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Ma J, Luu B, Ruderman SA, Whitney BM, Merrill JO, Mixson LS, Nance RM, Drumright LN, Hahn AW, Fredericksen RJ, Chander G, Lau B, McCaul ME, Safren S, O'Cleirigh C, Cropsey K, Mayer KH, Mathews WC, Moore RD, Napravnik S, Christopoulos K, Willig A, Jacobson JM, Webel A, Burkholder G, Mugavero MJ, Saag MS, Kitahata MM, Crane HM, Delaney JAC. Alcohol and drug use severity are independently associated with antiretroviral adherence in the current treatment era. AIDS Care 2024; 36:618-630. [PMID: 37419138 PMCID: PMC10771542 DOI: 10.1080/09540121.2023.2223899] [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: 09/13/2021] [Accepted: 06/05/2023] [Indexed: 07/09/2023]
Abstract
Substance use in people with HIV (PWH) negatively impacts antiretroviral therapy (ART) adherence. However, less is known about this in the current treatment era and the impact of specific substances or severity of substance use. We examined the associations of alcohol, marijuana, and illicit drug use (methamphetamine/crystal, cocaine/crack, illicit opioids/heroin) and their severity of use with adherence using multivariable linear regression in adult PWH in care between 2016 and 2020 at 8 sites across the US. PWH completed assessments of alcohol use severity (AUDIT-C), drug use severity (modified ASSIST), and ART adherence (visual analogue scale). Among 9400 PWH, 16% reported current hazardous alcohol use, 31% current marijuana use, and 15% current use of ≥1 illicit drugs. In multivariable analysis, current methamphetamine/crystal use, particularly common among men who had sex with men, was associated with 10.1% lower mean ART adherence (p < 0.001) and 2.6% lower adherence per 5-point higher severity of use (ASSIST score) (p < 0.001). Current and more severe use of alcohol, marijuana, and other illicit drugs were also associated with lower adherence in a dose-dependent manner. In the current HIV treatment era, individualized substance use treatment, especially for methamphetamine/crystal, and ART adherence should be prioritized.
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Affiliation(s)
- J Ma
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - B Luu
- Department of Medicine, University of Toronto, Toronto, Canada
| | - S A Ruderman
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - B M Whitney
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - J O Merrill
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - L S Mixson
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - R M Nance
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - L N Drumright
- Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, WA, USA
| | - A W Hahn
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - R J Fredericksen
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - G Chander
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - B Lau
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - M E McCaul
- Department of Psychiatry, Johns Hopkins University, Baltimore, MD, USA
| | - S Safren
- Department of Psychology, University of Miami, Miami, FL, USA
| | - C O'Cleirigh
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychology, Harvard Medical School, Boston, MA, USA
| | - K Cropsey
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - K H Mayer
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- The Fenway Institute, Boston, MA, USA
| | - W C Mathews
- Department of Medicine, University of California, San Diego, CA, USA
| | - R D Moore
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - S Napravnik
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA
| | - K Christopoulos
- Department of Medicine, University of California, San Francisco, CA, USA
| | - A Willig
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J M Jacobson
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - A Webel
- Department of Child, Family, and Population Health Nursing, Unviersity of Washington, Seattle, WA, USA
| | - G Burkholder
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - M J Mugavero
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - M S Saag
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - M M Kitahata
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - H M Crane
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - J A C Delaney
- Department of Medicine, University of Washington, Seattle, WA, USA
- College of Pharmacy, University of Manitoba, Winnipeg, Canada
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Fredericksen RJ, Baker R, Sibley A, Estadt AT, Colston D, Mixson LS, Walters S, Bresett J, Levander XA, Leichtling G, Davy-Mendez T, Powell M, Stopka TJ, Pho M, Feinberg J, Ezell J, Zule W, Seal D, Cooper HLF, Whitney BM, Delaney JAC, Crane HM, Tsui JI. Motivation and context of concurrent stimulant and opioid use among persons who use drugs in the rural United States: a multi-site qualitative inquiry. Harm Reduct J 2024; 21:74. [PMID: 38561753 PMCID: PMC10985853 DOI: 10.1186/s12954-024-00986-z] [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: 06/09/2023] [Accepted: 03/12/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND In recent years, stimulant use has increased among persons who use opioids in the rural U.S., leading to high rates of overdose and death. We sought to understand motivations and contexts for stimulant use among persons who use opioids in a large, geographically diverse sample of persons who use drugs (PWUD) in the rural settings. METHODS We conducted semi-structured individual interviews with PWUD at 8 U.S. sites spanning 10 states and 65 counties. Content areas included general substance use, injection drug use, changes in drug use, and harm reduction practices. We used an iterative open-coding process to comprehensively itemize and categorize content shared by participants related to concurrent use. RESULTS We interviewed 349 PWUD (64% male, mean age 36). Of those discussing current use of stimulants in the context of opioid use (n = 137, 39%), the stimulant most used was methamphetamine (78%) followed by cocaine/crack (26%). Motivations for co-use included: 1) change in drug markets and cost considerations; 2) recreational goals, e.g., seeking stronger effects after heightened opioid tolerance; 3) practical goals, such as a desire to balance or alleviate the effects of the other drug, including the use of stimulants to avoid/reverse opioid overdose, and/or control symptoms of opioid withdrawal; and 4) functional goals, such as being simultaneously energized and pain-free in order to remain productive for employment. CONCLUSION In a rural U.S. cohort of PWUD, use of both stimulants and opioids was highly prevalent. Reasons for dual use found in the rural context compared to urban studies included changes in drug availability, functional/productivity goals, and the use of methamphetamine to offset opioid overdose. Education efforts and harm reduction services and treatment, such as access to naloxone, fentanyl test strips, and accessible drug treatment for combined opioid and stimulant use, are urgently needed in the rural U.S. to reduce overdose and other adverse outcomes.
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Affiliation(s)
| | - R Baker
- Oregon Health & Science University, Portland, USA
| | - A Sibley
- University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - A T Estadt
- The Ohio State University, Colombus, USA
| | - D Colston
- University of North Carolina at Chapel Hill, Chapel Hill, USA
| | | | | | - J Bresett
- Southern Illinois University School of Medicine, Springfield, USA
| | - X A Levander
- Oregon Health & Science University, Portland, USA
| | | | - T Davy-Mendez
- University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - M Powell
- University of Washington, Seattle, USA
| | - T J Stopka
- Tufts University School of Medicine, Department of Public Health and Community Medicine, Medford, USA
| | - M Pho
- University of Chicago, Chicago, USA
| | - J Feinberg
- West Virginia University, Morgantown, USA
| | - J Ezell
- Cornell University, Ithaca, USA
| | - W Zule
- University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - D Seal
- Tulane University, New Orleans, USA
| | | | | | | | - H M Crane
- University of Washington, Seattle, USA
| | - J I Tsui
- University of Washington, Seattle, USA
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Stopka TJ, Estadt AT, Leichtling G, Schleicher JC, Mixson LS, Bresett J, Romo E, Dowd P, Walters SM, Young AM, Zule W, Friedmann PD, Go VF, Baker R, Fredericksen RJ. Barriers to opioid use disorder treatment among people who use drugs in the rural United States: A qualitative, multi-site study. Soc Sci Med 2024; 346:116660. [PMID: 38484417 PMCID: PMC10997882 DOI: 10.1016/j.socscimed.2024.116660] [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] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 11/26/2023] [Accepted: 02/05/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND In 2020, 2.8 million people required substance use disorder (SUD) treatment in nonmetropolitan or 'rural' areas in the U.S. Among this population, only 10% received SUD treatment from a specialty facility, and 1 in 500 received medication for opioid use disorder (MOUD). We explored the context surrounding barriers to SUD treatment in the rural United States. METHODS We conducted semi-structured, in-depth interviews from 2018 to 2019 to assess barriers to SUD treatment among people who use drugs (PWUD) across seven rural U.S. study sites. Using the social-ecological model (SEM), we examined individual, interpersonal, organizational, community, and policy factors contributing to perceived barriers to SUD treatment. We employed deductive and inductive coding and analytical approaches to identify themes. We also calculated descriptive statistics for participant characteristics and salient themes. RESULTS Among 304 participants (55% male, mean age 36 years), we identified barriers to SUD treatment in rural areas across SEM levels. At the individual/interpersonal level, relevant themes included: fear of withdrawal, the need to "get things in order" before entering treatment, close-knit communities and limited confidentiality, networks and settings that perpetuated drug use, and stigma. Organizational-level barriers included: strict facility rules, treatment programs managed like corrections facilities, lack of gender-specific treatment programs, and concerns about jeopardizing employment. Community-level barriers included: limited availability of treatment in local rural communities, long distances and limited transportation, waitlists, and a lack of information about treatment options. Policy-level themes included insurance challenges and system-imposed barriers such as arrest and incarceration. CONCLUSION Our findings highlight multi-level barriers to SUD treatment in rural U.S. communities. Salient barriers included the need to travel long distances to treatment, challenges to confidentiality due to small, close-knit communities where people are highly familiar with one another, and high-threshold treatment program practices. Our findings point to the need to facilitate the elimination of treatment barriers at each level of the SEM in rural America.
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Affiliation(s)
- T J Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA.
| | - A T Estadt
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA
| | | | - J C Schleicher
- University of Wisconsin-Madison, School of Medicine and Public Health, Department of Medicine, Madison, WI, USA
| | - L S Mixson
- University of Washington, Department of Medicine, Seattle, WA, USA
| | - J Bresett
- Southern Illinois University at Carbondale, Dept of Public Health, Carbondale, IL, USA
| | - E Romo
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - P Dowd
- Chan Medical School-Baystate, University of Massachusetts, Springfield, MA, USA
| | - S M Walters
- New York University's Grossman School of Medicine, New York, NY, USA
| | - A M Young
- College of Public Health, University of Kentucky, Lexington, KY, USA
| | - W Zule
- RTI International, Research Triangle, NC, USA
| | - P D Friedmann
- Chan Medical School-Baystate, University of Massachusetts, Springfield, MA, USA
| | - V F Go
- University, of North Carolina, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - R Baker
- Oregon Health & Science University-Portland State University School of Public Health, Portland, OR, USA
| | - R J Fredericksen
- University of Washington, Department of Medicine, Seattle, WA, USA
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Crane HM, Nance RM, Ruderman SA, Haidar L, Tenforde MW, Heckbert SR, Budoff MJ, Hahn AW, Drumright LN, Ma J, Mixson LS, Lober WB, Barnes GS, McReynolds J, Attia EF, Peter I, Moges T, Bamford L, Cachay E, Mathews WC, Christopolous K, Hunt PW, Napravnik S, Keruly J, Moore RD, Burkholder G, Willig AL, Lindstrom S, Whitney BM, Saag MS, Kitahata MM, Crothers KA, Delaney JAC. Venous Thromboembolism Among People With HIV: Design, Implementation, and Findings of a Centralized Adjudication System in Clinical Care Sites Across the United States. J Acquir Immune Defic Syndr 2024; 95:207-214. [PMID: 37988634 DOI: 10.1097/qai.0000000000003339] [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] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 08/30/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND People with HIV (PWH) are at increased risk for venous thromboembolism (VTE). We conducted this study to characterize VTE including provoking factors among PWH in the current treatment era. METHODS We included PWH with VTE between 2010 and 2020 at 6 sites in the CFAR Network of Integrated Clinical Systems cohort. We ascertained for possible VTE using diagnosis, VTE-related imaging, and VTE-related procedure codes, followed by centralized adjudication of primary data by expert physician reviewers. We evaluated sensitivity and positive predictive value of VTE ascertainment approaches. VTEs were classified by type and anatomic location. Reviewers identified provoking factors such as hospitalizations, infections, and other potential predisposing factors such as smoking. RESULTS We identified 557 PWH with adjudicated VTE: 239 (43%) had pulmonary embolism with or without deep venous thrombosis, and 318 (57%) had deep venous thrombosis alone. Ascertainment with clinical diagnoses alone missed 6% of VTEs identified with multiple ascertainment approaches. DVTs not associated with intravenous lines were most often in the proximal lower extremities. Among PWH with VTE, common provoking factors included recent hospitalization (n = 134, 42%), infection (n = 133, 42%), and immobilization/bed rest (n = 78, 25%). Only 57 (10%) PWH had no provoking factor identified. Smoking (46%), HIV viremia (27%), and injection drug use (22%) were also common. CONCLUSIONS We conducted a robust adjudication process that demonstrated the benefits of multiple ascertainment approaches followed by adjudication. Provoked VTEs were more common than unprovoked events. Nontraditional and modifiable potential predisposing factors such as viremia and smoking were common.
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Affiliation(s)
- Heidi M Crane
- Department of Medicine, University of Washington, Seattle, WA
| | - Robin M Nance
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Lara Haidar
- Department of Pharmacy, University of Manitoba, Manitoba, CA
| | - Mark W Tenforde
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Matthew J Budoff
- Department of Medicine, Lundquist Institute at Harbor-UCLA, Torrance, CA
| | - Andrew W Hahn
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Jimmy Ma
- Department of Medicine, University of Washington, Seattle, WA
| | - L S Mixson
- Department of Medicine, University of Washington, Seattle, WA
| | - William B Lober
- Department of Medicine and Clinical Informatics Research Group, University of Washington, Seattle, WA
| | - Gregory S Barnes
- Clinical Informatics Research Group, University of Washington, Seattle, WA
| | - Justin McReynolds
- Clinical Informatics Research Group, University of Washington, Seattle, WA
| | - Engi F Attia
- Department of Medicine, University of Washington, Seattle, WA
| | - Inga Peter
- Department of Genetics, Mount Sinai University, New York NY
| | - Tesfaye Moges
- Department of Medicine, University of California, San Diego, CA
| | - Laura Bamford
- Department of Medicine, University of California, San Diego, CA
| | - Edward Cachay
- Department of Medicine, University of California, San Diego, CA
| | | | | | - Peter W Hunt
- Department of Medicine, University of California, San Francisco, CA
| | - Sonia Napravnik
- Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Jeanne Keruly
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Richard D Moore
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Greer Burkholder
- Department of Medicine, University of Alabama Birmingham, Birmingham, AL
| | - Amanda L Willig
- Department of Medicine, University of Alabama Birmingham, Birmingham, AL
| | - Sara Lindstrom
- Department of Genetics, University of Washington, Seattle, WA; and
| | | | - Michael S Saag
- Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Mari M Kitahata
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Joseph A C Delaney
- Department of Medicine, University of Washington, Seattle, WA
- Department of Medicine, University of Manitoba, Manitoba, CA
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