4806-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Mat Kladney
- Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA. .,Division of General Internal Medicine and Clinical Innovation, New York University - Bellevue Hospital, New York, NY, USA.
| | - Paul Joudrey
- VA Connecticut Healthcare System, West Haven Campus, West Haven, CT, USA.,National Clinician Scholars Program, Yale School of Medicine, New Haven, CT, USA
| | - Chinazo O Cunningham
- Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Marcus A Bachhuber
- Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA
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Felsen UR, Torian LV, Futterman DC, Stafford S, Xia Q, Allan D, Esses D, Cunningham CO, Weiss JM, Zingman BS. An expanded HIV screening strategy in the Emergency Department fails to identify most patients with undiagnosed infection: insights from a blinded serosurvey. AIDS Care 2019; 32:202-208. [PMID: 31146539 DOI: 10.1080/09540121.2019.1619663] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Screening for HIV in Emergency Departments (EDs) is recommended to address the problem of undiagnosed HIV. Serosurveys are an important method for estimating the prevalence of undiagnosed HIV and can provide insight into the effectiveness of an HIV screening strategy. We performed a blinded serosurvey in an ED offering non-targeted HIV screening to determine the proportion of patients with undiagnosed HIV who were diagnosed during their visit. The study was conducted in a high-volume, urban ED and included patients who had blood drawn for clinical purposes and had sufficient remnant specimen to undergo deidentified HIV testing. Among 4752 patients not previously diagnosed with HIV, 1403 (29.5%) were offered HIV screening and 543 (38.7% of those offered) consented. Overall, undiagnosed HIV was present in 12 patients (0.25%): six among those offered screening (0.4%), and six among those not offered screening (0.2%). Among those with undiagnosed HIV, two (16.7%) consented to screening and were diagnosed during their visit. Despite efforts to increase HIV screening, more than 80% of patients with undiagnosed HIV were not tested during their ED visit. Although half of those with undiagnosed HIV were missed because they were not offered screening, the yield was further diminished because a substantial proportion of patients declined screening. To avoid missed opportunities for diagnosis in the ED, strategies to further improve implementation of HIV screening and optimize rates of consent are needed.
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Affiliation(s)
- Uriel R Felsen
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Lucia V Torian
- HIV Epidemiology and Field Services Program, New York City Department of Health and Mental Hygiene, New York, NY, USA
| | - Donna C Futterman
- Adolescent AIDS Program, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Stephen Stafford
- Adolescent AIDS Program, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Qiang Xia
- HIV Epidemiology and Field Services Program, New York City Department of Health and Mental Hygiene, New York, NY, USA
| | - David Allan
- Department of Emergency Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - David Esses
- Department of Emergency Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Chinazo O Cunningham
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Jeffrey M Weiss
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Barry S Zingman
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
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45
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Norton BL, Bachhuber MA, Singh R, Agyemang L, Arnsten JH, Cunningham CO, Litwin AH. Evaluation of contingency management as a strategy to improve HCV linkage to care and treatment in persons attending needle and syringe programs: A pilot study. Int J Drug Policy 2019; 69:1-7. [PMID: 31003171 DOI: 10.1016/j.drugpo.2019.02.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 02/13/2019] [Accepted: 02/15/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND A greater proportion of HCV-infected people who inject drugs (PWID) need to be linked to care for HCV antiviral treatment. This study sets out to evaluate the efficacy of contingency management (CM) for improving HCV linkage to care, treatment initiation, adherence, and cure for PWID recruited from a needle and syringe program. METHODS Between March 2015 and April 2016, 20 participants were enrolled into the CM arm, and then subsequently enrolled 20 participants in the enhanced standard of care (eSOC) arm. Participants in the eSOC arm received an expedited appointment and a round-trip transit card. Participants enrolled in the CM arm received eSOC plus $25 for up to ten HCV clinical visits and $10 for each returned weekly medication blister pack. Adherence was measured via electronic blister packs. RESULTS Overall the median age was 47 years; most were men (67%) and Hispanic (69%). There were no significant differences in demographic characteristics between participants in the study arms. In the CM arm 74% were linked to HCV care, compared to 30% in the eSOC arm (p = 0.01). In the CM arm, 75% (9/12) of treatment eligible participants initiated treatment, compared to 100%(4/4) in the eSOC arm (p = 0.53). All patients (9/9) achieved cure in the CM arm, as compared to 75% (3/4) of patients in the eSOC arm. There were no differences in adherence between study arms. CONCLUSIONS In this pilot study, contingency management led to higher rates of HCV linkage to care for PWID, as compared to standard of care. CM should be considered as a possible intervention to improve the HCV treatment cascade for PWID.
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Affiliation(s)
- B L Norton
- Division of General Internal Medicine, Montefiore Medical Center, United States.
| | - M A Bachhuber
- Division of General Internal Medicine, Montefiore Medical Center, United States
| | - R Singh
- New York University, United States
| | - L Agyemang
- Division of General Internal Medicine, Montefiore Medical Center, United States
| | - J H Arnsten
- Division of General Internal Medicine, Montefiore Medical Center, United States
| | - C O Cunningham
- Division of General Internal Medicine, Montefiore Medical Center, United States
| | - A H Litwin
- Division of General Internal Medicine, Montefiore Medical Center, United States.
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Jakubowski A, Pappas A, Isaacsohn L, Castillo F, Masyukova M, Silvera R, Holaday L, Rausch E, Farooq S, Veltri KT, Cunningham CO, Bachhuber MA. Development and evaluation of a pilot overdose education and naloxone distribution program for hospitalized general medical patients. Subst Abus 2018; 40:61-65. [PMID: 30475162 DOI: 10.1080/08897077.2018.1518836] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: Overdose education and naloxone distribution (OEND) to people at risk of witnessing or experiencing an opioid overdose has traditionally been provided through harm reduction agencies. Expanding OEND to inpatient general medical settings may reach at-risk individuals who do not access harm reduction services and have not been trained. An OEND program targeting inpatients was developed, piloted, and evaluated on 2 general medicine floors at Montefiore Medical Center, a large urban academic medical center in Bronx, New York. Methods: The planning committee consisted of 10 resident physicians and 2 faculty mentors. A consult service model was piloted, whereby the primary inpatient care team paged the consult team (consisting of rotating members from the planning committee) for any newly admitted patient who had used any opioid in the year prior to admission. Consult team members assessed patients for eligibility and provided OEND to eligible patients through a short video training. Upon completion, patients received a take-home naloxone kit. To evaluate the program, a retrospective chart review over the first year (April 2016 to March 2017) of the pilot was conducted. Results: Overall, consults on 80 patients were received. Of these, 74 were eligible and the consult team successfully trained 50 (68%). Current opioid analgesic use of ≥50 morphine milligram equivalents daily was the most common eligibility criterion met (38%). Twenty-four percent of patients were admitted for an opioid-related adverse event, the most common being opioid overdose (9%), then opioid withdrawal (8%), skin complication related to injecting (5%), and opioid intoxication (2%). Twenty-five percent had experienced an overdose, 35% had witnessed an overdose in their lifetime, and 83% had never received OEND previously. Conclusions: Integrating OEND into general inpatient medical care is possible and can reach high-risk patients who have not received OEND previously. Future research should identify the optimal way of implementing this service.
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Affiliation(s)
- Andrea Jakubowski
- a Division of General Internal Medicine, Department of Medicine , Montefiore Medical Center/Albert Einstein College of Medicine , Bronx , New York , USA.,b Department of Family and Social Medicine , Montefiore Medical Center/Albert Einstein College of Medicine , Bronx , New York , USA
| | - Alexander Pappas
- b Department of Family and Social Medicine , Montefiore Medical Center/Albert Einstein College of Medicine , Bronx , New York , USA
| | - Lee Isaacsohn
- b Department of Family and Social Medicine , Montefiore Medical Center/Albert Einstein College of Medicine , Bronx , New York , USA
| | - Felipe Castillo
- c Department of Psychiatry , Montefiore Medical Center/Albert Einstein College of Medicine , Bronx , New York , USA
| | - Mariya Masyukova
- b Department of Family and Social Medicine , Montefiore Medical Center/Albert Einstein College of Medicine , Bronx , New York , USA
| | - Richard Silvera
- a Division of General Internal Medicine, Department of Medicine , Montefiore Medical Center/Albert Einstein College of Medicine , Bronx , New York , USA.,b Department of Family and Social Medicine , Montefiore Medical Center/Albert Einstein College of Medicine , Bronx , New York , USA
| | - Louisa Holaday
- a Division of General Internal Medicine, Department of Medicine , Montefiore Medical Center/Albert Einstein College of Medicine , Bronx , New York , USA.,b Department of Family and Social Medicine , Montefiore Medical Center/Albert Einstein College of Medicine , Bronx , New York , USA
| | - Evan Rausch
- a Division of General Internal Medicine, Department of Medicine , Montefiore Medical Center/Albert Einstein College of Medicine , Bronx , New York , USA.,b Department of Family and Social Medicine , Montefiore Medical Center/Albert Einstein College of Medicine , Bronx , New York , USA
| | - Sameen Farooq
- a Division of General Internal Medicine, Department of Medicine , Montefiore Medical Center/Albert Einstein College of Medicine , Bronx , New York , USA.,b Department of Family and Social Medicine , Montefiore Medical Center/Albert Einstein College of Medicine , Bronx , New York , USA
| | - Keith T Veltri
- d Department of Pharmacy , Montefiore Medical Center/Albert Einstein College of Medicine , Bronx , New York , USA.,e Department of Pharmacy Practice , Touro College of Pharmacy , New York , New York , USA
| | - Chinazo O Cunningham
- a Division of General Internal Medicine, Department of Medicine , Montefiore Medical Center/Albert Einstein College of Medicine , Bronx , New York , USA
| | - Marcus A Bachhuber
- a Division of General Internal Medicine, Department of Medicine , Montefiore Medical Center/Albert Einstein College of Medicine , Bronx , New York , USA
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Pacek LR, Copeland J, Dierker L, Cunningham CO, Martins SS, Goodwin RD. Among whom is cigarette smoking declining in the United States? The impact of cannabis use status, 2002-2015. Drug Alcohol Depend 2018; 191:355-360. [PMID: 30179761 PMCID: PMC6432910 DOI: 10.1016/j.drugalcdep.2018.01.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 01/29/2018] [Accepted: 01/30/2018] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To 1) estimate changes in the prevalence of daily and non-daily cigarette smoking among current (past 30-day) daily, non-daily, and non-cannabis users in the United States (U.S.) population; 2) examine time trends in current (past 30-day) cigarette smoking in daily, non-daily, and non-cannabis users ages 12+ from 2002 to 2015. METHODS Data collected annually from the 2002 to 2015 National Survey on Drug Use and Health (NSDUH) were employed. Linear time trends of daily and non-daily cigarette smoking were assessed using logistic regression with year as the predictor. RESULTS In 2015, the prevalence of current (past 30-day) cigarette smoking was highest among daily (54.57%), followed by non-daily (40.17%) and non-cannabis users (15.06%). The prevalence of non-daily cigarette smoking increased among daily cannabis users from 2002 to 2015, whereas non-daily cigarette smoking declined among non-daily cannabis users and non-cannabis users from 2002 to 2015. Daily cigarette smoking declined among both cannabis users and non-users; the most rapid decline was observed among daily cannabis users, followed by non-daily and then by non-cannabis users. However, the relative magnitude of the change in prevalence of daily cigarette smoking was similar across the three cannabis groups. CONCLUSIONS Despite ongoing declines in cigarette smoking in the U.S., non-daily cigarette smoking is increasing among current cannabis users, a growing proportion of the U.S. POPULATION Daily and non-daily cigarette smoking continue to decline among those who do not use cannabis. Efforts to further tobacco control should consider novel co-use-oriented intervention strategies and outreach for the increasing population of cannabis users.
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Affiliation(s)
- Lauren R Pacek
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, 27705, USA
| | - Jan Copeland
- National Cannabis Prevention and Information Centre, UNSW Sydney, Sydney, Australia
| | - Lisa Dierker
- Department of Psychology, Wesleyan University, Middletown, CT, 06459, USA
| | - Chinazo O Cunningham
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10461, USA; Department of Family and Social Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10461, USA; Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10461, USA
| | - Silvia S Martins
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, 10032, USA
| | - Renee D Goodwin
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, 10032, USA; Institute for Implementation Science in Population Health, The City University of New York, New York, NY, 10027, USA; Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, The City University of New York, New York, NY, 10027, USA.
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Sohler NL, Starrels JL, Khalid L, Bachhuber MA, Arnsten JH, Nahvi S, Jost J, Cunningham CO. Cannabis Use is Associated with Lower Odds of Prescription Opioid Analgesic Use Among HIV-Infected Individuals with Chronic Pain. Subst Use Misuse 2018; 53:1602-1607. [PMID: 29338578 PMCID: PMC6037547 DOI: 10.1080/10826084.2017.1416408] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Chronic pain is common in the United States and prescribed opioid analgesics use for noncancer pain has increased dramatically in the past two decades, possibly accounting for the current opioid addiction epidemic. Co-morbid drug use in those prescribed opioid analgesics is common, but there are few data on polysubstance use patterns. OBJECTIVE We explored patterns of use of cigarette, alcohol, and illicit drugs in HIV-infected people with chronic pain who were prescribed opioid analgesics. METHODS We conducted a secondary data analysis of screening interviews conducted as part of a parent randomized trial of financial incentives to improve HIV outcomes among drug users. In a convenience sample of people with HIV and chronic pain, we collected self-report data on demographic characteristics; pain; patterns of opioid analgesic use (both prescribed and illicit); cigarette, alcohol, and illicit drug use (including cannabis, heroin, and cocaine) within the past 30 days; and current treatment for drug use and HIV. RESULTS Almost half of the sample of people with HIV and chronic pain reported current prescribed opioid analgesic use (N = 372, 47.1%). Illicit drug use was common (N = 505, 63.9%), and cannabis was the most commonly used illicit substance (N = 311, 39.4%). In multivariate analyses, only cannabis use was significantly associated with lower odds of prescribed opioid analgesic use (adjusted odds ratio = 0.57; 95% confidence interval: 0.38-0.87). Conclusions/Importance: Our data suggest that new medical cannabis legislation might reduce the need for opioid analgesics for pain management, which could help to address adverse events associated with opioid analgesic use.
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Affiliation(s)
- Nancy L Sohler
- a City University of New York, School of Medicine , New York City , NY , USA
| | - Joanna L Starrels
- b Albert Einstein College of Medicine , Bronx , New York , USA.,c Montefiore Medical Center , Bronx , New York , USA
| | - Laila Khalid
- b Albert Einstein College of Medicine , Bronx , New York , USA.,c Montefiore Medical Center , Bronx , New York , USA
| | - Marcus A Bachhuber
- b Albert Einstein College of Medicine , Bronx , New York , USA.,c Montefiore Medical Center , Bronx , New York , USA
| | - Julia H Arnsten
- b Albert Einstein College of Medicine , Bronx , New York , USA.,c Montefiore Medical Center , Bronx , New York , USA
| | - Shadi Nahvi
- b Albert Einstein College of Medicine , Bronx , New York , USA.,c Montefiore Medical Center , Bronx , New York , USA
| | - John Jost
- b Albert Einstein College of Medicine , Bronx , New York , USA.,c Montefiore Medical Center , Bronx , New York , USA
| | - Chinazo O Cunningham
- b Albert Einstein College of Medicine , Bronx , New York , USA.,c Montefiore Medical Center , Bronx , New York , USA
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Bachhuber MA, Nash D, Southern WN, Heo M, Berger M, Schepis M, Cunningham CO. Reducing the default dispense quantity for new opioid analgesic prescriptions: study protocol for a cluster randomised controlled trial. BMJ Open 2018; 8:e019559. [PMID: 29678969 PMCID: PMC5914704 DOI: 10.1136/bmjopen-2017-019559] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION As opioid analgesic consumption has grown, so have opioid use disorder and opioid-related overdoses. Reducing the quantity of opioid analgesics prescribed for acute non-cancer pain can potentially reduce risks to the individual receiving the prescription and to others who might unintentionally or intentionally consume any leftover tablets. Reducing the default dispense quantity for new opioid analgesic prescriptions in the electronic health record (EHR) is a promising intervention to reduce prescribing. METHODS AND ANALYSIS This study is a prospective cluster randomised controlled trial with two parallel arms. Primary care sites (n=32) and emergency departments (n=4) will be randomised in matched pairs to either a modification of the EHR so that new opioid analgesic prescriptions default to a dispense quantity of 10 tablets (intervention) or to no EHR change (control). The dispense quantity will remain fully modifiable by providers in both arms. From 6 months preintervention to 18 months postintervention, patient-level data will be analysed (ie, the patient is the unit of inference). Patient eligibility criteria are: (A) received a new opioid analgesic prescription, defined as no other opioid analgesic prescription in the prior 6 months; (B) age ≥18 years; and (C) no cancer diagnosis within 1 year prior to the new opioid analgesic prescription. The primary outcome will be the quantity of opioid analgesics prescribed in the initial prescription. Secondary outcomes will include opioid analgesic reorders and health service utilisation within 30 days after the initial prescription. Outcomes will be compared between study arms using a difference-in-differences analysis. ETHICS AND DISSEMINATION This study has been approved by the Montefiore Medical Center/Albert Einstein College of Medicine Institutional Review Board with a waiver of informed consent (2016-6036) and is registered on ClinicalTrials.gov (NCT03003832, 6 December 2016). Findings will be disseminated through publication, conferences and meetings with health system leaders. TRIAL REGISTRATION NUMBER NCT03003832; Pre-results.
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Affiliation(s)
- Marcus A Bachhuber
- Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, New York City, New York, USA
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York (CUNY), New York City, New York, USA
- Department of Epidemiology and Biostatistics, School of Public Health, City University of New York (CUNY), New York City, New York, USA
| | - William N Southern
- Division of Hospital Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, New York City, New York, USA
| | - Moonseong Heo
- Department of Epidemiology and Population Health, Montefiore Medical Center/Albert Einstein College of Medicine, New York City, New York, USA
| | - Matthew Berger
- Division of Hospital Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, New York City, New York, USA
- Montefiore Information Technology, Montefiore Medical Center, New York City, New York, USA
| | - Mark Schepis
- Montefiore Information Technology, Montefiore Medical Center, New York City, New York, USA
| | - Chinazo O Cunningham
- Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, New York City, New York, USA
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Cunningham CO. Opioids and HIV Infection: From Pain Management to Addiction Treatment. Top Antivir Med 2018; 25:143-146. [PMID: 29689538 PMCID: PMC5935219] [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] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
HIV-infected persons are more likely to have chronic pain, receive opioid analgesic treatment, receive higher doses of opioids, and to have substance use disorders and mental illness compared with the general population, putting them at increased risk for opioid use disorder. Management of opioid use in HIV-infected individuals can be complex, and the limited data on opioid treatment in this population are conflicting with regard to its effect on HIV outcomes. Buprenorphine treatment for opioid use disorder improves HIV outcomes and other outcomes. This article summarizes a presentation by Chinazo O. Cunningham, MD, MS at the IAS-USA continuing education program, Improving the Management of HIV Disease, held in Atlanta, Georgia, in March 2017.
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