Publications by authors named "Julia H Arnsten"

131 Publications

HIV And HCV adherence and treatment outcomes among people who inject drugs receiving opioid agonist therapy.

AIDS Care 2021 Sep 17:1-5. Epub 2021 Sep 17.

University of South Carolina School of Medicine - Greenville, Greenville, SC, USA.

Among people who inject drugs (PWID), 60% have HCV and 50-90% of HIV-infected PWID are co-infected with HCV. Data comparing adherence to direct-acting antiviral (DAA) therapy among HCV mono-infected and HIV/HCV co-infected PWID is limited. The impact of HCV treatment initiation on HIV antiretroviral therapy (ART) adherence is also poorly understood. We assessed DAA adherence in HCV mono-infected and HIV/HCV co-infected PWID and examined changes in ART adherence and HIV outcomes following HCV treatment. Study was conducted in three Medication for Opioid use Disorder (MOUD) programs in Bronx, New York. HCV treatment adherence was measured using electronic blister packs. 2-week DAA adherence rates were compared and controlled for study arm, psychiatric illness and alcohol intoxication within the past 30 days. ART adherence was measured using participant self-report and dichotomized to "excellent" or "other". ART adherence, CD4 count, and HIV viral load were identified six months prior to, during, and six months after HCV treatment. Statistical significance was assessed with mixed-effects regression linear or logistic models. Overall DAA adherence rates among HCV mono-infected and HIV/HCV co-infected PWID were 74% (95% CI=71-78%) and 76% (95%CI=70-83%), respectively (=.55). There were no significant changes in ART adherence, CD4 counts, or HIV viral loads prior to, during, or after HCV treatment. This is the first study assessing the impact of DAA therapy on ART adherence and HIV treatment outcomes among PWID. It is one of the first to compare DAA adherence among HCV and HIV/HCV co-infected PWID. Our data demonstrate no significant difference in DAA adherence and no significant impact of HCV treatment on ART adherence or HIV outcomes.
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http://dx.doi.org/10.1080/09540121.2021.1973659DOI Listing
September 2021

Analysis of State Cannabis Laws and Dispensary Staff Recommendations to Adults Purchasing Medical Cannabis.

JAMA Netw Open 2021 Sep 1;4(9):e2124511. Epub 2021 Sep 1.

Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon.

Importance: Over the last decade, cannabis has become more accessible through the proliferation of dispensaries in states that have legalized its use. Most patients using cannabis for medical purposes report getting advice from dispensaries, yet there has been little exploration of frontline dispensary staff practices.

Objective: To describe the practices of frontline dispensary workers who interact with customers purchasing cannabis for medical purposes and assess whether dispensary practices are associated with medicalization of state cannabis laws (degree to which they resemble regulation of prescription or over-the-counter drugs) and statewide adult use.

Design, Setting, And Participants: This nationwide cross-sectional survey study was conducted from February 13, 2020, to October 2, 2020, using an online survey tool. Potential respondents were eligible if they reported working in a dispensary that sells tetrahydrocannabinol-containing products and interacting with customers about cannabis purchases.

Main Outcomes And Measures: Participant responses to questions about formulating customer recommendations and talking to customers about risks.

Results: The 434 survey responses from 351 unique dispensaries were most often completed by individuals who identified as budtenders (40%), managers (32%), and pharmacists (13%). Most respondents reported basing customer recommendations on the customer's medical condition (74%), the experiences of other customers (70%), the customer's prior experience with cannabis (67%), and the respondent's personal experience (63%); fewer respondents relied on clinician input (40%), cost (45%), or inventory (12%). Most respondents routinely advised customers about safe storage and common adverse effects, but few counseled customers about cannabis use disorder, withdrawal, motor vehicle collision risk, or psychotic reactions. A higher state medicalization score was significantly associated with using employer training (odds ratio, 1.41; 95% CI, 1.18-1.67) and physician or clinician input (odds ratio, 1.23; 95% CI, 1.05-1.43) as a basis for recommendation. Medicalization score was not associated with counseling about cannabis risks.

Conclusions And Relevance: This survey study provides insight into how frontline dispensary staff base cannabis recommendations and counsel about risks. The findings may have utility for clinicians to counsel patients who purchase cannabis, customers who want to be prepared for a dispensary visit, and policy makers whose decisions affect cannabis laws.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.24511DOI Listing
September 2021

First-year trajectories of medical cannabis use among adults taking opioids for chronic pain: an observational cohort study.

Pain Med 2021 Aug 19. Epub 2021 Aug 19.

Division of General Internal Medicine, Department of Medicine, Montefiore Health System, Bronx, NY.

Objective: To describe first-year trajectories of medical cannabis use and identify characteristics associated with patterns of use in a cohort of adults using opioids for chronic pain.

Design: Latent class trajectory analysis of prospective cohort study using data on 14-day frequency of medical cannabis use.

Setting: Large academic medical center and four medical cannabis dispensaries in the New York City metropolitan area.

Subjects: Adults with chronic pain using opioids and newly certified for medical cannabis in New York between 2018-2020.

Methods: Using latent class trajectory analysis, we identified clusters of participants based on 14-day frequency of medical cannabis use. We used logistic regression to determine factors associated with cluster membership including sociodemographic characteristics, pain, substance use, and mental health symptoms.

Results: Among 99 participants, mean age was 53 years; 62% were women and 52% were White. We identified three clusters of medical cannabis use: infrequent use (n = 30, mean use = 1.5 days/14-day period), occasional use (n = 28, mean = 5.7 days/14-day period), and frequent use (n = 41, mean = 12.1 days/14-day period). Within clusters, use patterns did not vary significantly over 52 weeks. Differences were observed in two sociodemographic variables: frequent (vs. infrequent) use was associated with non-Hispanic White race/ethnicity (aOR 4.54, 95% CI 1.49-14.29), while occasional (vs. infrequent) use was associated with employment (aOR 13.84, 95% CI 1.21-158.74).

Conclusions: Three clusters of medical cannabis use patterns emerged and were stable over time. Results suggest that structural factors related to race/ethnicity and employment may be a major driver of medical cannabis utilization, even among adults certified for use.
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http://dx.doi.org/10.1093/pm/pnab257DOI Listing
August 2021

A pilot randomized controlled trial of smartphone-assisted mindfulness-based intervention with contingency management for smokers with mood disorders.

Exp Clin Psychopharmacol 2021 Jul 22. Epub 2021 Jul 22.

School of Nursing.

Cigarette smoking disproportionately affects individuals with mood disorders, but smoking cessation interventions have modest effects in this population. Home mindfulness practice during abstinence incentivized via contingency management (CM) may help those in affective distress quit smoking.

Method: Adult smokers receiving outpatient psychiatric treatment for mood disorders were randomized to receive a smartphone-assisted mindfulness-based smoking cessation intervention with contingency management (SMI-CM, = 25) or enhanced standard treatment (EST, = 24) with noncontingent rewards. Participants in SMI-CM were prompted to practice audio-guided mindfulness five times per day for 38 days (vs. no comparison intervention in EST), and received monetary incentives for carbon monoxide (CO) ≤ 6 ppm. The primary outcome was biochemically verified 7-day point prevalence abstinence rates 2, 4, and 13 weeks after a target quit day.

Results: Of the 49 participants, 63.3% were Latinx and 30.6% Black; 75.5% reported household incomes < $25,000. Abstinence rates for SMI-CM were 40.0%, 36.0%, and 16.0% versus 4.2%, 8.3%, and 4.2% in EST at weeks 2, 4, and 13. A generalized estimating equations (GEE) model showed significant overall differences in abstinence rates in SMI-CM versus EST (adjusted odds ratio [A] = 8.12, 95% CI = 1.42-46.6, = .019). Those who received SMI-CM reported significantly greater reduction in smoking-specific experiential avoidance from baseline to 3 days prior to quit date (β = -7.21, 95% CI = -12.1-2.33, = .006).

Conclusions: SMI-CM may increase cessation rates among smokers with mood disorders, potentially through reduced smoking-specific experiential avoidance. SMI-CM is a promising intervention, and warrants investigation in a fully powered randomized controlled trial (RCT). (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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http://dx.doi.org/10.1037/pha0000506DOI Listing
July 2021

Hepatitis C virus DAA treatment adherence patterns and SVR among people who inject drugs treated in opioid agonist therapy programs.

Clin Infect Dis 2021 Apr 20. Epub 2021 Apr 20.

Clemson University School of Health Research, Clemson University, Clemson, SC, USA.

Background: Adequate medication adherence is critical for achieving sustained viral response (SVR) of hepatitis C virus (HCV) among people who inject drugs (PWID). However, it is less known which patterns of direct-acting antiviral (DAA) treatment adherence are associated with SVR in this population or what factors are associated with each pattern.

Methods: The randomized three-arm PREVAIL study utilized electronic blister packs to obtain daily time frame adherence data in opiate agonist therapy program settings. Exact logistic regressions were applied to test the associations between SVR and six types of treatment adherence patterns.

Results: Of the 113 participants treated with combination DAAs, 109 (96.5%) achieved SVR. SVR was significantly associated with all pattern parameters except for number of switches between adherent and missed days: total adherent daily doses (exact AOR=1.12; 95%CI=1.04-1.22), percent total doses (1.09; 1.03-1.16), days on treatment (1.16; 1.05-1.32), maximum consecutive adherent days (1.34; 1.06-2.04), maximum consecutive non-adherent days (.85; .74-.95=.003). SVR was significantly associated with total adherent doses in the first two months of treatment, it was not in the last month. Compared to White participants (30.7±11.8(se)), Black (18.4±7.8) and Hispanic participants (19.2±6.1) had significantly shorter maximum consecutive adherent days. While alcohol intoxication was significantly associated with frequent switches, drug use was not associated with any adherence pattern.

Conclusion: Consistent maintenance of adequate total dose adherence over the entire course of HCV treatment is important in achieving SVR among PWID. Additional integrative addiction and medical care may be warranted for treating PWID experiencing alcohol intoxication.
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http://dx.doi.org/10.1093/cid/ciab334DOI Listing
April 2021

How medical are states' medical cannabis policies?: Proposing a standardized scale.

Int J Drug Policy 2021 08 23;94:103202. Epub 2021 Mar 23.

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

Background: There are important differences in medical cannabis laws across the U.S.. However, prior studies investigating the effect of medical cannabis laws on outcomes disregard this heterogeneity. Findings from the body of literature using a simple dichotomous assessment of whether a particular state has enacted a medical cannabis law are equivocal or conflicting. To advance the science, a national advisory group of experts in medical cannabis developed and utilized a systematic methodology, the "medicalization of cannabis laws standardized scale" (MCLaSS), to characterize and quantify state laws' degree of medicalization, the extent to which medical cannabis is treated similarly to pharmaceutical medications.

Methods: We conducted a systematic review of state-level medical cannabis laws in the U.S. Using the novel MCLaSS, we calculated seven domain scores (patient-clinician relationship, manufacturing and testing, product labeling, types of products, supply and dose limit, prescription drug monitoring program, and dispensing practices) and a summary score for each state which had enacted medical cannabis laws as of July 2019.

Results: There is substantial heterogeneity in the degree of medicalization of states' medical cannabis laws, as demonstrated by the MCLaSS summary score, which ranged from 23 (least medicalized) to 86 (most medicalized).

Conclusion: This methodology will advance the evidence base about the impact of medical cannabis laws on patient and public health outcomes, which is urgently needed to ensure the development of policies that minimize the risks and maximize the benefits of medical cannabis.
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http://dx.doi.org/10.1016/j.drugpo.2021.103202DOI Listing
August 2021

High HCV cure rates among people who inject drugs and have suboptimal adherence: A patient-centered approach to HCV models of care.

Int J Drug Policy 2021 07 2;93:103135. Epub 2021 Mar 2.

Department of Medicine, University of South Carolina School of Medicine - Greenville, Greenville, SC, United States; Department of Medicine, Prisma Health-Upstate, Greenville, SC, United States; Clemson University School of Health Research, Clemson, SC, United States.

Background: Though people who inject drugs (PWID) make up the majority of the hepatitis C virus (HCV) epidemic, concerns about adherence often exclude PWID from receiving direct-acting antiviral (DAA) medication. The most effective models of HCV care to promote sustained virologic response (SVR) and high adherence need to be evaluated.

Methods: We conducted a prospective cohort study in three opioid treatment programs (OTPs) in the Bronx, NY. Participants, in collaboration with providers, chose one of three models of onsite care: directly observed therapy (mDOT), group treatment (GT), or self-administered individual treatment (SIT).  SVR12, daily adherence, and participant characteristics were compared between groups.

Results: Of 61 participants, the majority were male (62%) and Latino (67%), with a mean age of 53 (SD 9). Participants received DAAs via one of three models of care: mDOT (21%), GT (25%), or SIT (54%). The majority (59%) used illicit drugs during treatment. Overall, SVR12 was 98% with no differences between models of care: mDOT (100%), GT (100%), and SIT (97%) (p = 1.0). Overall, daily adherence was 73% (SD 16); 86% among those who chose mDOT compared to 71% among those who chose GT (p<0.01) and 73% among those who chose SIT (p<0.01).

Conclusion: Despite ongoing illicit drug use and suboptimal adherence, SVR12 was high among PWID treated onsite at an OTP using any one of three models of care. Shared decision making in real world settings may be key to choosing the appropriate model of care for PWID.
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http://dx.doi.org/10.1016/j.drugpo.2021.103135DOI Listing
July 2021

New normal: caring for hospitalised patients in the Bronx, New York, during COVID-19.

Intern Med J 2021 02;51(2):288-290

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

The Bronx, New York, is the poorest congressional district in the United States and has the highest COVID-19 infection rate in New York City. COVID-19 has led to major changes in our healthcare system, including heightened infection-control practices, novel staffing patterns and widespread social distancing. In this article, we describe how our experience with inpatient care has changed in the wake of COVID-19.
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http://dx.doi.org/10.1111/imj.15040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8014146PMC
February 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

Effect of varenicline directly observed therapy versus varenicline self-administered therapy on varenicline adherence and smoking cessation in methadone-maintained smokers: a randomized controlled trial.

Addiction 2021 04 13;116(4):902-913. Epub 2020 Oct 13.

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

Background And Aims: Level of adherence to tobacco cessation medication regimens is believed to be causally related to medication effectiveness. This study aimed to evaluate the efficacy of varenicline directly observed therapy (DOT) on varenicline adherence and smoking cessation rates among smokers with opioid use disorder (OUD) receiving methadone treatment.

Design: Multicenter, parallel-group two-arm randomized controlled trial.

Setting: Urban opioid treatment program (OTP) in the Bronx, New York, USA.

Participants: Daily smokers of ≥ 5 cigarettes/day, interested in quitting (ladder of change score 6-8), in methadone treatment for ≥ 3 months, attending OTP ≥ 3 days/week. Participants' mean age was 49 years, 56% were male, 44% Latino, 30% Black, and they smoked a median of 10 cigarettes/day.

Interventions: Individual, block, random assignment to 12 weeks of varenicline, either directly observed with methadone (DOT, n = 50) or via unsupervised self-administered treatment (SAT, n = 50).

Measurements: The primary outcome was adherence measured by pill count. The secondary outcome was 7-day point prevalence tobacco abstinence verified by expired carbon monoxide (CO) < 8 parts per million.

Findings: Retention at 24 weeks was 92%. Mean adherence was 78.5% [95% confidence interval (CI) = 71.8-85.2%] in the DOT group versus 61.8% in the SAT group (95% CI = 55.0-68.6%); differences were driven by DOT effects in the first 6 weeks. CO-verified abstinence did not differ between groups during the intervention (P = 0.26), but was higher in the DOT than the SAT group at intervention end (DOT = 18% versus SAT = 10%, difference = 8%, 95% CI = -13, 28); this difference was not significant (P = 0.39) and was not sustained at 24-week follow-up.

Conclusions: Among daily smokers attending opioid treatment programs, opioid treatment program-based varenicline directly observed therapy was associated with early increases in varenicline adherence compared with self-administered treatment, but findings were inconclusive as to whether directly observed therapy was associated with a difference in tobacco abstinence.
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http://dx.doi.org/10.1111/add.15240DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7983847PMC
April 2021

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

Impact of an Opt-In eConsult Program on Primary Care Demand for Specialty Visits: Stepped-Wedge Cluster Randomized Implementation Study.

J Gen Intern Med 2020 11 10;35(Suppl 2):832-838. Epub 2020 Aug 10.

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

Background: eConsult programs have been instituted to increase access to specialty expertise. Opt-in choice eConsult programs maintain primary care physician (PCP) autonomy to decide whether to utilize eConsults versus traditional specialty referrals, but little is known about how this intervention may impact PCP eConsult adoption and traditional referral demand.

Objective: We assessed the feasibility of implementing an opt-in choice eConsult program and examined whether this intervention reduces demand for in-person visits for primary care patients requiring specialty expertise.

Design: Stepped-wedge, cluster randomized trial conducted from July 2018 to June 2019.

Participants: Sixteen primary care practices in a large, urban academic health care system.

Intervention: Our intervention was an opt-in choice eConsult available in addition to traditional specialty referral; our implementation strategy included in-person training, audit and feedback, and incentive payments.

Main Measures: Our implementation outcome measure was the eConsult rate: weekly proportion of eConsults per PCP visit at each site. Our intervention outcome measure was traditional referral rate: weekly proportion of referrals per PCP visit at each site. We also assessed PCP experiences with questionnaires.

Key Results: Of 305,915 in-person PCP visits, there were 31,510 traditional referrals to specialties participating in the eConsult program, and 679 eConsults. All but one primary care site utilized the opt-in choice eConsult program, with a weekly rate of 0.05 eConsults per 100 PCP visits by the end of the study period. The weekly rate of traditional referrals was 11 per 100 PCP visits at the end of the study period; this represents a significant increase in traditional referral rate after implementation of eConsults. PCPs were generally satisfied with the eConsult program and valued prompt provider-to-provider communication.

Conclusions: Implementation of an opt-in choice eConsult program resulted in widespread PCP adoption; however, this did not decrease the demand for traditional referrals. Future studies should evaluate different strategies to incentivize and increase eConsult utilization while maintaining PCP choice.
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http://dx.doi.org/10.1007/s11606-020-06101-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7652962PMC
November 2020

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

Toward better preparedness for the next pandemic.

J Clin Invest 2020 09;130(9):4543-4545

New York City has been described as the epicenter of the COVID-19 pandemic in the United States. While health care workers are notably at increased risk for COVID-19 infection, the impact on resident physicians remains unclear. In this issue of the JCI, Breazzano et al. surveyed resident physicians for their exposure to COVID-19 during the exponential phase of the COVID-19 pandemic. The researchers also assessed how personal protective equipment and COVID-19 testing protected health care workers from infection. This study highlights resident physician experiences of the first COVID-19 wave that can inform and improve preparedness for upcoming COVID-19 surges and other future epidemics.
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http://dx.doi.org/10.1172/JCI140296DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7456246PMC
September 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

Achieving Smoking Cessation Among Persons with Opioid Use Disorder.

CNS Drugs 2020 04;34(4):367-387

Albert Einstein College of Medicine/Montefiore Health System, 111 East 210th Street, Bronx, NY, 10467, USA.

While prevalence of tobacco use in the US general population is declining, prevalence among those with opioid use disorder (OUD) remains high and results in excessive tobacco-related disease and premature mortality. Among smokers with OUD, tobacco cessation rates are negligible without treatment. However, both low-intensity behavioral interventions and more intensive motivational interventions yield negligible cessation rates. While contingency management has potent short-term cessation effects, effects are not maintained at post-intervention follow-up. Evidence-based smoking cessation pharmacotherapies, such as nicotine replacement therapy, bupropion, and varenicline, result in very modest cessation rates among smokers with OUD. Intensification of pharmacotherapy, such as high-dose and combination nicotine replacement therapy or extended medication treatment, has failed to improve cessation outcomes compared with standard treatment regimens. Targeting the unique challenges faced by smokers with OUD, including nicotine-opioid interactions and poor medication adherence, has potential to improve cessation outcomes, but further research is needed to optimize intervention efficacy among smokers with OUD.
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http://dx.doi.org/10.1007/s40263-020-00701-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7609040PMC
April 2020

Evaluation of Algorithms Used for PrEP Surveillance Using a Reference Population From New York City, July 2016-June 2018.

Public Health Rep 2020 Mar/Apr;135(2):202-210. Epub 2020 Feb 6.

Division of General Internal Medicine, Department of Medicine, Montefiore Health System/Albert Einstein College of Medicine, Bronx, NY, USA.

Objective: Daily tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) use as HIV preexposure prophylaxis (PrEP) is monitored by identifying TDF/FTC prescriptions from pharmacy databases and applying diagnosis codes and antiretroviral data to algorithms that exclude TDF/FTC prescribed for HIV postexposure prophylaxis (PEP), HIV treatment, and hepatitis B virus (HBV) treatment. We evaluated the accuracy of 3 algorithms used by the Centers for Disease Control and Prevention (CDC), Gilead Sciences, and the New York State Department of Health (NYSDOH) using a reference population in Bronx, New York.

Methods: We extracted diagnosis codes and data on all antiretroviral prescriptions other than TDF/FTC from an electronic health record database for persons aged ≥16 prescribed TDF/FTC during July 2016-June 2018 at Montefiore Medical Center. We reviewed medical records to classify the true indication of first TDF/FTC use as PrEP, PEP, HIV treatment, or HBV treatment. We applied each algorithm to the reference population and compared the results with the medical record review.

Results: Of 2862 patients included in the analysis, 694 used PrEP, 748 used PEP, 1407 received HIV treatment, and 13 received HBV treatment. The algorithms had high specificity (range: 98.4%-99.0%), but the sensitivity of the CDC algorithm using a PEP definition of TDF/FTC prescriptions ≤30 days was lower (80.3%) than the sensitivity of the algorithms developed by Gilead Sciences (94.7%) or NYSDOH (96.1%). Defining PEP as TDF/FTC prescriptions ≤28 days improved CDC algorithm performance (sensitivity, 95.8%; specificity, 98.8%).

Conclusions: Adopting the definition of PEP as ≤28 days of TDF/FTC in the CDC algorithm should improve the accuracy of national PrEP surveillance.
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http://dx.doi.org/10.1177/0033354920904085DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7036610PMC
May 2020

Use of Cannabis to Relieve Pain and Promote Sleep by Customers at an Adult Use Dispensary.

J Psychoactive Drugs 2019 Nov-Dec;51(5):400-404. Epub 2019 Jul 2.

Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA.

Medical cannabis patients consistently report using cannabis as a substitute for prescription medications; however, little is known about individuals accessing cannabis through adult-use markets. A survey at two retail stores was conducted in Colorado, United States. Between August 2016 and October 2016, store staff asked customers if they wanted to participate and, if so, provided an electronic survey link. All customers reporting medical certification were excluded. Of 1,000 adult-use only customer respondents, 65% reported taking cannabis to relieve pain and 74% reported taking cannabis to promote sleep. Among respondents taking cannabis for pain, 80% reported that it was very or extremely helpful, and most of those taking over-the-counter pain medications (82%) or opioid analgesics (88%) reported reducing or stopping use of those medications. Among respondents taking cannabis for sleep, 84% found it very or extremely helpful, and most of those taking over-the-counter (87%) or prescription sleep aids (83%) reported reducing or stopping use of those medications. medical use of cannabis for symptom relief was common among adult-use dispensary customers and the majority reported that cannabis decreased their medication use. Adult use cannabis laws may broaden access to cannabis for the purpose of symptom relief.
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http://dx.doi.org/10.1080/02791072.2019.1626953DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6823130PMC
June 2020

Intensive Models of Hepatitis C Care for People Who Inject Drugs Receiving Opioid Agonist Therapy: A Randomized Controlled Trial.

Ann Intern Med 2019 05 9;170(9):594-603. Epub 2019 Apr 9.

University of South Carolina School of Medicine-Greenville and Greenville Health System, Greenville, South Carolina, and Clemson University School of Health Research, Clemson, South Carolina (A.H.L.).

Background: Many people who inject drugs (PWID) are denied treatment for hepatitis C virus (HCV) infection, even if they are receiving opioid agonist therapy (OAT). Research suggests that HCV in PWID may be treated effectively, but optimal models of care for promoting adherence and sustained virologic response (SVR) have not been evaluated in the direct-acting antiviral (DAA) era.

Objective: To determine whether directly observed therapy (DOT) and group treatment (GT) are more effective than self-administered individual treatment (SIT) in promoting adherence and achieving SVR among PWID receiving OAT.

Design: Three-group, randomized controlled trial conducted from October 2013 to April 2017. (ClinicalTrials.gov: NCT01857245).

Setting: Three OAT programs in Bronx, New York.

Participants: Persons aged 18 years and older with genotype 1 HCV infection who were willing to receive HCV therapy on site in the OAT program. Of 190 persons screened, 158 were randomly assigned to a study group and 150 initiated treatment: DOT (n = 51), GT (n = 48), and SIT (n = 51).

Intervention: 2 intensive interventions (DOT and GT) and 1 control condition (SIT).

Measurements: Primary: adherence, measured by using electronic blister packs. Secondary: HCV treatment completion and SVR 12 weeks after treatment completion.

Results: Mean age was 51 years; 65% of participants had positive results on urine drug testing during the 6 months before treatment, and 75% reported ever injecting drugs. Overall adherence, estimated from mixed-effects models using the daily timeframe, was 78% (95% CI, 75% to 81%) and was greater among participants randomly assigned to DOT (86% [CI, 80% to 92%]) than those assigned to SIT (75% [CI, 70% to 81%]; difference, 11% [CI, 5% to 18%]; Bonferroni-corrected P = 0.001). No significant difference in adherence was observed between participants randomly assigned to GT (80% [CI, 74% to 86%]) and those assigned to SIT (difference, 4.7% [CI, -2% to 11%]; Bonferroni-corrected P = 0.29). The HCV treatment completion rate was 97%, with no differences among groups (P = 0.53). Overall SVR was 94% (CI, 89% to 97%); the SVR rate was 98% in the DOT group, 94% in the GT group, and 90% in the SIT group (P = 0.152).

Limitation: These findings may not be generalizable to PWID not enrolled in OAT programs.

Conclusion: All models of onsite HCV care delivered to PWID in OAT programs resulted in high SVR, despite ongoing drug use. Directly observed therapy was associated with greater adherence than SIT.

Primary Funding Source: National Institute on Drug Abuse and Gilead Sciences.
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http://dx.doi.org/10.7326/M18-1715DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6868527PMC
May 2019

Missed opportunities to test the neuropsychiatric safety--and efficacy--of varenicline among smokers with substance use disorders.

Drug Alcohol Depend 2018 04 22;185:245-247. Epub 2018 Feb 22.

Departments of Medicine, of Psychiatry & Behavioral Sciences, and of Epidemiology & Population Health, Albert Einstein College of Medicine / Montefiore Medical Center, Bronx, NY, USA,

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http://dx.doi.org/10.1016/j.drugalcdep.2018.02.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6201286PMC
April 2018

Empowering With PrEP (E-PrEP), a Peer-Led Social Media-Based Intervention to Facilitate HIV Preexposure Prophylaxis Adoption Among Young Black and Latinx Gay and Bisexual Men: Protocol for a Cluster Randomized Controlled Trial.

JMIR Res Protoc 2018 Aug 28;7(8):e11375. Epub 2018 Aug 28.

Division of General Internal Medicine, Department of Medicine, Montefiore Health System / Albert Einstein College of Medicine, Bronx, NY, United States.

Background: Young black and Latinx, gay, bisexual, and other men who have sex with men (YBLGBM, aged 18-29 years) have among the highest rates of new HIV infections in the United States and are not consistently reached by existing prevention interventions. Preexposure prophylaxis (PrEP), an oral antiretroviral regimen taken daily by HIV-uninfected individuals to prevent HIV acquisition, is highly efficacious in reducing HIV acquisition and could help stop the HIV epidemic in YBLGBM. Use of social media (eg, Facebook, Twitter, online dating sites) is ubiquitous among young people, providing an efficient avenue to engage YBLGBM to facilitate PrEP adoption.

Objective: Our overall goal was to develop and pilot test a theoretically grounded, social media-based, peer-led intervention to increase PrEP uptake in YBLGBM. We used diffusion of innovation and information-motivation-behavioral skills frameworks to (1) identify potential factors associated with interest in and adoption of PrEP among YBLGBM; (2) develop Empowering with PrEP (E-PrEP), a social media-based, peer-led intervention to increase PrEP uptake in YBLGBM; and (3) pilot test the feasibility and acceptability of E-PrEP, and determine its preliminary efficacy for increasing adoption of PrEP by YBLGBM. We describe the development and protocol for E-PrEP.

Methods: Using a participatory research approach, we partnered with YBLGBM intervention development partners to develop a social media-based behavioral intervention to facilitate PrEP uptake, which involved an online messaging campaign disseminated by YBLGBM peer leaders to their existing online networks. We designed the 6-week campaign to provide education about PrEP, increase motivation to use PrEP, and facilitate access to PrEP. We then conducted a cluster-randomized trial of E-PrEP compared with an attention-matched general health control condition (E-Health) among YBLGBM aged 18 to 29 years to assess E-PrEP's feasibility, acceptability, preliminary efficacy for increasing self-reported intention to use PrEP, PrEP uptake, and impact on knowledge and attitudes about PrEP at 12-week follow-up (6 weeks after the end of the online campaign).

Results: From October 2016 to March 2017, we developed, pretested, and refined E-PrEP with 6 YBLGBM intervention development partners. From May to June 2017, we recruited, enrolled, and randomly assigned 10 peer leaders (n=5 for each condition). The 10 peer leaders then recruited and enrolled 152 participants from their existing online networks (range 3-33 per peer leader), during June and July 2017. Intervention follow-up was completed after 12 weeks, in November 2017, with analyses underway.

Conclusions: We hypothesize that, compared with E-Health, participants randomly assigned to E-PrEP will be more likely to express intention to use PrEP and greater PrEP uptake, and will also show changes in potential mediators of PrEP uptake (knowledge, attitudes, stigma, and access). A Web-based biobehavioral intervention model such as E-PrEP could be rapidly scaled even with limited resources and have significant population-level impact.

Trial Registration: ClinicalTrials.gov NCT03213366; https://clinicaltrials.gov/ct2/show/NCT03213366 (Archived by WebCite at http://www.webcitation.org/71onSdcXY).

Registered Report Identifier: RR1-10.2196/11375.
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http://dx.doi.org/10.2196/11375DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6134229PMC
August 2018

Does Medical Cannabis Use Increase or Decrease the Use of Opioid Analgesics and Other Prescription Drugs?

J Addict Med 2018 Jul/Aug;12(4):259-261

Division of General Internal Medicine, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY (MAB, JHA, COC); Community Health and Social Medicine, City University of New York, School of Medicine, New York, NY (NS).

: In observational and retrospective studies, people who use cannabis are more likely than people who do not use cannabis to also use other drugs. People who take medical cannabis are also more likely to report medical and non-medical use of opioid analgesics, stimulants, and tranquilizers. Given that people who take medical cannabis and those who do not are likely to have different underlying morbidity, it is possible that medical cannabis use reduces prescription drug use yet prescription drug use remains relatively high. Studies comparing people who take medical cannabis with people who do not take it cannot draw conclusions about the effect of medical cannabis on drug use. To fully understand the effect of medical cannabis on the use of other drugs, prospective longitudinal studies randomizing individuals to cannabis versus other treatments are urgently needed.
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http://dx.doi.org/10.1097/ADM.0000000000000404DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6066410PMC
March 2020

Willingness to Participate in Longitudinal Research Among People with Chronic Pain Who Take Medical Cannabis: A Cross-Sectional Survey.

Cannabis Cannabinoid Res 2018 1;3(1):45-53. Epub 2018 Mar 1.

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

Regulatory barriers limit clinical trials of medical cannabis in the United States. Longitudinal cohort studies may be one feasible alternative that could yield clinically relevant information. Willingness to participate in such studies is not known. In October 2016, we surveyed a convenience sample of patients with chronic pain from two New York registered organizations (responsible for growing, processing, distributing, and retailing medical cannabis products). After a vignette describing a longitudinal cohort study involving weekly patient-reported outcomes and quarterly assessments of physical functioning and urine and blood tests, we asked about respondents' willingness to participate. We examined willingness to participate, duration of participation, and frequency of data collections overall and by subgroups, using multivariable logistic regression models. Of 405 respondents (estimated response rate: 30%), 54% were women and 81% were white non-Hispanic. Neuropathy was the most common pain condition (67%) followed by inflammatory bowel disease (19%). Of respondents, 94% (95% CI 92-97%) thought that the study should be done, 85% (95% CI 81-88%) would definitely or probably enroll if asked, 76% (95% CI 72-81%) would participate for ≥1 year, and 59% (95% CI 54-64%) would respond to questions at least daily. Older age was the only factor associated with lower willingness to participate, lower willingness to participate for ≥1 year, and lower willingness to respond to questions at least daily. Nearly all respondents were supportive of the proposed study and most reported that they would enroll if asked. Enhanced engagement with older individuals may be needed to promote equal enrollment. Recruitment for longitudinal cohort studies with frequent data collection appears feasible in this patient population.
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http://dx.doi.org/10.1089/can.2017.0051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5870058PMC
March 2018

Authors' Response to Letter to the Editor: Adherence in ART: A Comment on Piña et al. (2017).

J Assoc Nurses AIDS Care 2018 May - Jun;29(3):355-356. Epub 2018 Mar 20.

Chief, Division of General Internal Medicine, Professor of Medicine, Psychiatry & Behavioral Sciences, Epidemiology & Population Health, Albert Einstein College of Medicine/Montefiore Health System, Bronx, New York, USA.

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http://dx.doi.org/10.1016/j.jana.2018.03.002DOI Listing
August 2019

Rationale, design, and methodology of a trial evaluating three models of care for HCV treatment among injection drug users on opioid agonist therapy.

BMC Infect Dis 2018 02 9;18(1):74. Epub 2018 Feb 9.

Department of Medicine, University of South Carolina School of Medicine-Greenville, Greenville, South Carolina, USA.

Background: People who inject drugs (PWID) constitute 60% of the approximately 5 million people in the U.S. infected with hepatitis C virus (HCV). Treatment of PWID is complex due to addiction, mental illness, poverty, homelessness, lack of positive social support, poor adherence-related skills, low motivation and knowledge, and poor access to and trust in the health care system. New direct-acting antiviral medications are available for HCV with high cure rates and few side effects. The life expectancy and economic benefits of new HCV treatments will not be realized unless we determine optimal models of care for the majority of HCV-infected patients. The purpose of this study is to evaluate the effectiveness of directly observed therapy and group treatment compared with self-administered individual treatment in a large, urban opioid agonist therapy clinic setting in the Bronx, New York.

Methods/design: In this randomized controlled trial 150 PWID with chronic HCV were recruited from opioid agonist treatment (OAT) clinics and randomized to one of three models of onsite HCV treatment in OAT: 1) modified directly observed therapy; 2) group treatment; or 3) control - self-administered individual treatment. Participants were age 18 or older, HCV genotype 1, English or Spanish speaking, treatment naïve (or treatment experienced after 12/3/14), willing to receive HCV treatment onsite, receiving methadone or buprenorphine at the medication window at least once per week, and able to provide informed consent. Outcomes of interest include adherence (as measured by self-report and electronic blister packs), HCV treatment completion, sustained virologic response, drug resistance, and cost-effectiveness.

Discussion: This paper describes the design and rationale of a randomized controlled trial comparing three models of care for HCV therapy delivered in an opioid agonist treatment program. Our trial will be critical to rigorously identify models of care that result in high adherence and cure rates. Use of blister pack technology will help us determine the role of adherence in successful cure of HCV. Moreover, the trial methodology outlined here can serve as a template for the development of future programs and studies among HCV-infected drug users receiving opioid agonist therapy, as well as the cost-effectiveness of such programs.

Trial Registration: This trial was registered with ClinicalTrials.gov ( NCT01857245 ). Trial registration was obtained prospectively on May 20th, 2013.
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http://dx.doi.org/10.1186/s12879-018-2964-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5807730PMC
February 2018

Cannabis Use is Associated with Lower Odds of Prescription Opioid Analgesic Use Among HIV-Infected Individuals with Chronic Pain.

Subst Use Misuse 2018 08 17;53(10):1602-1607. Epub 2018 Jan 17.

b Albert Einstein College of Medicine , Bronx , New York , USA.

Background: Chronic pain is common in the United States and prescribed opioid analgesics use for noncancer pain has increased dramatically in the past two decades, possibly accounting for the current opioid addiction epidemic. Co-morbid drug use in those prescribed opioid analgesics is common, but there are few data on polysubstance use patterns.

Objective: We explored patterns of use of cigarette, alcohol, and illicit drugs in HIV-infected people with chronic pain who were prescribed opioid analgesics.

Methods: We conducted a secondary data analysis of screening interviews conducted as part of a parent randomized trial of financial incentives to improve HIV outcomes among drug users. In a convenience sample of people with HIV and chronic pain, we collected self-report data on demographic characteristics; pain; patterns of opioid analgesic use (both prescribed and illicit); cigarette, alcohol, and illicit drug use (including cannabis, heroin, and cocaine) within the past 30 days; and current treatment for drug use and HIV.

Results: Almost half of the sample of people with HIV and chronic pain reported current prescribed opioid analgesic use (N = 372, 47.1%). Illicit drug use was common (N = 505, 63.9%), and cannabis was the most commonly used illicit substance (N = 311, 39.4%). In multivariate analyses, only cannabis use was significantly associated with lower odds of prescribed opioid analgesic use (adjusted odds ratio = 0.57; 95% confidence interval: 0.38-0.87). Conclusions/Importance: Our data suggest that new medical cannabis legislation might reduce the need for opioid analgesics for pain management, which could help to address adverse events associated with opioid analgesic use.
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http://dx.doi.org/10.1080/10826084.2017.1416408DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6037547PMC
August 2018

Rationale, design and pilot feasibility results of a smartphone-assisted, mindfulness-based intervention for smokers with mood disorders: Project mSMART MIND.

Contemp Clin Trials 2018 03 27;66:36-44. Epub 2017 Dec 27.

University of Texas at Austin, United States.

Background: Although individuals with psychiatric disorders are disproportionately affected by cigarette smoking, few outpatient mental health treatment facilities offer smoking cessation services. In this paper, we describe the development of a smartphone-assisted mindfulness smoking cessation intervention with contingency management (SMI-CM), as well as the design and methods of an ongoing pilot randomized controlled trial (RCT) targeting smokers receiving outpatient psychiatric treatment. We also report the results of an open-label pilot feasibility study.

Methods: In phase 1, we developed and pilot-tested SMI-CM, which includes a smartphone intervention app that prompts participants to practice mindfulness, complete ecological momentary assessment (EMA) reports 5 times per day, and submit carbon monoxide (CO) videos twice per day. Participants earned incentives if submitted videos showed CO≤6ppm. In phase 2, smokers receiving outpatient treatment for mood disorders are randomized to receive SMI-CM or enhanced standard treatment plus non-contingent CM (EST).

Results: The results from the pilot feasibility study (N=8) showed that participants practiced mindfulness an average of 3.4times/day (≥3min), completed 72.3% of prompted EMA reports, and submitted 68.0% of requested CO videos. Participants reported that the program was helpful overall (M=4.85/5) and that daily mindfulness practice was helpful for both managing mood and quitting smoking (Ms=4.50/5).

Conclusions: The results from the feasibility study indicated high levels of acceptability and satisfaction with SMI-CM. The ongoing RCT will allow evaluation of the efficacy and mechanisms of action underlying SMI-CM for improving cessation rates among smokers with mood disorders.
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http://dx.doi.org/10.1016/j.cct.2017.12.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5841579PMC
March 2018

The Use of Online Posts to Identify Barriers to and Facilitators of HIV Pre-exposure Prophylaxis (PrEP) Among Men Who Have Sex with Men: A Comparison to a Systematic Review of the Peer-Reviewed Literature.

AIDS Behav 2018 04;22(4):1080-1095

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

Pre-exposure prophylaxis (PrEP) remains an under-utilized HIV prevention tool among men who have sex with men (MSM). To more comprehensively elucidate barriers and facilitators to PrEP use among US MSM, we conducted a systematic review of peer-reviewed published articles and content analysis of online posts about PrEP. We searched peer-reviewed databases (Medline, Web of Science, Google Scholar) using MESH headings and keywords about PrEP and/or HIV prevention from 2005 to 2015. We included original studies among MSM in the US that reported on barriers, facilitators, or other factors related to PrEP use. We also searched online posts and associated comments (news articles, opinion pieces, blogs and other social media posts) in diverse venues (Facebook, Slate Outward, Huffington Post Gay Voices, Queerty, and My PrEP Experience blog) to identify posts about PrEP. We used content analysis to identify themes and compare potential differences between the peer-reviewed literature and online posts. We identified 25 peer-reviewed articles and 28 online posts meeting inclusion criteria. We identified 48 unique barriers and 46 facilitators to using PrEP. These 94 themes fit into six overarching categories: (1) access (n = 14), (2) attitudes/beliefs (n = 24), (3) attributes of PrEP (n = 13), (4) behaviors (n = 11), (5) sociodemographic characteristics (n = 8), and (6) social network (n = 6). In all categories, analysis of online posts resulted in identification of a greater number of unique themes. Thirty-eight themes were identified in the online posts that were not identified in the peer-reviewed literature. We identified barriers and facilitators to PrEP in online posts that were not identified in a systematic review of the peer-reviewed literature. By incorporating data both from a systematic review of peer-reviewed articles and from online posts, we have identified salient and novel information about barriers to and facilitators of PrEP use. Traditional research approaches may not comprehensively capture current factors important for designing and implementing PrEP related interventions.
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http://dx.doi.org/10.1007/s10461-017-2011-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5991474PMC
April 2018
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