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Babiarz J, Ryu H, Williams C, Ham Y, Rivera Sarti J, Levander XA. Slicing through silos: Development and evaluation of a hospital-based telehealth hepatitis C virus treatment program. Int J Drug Policy 2024; 127:104396. [PMID: 38593518 DOI: 10.1016/j.drugpo.2024.104396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 03/12/2024] [Accepted: 03/14/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND There exist many barriers to hepatitis C virus (HCV) treatment for those with substance use disorder (SUD) or who lack access to routine medical care. A hospital-based telehealth program was developed to provide treatment opportunities for hospitalized patients living with HCV. METHODS This single site prospective cohort study conducted from July 2022 to March 2023 aimed to measure linkage to care with an HCV clinician and initiation of HCV treatment in hospitalized patients. Patients were assessed in-person by a social worker then seen via telehealth by a clinician who prescribed either glecaprevir/pibrentasvir or sofosbuvir/velpatasvir. Treatment was initiated with pharmacist assistance. The team conducted in-person and/or telephonic outreach during and after hospitalization. Cure was confirmed by sustained virologic response at 12 weeks (SVR12) post-treatment. RESULTS A total of 25 patients were enrolled and completed telehealth visits. All patients had a history of SUD and 18 (72 %) were unstably housed. Nineteen patients (76 %) initiated treatment, and 14 (56 %) successfully completed treatment. Twelve patients (48 %) completed post-treatment labs, including two who prematurely discontinued treatment. Eleven patients (44 %) achieved confirmed cure with SVR12. CONCLUSION A hospital-based, multidisciplinary telehealth program can be an innovative care model to successfully treat HCV in a difficult-to-treat patient populations.
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Affiliation(s)
- J Babiarz
- Department of Medicine, Division of Internal Medicine and Geriatrics, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239 United States
| | - H Ryu
- Department of Pharmacy, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239 United States
| | - C Williams
- Department of Care Management, Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239 United States
| | - Y Ham
- Department of Pharmacy, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239 United States
| | - J Rivera Sarti
- Department of Medicine, Division of Infectious Disease, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239 United States
| | - X A Levander
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Section of Addiction Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239 United States
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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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Levander XA, VanDerSchaaf H, Barragán VG, Choxi H, Hoffman A, Morgan E, Wong E, Wusirika R, Cheng A. The Role of Human-Centered Design in Healthcare Innovation: a Digital Health Equity Case Study. J Gen Intern Med 2024; 39:690-695. [PMID: 37973709 DOI: 10.1007/s11606-023-08500-0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 10/20/2023] [Indexed: 11/19/2023]
Abstract
Healthcare delivery has become more complicated, particularly with the addition of digital tools and advanced technologies that can further exacerbate existing disparities. New approaches to solve complex, multi-faceted problems are needed. Human-centered design (HCD), also known as design thinking, is an innovative set of methods to develop solutions to these types of issues using collaborative, team-based, and empathetic approaches focused on end user experiences. Originally advanced in technology sectors, HCD has garnered growing attention in quality improvement, healthcare redesign, and public health and medical education. During the COVID-19 pandemic, our healthcare organization recognized notable differences in utilization of virtual (video-based) services among specific patient populations. In response, we mobilized, and using HCD, we collectively brainstormed ideas, rapidly developed prototypes, and iteratively adapted solutions to work toward addressing this digital divide and clinic and systems-level struggles with improving and maintaining digital health access. HCD approaches create a cohesive team-based structure that permits the dismantling of organizational hierarchies and departmental silos. Here we share lessons learned on implementing HCD into clinical care settings and how HCD can result in the development of site-specific, patient-centered innovations to address access disparities and to improve digital health equity.
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Affiliation(s)
- Ximena A Levander
- Department of Medicine, Division of General Internal Medicine & Geriatrics, Oregon Health & Science University, Portland, OR, USA.
| | - Hans VanDerSchaaf
- Office of Digital Health, Oregon Health & Science University, Portland, OR, USA
| | - Vanessa Guerrero Barragán
- Office of Digital Health, Oregon Health & Science University, Portland, OR, USA
- Digital Strategy, Oregon Health & Science University, Portland, OR, USA
| | - Hetal Choxi
- Department of Family Medicine, Division of Center for Women's Health, Oregon Health & Science University, Portland, OR, USA
| | - Amber Hoffman
- Office of Digital Health, Oregon Health & Science University, Portland, OR, USA
| | - Emily Morgan
- Department of Medicine, Division of General Internal Medicine & Geriatrics, Oregon Health & Science University, Portland, OR, USA
| | - Eva Wong
- Office of Digital Health, Oregon Health & Science University, Portland, OR, USA
| | - Raghav Wusirika
- Department of Medicine, Division of Nephrology & Hypertension, Oregon Health & Science University, Portland, OR, USA
| | - Anthony Cheng
- Office of Digital Health, Oregon Health & Science University, Portland, OR, USA
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
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Wyte-Lake T, Cohen DJ, Williams S, Casey D, Chan M, Frank B, Levander XA, Stein D, White KK, Bailey SR. Patients' and Clinicians' Experiences with In-person, Video, and Phone Modalities for Opioid Use Disorder Treatment: A Qualitative Study. J Gen Intern Med 2024:10.1007/s11606-023-08586-6. [PMID: 38228990 DOI: 10.1007/s11606-023-08586-6] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 12/22/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND Opioid use disorder (OUD) is a chronic condition that requires regular visits and care continuity. Telehealth implementation has created multiple visit modalities for OUD care. There is limited knowledge of patients' and clinicians' perceptions and experiences related to multi-modality care and when different modalities might be best employed. OBJECTIVE To identify patients' and clinicians' experiences with multiple visit modalities for OUD treatment in primary care. DESIGN Comparative case study, using video- and telephone-based semi-structured interviews. PARTICIPANTS Patients being treated for OUD (n = 19) and clinicians who provided OUD care (n = 15) from two primary care clinics within the same healthcare system. APPROACH Using an inductive approach, interviews were analyzed to identify patients' and clinicians' experiences with receiving/delivering OUD care via different visit modalities. Clinicians' and patients' experiences were compared using a group analytical process. KEY RESULTS Patients and clinicians valued having multiple modalities available for care, with flexibility identified as a key benefit. Patients highlighted the decreased burden of travel and less social anxiety with telehealth visits. Similarly, clinicians reported that telehealth decreased medical intrusion into the lives of patients stable in recovery. Patients and clinicians saw the value of in-person visits when establishing care and for patients needing additional support. In-person visits allowed the ability to conduct urine drug testing, and to foster relationships and trust building, which were more difficult, but not impossible via a telehealth visit. Patients preferred telephone over video visits, as these were more private and more convenient. Clinicians identified benefits of video, including being able to both hear and see the patient, but often deferred to patient preference. CONCLUSIONS Considerations for utilization of visit modalities for OUD care were identified based on patients' needs and preferences, which often changed over the course of treatment. Continued research is needed determine how visit modalities impact patient outcomes.
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Affiliation(s)
- Tamar Wyte-Lake
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Shannon Williams
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - David Casey
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Matt Chan
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Brian Frank
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Ximena A Levander
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Dan Stein
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Katie Kirkman White
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Steffani R Bailey
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
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Rains A, Sibley AL, Levander XA, Walters SM, Nolte K, Colston DC, Piscalko HM, Go VF, Friedmann PD, Seal DW. "I would do anything but that": Attitudes towards sex work among rural people who use drugs. Int J Drug Policy 2023; 122:104237. [PMID: 37865053 PMCID: PMC10842447 DOI: 10.1016/j.drugpo.2023.104237] [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: 06/17/2023] [Revised: 10/15/2023] [Accepted: 10/16/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND Stigma towards people who use drugs and those who engage in sex work is well-documented, leading to consequences such as reduced access to health services and support, especially in rural milieus. Stigma reduction has been recognized as a priority in the opioid overdose crisis, but little attention has been paid to within-group attitudes and beliefs. This study aimed to explore how people who use drugs in rural counties across the United States appraise sex work by themselves or other community members. METHODS Qualitative interview data came from the Rural Opioid Initiative (ROI), a project coordinated by research teams across 65 rural counties in 10 states. Interviews were individual and conducted from 2018 to 2020. All participants reported past 30-day opioid use and/or any injection drug use. A working group coded the data, then used an iterative inductive-deductive approach to organize data into themes of stigma among people who use drugs, focusing on stigma towards sex work. RESULTS Across sites, 355 interviews were conducted. Mean participant age was 36, 55 % of participants were male, and 93 % were white. Participants expressed negative attitudes towards sex work as a function of its criminal-legal repercussions or framed sex work as morally transgressive. Many appraisals were gendered, with the behavior conveyed as being "easier" for women who were often described as "whores," with more neutral terms used to describe men. Some viewed sex work as an implicit "exchange" for drugs. Several participants noted a lack of agency as a feature leading to involvement in sex work, with partner power dynamics influencing an individual's behavior. Finally, a few participants acknowledged the circumstances under which they would newly engage in sex work. CONCLUSION We identified several patterns by which people who use drugs evaluate community members who sell sex. These included gendered and morally-charged forms of stigma, which may represent barriers to community acceptance and support among this subgroup.
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Affiliation(s)
- Alex Rains
- University of Chicago Pritzker School of Medicine, 5841 S. Maryland Avenue, Chicago, IL 60637, USA.
| | - Adams L Sibley
- Department of Health Behavior, UNC Gillings School of Global Public Health, 170 Rosenau Hall CB #7400, 135 Dauer Dr., Chapel Hill, NC 27599, USA
| | - Ximena A Levander
- Division of General Internal Medicine & Geriatrics, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
| | - Suzan M Walters
- Division of Epidemiology, Department of Population Health, NYU Langone Health, 180 Madison, New York, NY 10018, USA
| | - Kerry Nolte
- Department of Nursing, College of Health and Human Services, University of New Hampshire, Hewitt Hall, 4 Library Way, Durham, NH 03824, USA
| | - David C Colston
- Department of Health Behavior, UNC Gillings School of Global Public Health, 170 Rosenau Hall CB #7400, 135 Dauer Dr., Chapel Hill, NC 27599, USA
| | - Hannah M Piscalko
- Division of Epidemiology, The Ohio State University College of Public Health, Cunz Hall 1841 Neil Ave, Columbus, OH 43210, USA
| | - Vivian F Go
- Department of Health Behavior, UNC Gillings School of Global Public Health, 170 Rosenau Hall CB #7400, 135 Dauer Dr., Chapel Hill, NC 27599, USA
| | - Peter D Friedmann
- Baystate Health and UMass Chan Medical School-Baystate, Office of Research, 3601 Main Street, 3rd Floor, Springfield, MA 01199, USA
| | - David W Seal
- Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, Suite 2200, New Orleans, LA 70112, USA
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Button D, Levander XA, Cook RR, Miller WC, Salisbury-Afshar EM, Tsui JI, Ibragimov U, Jenkins WD, Westergaard RP, Korthuis PT. Substance use disorder treatment and technology access among people who use drugs in rural areas of the United States: A cross-sectional survey. J Rural Health 2023; 39:772-779. [PMID: 36575145 PMCID: PMC10293469 DOI: 10.1111/jrh.12737] [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] [Indexed: 12/29/2022]
Abstract
PURPOSE To evaluate how technology access affected substance use disorder (SUD) treatment prior to COVID-19 for people who use drugs in rural areas. METHODS The Rural Opioid Initiative (January 2018-March 2020) was a cross-sectional study of people with prior 30-day injection drug or nonprescribed opioid use from rural areas of 10 states. Using multivariable mixed-effect regression models, we examined associations between participant technology access and SUD treatment. FINDINGS Of 3,026 participants, 71% used heroin and 76% used methamphetamine. Thirty-five percent had no cell phone and 10% had no prior 30-day internet use. Having both a cell phone and the internet was associated with increased days of medication for opioid use disorder (MOUD) use (aIRR 1.29 [95% CI 1.11-1.52]) and a higher likelihood of SUD counseling in the prior 30 days (aOR 1.28 [95% CI 1.05-1.57]). Lack of cell phone was associated with decreased days of MOUD (aIRR 0.77 [95% CI 0.66-0.91]) and a lower likelihood of prior 30-day SUD counseling (aOR 0.77 [95% CI 0.62-0.94]). CONCLUSIONS Expanding US rural SUD treatment engagement via telemedicine may require increased cell phone and mobile network access.
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Affiliation(s)
- Dana Button
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Ximena A. Levander
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Ryan R. Cook
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - William C. Miller
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Elizabeth M. Salisbury-Afshar
- Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Judith I. Tsui
- Division of General Internal Medicine, University of Washington, Seattle, Washington, USA
| | - Umedjon Ibragimov
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Wiley D. Jenkins
- Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Ryan P. Westergaard
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - P. Todd Korthuis
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Levander XA, Carmody T, Cook RR, Potter JS, Trivedi MH, Korthuis PT, Shoptaw S. A gender-based secondary analysis of the ADAPT-2 combination naltrexone and bupropion treatment for methamphetamine use disorder trial. Addiction 2023; 118:1320-1328. [PMID: 36864016 PMCID: PMC10330044 DOI: 10.1111/add.16163] [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: 09/05/2022] [Accepted: 01/20/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND AND AIMS Socio-cultural (gender) and biological (sex)-based differences contribute to psychostimulant susceptibility, potentially affecting treatment responsiveness among women with methamphetamine use disorder (MUD). The aims were to measure (i) how women with MUD independently and compared with men respond to treatment versus placebo and (ii) among women, how the hormonal method of contraception (HMC) affects treatment responsiveness. DESIGN This was a secondary analysis of ADAPT-2, a randomized, double-blind, placebo-controlled, multicenter, two-stage sequential parallel comparison design trial. SETTING United States. PARTICIPANTS This study comprised 126 women (403 total participants); average age = 40.1 years (standard deviation = 9.6) with moderate to severe MUD. INTERVENTIONS Interventions were combination intramuscular naltrexone (380 mg/3 weeks) and oral bupropion (450 mg daily) versus placebo. MEASUREMENTS Treatment response was measured using a minimum of three of four negative methamphetamine urine drug tests during the last 2 weeks of each stage; treatment effect was the difference between weighted treatment responses of each stage. FINDINGS At baseline, women used methamphetamine intravenously fewer days than men [15.4 versus 23.1% days, P = 0.050, difference = -7.7, 95% confidence interval (CI) = -15.0 to -0.3] and more women than men had anxiety (59.5 versus 47.6%, P = 0.027, difference = 11.9%, 95% CI = 1.5 to 22.3%). Of 113 (89.7%) women capable of pregnancy, 31 (27.4%) used HMC. In Stage 1 29% and Stage 2 5.6% of women on treatment had a response compared with 3.2% and 0% on placebo, respectively. A treatment effect was found independently for females and males (P < 0.001); with no between-gender treatment effect (0.144 females versus 0.100 males; P = 0.363, difference = 0.044, 95% CI = -0.050 to 0.137). Treatment effect did not differ by HMC use (0.156 HMC versus 0.128 none; P = 0.769, difference = 0.028, 95% CI -0.157 to 0.212). CONCLUSIONS Women with methamphetamine use disorder receiving combined intramuscular naltrexone and oral bupropion treatment achieve greater treatment response than placebo. Treatment effect does not differ by HMC.
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Affiliation(s)
- Ximena A. Levander
- Oregon Health and Science University, Department of Medicine, Division of General Internal Medicine and Geriatrics, Addiction Medicine Section, Portland, OR, USA
| | - Thomas Carmody
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ryan R. Cook
- Oregon Health and Science University, Department of Medicine, Division of General Internal Medicine and Geriatrics, Addiction Medicine Section, Portland, OR, USA
| | - Jennifer S. Potter
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center San Antonio, San Antonio, TX, USA
| | - Madhukar H. Trivedi
- Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Philip Todd Korthuis
- Oregon Health and Science University, Department of Medicine, Division of General Internal Medicine and Geriatrics, Addiction Medicine Section, Portland, OR, USA
| | - Steven Shoptaw
- Department of Family Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, USA
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Priest KC, Balasanova AA, Levander XA, Chan B, Blazes CK, Mahan J, Brown J, Mahoney S, Peng L, Mahoney S, Lundy T, Englander H. Caring for Hospitalized Adults with Methamphetamine Use Disorder: A Proposed Clinical Roadmap. Am J Med 2023; 136:507-509. [PMID: 36739062 PMCID: PMC10947159 DOI: 10.1016/j.amjmed.2023.01.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 01/04/2023] [Indexed: 02/05/2023]
Affiliation(s)
- Kelsey C Priest
- School of Medicine, MD/PhD Program, Oregon Health & Science University, Portland, OR; Department of Psychiatry, Stanford University School of Medicine, Stanford, CA; Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Alëna A Balasanova
- Department of Psychiatry, University of Nebraska Medical Center, Omaha, NE
| | - Ximena A Levander
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR; IMPACT Team, Oregon Health & Science University, Portland, OR
| | - Brian Chan
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR; IMPACT Team, Oregon Health & Science University, Portland, OR
| | | | - John Mahan
- Jackson County Health and Human Services, Medford, OR
| | - Jessica Brown
- IMPACT Team, Oregon Health & Science University, Portland, OR
| | - Stacey Mahoney
- IMPACT Team, Oregon Health & Science University, Portland, OR; Harmony Academy Recovery High School, Lake Oswego, OR
| | - Linda Peng
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR; IMPACT Team, Oregon Health & Science University, Portland, OR
| | - Sean Mahoney
- IMPACT Team, Oregon Health & Science University, Portland, OR; Mental Health & Addiction Association of Oregon, Portland, OR
| | - Traci Lundy
- IMPACT Team, Oregon Health & Science University, Portland, OR; Mental Health & Addiction Association of Oregon, Portland, OR
| | - Honora Englander
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR; IMPACT Team, Oregon Health & Science University, Portland, OR
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Sibley AL, Baker R, Levander XA, Rains A, Walters SM, Nolte K, Colston DC, Piscalko HM, Schalkoff CA, Bianchet E, Chen S, Dowd P, Jaeb M, Friedmann PD, Fredericksen RJ, Seal DW, Go VF. "I am not a junkie": Social categorization and differentiation among people who use drugs. Int J Drug Policy 2023; 114:103999. [PMID: 36905779 PMCID: PMC10066877 DOI: 10.1016/j.drugpo.2023.103999] [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: 11/18/2022] [Revised: 02/28/2023] [Accepted: 03/01/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Substance use stigma is a form of group-based exclusion, and delineating pathways from stigma to poor health requires a deeper understanding of the social dynamics of people who use drugs (PWUD). Outside of recovery, scant research has examined the role of social identity in addiction. Framed by Social Identity Theory/Self-Categorization Theory, this qualitative study investigated strategies of within-group categorization and differentiation among PWUD and the roles these social categories may play in shaping intragroup attitudes, perceptions, and behaviors. METHODS Data come from the Rural Opioid Initiative, a multi-site study of the overdose epidemic in rural United States. We conducted in-depth interviews with people who reported using opioids or injecting any drug (n=355) living in 65 counties across 10 states. Interviews focused on participants' biographical histories, past and current drug use, risk behaviors, and experiences with healthcare providers and law enforcement. Social categories and dimensions along which categories were evaluated were inductively identified using reflexive thematic analysis. RESULTS We identified seven social categories that were commonly appraised by participants along eight evaluative dimensions. Categories included drug of choice, route of administration, method of attainment, gender, age, genesis of use, and recovery approach. Categories were evaluated by participants based on ascribed characteristics of morality, destructiveness, aversiveness, control, functionality, victimhood, recklessness, and determination. Participants performed nuanced identity work during interviews, including reifying social categories, defining 'addict' prototypicality, reflexively comparing self to other, and disidentifying from the PWUD supra-category. CONCLUSION We identify several facets of identity, both behavioral and demographic, along which people who use drugs perceive salient social boundaries. Beyond an addiction-recovery binary, identity is shaped by multiple aspects of the social self in substance use. Patterns of categorization and differentiation revealed negative intragroup attitudes, including stigma, that may hinder solidary-building and collective action in this marginalized group.
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Affiliation(s)
- Adams L Sibley
- Department of Health Behavior, UNC Gillings School of Global Public Health, 170 Rosenau Hall CB #7400, 135 Dauer Dr., Chapel Hill, NC, 27599, USA.
| | - Robin Baker
- OHSU-PSU School of Public Health, Oregon Health & Science University, 1805 SW 4th Ave, Suite 510, Portland, OR, 97201, USA
| | - Ximena A Levander
- Division of General Internal Medicine & Geriatrics, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Alex Rains
- University of Chicago Pritzker School of Medicine, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA
| | - Suzan M Walters
- Department of Epidemiology, School of Global Public Health, New York University, 708 Broadway, New York, NY 10003, USA
| | - Kerry Nolte
- Department of Nursing, College of Health and Human Services, University of New Hampshire, Hewitt Hall, 4 Library Way, Durham, NH, 03824, USA
| | - David C Colston
- Department of Health Behavior, UNC Gillings School of Global Public Health, 170 Rosenau Hall CB #7400, 135 Dauer Dr., Chapel Hill, NC, 27599, USA
| | - Hannah M Piscalko
- Division of Epidemiology, The Ohio State University College of Public Health, Cunz Hall 1841 Neil Ave, Columbus, OH, 43210, USA
| | - Christine A Schalkoff
- Department of Health Behavior, UNC Gillings School of Global Public Health, 170 Rosenau Hall CB #7400, 135 Dauer Dr., Chapel Hill, NC, 27599, USA
| | - Elyse Bianchet
- Baystate Medical Center, University of Massachusetts, Office of Research, UMass Chan Medical School-Baystate, 3601 Main Street, 3rd Floor, Springfield, MA, 01199, USA
| | - Samuel Chen
- University of Chicago Pritzker School of Medicine, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA
| | - Patrick Dowd
- Baystate Medical Center, University of Massachusetts, Office of Research, UMass Chan Medical School-Baystate, 3601 Main Street, 3rd Floor, Springfield, MA, 01199, USA
| | - Michael Jaeb
- School of Nursing, University of Wisconsin-Madison, 4244 #4 Signe Skott Cooper Hall, 701 Highland Avenue, Madison, WI, 53705, USA
| | - Peter D Friedmann
- Baystate Medical Center, University of Massachusetts, Office of Research, UMass Chan Medical School-Baystate, 3601 Main Street, 3rd Floor, Springfield, MA, 01199, USA
| | - Rob J Fredericksen
- University of Washington Harborview Medical Center, 325 9th Ave, Box 359931, Seattle, WA, 98106, USA
| | - David W Seal
- Tulane University School of Public Health and Tropical Medicine, 1440 Canal Street, Suite 2210, New Orleans, LA, 70112, USA
| | - Vivian F Go
- Department of Health Behavior, UNC Gillings School of Global Public Health, 170 Rosenau Hall CB #7400, 135 Dauer Dr., Chapel Hill, NC, 27599, USA
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Wirth AN, Cushman NA, Reilley BA, Leston JD, Mera JR, Levander XA, Stephens DJ. Evaluation of treatment access and scope of a multistate hepatitis C virus Extension for Community Healthcare Outcomes telehealth service in the US Indian Health System, 2017-2021. J Rural Health 2023; 39:358-366. [PMID: 36526593 PMCID: PMC10038839 DOI: 10.1111/jrh.12733] [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] [Indexed: 12/23/2022]
Abstract
PURPOSE American Indians/Alaska Native (AI/AN) persons are disproportionately affected by hepatitis C virus (HCV). The Northwest Portland Area Indian Health Board Indian Country Extension for Community Healthcare Outcomes (ECHO) telehealth clinic supports primary care providers (PCPs) in treating HCV. We evaluated the extent to which Indian Country ECHO increases access to HCV treatment and holistically serves AI/AN patients. METHODS We conducted a retrospective descriptive analysis of Indian Country ECHO treatment recommendations from 2017 to 2021. Recommendations were classified into the following categories: HCV treatment with direct-acting antiviral medication, prevention, substance use disorder treatment, lab or imaging orders, pharmacological considerations, behavior changes, other, and referral. Subanalysis of treatment recommendations was completed for patients with cirrhosis. FINDINGS Of the 776 patients from 77 Indian Health System facilities who presented at Indian Country ECHO, 718 (93%) received treatment recommendations. Most patients (93%) received recommendations for HCV treatment by their PCP; only 3% received a recommendation for referral to a hepatologist or liver transplant center for additional care. Most patients received at least 1 recommendation beyond the scope of HCV treatment provision. Cirrhosis criteria were met by 8% of patients, of which 80% received recommendations for HCV treatment by their PCP and 25% received recommendations for referral to a specialist for additional care. CONCLUSIONS Most patients presented at the Indian Country ECHO received recommendations for HCV treatment by their PCP, along with recommendations beyond the scope of HCV. Indian Country ECHO telehealth clinic provides comprehensive recommendations to effectively integrate evidence-based HCV treatment with holistic care at the primary care level.
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Affiliation(s)
- Ashley N. Wirth
- Northwest Portland Area Indian Health Board, Portland, Oregon, USA
- School of Medicine, Oregon Health & Sciences University, Portland, Oregon, USA
| | | | - Brigg A. Reilley
- Northwest Portland Area Indian Health Board, Portland, Oregon, USA
| | | | - Jorge R. Mera
- Northwest Portland Area Indian Health Board, Portland, Oregon, USA
- Cherokee Nation Health Services, Tahlequah, Oklahoma, USA
| | - Ximena A. Levander
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Addiction Medicine Section, Oregon Health & Sciences University, Portland, Oregon, USA
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Cook RR, Foot C, Arah OA, Humphreys K, Rudolph KE, Luo SX, Tsui JI, Levander XA, Korthuis PT. Estimating the impact of stimulant use on initiation of buprenorphine and extended-release naltrexone in two clinical trials and real-world populations. Addict Sci Clin Pract 2023; 18:11. [PMID: 36788634 PMCID: PMC9930351 DOI: 10.1186/s13722-023-00364-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 02/01/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Co-use of stimulants and opioids is rapidly increasing. Randomized clinical trials (RCTs) have established the efficacy of medications for opioid use disorder (MOUD), but stimulant use may decrease the likelihood of initiating MOUD treatment. Furthermore, trial participants may not represent "real-world" populations who would benefit from treatment. METHODS We conducted a two-stage analysis. First, associations between stimulant use (time-varying urine drug screens for cocaine, methamphetamine, or amphetamines) and initiation of buprenorphine or extended-release naltrexone (XR-NTX) were estimated across two RCTs (CTN-0051 X:BOT and CTN-0067 CHOICES) using adjusted Cox regression models. Second, results were generalized to three target populations who would benefit from MOUD: Housed adults identifying the need for OUD treatment, as characterized by the National Survey on Drug Use and Health (NSDUH); adults entering OUD treatment, as characterized by Treatment Episodes Dataset (TEDS); and adults living in rural regions of the U.S. with high rates of injection drug use, as characterized by the Rural Opioids Initiative (ROI). Generalizability analyses adjusted for differences in demographic characteristics, substance use, housing status, and depression between RCT and target populations using inverse probability of selection weighting. RESULTS Analyses included 673 clinical trial participants, 139 NSDUH respondents (weighted to represent 661,650 people), 71,751 TEDS treatment episodes, and 1,933 ROI participants. The majority were aged 30-49 years, male, and non-Hispanic White. In RCTs, stimulant use reduced the likelihood of MOUD initiation by 32% (adjusted HR [aHR] = 0.68, 95% CI 0.49-0.94, p = 0.019). Stimulant use associations were slightly attenuated and non-significant among housed adults needing treatment (25% reduction, aHR = 0.75, 0.48-1.18, p = 0.215) and adults entering OUD treatment (28% reduction, aHR = 0.72, 0.51-1.01, p = 0.061). The association was more pronounced, but still non-significant among rural people injecting drugs (39% reduction, aHR = 0.61, 0.35-1.06, p = 0.081). Stimulant use had a larger negative impact on XR-NTX initiation compared to buprenorphine, especially in the rural population (76% reduction, aHR = 0.24, 0.08-0.69, p = 0.008). CONCLUSIONS Stimulant use is a barrier to buprenorphine or XR-NTX initiation in clinical trials and real-world populations that would benefit from OUD treatment. Interventions to address stimulant use among patients with OUD are urgently needed, especially among rural people injecting drugs, who already suffer from limited access to MOUD.
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Affiliation(s)
- R R Cook
- Section of Addiction Medicine, Department of Medicine, Oregon Health & Science University, Sam Jackson Hall, Suite 3370, 3245 SW Pavilion Loop, Portland, OR, 97239, USA.
| | - C Foot
- Section of Addiction Medicine, Department of Medicine, Oregon Health & Science University, Sam Jackson Hall, Suite 3370, 3245 SW Pavilion Loop, Portland, OR, 97239, USA
| | - O A Arah
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, CA, USA
- Division of Physical Sciences, Department of Statistics, UCLA College, Los Angeles, CA, USA
- Research Unit for Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - K Humphreys
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, CA, USA
| | - K E Rudolph
- Department of Epidemiology, School of Public Health, Columbia University, New York, NY, USA
| | - S X Luo
- Division on Substance Use Disorders, Department of Psychiatry, Columbia University, New York, USA
| | - J I Tsui
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - X A Levander
- Section of Addiction Medicine, Department of Medicine, Oregon Health & Science University, Sam Jackson Hall, Suite 3370, 3245 SW Pavilion Loop, Portland, OR, 97239, USA
| | - P T Korthuis
- Section of Addiction Medicine, Department of Medicine, Oregon Health & Science University, Sam Jackson Hall, Suite 3370, 3245 SW Pavilion Loop, Portland, OR, 97239, USA
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Englander H, Gregg J, Levander XA. Envisioning Minimally Disruptive Opioid Use Disorder Care. J Gen Intern Med 2023; 38:799-803. [PMID: 36401107 PMCID: PMC9676870 DOI: 10.1007/s11606-022-07939-x] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 11/04/2022] [Indexed: 11/21/2022]
Abstract
Most people who need and want treatment for opioid addiction cannot access it. Among those who do get treatment, only a fraction receive evidence-based, life-saving medications for opioid use disorder (MOUD). MOUD access is not simply a matter of needing more clinicians or expanding existing treatment capacity. Instead, many facets of our health systems and policies create unwarranted, inflexible, and punitive practices that create life-threatening barriers to care. In the USA, opioid use disorder care is maximally disruptive. Minimally disruptive medicine (MDM) is a framework that focuses on achieving patient goals while imposing the smallest possible burden on patients' lives. Using MDM framing, we highlight how current medical practices and policies worsen the burden of treatment and illness, compound life demands, and strain resources. We then offer suggestions for programmatic and policy changes that would reduce disruption to the lives of those seeking care, improve health care quality and delivery, begin to address disparities and inequities, and save lives.
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Affiliation(s)
- Honora Englander
- Section of Addiction Medicine in Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Portland, OR, USA. .,Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
| | | | - Ximena A Levander
- Section of Addiction Medicine in Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
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Levander XA, Foot CA, Magnusson SL, Cook RR, Ezell JM, Feinberg J, Go VF, Lancaster KE, Salisbury-Afshar E, Smith GS, Westergaard RP, Young AM, Tsui JI, Korthuis PT. Contraception and Healthcare Utilization by Reproductive-Age Women Who Use Drugs in Rural Communities: a Cross-Sectional Survey. J Gen Intern Med 2023; 38:98-106. [PMID: 35731368 PMCID: PMC9849531 DOI: 10.1007/s11606-022-07558-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 12/01/2021] [Accepted: 03/30/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Women who use drugs (WWUD) have low rates of contraceptive use and high rates of unintended pregnancy. Drug use is common among women in rural U.S. communities, with limited data on how they utilize reproductive, substance use disorder (SUD), and healthcare services. OBJECTIVE We determined contraceptive use prevalence among WWUD in rural communities then compared estimates to women from similar rural areas. We investigated characteristics of those using contraceptives, and associations between contraceptive use and SUD treatment, healthcare utilization, and substance use. DESIGN Rural Opioids Initiative (ROI) - cross-sectional survey using respondent-driven sampling (RDS) involving eight rural U.S. regions (January 2018-March 2020); National Survey on Family Growth (NSFG) - nationally-representative U.S. household reproductive health survey (2017-2019). PARTICIPANTS Women aged 18-49 with prior 30-day non-prescribed opioid and/or non-opioid injection drug use; fecundity determined by self-reported survey responses. MAIN MEASURES Unweighted and RDS-weighted prevalence estimates of medical/procedural contraceptive use; chi-squared tests and multi-level linear regressions to test associations. KEY RESULTS Of 855 women in the ROI, 36.8% (95% CI 33.7-40.1, unweighted) and 38.6% (95% CI 30.7-47.2, weighted) reported contraceptive use, compared to 66% of rural women in the NSFG sample. Among the ROI women, 27% had received prior 30-day SUD treatment via outpatient counseling or inpatient program and these women had increased odds of contraceptive use (aOR 1.50 [95% CI 1.08-2.06]). There was a positive association between contraception use and recent medications for opioid use disorder (aOR 1.34 [95% CI 0.95-1.88]) and prior 6-month primary care utilization (aOR 1.32 [95% CI 0.96-1.82]) that did not meet the threshold for statistical significance. CONCLUSION WWUD in rural areas reported low contraceptive use; those who recently received SUD treatment had greater odds of contraceptive use. Improvements are needed in expanding reproductive and preventive health within SUD treatment and primary care services in rural communities.
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Affiliation(s)
- Ximena A Levander
- Division of General Internal Medicine & Geriatrics, Addiction Medicine Section, Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Canyon A Foot
- Division of General Internal Medicine & Geriatrics, Addiction Medicine Section, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | | | - Ryan R Cook
- Division of General Internal Medicine & Geriatrics, Addiction Medicine Section, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Jerel M Ezell
- Africana Studies and Research Center, Cornell Center for Health Equity, Cornell University, Ithaca, NY, USA
| | - Judith Feinberg
- Department of Behavioral Medicine and Psychiatry, West Virginia University, Morgantown, WV, USA
- Department of Medicine Section of Infectious Diseases, West Virginia University, Morgantown, WV, USA
| | - Vivian F Go
- Department of Health Behavior, School of Global Public Health, University of North Carolina - Chapel Hill, Chapel Hill, NC, USA
| | - Kathryn E Lancaster
- Division of Epidemiology, College of Public Health, Ohio State University, Columbus, OH, USA
| | | | - Gordon S Smith
- Department of Epidemiology and Biostatistics, School of Public Health, West Virginia University, Morgantown, WV, USA
| | - Ryan P Westergaard
- Division of Infectious Diseases, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - April M Young
- Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY, USA
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, KY, USA
| | - Judith I Tsui
- Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - P Todd Korthuis
- Division of General Internal Medicine & Geriatrics, Addiction Medicine Section, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
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Pertl K, Petluri R, Wiest K, Hoffman K, McCarty D, Levander XA, Chan B, Martin SA, Korthuis PT. Recruitment challenges for a prospective telehealth cohort study. Contemp Clin Trials Commun 2022; 31:101043. [PMID: 36475092 PMCID: PMC9715261 DOI: 10.1016/j.conctc.2022.101043] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/10/2022] [Accepted: 11/27/2022] [Indexed: 12/03/2022] Open
Abstract
Background The COVID-19 pandemic presents challenges in participant recruitment strategies for clinical research involving people with opioid use disorders recently engaged in treatment. We describe challenges to participant recruitment in a trial comparing virtual buprenorphine treatment platform to office-based buprenorphine treatment. Methods The parent study was a cohort trial of telehealth delivered buprenorphine treatment compared to office-based buprenorphine treatment, however, due to the pandemic potential participant recruitment for both arms became virtual. Between 9/27/2021 and 7/11/2022, telephone, email, flyers, and word-of-mouth were used to recruit study participants from each treatment setting. Recruitment tracking documents recorded the primary outcomes: number of outreach attempts and most effective contact methods. Results Treatment settings provided contact information for 1485 potential study participants. Information was incorrect or disconnected for 282 (19%) individuals, 695 (47%) did not respond to outreach, and 508 (34%) responded to outreach. Of these responders, 369 were interested in study participation, 259 completed the online informed consent and screening assessment, and 148 met eligibility criteria and enrolled in the study. A total of 3804 virtual outreach attempts across 1485 potential participants were made, resulting in an average of 2.7 attempts per contact and a mean of 25.7 attempts per enrolled participant (n = 148). Conclusion Conducting research during the COVID-19 pandemic required shifting from in-person to virtual recruitment strategies to contact and engage potential study participants. Virtual recruitment for this population during a pandemic appears to be less efficient and hindered efforts to meet recruitment goals.
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Affiliation(s)
| | | | | | - Kim Hoffman
- OHSU – PSU School of Public Health, Oregon Health & Science University, Portland, OR, USA,Corresponding author. Department of General Internal Medicine, 3181 S.W. Sam Jackson Park Road, Portland, OR, 97239-3098, USA.
| | - Dennis McCarty
- OHSU – PSU School of Public Health, Oregon Health & Science University, Portland, OR, USA
| | - Ximena A. Levander
- Addiction Medicine Section, Department of Medicine, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Brian Chan
- Addiction Medicine Section, Department of Medicine, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Stephen A. Martin
- Boulder Care, Portland, OR, USA,Department of Family Medicine and Community Health, UMass Chan Medical School, Worcester, MA, USA
| | - P. Todd Korthuis
- OHSU – PSU School of Public Health, Oregon Health & Science University, Portland, OR, USA,Addiction Medicine Section, Department of Medicine, School of Medicine, Oregon Health & Science University, Portland, OR, USA
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15
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Brown PCM, Button DA, Bethune D, Kelly E, Tierney HR, Nerurkar RM, Nicolaidis C, Harrison RA, Levander XA. Assessing Student Readiness to Work with People Who Use Drugs: Development of a Multi-disciplinary Addiction Educational Survey. J Gen Intern Med 2022; 37:3900-3906. [PMID: 35419741 PMCID: PMC9640533 DOI: 10.1007/s11606-022-07494-5] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 03/22/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND As health profession schools implement addiction curricula, they need survey instruments to evaluate the impact of the educational interventions. However, existing measures do not use current non-stigmatizing language and fail to capture core concepts. OBJECTIVE To develop a brief measure of health profession student readiness to work with people who use drugs (PWUDs) and establish its content validity. METHODS We conducted a literature review of existing instruments and desired clinical competencies related to providing care to PWUD and used results and expert feedback to create and revise a pool of 72 items. We conducted cognitive interviews with ten pre-clinical health profession students from various US schools of nursing, pharmacy, and medicine to ensure the items were easy to understand. Finally, we used a modified Delphi process with twenty-four health professions educators and addiction experts (eight each from nursing, pharmacy, and medicine) to select items for inclusion in the final scale. We analyzed expert ratings of individual items and interdisciplinary agreement on ratings to decide how to prioritize items. We ultimately selected 12 attitudes and 12 confidence items to include in the REadiness to Discuss Use, Common Effects, and HArm Reduction Measure (REDUCE-HARM). Experts rated their overall assessment of the final scale. RESULTS Twenty-two of twenty-four experts agreed or strongly agreed that the attitudes scale measures student attitudes that impact readiness to work with PWUDs. Twenty-three of twenty-four experts agreed or strongly agreed that the confidence scale measures student self-efficacy in competencies that impact readiness to work with PWUDs. Seven of 72 initial items and none of the 24 selected items had statistically significant differences between disciplines. CONCLUSIONS The REDUCE-HARM instrument has strong content validity and may serve as a useful tool in evaluating addiction education. Additional research is needed to establish its reliability, construct validity, and responsiveness to change.
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Affiliation(s)
- Patrick C M Brown
- School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Dana A Button
- School of Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Danika Bethune
- School of Medicine, University of Washington, Seattle, WA, USA
| | - Emily Kelly
- School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Hannah R Tierney
- School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | - Christina Nicolaidis
- School of Social Work, Portland State University, Portland, OR, USA
- Division of General Internal Medicine & Geriatrics, Oregon Health & Science University, Portland, OR, USA
| | - Rebecca A Harrison
- Division of Hospital Medicine, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Ximena A Levander
- Division of General Internal Medicine & Geriatrics, Addiction Medicine Section, School of Medicine, Oregon Health & Science University, Portland, OR, USA
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Hoffman KA, Foot C, Levander XA, Cook R, Terashima JP, McIlveen JW, Korthuis PT, McCarty D. Treatment retention, return to use, and recovery support following COVID-19 relaxation of methadone take-home dosing in two rural opioid treatment programs: A mixed methods analysis. J Subst Abuse Treat 2022; 141:108801. [PMID: 35589443 PMCID: PMC9080674 DOI: 10.1016/j.jsat.2022.108801] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 03/21/2022] [Accepted: 05/04/2022] [Indexed: 11/25/2022]
Abstract
Objectives In March 2020, the Substance Abuse and Mental Health Services Administration permitted Opioid Treatment Programs (OTPs) to relax restrictions on take-home methadone and promoted telehealth to minimize potential exposures to COVID-19. We assessed the effects of COVID-19-related changes on take-home methadone dosing in two OTPs serving five rural Oregon counties. Methods We used a mixed-methods convergent design. The OTPs extracted urine drug test (UDT) results, take-home methadone regimens, and treatment retention from the electronic health record (EHR) for patients (n = 377). A mixed-effects negative binomial regression model assessed patient-level differences in take-home doses before and after the COVID-19 policy changes and the associations with treatment discontinuation, and UDT positivity. Semi-structured qualitative interviews (n = 32) explored patient reactions to increased take-home dosing and reduced clinic visits to provide context for quantitative findings. Results The number of take-home doses increased in the post-COVID-19 period for patients engaged in treatment for more than 180 days (median: 8 vs 13 take-home doses per month, p = 0.011). Take-homes did not increase for patients with fewer days of treatment. Each percentage point increase in take-home dosing above what would be expected without COVID-19 policy changes was negatively associated with the percent of UDT positive for opioids (B = −0.12, CI [−0.21, −0.04], p = 0.005) and the probability of treatment discontinuation (aOR = 0.97, CI [0.95, 0.99], p = 0.003). Qualitative analysis revealed three themes explaining how increased take-home dosing supported recovery: 1) value of feeling trusted with increased responsibility; 2) reduced travel time permitted increased employment and recreation; and 3) reduced exposure to individuals less stable in recovery and potential triggers. Conclusions Take-home methadone dose relaxations were associated with increased methadone take-home doses, improved retention, and decreased UDT opioid positive results among clinically stable patients. Qualitative findings suggest that fewer take-home restrictions are feasible and desirable and do not pose safety or public health harms.
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Abstract
BACKGROUND Over the last 10 years, an increasing number of unregulated novel psychoactive substances, including "designer benzodiazepines" (DBZDs), have emerged on the recreational drug market. Despite the rapidly increasing usage of DBZDs, there is a significant lack of information regarding clinical management. Here we present a case illustrating the difficulties of diagnosing and managing DBZD related sedative-hypnotic use disorder. CASE PRESENTATION Our patient is a 30-year-old man with severe opioid and sedative-hypnotic use disorders. He had a 10-year history of using heroin, clonazolam, and alprazolam. He stopped using heroin when on methadone maintenance therapy but continued using clonazolam and nonprescribed alprazolam. His opioid treatment program discontinued methadone due to benzodiazepine intoxication, and he returned to heroin use. He then presented for residential withdrawal management where he underwent successful buprenorphine induction and benzodiazepine withdrawal management. During a 3-month period of benzodiazepine abstinence, he struggled with ongoing cravings and post-acute withdrawal syndrome, ultimately leading to return to DBZD use. DISCUSSION Despite the increasing prevalence of DBZD use, the usage of DBZDs is likely under-recognized because these compounds are generally not included on standard in-office urine drug immunoassay tests. Initial studies suggest that DBZDs have high potencies, shorter half-lives, are more addictive, and can result in more severe withdrawal symptoms compared to known benzodiazepines. However, there remains a lack of information about the pharmacokinetics and pharmacodynamics of DBZDs, making clinical management for DBZD related sedative-hypnotic use disorders challenging to treat.
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Affiliation(s)
- Linda Peng
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR (LP, DL, XAL); Hooper Detoxification and Stabilization Center, Central City Concern, Portland, OR (DL)
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18
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Button D, Hartley J, Robbins J, Levander XA, Smith NJ, Englander H. Low-dose Buprenorphine Initiation in Hospitalized Adults With Opioid Use Disorder: A Retrospective Cohort Analysis. J Addict Med 2022; 16:e105-e111. [PMID: 34001775 PMCID: PMC8595358 DOI: 10.1097/adm.0000000000000864] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [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] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Patients with opioid use disorder (OUD) can initiate buprenorphine without requiring a withdrawal period through a low-dose (sometimes referred to as "micro-induction") approach. Although there is growing interest in low-dose buprenorphine initiation, current evidence is limited to case reports and small case series. METHODS We performed a retrospective cohort study of patients with OUD seen by a hospital-based addiction medicine consult service who underwent low-dose buprenorphine initiation starting during hospital admission. We then integrated our practice-based experiences with results from the existing literature to create practice considerations. RESULTS Sixty-eight individuals underwent 72 low-dose buprenorphine initiations between July 2019 and July 2020. Reasons for low-dose versus standard buprenorphine initiation included co-occurring pain (91.7%), patient anxiety around the possibility of withdrawal (69.4%), history of precipitated withdrawal (9.7%), opioid withdrawal intolerance (6.9%), and other reason/not specified (18.1%). Of the 72 low-dose buprenorphine initiations, 50 (69.4%) were completed in the hospital, 9 (12.5%) transitioned to complete as an outpatient, and 13 (18.1%) were terminated early. We apply our experiences and findings from literature to recommendations for varied clinical scenarios, including acute illness, co-occurring pain, opioid withdrawal intolerance, transition from high dose methadone to buprenorphine, history of precipitated withdrawal, and rapid hospital discharge. We share a standard low-dose initiation protocol with potential modifications based on above scenarios. CONCLUSIONS Low-dose buprenorphine initiation offers a well-tolerated and versatile approach for hospitalized patients with OUD. We share lessons from our experiences and the literature, and provide practical considerations for providers.
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Affiliation(s)
- Dana Button
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University
| | | | - Jonathan Robbins
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University
| | - Ximena A. Levander
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University
| | - Natashia J. Smith
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University
| | - Honora Englander
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University
- Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University
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19
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Abstract
Benzodiazepine and related sedative use has been increasing. There has been a growing number of unregulated novel psychoactive substances, including designer benzodiazepines. Benzodiazepines have neurobiological and pharmacologic properties that result in a high potential for misuse and physical dependence. Options for discontinuing long-term benzodiazepine use include an outpatient benzodiazepine taper or inpatient withdrawal management at a hospital or detoxification facility. The quality of evidence on medications for benzodiazepine discontinuation is overall low, whereas cognitive behavioral therapy has shown the most benefit in terms of behavioral treatments. Benzodiazepines may also have significant adverse effects, increasing the risk of overdose and death.
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Affiliation(s)
- Linda Peng
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Addiction Medicine Section, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code L475, Portland, Oregon 97239, USA.
| | - Kenneth L Morford
- Department of Internal Medicine, Section of General Internal Medicine, Program in Addiction Medicine, Yale School of Medicine, 367 Cedar Street, ES Harkness A, Room 417A, New Haven, Connecticut 06510, USA
| | - Ximena A Levander
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Addiction Medicine Section, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code L475, Portland, Oregon 97239, USA. https://twitter.com/XimenaLevander
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20
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Levander XA, Wheelock H, Pope J, Lee A, Hartmann K, Abuelkhair S, Gregg JL, Buchheit BM. Low-Threshold Buprenorphine via Community Partnerships and Telemedicine-Case Reports of Expanding Access to Addiction Treatment During COVID-19. J Addict Med 2022; 16:e56-e58. [PMID: 34374502 PMCID: PMC8815644 DOI: 10.1097/adm.0000000000000811] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 12/15/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND To reduce coronavirus disease 2019 (COVID-19) spread, federal agencies eased telemedicine restrictions including audio-only appointments. These changes permitted clinicians to prescribe buprenorphine to patients with opioid use disorder (OUD) without in-person or audio/video assessment. Our clinic utilized existing community collaborations to implement protocols and extend outreach. We describe 3 patients with OUD who engaged with treatment through outreach with trusted community partners and low-threshold telemedicine. CASE PRESENTATIONS Patient 1-a 40-year-old man with severe OUD who injected heroin and was living outside. A weekend harm reduction organization volunteer the patient previously knew used her mobile phone to facilitate an audio-only intake appointment during clinic hours. He completed outpatient buprenorphine initiation. Patient 2-a 48-year-old man with severe opioid and methamphetamine use disorders who injected both and was living in his recreational vehicle. He engaged regularly with syringe services program (SSP), but utilized no other healthcare services. Initially, an SSP worker connected him to our clinic for audio-only appointment using their landline to initiate buprenorphine; a harm reduction volunteer coordinated follow-up. Patient 3-a 66-year-old man with moderate OUD used non-prescribed pill opioids without prior buprenorphine experience. He lived over 5 hours away in a rural town. He underwent virtual appointment and completed home buprenorphine initiation. CONCLUSION These 3 cases illustrate examples of how policy changes allowing for telemedicine buprenorphine prescribing can expand availability of addiction services for patients with OUD who were previously disengaged for reasons including geography, lack of housing, transportation difficulties, and mistrust of traditional healthcare systems.
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Affiliation(s)
- Ximena A Levander
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Section of Addiction Medicine, Oregon Health and Science University, Portland, OR (XAL, AL, KH, JLG, BMB); Outside In's Injection Drug Users Health Services, Portland, OR (HW); Comagine Health, Portland, OR (JP); The People's Harm Reduction Alliance/Portland People's Outreach Project, Portland, OR (JP, SA) and Department of Family Medicine, Oregon Health and Science University, Portland, OR (BMB)
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21
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Levander XA, Pytell JD, Stoller KB, Korthuis PT, Chander G. COVID-19-related policy changes for methadone take-home dosing: A multistate survey of opioid treatment program leadership. Subst Abus 2022; 43:633-639. [PMID: 34666636 PMCID: PMC8810732 DOI: 10.1080/08897077.2021.1986768] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 01/03/2023]
Abstract
Background: In the United States, methadone for treatment of opioid use disorder is dispensed via highly-regulated accredited opioid treatment programs (OTP). During the COVID-19 pandemic, federal regulations were loosened, allowing for greater use of take-home methadone doses. We sought to understand how OTP leaders responded to these policy changes. Methods: We distributed a multistate electronic survey from September to November 2020 of OTP leadership to members of the American Association for the Treatment of Opioid Dependence (AATOD) who self-identified as leaders of OTPs. We asked study participants about how their OTP(s) implemented COVID-19-related policy changes into their clinical practice focusing on provision of take-home methadone doses, factors used to determine patient stability, and potential concerns about increased take-home doses. We used Chi-square test to compare survey responses between characterizations of the OTPs. Results: Of 170 survey respondents (17% response rate), the majority represented leadership of for-profit OTPs (69%) and were in a Southern state (54%). Routine allowances and practices related to take-home methadone doses varied across OTPs during the COVID-19 pandemic: 80 (47%) reported 14 days for newly enrolled patients (within past 90 days), 89 (52%) reported 14 days for "less stable" patients, and 112 (66%) reported 28 days for "stable" patients. Conclusions: We found that not all eligible OTP leaders adopted the practice of routinely allowing newly enrolled, "less stable," and "stable" patients on methadone to have increased take-home doses up to the limit allowed by federal regulations during COVID-19. The pandemic provides an opportunity to critically re-evaluate long-established methadone and OTP regulations in preparation for future emergencies.
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Affiliation(s)
- Ximena A. Levander
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Jarratt D. Pytell
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Kenneth B. Stoller
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - P. Todd Korthuis
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Geetanjali Chander
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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22
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Levander XA, Vega TA, Seaman A, Korthuis PT, Englander H. Exploring how hospitalization can alter hepatitis c virus treatment prioritization and trajectories in people who use drugs: A qualitative analysis. Subst Abus 2022; 43:245-252. [PMID: 34161198 PMCID: PMC8695635 DOI: 10.1080/08897077.2021.1932699] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: People who use drugs (PWUD) have high rates of hepatitis C virus (HCV) infection. Hospitalization can be a time for PWUD to engage in addiction treatment, but little is known about how hospitalization shapes HCV treatment readiness. We aimed to describe how hospitalization and addiction medicine consult service (AMCS) can alter HCV prioritization of inpatient PWUD with HCV. Methods: We conducted a qualitative study consisting of semi-structured interviews (n = 27) of hospitalized adults with addiction and HCV infection seen by an AMCS at a single, urban, academic center. Interviews were audio-recorded, transcribed, and coded iteratively at the semantic level, and analyzed for themes. Results: Of the 27 participants, most identified as Caucasian (85%), male gender (67%), and they primarily used opioids (78%); approximately half (48%) reported HCV diagnosis over 5 years ago. We identified three main themes around hospitalization altering the prioritizations and HCV treatment preferences for PWUD: (1) HCV treatment non-engaged (2) HCV treatment urgency, and (3) HCV treatment in the future. Those wanting to treat HCV-whether urgently or in the future-shared the overlapping theme of hospitalization as a reachable moment for their addiction and HCV. These participants recognized the long-term benefits of addressing HCV and connected their hospitalization to substance use. Conclusion: In our study, PWUD with HCV expressed varying and competing priorities and life circumstances contributing to three main HCV treatment trajectories. Our results suggest ways hospitalization can serve as an HCV touchpoint for PWUD, especially in the context of addressing substance use, and could be used when designing and implementing targeted interventions to improve the HCV care continuum for PWUD.
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Affiliation(s)
- Ximena A. Levander
- Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Department of Medicine Oregon Health and Science University, Portland, OR, USA
| | - Taylor A. Vega
- School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Andrew Seaman
- Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Department of Medicine Oregon Health and Science University, Portland, OR, USA;,Central City Concern, Portland, OR, USA
| | - P. Todd Korthuis
- Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Department of Medicine Oregon Health and Science University, Portland, OR, USA
| | - Honora Englander
- Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Department of Medicine Oregon Health and Science University, Portland, OR, USA;,Division of Hospital Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
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23
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Levander XA, Hoffman KA, McIlveen JW, McCarty D, Terashima JP, Korthuis PT. Rural opioid treatment program patient perspectives on take-home methadone policy changes during COVID-19: a qualitative thematic analysis. Addict Sci Clin Pract 2021; 16:72. [PMID: 34895346 PMCID: PMC8665717 DOI: 10.1186/s13722-021-00281-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [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] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 11/22/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND In the United States, methadone for opioid use disorder (OUD) is highly regulated. Federal agencies announced guidelines in March 2020 allowing for relaxation of take-home methadone dispensing at opioid treatment programs (OTPs) to improve treatment access and reduce COVID-19 transmission risk during the public health emergency. We explored patient perspectives at three OTPs serving rural communities on how take-home policy changes were received and implemented and how these changes impacted their addiction treatment and recovery. METHODS We completed semi-structured individual qualitative interviews in 2 phases: (1) August-October 2020 and (2) November 2020-January 2021 (total n = 46), anticipating possible policy changes as the pandemic progressed. We interviewed patients with OUD enrolled at 3 rural OTPs in Oregon. Participants received varying take-home methadone allowances following the COVID-19-related policy changes. All interviews were conducted via phone, audio-recorded, and transcribed. We conducted a thematic analysis, iteratively coding transcripts, and deductively and inductively generating codes. RESULTS The 46 participants included 50% women and 89% had Medicaid insurance. Three main themes emerged in the analysis, with no differences between study phases: (1) Adapting to changing OTP policies throughout the pandemic; (2) Recognizing the benefits, and occasional struggles, with increased take-home methadone dosing; and (3) Continuing policies and procedures post-pandemic. Participants described fears and anxieties around ongoing methadone access and safety concerns prior to OTP policy changes, but quickly adapted as protocols soon seemed "natural." The majority of participants acknowledged significant benefits to increased take-homes independent of reducing COVID-19 infection risk including feeling "more like a normal person," improved recovery support, reduced time traveling, and having more time with family and for work. Looking to a post-pandemic future, participants thought some COVID-19-related safety protocols should continue that would reduce risk of other infections, make OTP settings less stressful, and result in more individualized care. CONCLUSIONS As the pandemic progressed, study participants adapted to rapidly changing OTP policies. Participants noted many unanticipated benefits to increased take-home methadone and other COVID-19 protocols including strengthened self-efficacy and recovery and reduced interpersonal conflict, with limited evidence of diversion. Patient perspectives should inform future policies to better address the ongoing overdose epidemic.
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Affiliation(s)
- Ximena A Levander
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Addiction Medicine Section, Oregon Health & Science University, 3181 SW Sam Jackson Park Road Mail Code - L475, Portland, OR, 97239-3098, USA.
| | - Kim A Hoffman
- Oregon Health & Science University-Portland State University School of Public Health, Portland, OR, USA
| | - John W McIlveen
- Oregon Health Authority State Opioid Treatment Authority, Salem, OR, USA
| | - Dennis McCarty
- Oregon Health & Science University-Portland State University School of Public Health, Portland, OR, USA
| | | | - P Todd Korthuis
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Addiction Medicine Section, Oregon Health & Science University, 3181 SW Sam Jackson Park Road Mail Code - L475, Portland, OR, 97239-3098, USA
- Oregon Health & Science University-Portland State University School of Public Health, Portland, OR, USA
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24
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Seaman A, King CA, Kaser T, Geduldig A, Ronan W, Cook R, Chan B, Levander XA, Priest KC, Korthuis PT. A hepatitis C elimination model in healthcare for the homeless organization: A novel reflexive laboratory algorithm and equity assessment. Int J Drug Policy 2021; 96:103359. [PMID: 34325969 PMCID: PMC8720290 DOI: 10.1016/j.drugpo.2021.103359] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 06/16/2021] [Accepted: 06/18/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Reaching World Health Organization hepatitis C (HCV) elimination targets requires diagnosis and treatment of people who use drugs (PWUD) with direct acting antivirals (DAAs). PWUD experience challenges engaging in HCV treatment, including needing multiple provider and laboratory appointments. Women, minoritized racial communities, and homeless individuals are less likely to complete treatment. METHODS We implemented a streamlined opt-out HCV screening and linkage-to-care program in two healthcare for the homeless clinics and a medically supported withdrawal center. Front-line staff initiated a single-order reflex laboratory bundle combining screening, confirmation, and pre-treatment laboratory evaluation from a single blood draw. Multinomial logistic regression models identified characteristics influencing movement through each stage of the HCV treatment cascade. Multiple logistic regression models identified patient characteristics associated with HCV care cascade progression and Cox proportional hazards models assessed time to initiation of DAAs. RESULTS Of 11,035 clients engaged in services between May 2017 and March 2020, 3,607 (32.7%) were screened. Of those screened, 1,020 (28.3%) were HCV PCR positive. Of those with detectable RNA, 712 (69.8%) initiated treatment and 670 (94.1%) completed treatment. Of those initiating treatment, 407 (57.2%) achieved SVR12. There were eight treatment failures and six reinfections. In the unadjusted model, the bundle intervention was associated with increased care cascade progression, and in the survival analysis, decreased time to initiation; these differences were attenuated in the adjusted model. Women were less likely to complete treatment and SVR12 labs than men. Homelessness increased likelihood of screening and diagnosis but was negatively associated with completing SVR12 labs. Presence of opioid and stimulant use disorder diagnoses predicted increased care cascade progression. CONCLUSIONS The laboratory bundle and referral pathways improved treatment initiation, time to initiation, and movement across the cascade. Despite overall population improvements, women and homeless individuals experienced important gaps across the HCV care cascade.
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Affiliation(s)
- A Seaman
- Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, Oregon, United States; Hepatitis C Elimination Program, Central City Concern, Portland, Oregon, United States.
| | - C A King
- Dept. of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, Oregon, United States
| | - T Kaser
- Hepatitis C Elimination Program, Central City Concern, Portland, Oregon, United States
| | - A Geduldig
- Hepatitis C Elimination Program, Central City Concern, Portland, Oregon, United States
| | - W Ronan
- Hepatitis C Elimination Program, Central City Concern, Portland, Oregon, United States
| | - R Cook
- Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, Oregon, United States
| | - B Chan
- Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, Oregon, United States; Hepatitis C Elimination Program, Central City Concern, Portland, Oregon, United States
| | - X A Levander
- Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, Oregon, United States
| | - K C Priest
- School of Medicine, MD/PhD Program, Oregon Health & Science University, Portland, Oregon, United States
| | - P T Korthuis
- Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, Oregon, United States
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25
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Vega TA, Levander XA, Seaman A, Korthuis PT, Englander H. "Sobriety equals getting rid of hepatitis C": A qualitative study exploring the interplay of substance use disorder and hepatitis C among hospitalized adults. J Subst Abuse Treat 2021; 127:108337. [PMID: 34134860 PMCID: PMC8217723 DOI: 10.1016/j.jsat.2021.108337] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 12/18/2020] [Accepted: 02/15/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND People who use drugs (PWUD) commonly experience complex illness, psychosocial stressors, housing insecurity, and stigma, which may play key roles in their struggles with addiction. In a study of hospitalized PWUD with hepatitis C virus infection (HCV), participants described treating HCV as "part of recovery." These findings led us to explore how hospitalization and acute illness altered patients' perceptions of substance use disorder (SUD) and HCV. METHODS Researchers audio recorded in-depth semi-structured individual interviews of 27 hospitalized adults with SUD and HCV seen by an addiction consult service (ACS) at an urban academic medical center between June and November 2019. Research staff transcribed interviews and dual coded them deductively and inductively at the semantic level. Researchers used a matrix visualization to discern relationships among codes and conducted a thematic analysis. RESULTS Many participants believed addictions treatment should precede an HCV cure for varying reasons. Some wanted to avoid reinfection; others believed "getting clean" afforded the mental clarity to address health issues, including HCV. Patients newly engaged in SUD treatment described HCV treatment as a "step towards recovery" and could serve as motivation to continue SUD treatment. Participants believed HCV cure could facilitate sobriety by "mentally putting drugs in the past" and was a future-oriented action toward "better health." Many participants described the compounded stigma of having HCV infection and SUD by multiple groups, including friends/family who do not use drugs, other drug users, and health care workers. CONCLUSION Hospitalized adults with SUD and HCV believed addictions engagement should precede HCV treatment and HCV cure could play an important role in their "recovery" journey. Discussing HCV treatment during hospitalization may be an opportunity to support engagement in SUD treatment and targets an untreated patient population critical for achieving HCV elimination.
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Affiliation(s)
- Taylor A Vega
- School of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, United States.
| | - Ximena A Levander
- Department of Medicine, Division of General Internal Medicine, Section of Addiction Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, United States.
| | - Andrew Seaman
- Department of Medicine, Division of General Internal Medicine, Section of Addiction Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, United States; Central City Concern, 232 NW6th Ave., Portland, OR 97209, United States.
| | - P Todd Korthuis
- Department of Medicine, Division of General Internal Medicine, Section of Addiction Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, United States.
| | - Honora Englander
- Department of Medicine, Division of Hospital Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239, United States.
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26
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Kazerouni NJ, Irwin AN, Levander XA, Geddes J, Johnston K, Gostanian CJ, Mayfield BS, Montgomery BT, Graalum DC, Hartung DM. Pharmacy-related buprenorphine access barriers: An audit of pharmacies in counties with a high opioid overdose burden. Drug Alcohol Depend 2021; 224:108729. [PMID: 33932744 DOI: 10.1016/j.drugalcdep.2021.108729] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [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: 12/22/2020] [Revised: 03/10/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pharmacies sometimes restrict access to buprenorphine-naloxone (buprenorphine) for individuals with opioid use disorder. The objective of this study was to quantify the frequency of barriers encountered by patients seeking to fill buprenorphine prescriptions from pharmacies in United States (US) counties with high opioid-related mortality. METHODS To characterize buprenorphine availability, we conducted a telephone audit ("secret shopper") study using a standardized script in two randomly selected pharmacies (one chain, one independent) in US counties reporting higher than average opioid overdose rates. Availability across pharmacy type (chain versus independent), county characteristics (rurality, region, overdose rate), and day of week were analyzed using univariate tests of categorical data. Independent predictors of buprenorphine availability were then identified using a multivariable binomial regression model. RESULTS Among 921 pharmacies contacted (467 chain, 454 independent), 73 % were in urban counties and 42 % were in Southern states. Of these pharmacies, 675 (73 %) reported being able to dispense buprenorphine. There were 183 (20 %) pharmacies that indicated they would not dispense buprenorphine. Independent pharmacies (adjusted prevalence ratio [aPR], 1.59; 95 % CI 1.21-2.08) and pharmacies in Southern states (aPR 2.06; 95 % CI 1.43-2.97) were significantly more likely to restrict buprenorphine. CONCLUSIONS In US counties with high overdose mortality rates, one in five pharmacies indicated they would not dispense buprenorphine. Buprenorphine access limitations were more common among independent pharmacies and those in Southern states. Pharmacy-directed interventions may be necessary to ensure timely buprenorphine access for patients with opioid use disorder.
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Affiliation(s)
- Neda J Kazerouni
- College of Pharmacy, Oregon State University/Oregon Health & Science University, Portland, OR, United States
| | - Adriane N Irwin
- College of Pharmacy, Oregon State University/Oregon Health & Science University, Portland, OR, United States
| | - Ximena A Levander
- Oregon Health & Science University, Department of Medicine Division of General Internal Medicine Section of Addiction Medicine, 3181 SW Sam Jackson Park Rd., Portland, OR, 97239, United States.
| | - Jonah Geddes
- College of Pharmacy, Oregon State University/Oregon Health & Science University, Portland, OR, United States
| | - Kirbee Johnston
- College of Pharmacy, Oregon State University/Oregon Health & Science University, Portland, OR, United States
| | - Carly J Gostanian
- College of Pharmacy, Oregon State University/Oregon Health & Science University, Portland, OR, United States
| | - Baylee S Mayfield
- College of Pharmacy, Oregon State University/Oregon Health & Science University, Portland, OR, United States
| | - Brandon T Montgomery
- College of Pharmacy, Oregon State University/Oregon Health & Science University, Portland, OR, United States
| | - Diana C Graalum
- MedSavvy/Cambia Health Solutions, Portland, OR, United States
| | - Daniel M Hartung
- College of Pharmacy, Oregon State University/Oregon Health & Science University, Portland, OR, United States.
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27
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Abstract
As more women have joined the US military, there has been a shift in the overall veteran population. Those who served in the US military, especially women, have undergone experiences that will impact their overall health and wellbeing. It is therefore critical for providers to better understand US military culture and be prepared on how to ask patients about their military experience. Health care providers need to be aware of the unique medical, psychiatric, and psychosocial needs of women veterans in order to best serve this patient population.
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Affiliation(s)
- Ximena A Levander
- Department of Medicine, VA Puget Sound Health Care System, University of Washington, 1959 Northeast Pacific Street, Seattle, WA 98195-6421, USA.
| | - Maryann K Overland
- Department of Medicine, VA Puget Sound Health Care System, University of Washington, 1959 Northeast Pacific Street, Seattle, WA 98195-6421, USA
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28
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Thirumalai A, Levander XA, Mookherjee S, White AA. Insulinoma presenting with cardiac arrest and cardiomyopathy. BMJ Case Rep 2013; 2013:bcr-2013-009193. [PMID: 24154997 DOI: 10.1136/bcr-2013-009193] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 33-year-old woman presented with ventricular fibrillation cardiac arrest and was found to have a blood glucose of 1.83 mmol/L. Cardiac catheterisation revealed a dilated left ventricle with an ejection fraction (EF) of 26% and angiographically normal coronary arteries. Continuous dextrose infusion was required to treat hypoglycaemia, which prompted consideration of insulinoma as a possible cause for her cardiomyopathy. Whipple's triad was demonstrated; a 72 h fast provided biochemical evidence of insulinoma, and imaging localised a tumour in her pancreas. The tumour was resected and pathology confirmed insulinoma; pancreaticoduodenectomy cured her hypoglycaemia. No alternate cause of cardiomyopathy was found and 4 months after surgery her EF improved to 41%. High insulin levels can close cardiac K(ATP) channels associated with dilated cardiomyopathy; the catecholamine surge from hypoglycaemia may also contribute to ventricular remodelling. Hypoglycaemia can cause QT segment prolongation, and may have precipitated fibrillation in this patient's arrhythmia-prone myocardium.
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Affiliation(s)
- Arthi Thirumalai
- Internal Medicine Residency Program, University of Washington, Seattle, Washington, USA
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29
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Mostert V, Nakayama A, Austin LM, Levander XA, Ferris CD, Hill KE, Burk RF. Serum Iron Increases with Acute Inductionof Hepatic Heme Oxygenase-1 in Mice. Drug Metab Rev 2008; 39:619-26. [PMID: 17786642 DOI: 10.1080/03602530701468342] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [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] [Indexed: 12/13/2022]
Abstract
Heme oxygenase (HO)-1 is induced by oxidative stress and protects against oxidant injury. We examined the effect of rapid induction of hepatic HO-1 on serum iron level. Serum iron was approximately doubled within 6 h when HO-1 was induced by phenobarbital treatment of selenium-deficient mice. Blocking heme synthesis with diethyl 1,4-dihydro-2,4,6-trimethyl-3,5-pyridinedicarboxylate (DDC) prevented the induction of HO-1 and the rise in serum iron. DDC did not block HO-1 induction by hemin. Inhibition of HO activity by tin protoporphyrin prevented a rise in serum iron that occurred following phorone treatment. These results indicate that heme synthesis or an exogenous source of heme is needed to allow induction of HO-1. Further, they link HO-1 induction with a rise in serum iron, suggesting that the iron resulting from catabolism of heme by HO-1 is released by the liver.
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Affiliation(s)
- Volker Mostert
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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30
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Burk RF, Hill KE, Nakayama A, Mostert V, Levander XA, Motley AK, Johnson DA, Johnson JA, Freeman ML, Austin LM. Selenium deficiency activates mouse liver Nrf2-ARE but vitamin E deficiency does not. Free Radic Biol Med 2008; 44:1617-23. [PMID: 18279678 PMCID: PMC2346531 DOI: 10.1016/j.freeradbiomed.2008.01.016] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [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: 11/01/2007] [Revised: 01/10/2008] [Accepted: 01/15/2008] [Indexed: 11/24/2022]
Abstract
Selenium (Se) and vitamin E are antioxidant micronutrients. Se functions through selenoproteins and vitamin E reacts with oxidizing molecules in membranes. The relationship of these micronutrients with the Nrf2-antioxidant response element (ARE) pathway was investigated using ARE-reporter mice and Nrf2-/- mice. Weanling males were fed Se-deficient (0 Se), vitamin E-deficient (0 E), or control diet for 16 or 22 weeks. The ARE reporter was elevated 450-fold in 0 Se liver but was not elevated in 0 E liver. Antioxidant enzymes induced by Nrf2-ARE (glutathione S-transferase (GST), NAD(P)H quinone oxidoreductase (NQOR), and heme oxygenase-1 (HO-1)) were elevated in 0 Se livers but not in 0 E livers. Deletion of Nrf2 had varying effects on the inductions, with GST induction being abolished by it but induction of NQOR and HO-1 still occurring. Thus, Se deficiency, but not vitamin E deficiency, induces a number of enzymes that protect against oxidative stress and modify xenobiotic metabolism through Nrf2-ARE and other stress-response pathways. We conclude that Se deficiency causes cytosolic oxidative stress but that vitamin E deficiency does not. This suggests that the oxidant defense mechanisms in which these antioxidant nutrients function are independent of one another.
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Affiliation(s)
- Raymond F Burk
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232-0252, USA.
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Burk RF, Hill KE, Nakayama A, Mostert V, Levander XA, Motley AK, Freeman ML, Austin LM. Selenium Deficiency, but Not Vitamin E Deficiency, Activates the Mouse Liver Nrf2‐ARE Pathway. FASEB J 2008. [DOI: 10.1096/fasebj.22.1_supplement.156.4] [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: 11/11/2022]
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