Publications by authors named "Chinazo O Cunningham"

121 Publications

Shorter outpatient wait-times for buprenorphine are associated with linkage to care post-hospital discharge.

Drug Alcohol Depend 2021 Jul 20;224:108703. Epub 2021 Apr 20.

Department of Medicine, Boston University School of Medicine, 801 Massachusetts Ave, Boston, MA, 02118, USA.

Background: Inpatient addiction consult services (ACS) lower barriers to accessing medications for opioid use disorder (MOUD), however not every patient recommended for MOUD links to outpatient care. We hypothesized that fewer days between discharge date and outpatient appointment date was associated with improved linkage to buprenorphine treatment among patients evaluated by an ACS.

Methods: We extracted appointment and demographic data from electronic medical records and conducted retrospective chart review of adults diagnosed with opioid use disorder (OUD) evaluated by an ACS in Boston, MA between July 2015 and August 2017. These patients were initiated on or recommended buprenorphine treatment on discharge and provided follow-up appointment at our hospital post-discharge. Multivariable logistic regression assessed whether arrival to the appointment post-discharge was associated with shorter wait-times (0-1 vs. 2+ days).

Results: In total, 142 patients were included. Among patients who had wait-times of 0-1 day, 63 % arrived to their appointment compared to wait-times of 2 or more days (42 %). There were no significant differences between groups based on age, gender, distance of residence from the hospital, insurance status, co-occurring alcohol use disorder diagnosis, or discharge with buprenorphine prescription. After adjusting for covariates, patients with 0-1 day of wait-time had 2.6 times the odds of arriving to their appointment [95 % CI 1.3-5.5] compared to patients who had 2+ days of wait-time.

Conclusion: For hospitalized patients with OUD evaluated for initiating MOUD, same- and next-day appointments are associated with increased odds of linkage to outpatient MOUD care post-discharge compared to waiting two or more days.
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http://dx.doi.org/10.1016/j.drugalcdep.2021.108703DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8180499PMC
July 2021

Effect of Changing Electronic Health Record Opioid Analgesic Dispense Quantity Defaults on the Quantity Prescribed: A Cluster Randomized Clinical Trial.

JAMA Netw Open 2021 Apr 1;4(4):e217481. Epub 2021 Apr 1.

Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York.

Importance: Interventions to improve judicious prescribing of opioid analgesics for acute pain are needed owing to the risks of diversion, misuse, and overdose.

Objective: To assess the effect of modifying opioid analgesic prescribing defaults in the electronic health record (EHR) on prescribing and health service use.

Design, Setting, And Participants: A cluster randomized clinical trial with 2 parallel arms was conducted between June 13, 2016, and June 13, 2018, in a large urban health care system comprising 32 primary care and 4 emergency department (ED) sites in the Bronx, New York. Data were analyzed using a difference-in-differences method from 6 months before implementation through 18 months after implementation. Data were analyzed from January 2019 to February 2020.

Interventions: A default dispense quantity for new opioid analgesic prescriptions of 10 tablets (intervention) vs no change (control) in the EHR.

Main Outcomes And Measures: The primary outcome was the quantity of opioid analgesics prescribed with the new default prescription. Secondary outcomes were opioid analgesic reorders and health service use within 30 days after the new prescription. Intention-to-treat analysis was conducted.

Results: Overall, 21 331 patients received a new opioid analgesic prescription from 490 prescribers. Comparing the intervention and control arms, site, prescriber, and patient characteristics were similar. For the new prescription, compared with the control arm, patients in the intervention arm had significantly more prescriptions for 10 tablets or fewer (7.6 percentage points; 95% CI, 6.1-9.2 percentage points), a lower number of tablets prescribed (-2.1 tablets; 95% CI, -3.3 to -0.9 tablets), and lower morphine milligram equivalents (MME) prescribed (-14.6 MME; 95% CI, -22.6 to -6.6 MME). Within 30 days after the new prescription, significant differences remained in the number of tablets prescribed (-2.7 tablets; 95% CI, -4.8 to -0.6 tablets), but not MME (-15.8 MME; 95% CI, -33.8 to 2.2 MME). Within this 30-day period, there were no significant differences between the arms in health service use.

Conclusions And Relevance: In this study, implementation of a uniform reduced default dispense quantity of 10 tablets for opioid analgesic prescriptions led to a modest reduction in the quantity prescribed initially, without significantly increasing health service use. However, during 30 days after implementation, the influence on prescribing was mixed. Reducing EHR default dispense quantities for opioid analgesics is a feasible strategy that can be widely disseminated and may modestly reduce prescribing.

Trial Registration: ClinicalTrials.gov Identifier: NCT03003832.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.7481DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8063068PMC
April 2021

"We'll be able to take care of ourselves" - A qualitative study of client attitudes toward implementing buprenorphine treatment at syringe services programs.

Subst Abus 2021 Mar 24:1-7. Epub 2021 Mar 24.

Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA.

Background: Syringe services programs (SSPs) complement substance use disorder treatment in providing services that improve the health of people who use drugs (PWUD). Buprenorphine treatment is an effective underutilized opioid use disorder treatment. Regulations allow buprenorphine prescribing from office-based settings, potentially including SSPs although few studies have examined this approach. Our objective was to assess the attitudes among PWUD toward the potential introduction of buprenorphine treatment in an SSP. : In this qualitative study, we recruited 34 participants who were enrolled at a New York City-based SSP to participate in one of seven focus group sessions. The focus group facilitators prompted participants to share their thoughts in five domains: attitudes toward (1) medical clinics; (2) harm reduction in general; (3) SSP-based buprenorphine treatment; (4) potential challenges of SSP-based treatment; and (5) logistical considerations of an SSP-based buprenorphine treatment program. Four researchers analyzed focus group transcripts using thematic analysis. : Of the 34 participants, most were white (68%), over the age of 40 years old (56%), and had previously tried buprenorphine (89%). Common themes were: 1) The SSP is a supportive community for people who use drugs; 2) Participants felt less stigmatized at the SSP than in general medical settings; 3) Offering buprenorphine treatment could change the SSP's culture; and 4) SSP participants receiving buprenorphine may be tempted to divert their medication. Participants offered suggestions for a slow intentional introduction of buprenorphine treatment at the SSP including structured appointments, training medical providers in harm reduction, and program eligibility criteria. : Overall, participants expressed enthusiasm for onsite buprenorphine treatment at SSPs. Research on SSP-based buprenorphine treatment should investigate standard buprenorphine treatment outcomes but also any effects on the program itself and medication diversion. Implementation should consider cultural and environmental aspects of the SSP and consult program staff and participants.
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http://dx.doi.org/10.1080/08897077.2021.1901173DOI Listing
March 2021

Prevalence and Medication Treatment of Opioid Use Disorder Among Primary Care Patients with Hepatitis C and HIV.

J Gen Intern Med 2021 04 10;36(4):930-937. Epub 2021 Feb 10.

Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, STE 1600, Seattle, WA, 98101 (206) 948-1933, USA.

Background: Hepatitis C and HIV are associated with opioid use disorders (OUD) and injection drug use. Medications for OUD can prevent the spread of HCV and HIV.

Objective: To describe the prevalence of documented OUD, as well as receipt of office-based medication treatment, among primary care patients with HCV or HIV.

Design: Retrospective observational cohort study using electronic health record and insurance data.

Participants: Adults ≥ 18 years with ≥ 2 visits to primary care during the study (2014-2016) at 6 healthcare systems across five states (CO, CA, OR, WA, and MN).

Main Measures: The primary outcome was the diagnosis of OUD; the secondary outcome was OUD treatment with buprenorphine or oral/injectable naltrexone. Prevalence of OUD and OUD treatment was calculated across four groups: HCV only; HIV only; HCV and HIV; and neither HCV nor HIV. In addition, adjusted odds ratios (AOR) of OUD treatment associated with HCV and HIV (separately) were estimated, adjusting for age, gender, race/ethnicity, and site.

Key Results: The sample included 1,368,604 persons, of whom 10,042 had HCV, 5821 HIV, and 422 both. The prevalence of diagnosed OUD varied across groups: 11.9% (95% CI: 11.3%, 12.5%) for those with HCV; 1.6% (1.3%, 2.0%) for those with HIV; 8.8% (6.2%, 11.9%) for those with both; and 0.92% (0.91%, 0.94%) among those with neither. Among those with diagnosed OUD, the prevalence of OUD medication treatment was 20.9%, 16.0%, 10.8%, and 22.3%, for those with HCV, HIV, both, and neither, respectively. HCV was not associated with OUD treatment (AOR = 1.03; 0.88, 1.21), whereas patients with HIV had a lower probability of OUD treatment (AOR = 0.43; 0.26, 0.72).

Conclusions: Among patients receiving primary care, those diagnosed with HCV and HIV were more likely to have documented OUD than those without. Patients with HIV were less likely to have documented medication treatment for OUD.
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http://dx.doi.org/10.1007/s11606-020-06389-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8041979PMC
April 2021

Medical Marijuana and Opioids (MEMO) Study: protocol of a longitudinal cohort study to examine if medical cannabis reduces opioid use among adults with chronic pain.

BMJ Open 2020 12 29;10(12):e043400. Epub 2020 Dec 29.

Division of General Internal Medicine, Montefiore Health System, Bronx, New York, USA.

Introduction: In the USA, opioid analgesic use and overdoses have increased dramatically. One rapidly expanding strategy to manage chronic pain in the context of this epidemic is medical cannabis. Cannabis has analgesic effects, but it also has potential adverse effects. Further, its impact on opioid analgesic use is not well studied. Managing pain in people living with HIV is particularly challenging, given the high prevalence of opioid analgesic and cannabis use. This study's overarching goal is to understand how medical cannabis use affects opioid analgesic use, with attention to Δ9-tetrahydrocannabinol and cannabidiol content, HIV outcomes and adverse events.

Methods And Analyses: We are conducting a cohort study of 250 adults with and without HIV infection with (a) severe or chronic pain, (b) current opioid use and (c) who are newly certified for medical cannabis in New York. Over 18 months, we collect data via in-person visits every 3 months and web-based questionnaires every 2 weeks. Data sources include: questionnaires; medical, pharmacy and Prescription Monitoring Program records; urine and blood samples; and physical function tests. Using marginal structural models and comparisons within participants' 2-week time periods (unit of analysis), we will examine how medical cannabis use (primary exposure) affects (1) opioid analgesic use (primary outcome), (2) HIV outcomes (HIV viral load, CD4 count, antiretroviral adherence, HIV risk behaviours) and (3) adverse events (cannabis use disorder, illicit drug use, diversion, overdose/deaths, accidents/injuries, acute care utilisation).

Ethics And Dissemination: This study is approved by the Montefiore Medical Center/Albert Einstein College of Medicine institutional review board. Findings will be disseminated through conferences, peer-reviewed publications and meetings with medical cannabis stakeholders.

Trial Registration Number: ClinicalTrials.gov Registry (NCT03268551); Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2020-043400DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7778768PMC
December 2020

Abstinence-reinforcing contingency management improves HIV viral load suppression among HIV-infected people who use drugs: A randomized controlled trial.

Drug Alcohol Depend 2020 11 11;216:108230. Epub 2020 Aug 11.

City University of New York, School of Medicine, 160 Convent Ave, New York, NY 10031, United States.

Background: HIV-infected people who use drugs (PWUD) have poor HIV outcomes. Few studies tested interventions to improve HIV outcomes among PWUD. Abstinence-reinforcing contingency management (CM) reduces drug use and could also improve HIV outcomes.

Methods: From 2012-2017, we conducted a randomized controlled trial testing whether a 16-week abstinence-reinforcing CM intervention improved HIV viral load (VL) among HIV-infected adults using opioids or cocaine. In the CM intervention, drug-free urines led to escalating value of vouchers ($2.50-$80/voucher, $1320 total maximum). In intention-to-treat mixed-effects linear and logistic regression analyses, we examined whether the CM intervention improved log VL (primary outcome), abstinence and antiretroviral adherence (secondary outcomes).

Results: Thirty-seven participants were randomized to the CM intervention and 36 to control. Median age was 49.2 years; most were male (61.6%) and non-Hispanic black (46.6%). In CM (vs. control) participants, mean reduction in log VL was greater (-0.16 log VL copies/mL per 4-week period; 95% CI: -0.29 to -0.03, p < 0.05). Over 16 weeks, CM participants had a mean reduction of 0.64 copies/mL in log VL greater than control participants. The CM intervention was not significantly associated with abstinence or adherence.

Conclusions: This is the first study to demonstrate improvements in HIV VL via an abstinence-reinforcing CM intervention. Because the CM intervention did not significantly affect abstinence or adherence, the mechanism of its effect is unclear. To end the HIV epidemic, innovative strategies must address individuals with poor HIV outcomes. Abstinence-reinforcing CM may be one potential strategy to improve HIV outcomes among a select group of PWUD.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108230DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7606653PMC
November 2020

Daily and near-daily cannabis use is associated with HIV viral load suppression in people living with HIV who use cocaine.

AIDS Care 2020 Aug 4:1-8. Epub 2020 Aug 4.

Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA.

Disparities remain in HIV viral load (VL) suppression between people living with HIV (PLWH) who use cocaine and those who do not. It is not known how cannabis use affects VL suppression in PLWH who use cocaine. We evaluated the relationship between cannabis use and VL suppression among PLWH who use cocaine. We conducted a secondary data analysis of 119 baseline interviews from a randomized controlled trial in the Bronx, NY (6/2012 to 1/2017). Participants were adult PLWH prescribed antiretrovirals for ≥16 weeks, who endorsed imperfect antiretroviral adherence and used cocaine in the past 30-days. In bivariate and multivariable regression analyses, we examined how cannabis use, is associated with VL suppression among PLWH who use cocaine. Participants were a mean age of 50 years; most were male (64%) and non-Hispanic black (55%). Participants with VL suppression used cocaine less frequently than those with no VL suppression ( < 0.01); cannabis use was not significantly different. In regression analysis, compared with no use, daily/near-daily cannabis use was associated with VL suppression (aOR = 4.2, 95% CI: 1.1-16.6,  < 0.05). Less-frequent cannabis use was not associated with VL suppression. Further investigation is needed to understand how cannabis use impacts HIV outcomes among PLWH who use cocaine.
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http://dx.doi.org/10.1080/09540121.2020.1799922DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7858684PMC
August 2020

A Pilot Study to Evaluate a Novel Pre-exposure Prophylaxis Peer Outreach and Navigation Intervention for Women at High Risk for HIV Infection.

AIDS Behav 2021 May;25(5):1411-1422

Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 3300 Kossuth Avenue, Bronx, NY, 10467, USA.

Pre-exposure prophylaxis (PrEP) uptake remains woefully low among U.S. women at high risk for HIV acquisition. We evaluated a pilot intervention which involved Peers providing brief PrEP education and counseling at mobile syringe exchange sites and at sex worker and syringe exchange drop-in centers followed by navigation to PrEP care. Peers recruited English-proficient, self-identified women (i.e., cisgender and transgender women and persons with other transfeminine identities) over a 3-month period and delivered the intervention to 52 HIV-negative/status unknown participants. Thirty-eight participants (73.1%) reported PrEP interest, 27 (51.9%) accepted the offer of a PrEP appointment, 13 (25.0%) scheduled a PrEP appointment, 3 (5.8%) attended an initial PrEP appointment, and none were prescribed PrEP. We found a gap between PrEP interest and connecting women to PrEP care. Further study is needed to understand this gap, including exploring innovative approaches to delivering PrEP care to women at highest risk for HIV.
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http://dx.doi.org/10.1007/s10461-020-02979-yDOI Listing
May 2021

Treatment with buprenorphine prior to EcoHIV infection of mice prevents the development of neurocognitive impairment.

J Leukoc Biol 2021 03 24;109(3):675-681. Epub 2020 Jun 24.

Department of Pathology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA.

Approximately 15-40% of people living with HIV develop HIV-associated neurocognitive disorders, HAND, despite successful antiretroviral therapy. There are no therapies to treat these disorders. HIV enters the CNS early after infection, in part by transmigration of infected monocytes. Currently, there is a major opioid epidemic in the United States. Opioid use disorder in the context of HIV infection is important because studies show that opioids exacerbate HIV-mediated neuroinflammation that may contribute to more severe cognitive deficits. Buprenorphine is an opioid derivate commonly prescribed for opiate agonist treatment. We used the EcoHIV mouse model to study the effects of buprenorphine on cognitive impairment and to correlate these with monocyte migration into the CNS. We show that buprenorphine treatment prior to mouse EcoHIV infection prevents the development of cognitive impairment, in part, by decreased accumulation of monocytes in the brain. We propose that buprenorphine has a novel therapeutic benefit of limiting the development of neurocognitive impairment in HIV-infected opioid abusers as well as in nonabusers, in addition to decreasing the use of harmful opioids. Buprenorphine may also be used in combination with HIV prevention strategies such as pre-exposure prophylaxis because of its safety profile.
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http://dx.doi.org/10.1002/JLB.5AB0420-531RDOI Listing
March 2021

Internal Medicine Residents' Feelings of Responsibility, Confidence, and Clinical Practice in Opioid Overdose Prevention and Naloxone Prescribing.

J Addict Med 2020 Sep/Oct;14(5):e147-e152

Icahn School of Medicine at Mount Sinai, NY (LW); Albert Einstein College of Medicine/Montefiore Medical Center, NY (COC, CB, SI).

Objectives: We assessed internal medicine residents' attitudes and clinical practices regarding opioid overdose prevention education and naloxone prescribing as a first step in developing curriculum to train residents on these topics.

Methods: We adapted a previously validated questionnaire to assess residents' feelings of responsibility, confidence and clinical practice in opioid overdose prevention and naloxone prescribing.

Results: Nearly all 90 residents (62% response rate) felt responsible and most felt confident in: assessing patients for risk of opioid overdose (95% and 57%, respectively), assessing patients' readiness to reduce risk of opioid overdose (95% and 73%, respectively), and advising behavior change to minimize opioid overdose risk (98% and 71%, respectively). Most felt responsible to refer patients for opioid use disorder (OUD) treatment (98%), and provide overdose prevention education and prescribe naloxone (87%). Most felt confident referring patients for OUD treatment (60%), and nearly half felt confident in providing overdose prevention education and prescribing naloxone (45%). In clinical practice, over a third reported assessing patients' risk of overdose (35%), assessing patients' readiness to reduce risk of overdose (57%), and advising behavior change to minimize overdose risk (57%). Only 17% reported providing overdose prevention education and prescribing naloxone.

Conclusions: Despite feeling responsible and confident in addressing opioid overdose prevention strategies, few residents report implementing these strategies in clinical care. Residency programs must not only include curricula addressing overdose risk assessment and counseling, referral to or provision of OUD treatment, but also include curricula that impact implementation of opioid overdose prevention strategies.
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http://dx.doi.org/10.1097/ADM.0000000000000656DOI Listing
May 2020

Having a Primary Care Provider is the Strongest Predictor of Successful Follow-up of Participants in a Clinical Trial.

J Am Board Fam Med 2020 May-Jun;33(3):431-439

From Department of Radiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (SHF, LBH, JML); Department of Family and Social Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (COC); Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (COC, LBH, JML); Department of Epidemiology & Population Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (JL); Current Address: Department of Family Medicine, Overlook Medical Center, Summit, NJ (SHF).

Purpose: Ethnic minorities, women, and those of low socioeconomic status are widely underrepresented in clinical trials. Few studies have explored factors associated with successful follow-up in these historically difficult-to-reach patients. This study's objective was to identify patient characteristics and methods of contact that predict successful contact for follow-up in an urban, predominantly ethnic minority, majority-women, poor population to help devise strategies to improve retention.

Methods: We retrospectively reviewed records from a prospective randomized control trial of 400 hospitalized chest pain patients to determine which characteristics were associated with successful telephone follow-up at 1 year after enrollment. We assessed demographic variables, medical history, and social factors by using bivariate analyses. A multivariate analysis was performed using variables from the bivariate analysis with ≤ .2.

Results: The overall successful 1-year follow-up rate was 95% (381/400). Study participants who completed follow-up were significantly more likely to have a primary care physician (PCP) (88% [337/381] versus 68% [13/19]), speak English natively (52% [199/381] versus 26% [5/19]), have a higher Charlson comorbidity index score, and identify as women (64.0% [244/381] versus 42.1% [8/19]). Having a PCP and native English language remained significant at multivariate analysis. Socioeconomic status score, quantity of contact information recorded at recruitment, and insurance status were not significantly associated with successful follow-up.

Conclusions: Patients engaged with the health care system by having a PCP are significantly more likely to achieve follow-up. Successful follow-up is also associated with native English speaking. The potential of improving follow-up by facilitating connections with health care providers requires further study.
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http://dx.doi.org/10.3122/jabfm.2020.03.190018DOI Listing
January 2019

The Importance of Pediatric Safety in Tetrahydrocannabinol Education-Reply.

JAMA Intern Med 2020 07;180(7):1027

Division of General Internal Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York.

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http://dx.doi.org/10.1001/jamainternmed.2020.1394DOI Listing
July 2020

COVID-19: The Worst Days of Our Careers.

Ann Intern Med 2020 06 13;172(11):764-765. Epub 2020 Apr 13.

Montefiore Health System and Albert Einstein College of Medicine, Bronx, New York (C.O.C., C.D., D.E.S.).

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http://dx.doi.org/10.7326/M20-1715DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7161307PMC
June 2020

Documented opioid use disorder and its treatment in primary care patients across six U.S. health systems.

J Subst Abuse Treat 2020 03;112S:41-48

Kaiser Permanente Washington Health Research Institute, United States of America.

Background: The United States is in the middle of an opioid overdose epidemic, and experts are calling for improved detection of opioid use disorders (OUDs) and treatment with buprenorphine or extended release (XR) injectable naltrexone, which can be prescribed in general medical settings. To better understand the magnitude of opportunities for treatment among primary care (PC) patients, we estimated the prevalence of documented OUD and medication treatment of OUD among PC patients.

Methods: This cross-sectional study included patients with ≥2 visits to PC clinics across 6 healthcare delivery systems who were ≥16 years of age during the study period (fiscal years 2014-2016). Diagnoses, prescriptions, and healthcare utilization were ascertained from electronic health records and insurance claims (5 systems that also offer health insurance). Documented OUDs were defined as ≥1 International Classification of Diseases code for OUDs (active or remission), and OUD treatment was defined as ≥1 prescription(s) for buprenorphine formulations indicated for OUD or naltrexone XR, during the 3-year study period. The prevalence of documented OUD and treatment (95% confidence intervals) across health systems were estimated, and characteristics of patients by treatment status were compared. Prevalence of OUD and OUD treatment were adjusted for age, gender, and race/ethnicity. Combined results were also adjusted for site.

Result: Among 1,403,327 eligible PC patients, 54-62% were female and mean age ranged from 46 to 51 years across health systems. The 3-year prevalence of documented OUD ranged from 0.7-1.4% across the health systems. Among patients with documented OUD, the prevalence of medication treatment (primarily buprenorphine) varied across health systems: 3%, 12%, 16%, 20%, 22%, and 36%.

Conclusion: The prevalence of documented OUD and OUD treatment among PC patients varied widely across health systems. The majority of PC patients with OUD did not have evidence of treatment with buprenorphine or naltrexone XR, highlighting opportunities for improved identification and treatment in medical settings. These results can inform initiatives aimed at improving treatment of OUD in PC. Future research should focus on why there is such variation and how much of the variation can be addressed by improving access to medication treatment.
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http://dx.doi.org/10.1016/j.jsat.2020.02.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7107675PMC
March 2020

Medical Record Documentation About Opioid Tapering: Examining Benefit-to-Harm Framework and Patient Engagement.

Pain Med 2020 10;21(10):2574-2582

Department of Medicine, Albert Einstein College of Medicine and Montefiore Health System, Bronx, New York.

Objective: Guidelines recommend that clinicians make decisions about opioid tapering for patients with chronic pain using a benefit-to-harm framework and engaging patients. Studies have not examined clinician documentation about opioid tapering using this framework.

Design And Setting: Thematic and content analysis of clinician documentation about opioid tapering in patients' medical records in a large academic health system.

Methods: Medical records were reviewed for patients aged 18 or older, without cancer, who were prescribed stable doses of long-term opioid therapy between 10/2015 and 10/2016 then experienced an opioid taper (dose reduction ≥30%) between 10/2016 and 10/2017. Inductive thematic analysis of clinician documentation within six months of taper initiation was conducted to understand rationale for taper, and deductive content analysis was conducted to determine the frequencies of a priori elements of a benefit-to-harm framework.

Results: Thematic analysis of 39 patients' records revealed 1) documented rationale for tapering prominently cited potential harms of continuing opioids, rather than observed harms or lack of benefits; 2) patient engagement was variable and disagreement with tapering was prominent. Content analysis found no patients' records with explicit mention of benefit-to-harm assessments. Benefits of continuing opioids were mentioned in 56% of patients' records, observed harms were mentioned in 28%, and potential harms were mentioned in 90%.

Conclusions: In this study, documentation of opioid tapering focused on potential harms of continuing opioids, indicated variable patient engagement, and lacked a complete benefit-to-harm framework. Future initiatives should develop standardized ways of incorporating a benefit-to-harm framework and patient engagement into clinician decisions and documentation about opioid tapering.
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http://dx.doi.org/10.1093/pm/pnz361DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7593794PMC
October 2020

Drug use and HIV medication adherence in people living with HIV.

Subst Abus 2020 Jan 17:1-7. Epub 2020 Jan 17.

Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA.

Opioid and cocaine use epidemics continue to be substantial in the United States and intersect with the HIV epidemic. Antiretroviral medication (ARV) adherence is critical for optimum HIV outcomes. While previous research explored harm reduction strategies to prevent HIV spread for people who use drugs (PWUD), little is known about strategies used by PWUD living with HIV to maintain ARV adherence. We explored whether PWUD modify their drug use explicitly to maintain ARV adherence, and identified factors associated with this process. We conducted 23 semi-structured interviews. Data were analyzed using a modified framework analysis approach. Participants had a mean age of 54 years and were predominantly male (70%) and non-Hispanic black (65%). Most described periods of being able to adhere to ARVs while still using drugs, difficulty adhering to ARVs while using drugs, and abstinence/near abstinence from drug use. In exploring factors that influenced changes in drug use and ARV adherence behaviors, we noted consistent acknowledgment of the roles of family, partners, or providers. PWUD living with HIV often modify their drug use to improve ARV adherence. Providers caring for this population might consider family or group education models to encourage harm reduction to improve outcomes.
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http://dx.doi.org/10.1080/08897077.2019.1706695DOI Listing
January 2020

A Multicenter Randomized Controlled Trial of Intensive Group Therapy for Tobacco Treatment in HIV-Infected Cigarette Smokers.

J Acquir Immune Defic Syndr 2020 04;83(4):405-414

Departments of Epidemiology and Population Health.

Background: Tobacco use has emerged as the leading killer of persons living with HIV (PLWH) in the United States. Little is known about the efficacy of tobacco treatment strategies in PLWH.

Design: Randomized controlled trial comparing Positively Smoke Free (PSF), an intensive group therapy intervention targeting HIV-infected smokers, to brief advice to quit. All participants were offered a 12-week supply of nicotine patches.

Methods: A cohort of 450 PLWH smokers, recruited from HIV-care centers in the Bronx, New York, and Washington, DC, were randomized 1:1 into the PSF or brief advice to quit conditions. PSF is an 8-session program tailored to address the needs and concerns of HIV-infected smokers and delivered by a trained smoking cessation counselor and PLWH ex-smoker peer pair. The primary outcome was biochemically confirmed, 7-day point-prevalence abstinence at 6 months.

Results: In the intention to treat analysis, PSF condition subjects had nearly double the quit rate of controls, 13% vs. 6.6% [odds ratio = 2.10 (95% confidence interval = 1.10 to 4.14), P = 0.04], at 3 months, but no significant difference in abstinence was observed at 6 months. PSF participants exhibited lower nicotine dependence and higher self-efficacy to resist smoking temptations at both 3 and 6 months compared with controls. Lower educational attainment, current cocaine use, past use of nicotine patches, and higher distress tolerance were significant predictors of continued smoking at 6 months.

Conclusions: These findings suggest a role for group therapy among tobacco treatments for PLWH smokers, but strategies to augment the durability of early effects are needed.
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http://dx.doi.org/10.1097/QAI.0000000000002271DOI Listing
April 2020

The Void in Clinician Counseling of Cannabis Use.

J Gen Intern Med 2020 06 2;35(6):1875-1878. Epub 2020 Jan 2.

Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.

As more states legalize cannabis for medical use, people increasingly use cannabis to treat medical conditions. Well-documented harms of cannabis use include increased risk of fatal auto accidents, neurocognitive deficits, and increased risk of addiction. Observational data supports the use of cannabis for pain, nausea and vomiting related to chemotherapy, and multiple sclerosis spasticity symptoms. Given potential harms versus benefits of cannabis use, how should physicians counsel patients regarding their cannabis use? This paper briefly reviews the evidence supporting medical cannabis use for pain. We consider cannabis use as a harm reduction strategy for pain management. We encourage routine, longitudinal assessments of cannabis use among patients. We discuss the commercialization of cannabis for financial gain, contributing to potent and addictive cannabis. We highlight the concerning phenomena of cannabis dispensary workers as proxy clinicians. Finally, we present three strategies to reduce public harms associated with potent cannabis use including required testing and reporting of tetrahydrocannabinol/cannabidiol concentrations, rigorous study of high-potency cannabis available for purchase in dispensaries across the USA, and large-scale efforts to measure cannabis consumption in medical records so prospective, longitudinal studies can be conducted to correlate consumption measures with medical and psychiatric outcomes.
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http://dx.doi.org/10.1007/s11606-019-05612-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7280395PMC
June 2020

Preferences for implementation of HIV pre-exposure prophylaxis (PrEP): Results from a survey of primary care providers.

Prev Med Rep 2020 Mar 21;17:101012. Epub 2019 Oct 21.

Albert Einstein College of Medicine, Montefiore Health System, Bronx, NY, United States.

Primary care physicians (PCPs) are critical for promoting HIV prevention by prescribing pre-exposure prophylaxis (PrEP). Yet, there are limited data regarding PCP's preferred approaches for PrEP implementation. In 2015, we conducted an online survey of PCPs' PrEP prescribing and implementation. Participants were general internists recruited from a national professional organization. We examined provider and practice characteristics and perceived implementation barriers and facilitators associated with preferred models for PrEP implementation. Among 240 participants, the majority (85%) favored integrating PrEP into primary care, either by training all providers ("all trained") (42%) or having an onsite PrEP specialist ("on-site specialist") (43%). Only 15% preferred referring patients out of the practice to a specialist ("refer out"). Compared to those who preferred to "refer out," participants who preferred the "all trained" model were more likely to spend most of their time delivering direct patient care and to practice in the Northeast. Compared to participants who preferred the "refer out" or on-site specialist" models, PCPs preferring the all trained model were less likely to perceive lack of clinic PrEP guidelines/protocols as a barrier to PrEP. Most PCPs favored integrating PrEP into primary care by either training all providers or having an on-site specialist. Time devoted to clinical care and geography may influence preferences for PrEP implementation. Establishing clinic-specific PrEP protocols may promote on-site PrEP implementation. Future studies should focus on evaluating the effectiveness of different PrEP implementation models on PrEP delivery.
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http://dx.doi.org/10.1016/j.pmedr.2019.101012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6926349PMC
March 2020

Factor structure, internal reliability and construct validity of the Methadone Maintenance Treatment Stigma Mechanisms Scale (MMT-SMS).

Addiction 2020 02 27;115(2):354-367. Epub 2019 Nov 27.

Department of Human Development and Family Sciences, University of Delaware, Newark, DE, USA.

Background And Aim: Experience of stigma towards methadone maintenance treatment (MMT) may be a barrier to the use of this treatment by people with opioid use disorder. We evaluated the factor structure, internal reliability, construct and criterion validity of a theory-based stigma measure, the Methadone Maintenance Treatment Stigma Mechanisms Scale (MMT-SMS) and compared this with the Substance Use Stigma Mechanism Scale (SU-SMS).

Design: Surveys at the beginning and end of a prospective study together with records of drug use and treatment attendance during that study.

Setting: Community methadone clinic in the Northeastern USA.

Participants: Ninety-three participants who were receiving MMT; the average daily methadone dose was 84.8 mg/day (standard deviation = 28.39 mg/day).

Measurements: The MMT-SMS uses a self-report questionnaire to assess three dimensions reflecting experiences of anticipated (nine items), enacted (nine items) and internalized stigma (seven items) specifically related to receiving MMT. Anticipated and enacted scales include three stigma source subscales (family, employers, health care workers; three items each). Responses are recorded on a five-point Likert-type scale, then averaged to produce the MMT-SMS scale/subscale scores. The SU-SMS is a self-report questionnaire to assess experiences of anticipated, enacted and internalized stigma regarding substance use history. Both scales were administered at the final parent study visit. Other measures included were assessed in the parent study and used to assess life-time and recent MMT (e.g. current MMT dose) and drug use experiences (e.g. past 30-day heroin injection).

Findings: The MMT-SMS demonstrated good internal reliability (α = 0.806-0.952 for components). Confirmatory factor analysis supported the seven-factor scale structure, distinguishing between experiences of anticipated, enacted and internalized stigma, and anticipated and enacted stigma source subscales (family, employers, health care workers) [root mean square error of approximation (RMSEA) = 0.076, 90% confidence interval (CI) = 0.061-0.090, P-close = 0.003; confirmatory fit index (CFI) = 0.974; Tucker-Lewis index (TLI) = 0.971]. Construct validity helped to distinguish the MMT-SMS from established substance use stigma constructs. Criterion validity observed associations with substance use experiences while on MMT, likely to predict future MMT success. Internalized MMT stigma was uniquely associated with daily MMT dose. Regarding criterion validity: anticipated MMT and enacted substance use stigma were associated with past 30-day heroin injection, MMT stigma uniquely associated with opioid use behaviors while receiving MMT, and substance use stigma broadly associated with injection-related behaviors.

Conclusions: The Methadone Maintenance Treatment Stigma Mechanisms Scale appears to be a reliable measure of methadone maintenance treatment stigma with robust validity in a sample of people with opioid use disorders receiving methadone maintenance treatment.
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http://dx.doi.org/10.1111/add.14799DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7089617PMC
February 2020

Opioid Taper Is Associated with Subsequent Termination of Care: a Retrospective Cohort Study.

J Gen Intern Med 2020 01 19;35(1):36-42. Epub 2019 Aug 19.

Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.

Background: Opioid tapering is increasingly utilized by providers to decrease risks of chronic opioid therapy, but it is unknown whether tapering is associated with termination of care.

Objective: To determine whether patients taking chronic opioid therapy who experienced opioid tapers were at greater risk of subsequently terminating their care compared with those who were continued on their doses.

Design: Retrospective cohort study of patients in a large, urban health system between 2008 and 2012 with 2 years of follow-up.

Participants: Adult patients prescribed a stable baseline dose of chronic opioid therapy of at least 25 morphine milligram equivalents per day during a baseline year.

Main Measures: An opioid taper during an exposure year, defined as a reduction in the average daily dose of at least 30% from the baseline dose in both of the two 6-month periods in the year following the baseline year. Opioid dose continuation was defined as any increase in dose, no change in dose, or any decrease up to 30% compared with baseline dose in the exposure year. The primary outcome was termination of care, defined as no outpatient encounters in the health system, in the year following the exposure year.

Key Results: Of 1624 patients on chronic opioid therapy, 207 (15.5%) experienced an opioid taper and 78 (4.8%) experienced termination of care. Compared with opioid dose continuation, opioid taper was significantly associated with termination of care (AOR 4.3 [95% CI 2.2-8.5]).

Conclusions: Opioid taper is associated with subsequent termination of care. These findings invite caution and demonstrate the need to fully understand the risks and benefits of opioid tapers.
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http://dx.doi.org/10.1007/s11606-019-05227-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6957663PMC
January 2020

Undocumented African Immigrants' Experiences of HIV Testing and Linkage to Care.

AIDS Patient Care STDS 2019 07 13;33(7):336-341. Epub 2019 Jun 13.

4 New York City Department of Health and Mental Hygiene, New York, New York.

In the United States, undocumented African immigrants living with HIV enter care late, potentially leading to adverse individual and population health outcomes, yet little is known about the specific experiences of HIV diagnosis and linkage to care among this population. We conducted individual, semi-structured interviews with adults who were undocumented African immigrants living with HIV in New York City. Interviews explored perspectives regarding individual, social, institutional, and societal barriers and facilitators of HIV testing and linkage to care. Of 14 participants from 9 different African countries, 9 were women and the median age was 44 years (interquartile range: 42-50). Participants described fear of discovery by immigration authorities as a substantial barrier to HIV testing and linking to initial medical appointments. Actual and perceived structural barriers to both testing and care linkage included difficulty obtaining health insurance and a belief that undocumented immigrants are ineligible for any health services. Participants also expressed reluctance to be tested because of HIV-related stigma within the immigrant communities that they heavily relied on. After diagnosis, however, participants overwhelmingly described a positive role of health and social service providers in facilitating linkage to HIV care. Concerns about immigration status and HIV-related stigma are significant barriers to HIV testing and linkage to care among undocumented African immigrants. Multilevel efforts to reduce stigma and increase awareness of available services could enhance rates of HIV testing and care linkage in this population.
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http://dx.doi.org/10.1089/apc.2019.0036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6602100PMC
July 2019

An expanded HIV screening strategy in the Emergency Department fails to identify most patients with undiagnosed infection: insights from a blinded serosurvey.

AIDS Care 2020 02 30;32(2):202-208. Epub 2019 May 30.

Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA.

Screening for HIV in Emergency Departments (EDs) is recommended to address the problem of undiagnosed HIV. Serosurveys are an important method for estimating the prevalence of undiagnosed HIV and can provide insight into the effectiveness of an HIV screening strategy. We performed a blinded serosurvey in an ED offering non-targeted HIV screening to determine the proportion of patients with undiagnosed HIV who were diagnosed during their visit. The study was conducted in a high-volume, urban ED and included patients who had blood drawn for clinical purposes and had sufficient remnant specimen to undergo deidentified HIV testing. Among 4752 patients not previously diagnosed with HIV, 1403 (29.5%) were offered HIV screening and 543 (38.7% of those offered) consented. Overall, undiagnosed HIV was present in 12 patients (0.25%): six among those offered screening (0.4%), and six among those not offered screening (0.2%). Among those with undiagnosed HIV, two (16.7%) consented to screening and were diagnosed during their visit. Despite efforts to increase HIV screening, more than 80% of patients with undiagnosed HIV were not tested during their ED visit. Although half of those with undiagnosed HIV were missed because they were not offered screening, the yield was further diminished because a substantial proportion of patients declined screening. To avoid missed opportunities for diagnosis in the ED, strategies to further improve implementation of HIV screening and optimize rates of consent are needed.
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http://dx.doi.org/10.1080/09540121.2019.1619663DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6884659PMC
February 2020

Primary care engagement is associated with increased pharmacotherapy prescribing for alcohol use disorder (AUD).

Addict Sci Clin Pract 2019 05 1;14(1):19. Epub 2019 May 1.

Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, 111 E. 210th Street, Bronx, NY, 10467, USA.

Background: Primary care provider skills such as screening, longitudinal monitoring, and medication management are generalizable to prescribing alcohol use disorder (AUD) pharmacotherapy. The association between primary care engagement (i.e., longitudinal utilization of primary care services) and prescribing of AUD pharmacotherapy is unknown.

Methods: We examined a 5-year (2010-2014) retrospective cohort of patients with AUD, 18 years and older, at an urban academic medical center in the Bronx, NY, USA. Our main exposure was level of primary care engagement (no primary care, limited primary care, and engaged with primary care) and our outcome was any AUD pharmacotherapy prescription within 2 years of AUD diagnosis. Using multivariable logistic regression, we examined the association between primary care engagement and pharmacotherapy prescribing, accounting for demographic and clinical factors.

Results: Of 21,159 adults (28.9% female) with AUD, 2.1% (n = 449) were prescribed pharmacotherapy. After adjusting for confounders, the probability of receiving an AUD pharmacotherapy prescription for patients with no primary care was 1.61% (95% CI 1.39, 1.84). The probability of AUD pharmacotherapy prescribing was 2.56% (95% CI 2.06, 3.06) for patients with limited primary care and 2.89% (95% CI 2.44, 3.34%) for patients engaged with primary care.

Conclusions: The percentage of AUD patients prescribed AUD pharmacotherapy was low; however, primary care engagement was associated with a higher, but modest, probability of receiving a prescription. Efforts to increase primary care engagement among patients with AUD may translate into increased AUD pharmacotherapy prescribing; however, strategies to increase prescribing across health care settings are needed.
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http://dx.doi.org/10.1186/s13722-019-0147-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6492411PMC
May 2019

Pharmacotherapy Prescribing to Patients with Concurrent Tobacco and Alcohol Use Disorder in a Large, Urban, Integrated Health System.

J Gen Intern Med 2019 06;34(6):804-805

Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, USA.

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http://dx.doi.org/10.1007/s11606-018-4806-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6544704PMC
June 2019

Development and evaluation of a pilot overdose education and naloxone distribution program for hospitalized general medical patients.

Subst Abus 2019 26;40(1):61-65. Epub 2018 Nov 26.

a Division of General Internal Medicine, Department of Medicine , Montefiore Medical Center/Albert Einstein College of Medicine , Bronx , New York , USA.

Overdose education and naloxone distribution (OEND) to people at risk of witnessing or experiencing an opioid overdose has traditionally been provided through harm reduction agencies. Expanding OEND to inpatient general medical settings may reach at-risk individuals who do not access harm reduction services and have not been trained. An OEND program targeting inpatients was developed, piloted, and evaluated on 2 general medicine floors at Montefiore Medical Center, a large urban academic medical center in Bronx, New York. The planning committee consisted of 10 resident physicians and 2 faculty mentors. A consult service model was piloted, whereby the primary inpatient care team paged the consult team (consisting of rotating members from the planning committee) for any newly admitted patient who had used any opioid in the year prior to admission. Consult team members assessed patients for eligibility and provided OEND to eligible patients through a short video training. Upon completion, patients received a take-home naloxone kit. To evaluate the program, a retrospective chart review over the first year (April 2016 to March 2017) of the pilot was conducted. Overall, consults on 80 patients were received. Of these, 74 were eligible and the consult team successfully trained 50 (68%). Current opioid analgesic use of ≥50 morphine milligram equivalents daily was the most common eligibility criterion met (38%). Twenty-four percent of patients were admitted for an opioid-related adverse event, the most common being opioid overdose (9%), then opioid withdrawal (8%), skin complication related to injecting (5%), and opioid intoxication (2%). Twenty-five percent had experienced an overdose, 35% had witnessed an overdose in their lifetime, and 83% had never received OEND previously. Integrating OEND into general inpatient medical care is possible and can reach high-risk patients who have not received OEND previously. Future research should identify the optimal way of implementing this service.
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http://dx.doi.org/10.1080/08897077.2018.1518836DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6778336PMC
April 2020

Among whom is cigarette smoking declining in the United States? The impact of cannabis use status, 2002-2015.

Drug Alcohol Depend 2018 10 11;191:355-360. Epub 2018 Apr 11.

Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, 10032, USA; Institute for Implementation Science in Population Health, The City University of New York, New York, NY, 10027, USA; Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, The City University of New York, New York, NY, 10027, USA. Electronic address:

Objectives: To 1) estimate changes in the prevalence of daily and non-daily cigarette smoking among current (past 30-day) daily, non-daily, and non-cannabis users in the United States (U.S.) population; 2) examine time trends in current (past 30-day) cigarette smoking in daily, non-daily, and non-cannabis users ages 12+ from 2002 to 2015.

Methods: Data collected annually from the 2002 to 2015 National Survey on Drug Use and Health (NSDUH) were employed. Linear time trends of daily and non-daily cigarette smoking were assessed using logistic regression with year as the predictor.

Results: In 2015, the prevalence of current (past 30-day) cigarette smoking was highest among daily (54.57%), followed by non-daily (40.17%) and non-cannabis users (15.06%). The prevalence of non-daily cigarette smoking increased among daily cannabis users from 2002 to 2015, whereas non-daily cigarette smoking declined among non-daily cannabis users and non-cannabis users from 2002 to 2015. Daily cigarette smoking declined among both cannabis users and non-users; the most rapid decline was observed among daily cannabis users, followed by non-daily and then by non-cannabis users. However, the relative magnitude of the change in prevalence of daily cigarette smoking was similar across the three cannabis groups.

Conclusions: Despite ongoing declines in cigarette smoking in the U.S., non-daily cigarette smoking is increasing among current cannabis users, a growing proportion of the U.S.

Population: Daily and non-daily cigarette smoking continue to decline among those who do not use cannabis. Efforts to further tobacco control should consider novel co-use-oriented intervention strategies and outreach for the increasing population of cannabis users.
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http://dx.doi.org/10.1016/j.drugalcdep.2018.01.040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6432910PMC
October 2018

Race and Gender Are Associated with Opioid Dose Reduction Among Patients on Chronic Opioid Therapy.

Pain Med 2019 08;20(8):1519-1527

Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York.

Objective: Among patients with chronic pain, risk of opioid use is elevated with high opioid dose or concurrent benzodiazepine use. This study examined whether these clinical factors, or sociodemographic factors of race and gender, are associated with opioid dose reduction.

Design And Setting: A retrospective cohort study of outpatients prescribed chronic opioid therapy between 2007 and 2012 within a large, academic health care system in Bronx, New York, using electronic medical record data. Included patients were prescribed a stable dose of chronic opioid therapy over a one-year "baseline period" and did not have cancer.

Methods: The primary outcome was opioid dose reduction (≥30% reduction from baseline) within two years. Multivariable logistic regression tested the associations of two clinical variables (baseline daily opioid dose and concurrent benzodiazepine prescription) and two sociodemographic variables (race/ethnicity and gender) with opioid dose reduction.

Results: Of 1,097 patients, 463 (42.2%) had opioid dose reduction. High opioid dose (≥100 morphine-milligram equivalents [MME]) was associated with lower odds of opioid dose reduction compared with an opioid dose <100 MME (adjusted odds ratio [AOR] = 0.69, 95% confidence interval [CI] = 0.54-0.89). Concurrent benzodiazepine prescription was not associated with opioid dose reduction. Black (vs white) race and female (vs male) gender were associated with greater odds of opioid dose reduction (AOR = 1.82, 95% CI = 1.22-2.70; and AOR = 1.43, 95% CI = 1.11-1.83, respectively).

Conclusions: Black race and female gender were associated with greater odds of opioid dose reduction, whereas clinical factors of high opioid dose and concurrent benzodiazepine prescription were not. Efforts to reduce opioid dose should target patients based on clinical factors and address potential biases in clinical decision-making.
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http://dx.doi.org/10.1093/pm/pny137DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6686117PMC
August 2019