Publications by authors named "Shadi Nahvi"

32 Publications

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

The impact of menthol cigarette use on quit attempts and abstinence among smokers with opioid use disorder.

Addict Behav 2021 07 23;118:106880. Epub 2021 Feb 23.

Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, USA. Electronic address:

An exceedingly high proportion of persons with opioid use disorder (OUD) smoke cigarettes. Smokers with OUD face multiple barriers to smoking cessation. While menthol cigarette use has been associated with low cessation rates, research has not explored the impact of menthol cigarette use on tobacco use outcomes among smokers with OUD. Participants were current smokers, in methadone treatment for OUD, participating in randomized controlled trials of smoking cessation therapies. We examined the use of menthol cigarettes, and the association between menthol cigarette use and achieving 24-hour quit attempts and seven-day point prevalence abstinence. Of 268 participants, 237 (88.4%) reported menthol use. A similar proportion of menthol and non-menthol smokers achieved a 24-hour quit attempt (83.1% vs. 83.8%, p = 0.92). Though fewer menthol smokers (vs. non-menthol smokers) achieved abstinence (12.7% vs. 22.6%), this did not reach statistical significance (p = 0.14). In this sample of smokers with OUD, menthol smoking was nearly ubiquitous. Menthol smoking was not associated with differences in quit attempts, but was associated with differences in cessation that were not statistically significant. Menthol smoking may contribute to the challenges in achieving abstinence among smokers with OUD.
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http://dx.doi.org/10.1016/j.addbeh.2021.106880DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8059772PMC
July 2021

"An undercover problem in the Muslim community": A qualitative study of imams' perspectives on substance use.

J Subst Abuse Treat 2021 04 3;123:108224. Epub 2020 Dec 3.

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

Background: Mainstream Islam prohibits alcohol and other drugs, yet substance use is prevalent in Muslim-American communities. Previous studies have not examined how imams, leaders of mosques, address substance use in their communities. This study aimed to explore imams' perspectives and approaches toward Muslim Americans with substance use disorders (SUD).

Methods: Qualitative study of imams in New York City recruited by convenience sampling. We conducted one-on-one semi-structured interviews to address how imams perceive and address substance use. Using an inductive thematic analysis approach, we created an initial coding scheme which was refined iteratively, identified prominent themes, and created an explanatory model to depict relationships between themes.

Results: All imams described substance use within a shared underlying framework of religious prohibition of alcohol and other drugs. Their perceptions of individuals with SUD diverged between a focus on sin, shame, and social disruption vs. a focus on acceptance and forgiveness. Furthermore, imams diverged between conceptualizing their communities as comprising mosque-going individuals without SUD vs. broader communities that include individuals with SUD. While imams acknowledged how some imams' judgmental language toward SUD may perpetuate stigma, they also identified therapeutic approaches toward SUD: non-judgmental engagement, encouragement of recovery, prayer, and referral to resources.

Conclusions: This study is among the first to illustrate the range of perceptions and approaches to substance use among Muslim American imams. These perceptions have potentially divergent impacts- shaming or assisting individuals with SUD. An understanding of these complexities can inform provision of culturally competent care to Muslim-American patients with SUD.
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http://dx.doi.org/10.1016/j.jsat.2020.108224DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7900615PMC
April 2021

Prevalence and impact of comorbid chronic pain and cigarette smoking among people living with HIV.

AIDS Care 2021 Feb 17:1-9. Epub 2021 Feb 17.

Department of Psychology, Syracuse University, Syracuse, NY, USA.

Rates of chronic pain and cigarette smoking are each substantially higher among people living with HIV (PLWH) than in the general population. The goal of these analyses was to examine the prevalence and impact of comorbid chronic pain and cigarette smoking among PLWH. Participants included 3289 PLWH (83% male) who were recruited from five HIV clinics. As expected, the prevalence of smoking was higher among PLWH with chronic pain (41.9%), than PLWH without chronic pain (26.6%, < .0001), and the prevalence of chronic pain was higher among current smokers (32.9%), than among former (23.6%) or never (17%) smokers (s < .0001). PLWH who endorsed comorbid chronic pain and smoking (vs. nonsmokers without chronic pain) were more likely to report cocaine/crack and cannabis use, be prescribed long-term opioid therapy, and have virologic failure, even after controlling for relevant sociodemographic and substance-related variables (s < .05). These results contribute to a growing empirical literature indicating that chronic pain and cigarette smoking frequently co-occur, and extend this work to a large sample of PLWH. Indeed, PLWH may benefit from interventions that are tailored to address bidirectional pain-smoking effects in the context of HIV.
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http://dx.doi.org/10.1080/09540121.2021.1883511DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8368072PMC
February 2021

Reimagining patient-centered care in opioid treatment programs: Lessons from the Bronx during COVID-19.

J Subst Abuse Treat 2021 03 3;122:108219. Epub 2020 Dec 3.

Montefiore Health System, 111 East 210th Street, Bronx, NY 10467, USA. Electronic address:

Opioid treatment programs (OTPs) operate within a rigid set of clinical guidelines and regulations that specify the number of required OTP visits for supervised administration of methadone. To ensure physical distancing in light of COVID-19, the federal government loosened regulations to allow for additional flexibility. As OTP providers in the Bronx, NY, caring for more than 3600 patients in the epicenter of both the overdose and COVID-19 pandemics, we describe how our clinical practice changed with COVID-19. We halted toxicology testing, and to promote physical distancing and prevent interruptions in access to treatment for medications for opioid use disorder (MOUD), we drastically increased unsupervised take-home doses of MOUD. Within two weeks, we reduced the proportion of patients with 5-6 OTP visits per week from 47.2% to 9.4%. To guide treatment decision-making, we shifted focus from toxicology tests to other patient-centered measures, such as engagement in care and patient goals. In the initial three months, our patients experienced six nonfatal overdoses, no fatal overdoses, and 20 deaths attributable to COVID-19. This experience provides an opportunity to re-imagine care in OTPs going forward. We advocate that OTPs rely less on toxicology testing and more on the other patient-centered measures to guide decisions about distribution of take-home doses of MOUD. To minimize financial risk to OTPs and facilitate their transition to a more flexible model of care, we advocate for the reassessment of OTP reimbursement models.
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http://dx.doi.org/10.1016/j.jsat.2020.108219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7833302PMC
March 2021

Same-day vs. delayed buprenorphine prescribing and patient retention in an office-based buprenorphine treatment program.

J Subst Abuse Treat 2020 12 22;119:108140. Epub 2020 Sep 22.

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

Background: Buprenorphine is a safe and effective treatment for opioid use disorder (OUD), yet a small fraction of people with OUD receive it, and rates of retention in treatment are suboptimal. Dropout most commonly occurs within 30 days of treatment initiation. Therefore, research needs to investigate modifiable factors contributing to early dropout. Requiring multiple visits for evaluation prior to providing an initial buprenorphine prescription (delayed prescription) may lead to more early dropout when compared with prescribing at the first medical visit (same-day prescription). Our objective was to determine whether same-day (vs. delayed) buprenorphine prescription was associated with 30-day retention in treatment.

Methods: We conducted a retrospective cohort study of 237 patients who initiated buprenorphine treatment at an urban federally qualified community health center (FQHC) between June 1, 2015, and December 31, 2017. We measured prescription delays by determining the time between patients' first request for buprenorphine treatment (by calling, presenting to the FQHC in-person, or requesting treatment during a visit) and when providers wrote buprenorphine prescriptions. We included only patients with prescription delays less than or equal to 30 days in the analysis. We defined same-day prescription as the patient experiencing no delays in starting treatment and receiving a prescription during the first medical visit. We examined whether patients who received same-day prescriptions had different sociodemographic and clinical characteristics than patients who received delayed prescriptions. We also evaluated whether there was an association between the initial provider who made the decision about same-day vs. delayed buprenorphine prescribing and same-day prescription. We built a multivariable logistic regression model to evaluate the independent association between same-day vs. delayed prescription receipt and odds of 30-day retention in treatment.

Results: Of the 237 patients who initiated buprenorphine treatment from June 1, 2015, to December 31, 2017, 222 had delays less than or equal to 30 days and we included them in the analysis. Of the 222 patients, the mean age was 46 (SD 10.4), the majority were Hispanic (n = 160, 72%), male (n = 175, 79%), and publicly insured (n = 165, 74%). The majority of patients experienced delayed buprenorphine prescription receipt (n = 133, 60%). The median time to buprenorphine prescription was 5 days (IQR 0-11). Of those who experienced a delay (n = 133), the median delay time was 8 days (IQR 5-20). Compared to those with same-day prescription receipt, more patients with delayed prescription receipt were non-Hispanic white (11% vs. 2%, p = 0.01), had a history of alcohol use (43% vs. 21%, p < 0.01) or benzodiazepine use (22% vs. 9%, p = 0.01), and had the buprenorphine coordinator as their initial provider (57 vs. 13%, p < 0.01). Same-day prescription receipt was not significantly associated with 30-day treatment retention in the adjusted analysis (AOR 1.92, 95% CI 0.81-4.56).

Conclusion: Patients who received buprenorphine prescriptions on the same day as their initial evaluation differed from those who received delayed prescriptions. After adjustment for these differences, same-day prescription was not significantly associated with higher 30-day treatment retention. Providers may be delaying treatment when there is concern about alcohol and/or benzodiazepine use; however, providers could institute enhanced monitoring based on clinical concern for sedation or overdose risk without delaying buprenorphine prescription. Prospective studies of same-day vs. delayed buprenorphine receipt would elucidate the association between delays and retention more definitively.
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http://dx.doi.org/10.1016/j.jsat.2020.108140DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7609975PMC
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

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

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

Text2Connect: a health system approach to engage tobacco users in quitline cessation services via text messaging.

Transl Behav Med 2020 02;10(1):292-301

Department of Population Health, NYU School of Medicine, New York, NY, USA.

Mobile technology has created the opportunity for health systems to provide low cost tobacco cessation assistance to patients. The goal of the present study was to examine the feasibility and effectiveness of an intervention (Text2Connect) that uses text messages to offer proactive connection to the New York State Smokers' Quitline. The electronic health record at two urban health systems was queried for patients who were current smokers and who had an outpatient visit between March 2015 and February 2016. Smokers (N = 4000) were sent an informational letter. Those who did not opt out (N = 3719) were randomized to one of 6 message sequences in order to examine the effect of theoretically informed message frames on response rates. Participants were sent a series of text messages at baseline and at 1 month and were asked to reply in order to be contacted by the state quitline (QL). After removing 1403 nonworking numbers, texts were sent to 2316 patients, and 10.0% (205/2060) responded with a QL request. Almost one quarter (23.6%, 486/2060) replied STOP and 66.4% (1369/2060) never responded. QL request rates were significantly higher when response efficacy messages were not used (p < .001). There were no differences by message framing on STOP requests (p > .05). The Text2Connect intervention was well accepted with a minority opting out. A 10% QL response rate is noteworthy given that only 5-7 brief outreach text messages were used. Results indicate that simple self-efficacy-focused messaging is most effective at supporting response rates.
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http://dx.doi.org/10.1093/tbm/ibz033DOI Listing
February 2020

Impact of the Society for Research on Nicotine and Tobacco Health Disparities Network's Scholarship on Professional Development of Its Recipients.

Nicotine Tob Res 2020 01;22(1):141-143

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

Introduction: Diversifying the workforce is an important strategy to reducing health disparities. Since 2007, the Society for Research on Nicotine and Tobacco (SRNT) Health Disparities Network has funded a travel scholarship to promote inclusion, professional development, and diversity among investigators interested in tobacco-related health disparities research. This study examined indicators of productivity among former scholarship recipients.Methods: Scholarship recipients between 2007 and 2014 were invited to complete a survey online. The survey assessed demographic characteristics, academic productivity, and perceived professional benefit resulting from the scholarship.Results: Of the 117 scholarships recipients, 89 (77%) responded. Respondents were 67% female and had a mean age of 37.8 years. Twenty eight percent were African American, 25% Asian American, and 17% Latino. Most respondents worked in academia (80%) and nearly three-quarters (74%) reported publishing manuscripts on tobacco-related disparities, with a mean of 3.8 (SD 4.4) disparities-related publications since receiving the scholarship. Respondents' work focused on a wide range of health disparities topics and nearly all respondents reported that the scholarship removed barriers to attending the meeting and reported professional benefit from receiving the travel scholarship. Following receipt of the SRNT travel scholarship, a diverse group of scientists demonstrated scholarly productivity, professional development, and advancement of health disparities research. Similar efforts are encouraged in other professional societies.

Implications: This study examines the productivity of early career recipients of the SRNT Health Disparities Scholarship. Results suggest that the investment in annual travel scholarships by a professional organization is an important support system for emerging scientists from diverse backgrounds. This investment may help to advance the science of health disparities and engage researchers in an area where there are critical gaps in the research workforce.
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http://dx.doi.org/10.1093/ntr/nty253DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7297010PMC
January 2020

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

Trends in cannabis use disorder by cigarette smoking status in the United States, 2002-2016.

Drug Alcohol Depend 2018 10 20;191:45-51. Epub 2018 Jul 20.

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

Background: Cannabis use is on the rise in the United States (US) and is disproportionately common among cigarette smokers. Cannabis use disorder (CUD) occurs among a small subset of cannabis users and may impact cigarette use. The objective of this study was to estimate trends in the prevalence of CUD among daily, non-daily, former, and never cigarette smokers from 2002 to 2016.

Methods: Data were drawn from cross-sectional, nationally representative samples of individuals ages 12 and older in the US that were collected annually. The prevalence of past 12-month CUD was estimated each year from 2002 to 2016 among daily, non-daily, former, and never cigarette smokers (total analytic N = 837,326).

Results: Overall, the prevalence of CUD decreased from 2002 to 2016. Yet, trends differed by cigarette smoking status. Adjusting for demographics, the prevalence of CUD increased significantly among non-daily smokers (aOR = 1.02; 95% CI = 1.01-1.03) from 2002 to 2016 and did not change among daily, former, or never smokers. CUD was significantly more common among non-daily (4.32%) and daily cigarette smokers (2.92%) compared with former (0.99%) and never smokers (1.11%) in 2016. Approximately one in five (18.11%-22.87%) youth ages 12-17 who smoke cigarettes met criteria for CUD in 2016, compared with approximately 2% of non-smoking youth.

Conclusions: Despite downward trends in CUD observed at the general population level, the prevalence of CUD significantly increased among non-daily cigarette smokers from 2002 to 2016. In the US, CUD remains significantly higher among cigarette smokers relative to non-cigarette smokers.
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http://dx.doi.org/10.1016/j.drugalcdep.2018.06.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6859449PMC
October 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

Feasibility and Preliminary Effectiveness of Varenicline for Treating Co-Occurring Cannabis and Tobacco Use.

J Psychoactive Drugs 2018 Jan-Mar;50(1):12-18. Epub 2017 Sep 27.

e Associate Professor, Departments of Medicine and Psychiatry & Behavioral Sciences , Albert Einstein College of Medicine/Montefiore Medical Center , Bronx , NY , USA.

Few studies have evaluated treatment for co-occurring cannabis and tobacco use. The objective of this pilot study was to evaluate the feasibility and preliminary effectiveness of varenicline for co-occurring cannabis and tobacco use. Participants who reported cannabis use on ≥5 days per week were recruited from an urban, outpatient opioid treatment program (OTP). Participants were randomized to either four weeks of standard OTP clinical care (SCC; medication-assisted treatment for opioid use disorder and individual behavioral counseling), followed by four weeks of SCC plus varenicline (SCC+VT), or to four weeks of SCC+VT followed by four weeks of SCC. All participants contributed feasibility and outcome data during both study phases. Of 193 persons screened, seven were enrolled. Retention at eight weeks was 100%. No adverse effects prompted varenicline discontinuation. Participants reported lower cannabis craving during the SCC+VT phase compared to baseline, and lower frequencies and quantities of cannabis use compared to both baseline and the SCC alone phase. In the SCC+VT phase, participants also reported fewer cigarettes per day. Among persons with co-occurring cannabis and tobacco use, varenicline is well-tolerated and may reduce cannabis craving, cannabis use, and tobacco use.
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http://dx.doi.org/10.1080/02791072.2017.1370746DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5871554PMC
October 2019

Use of Smoking Cessation Methods Among Patients Receiving Office-based Buprenorphine Maintenance Treatment.

J Addict Med 2017 Nov/Dec;11(6):494-497

University of California, San Francisco School of Medicine, San Francisco, CA (PAS); Albert Einstein College of Medicine & Montefiore Medical Center, Bronx, NY (COC, MTB, JPD, SN).

Objectives: Provision of smoking-cessation treatment is limited in office-based buprenorphine maintenance treatment (BMT) settings. This study describes smoking and smoking-cessation behaviors among patients receiving office-based BMT.

Methods: Cross-sectional study of patients receiving office-based BMT at a community health center in the Bronx, NY. We interviewed patients assessing sociodemographic, and substance use and tobacco use characteristics, including methods used for smoking cessation. We reported simple frequencies and explored associations of BMT characteristics with smoking behaviors.

Results: Of 68 patients, 87.7% were current cigarette smokers, 7.9% were former smokers, and 4.4% had never smoked. Of lifetime smokers, 83.1% reported at least 1 prior quit attempt, and 78.5% had used medication (75.4% used nicotine replacement therapy, 29.2% varenicline, and 9.2% bupropion). Ten patients (15.4%) reported using electronic cigarettes to try to quit smoking. Stopping "cold turkey" (40.0%) and gradually decreasing the number of cigarettes smoked (32.3%) were nonpharmacological methods of quitting tried most often. Use of behavioral support, including stop-smoking programs and counseling, was low. Higher dose and longer duration of BMT was associated with greater smoking frequency.

Conclusions: Patients receiving BMT have a high prevalence of cigarette smoking, though most have tried to quit, and have prior experience with pharmacotherapy for smoking cessation. Efforts to optimize smoking-cessation treatments among BMT patients are needed.
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http://dx.doi.org/10.1097/ADM.0000000000000356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5659878PMC
June 2018

Improving Quality of Care for Hospitalized Smokers with HIV: Tobacco Dependence Treatment Referral and Utilization.

Jt Comm J Qual Patient Saf 2016 May;42(5):219-24

Department of Preventive Medicine and Public Health, University of Kansas Medical Center (KUMC), Kansas City, Kansas, USA.

Background: Most persons living with HIV smoke cigarettes and tend to be highly dependent, heavy smokers. Few such persons receive tobacco treatment, and many die from tobacco-related illness. Although advancements in antiretroviral therapy (ART) have increased the quality and quantity of life, the health harms from tobacco use diminish these gains. Without cessation assistance, thousands will benefit from costly ART, only to suffer the consequences of tobacco-related disease and death. A study was conducted to examine in detail inpatient tobacco treatment for smokers with HIV.

Methods: Data collected at hospital admission and data collected by tobacco treatment specialists were examined retrospectively for all inpatients with HIV who were admitted to an academic medical center for a five-year period. Specifically, the prevalence of cigarette smoking, factors predictive of referral to tobacco treatment, referral for tobacco treatment, treatment participation, and abstinence at six months posttreatment were measured. Differences in referral and treatment participation between all smokers and smokers with HIV were also assessed.

Results: Among the 422 admitted persons with HIV, 54.5% smoked and 21.7% were referred to inpatient tobacco treatment services. Substance abuse and tobacco-related diagnoses were predictive of referral to inpatient tobacco treatment specialists. Among the 14 treatment participants reached for follow-up, 11 (78.6%) made quit attempts and 3 (21.4%) reported abstinence. Smokers with HIV were less likely to be referred to and treated by tobacco treatment services than all smokers admitted during the same time frame.

Conclusions: Although tobacco is a major cause of mortality, few smokers with HIV are offered treatment during hospitalization. Those who are treated attempt to quit. Hospitalization offers a prime opportunity for initiating smoking cessation among those with HIV.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4969005PMC
http://dx.doi.org/10.1016/s1553-7250(16)42028-3DOI Listing
May 2016

"I Kicked the Hard Way. I Got Incarcerated." Withdrawal from Methadone During Incarceration and Subsequent Aversion to Medication Assisted Treatments.

J Subst Abuse Treat 2016 Mar 25;62:49-54. Epub 2015 Nov 25.

Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, 10461; Montefiore Medical Center, 111 East 210th Street, Bronx, NY, 10467. Electronic address:

Incarceration is a common experience for individuals with opioid use disorder, including those receiving medication assisted treatments (MAT), such as buprenorphine or methadone. In the United States, MAT is rarely available during incarceration. We were interested in whether challenges with methadone maintenance treatment during incarceration affected subsequent attitudes toward MAT following release. We conducted semi-structured interviews with 21 formerly incarcerated individuals with opioid use disorder in community substance abuse treatment settings. Interviews were audio recorded, transcribed, and analyzed using a grounded theory approach. Themes that emerged upon iterative readings of transcripts were discussed by the research team. The three main themes relating to methadone were: 1) rapid dose reduction during incarceration; 2) discontinuity of methadone during incarceration; and 3) post incarceration aversion to methadone. Participants who received methadone maintenance treatment prior to incarceration reported severe and prolonged withdrawal symptoms from rapid dose reductions or disruption of their methadone treatment during incarceration. The severe withdrawal during incarceration contributed to a subsequent aversion to methadone and adversely affected future decisions regarding reengagement in MAT. Though MAT is the most efficacious treatment for opioid use disorder, current penal policy, which typically requires cessation of MAT during incarceration, may dissuade individuals with opioid use disorder from considering and engaging in MAT after release from incarceration.
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http://dx.doi.org/10.1016/j.jsat.2015.11.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4888768PMC
March 2016

Barriers to Telephone Quitline Use Among Methadone-Maintained Smokers.

Nicotine Tob Res 2015 Aug;17(8):931-6

Department of Medicine, Albert Einstein College of Medicine, Bronx, NY; Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, NY

Introduction: Drug users have high rates of tobacco use and tobacco-related disease. Telephone quitlines promote smoking cessation, but their reach among drug users is unknown. We thus aimed to assess utilization of and barriers to telephone quitlines among methadone-maintained smokers.

Methods: Subjects were opioid-dependent smokers in Bronx, New York, methadone treatment programs who were enrolled in a clinical trial of varenicline. All subjects were offered referral to a free, proactive quitline. We examined quitline records, surveyed barriers to quitline use, and queried reasons for declining referral.

Results: Of the 112 subjects enrolled, 47% were male, 54% were Hispanic, and 28% were Black. All subjects were offered referral, and 25 (22% of study participants) utilized the quitline. Quitline utilizers (vs. nonutilizers) were significantly more likely to have landline phone service (72 vs. 42%, p = .01), interest in quitline participation (92 vs. 62%, p < .01), and willingness to receive calls (96 vs. 76%, p = .02). Nonutilizers were significantly more likely to report cell phone service lapse (38 vs. 14%, p = .04), and difficulty charging cell phones (19 vs. 0%, p = .02). Reasons for quitline refusal included: (a) skepticism of quitline efficacy; (b) aversion to telephone communication; (c) competing life demands (e.g., drug treatment, shelter); and (d) problems with cell phone service or minutes.

Conclusions: Despite several limitations to quitline access among methadone-maintained smokers, routine quitline referral was associated with 22% utilization. To expand provision of smoking cessation treatment to opioid-dependent smokers, interventions to promote routine quitline referral in substance abuse treatment programs warrant investigation.
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http://dx.doi.org/10.1093/ntr/ntu267DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4542843PMC
August 2015

Rationale and design of a randomized controlled trial of varenicline directly observed therapy delivered in methadone clinics.

Addict Sci Clin Pract 2014 Jun 13;9. Epub 2014 Jun 13.

Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, 111 East 210th Street, 10467 Bronx, NY, USA.

Background: Tobacco cessation medication adherence is one of the few factors shown to improve smoking cessation rates among methadone-maintained smokers, but interventions to improve adherence to smoking cessation medications have not yet been tested among methadone treatment patients. Methadone clinic-based, directly observed therapy (DOT) programs for HIV and tuberculosis improve adherence and clinical outcomes, but have not been evaluated for smoking cessation. We describe a randomized controlled trial to evaluate whether a methadone clinic-based, directly observed varenicline therapy program increases adherence and tobacco abstinence among opioid-dependent drug users receiving methadone treatment.

Methods/design: We plan to enroll 100 methadone-maintained smokers and randomize them to directly observed varenicline dispensed with daily methadone doses or treatment as usual (self-administered varenicline) for 12 weeks. Our outcome measures are: 1) pill count adherence and 2) carbon monoxide-verified tobacco abstinence. We will assess differences in adherence and abstinence between the two treatment arms using repeated measures models.

Discussion: This trial will allow for rigorous evaluation of the efficacy of methadone clinic-based, directly observed varenicline for improving adherence and smoking cessation outcomes. This detailed description of trial methodology can serve as a template for the development of future DOT programs and can guide protocols for studies among opioid-dependent smokers receiving methadone treatment.

Trial Registration: clinicaltrials.gov NCT01378858.
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http://dx.doi.org/10.1186/1940-0640-9-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4084498PMC
June 2014

Smoking cessation treatment among office-based buprenorphine treatment patients.

J Subst Abuse Treat 2014 Aug 27;47(2):175-9. Epub 2014 Apr 27.

Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, 10467, USA.

Opioid-dependent patients smoke at high rates, and office-based buprenorphine treatment provides an opportunity to offer cessation treatment. We examined tobacco use and smoking cessation treatment patterns among office-based buprenorphine treatment patients. We reviewed records of 319 patients treated with buprenorphine from 2005 to 2010. We examined smoking status, cessation medication prescriptions, and factors associated with receipt of cessation prescriptions. Mean age was 43.9 years; most were men (74.2%) and Hispanic (70.9%). At buprenorphine initiation, 21.9% had no documentation of smoking status, while 67.4% were current, 10% former, and 0.9% never smokers. Of current smokers, 16.8% received smoking cessation prescriptions. Patients retained (vs. not retained) in buprenorphine treatment were more likely to receive smoking cessation medications (26.3% vs. 11.2%, p<0.005). We observed a high tobacco use prevalence among buprenorphine patients, and limited provision of cessation treatment. This is a missed opportunity to impact the high tobacco use burden in opioid-dependent persons.
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http://dx.doi.org/10.1016/j.jsat.2014.04.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4104355PMC
August 2014

Varenicline efficacy and safety among methadone maintained smokers: a randomized placebo-controlled trial.

Addiction 2014 Sep 27;109(9):1554-63. Epub 2014 Jun 27.

Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA; Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, NY, USA.

Aims: To test the efficacy and safety of varenicline as an aid to smoking cessation in methadone-maintained smokers.

Design: Multicenter, randomized, double-blind, placebo-controlled trial with random assignment to 12 weeks of varenicline 1 mg twice daily (n = 57) or matched placebo (n = 55), with in-person and telephone counseling.

Setting: Urban methadone programs in the Bronx, New York City, New York, USA.

Participants: Methadone maintenance patients, smoking ≥5 cigarettes/day, interested in quitting, stable in methadone treatment, without current Axis I psychiatric disorders, suicidal ideation or recent suicide attempts.

Measurements: Seven-day point prevalence abstinence verified by expired carbon monoxide (CO) < 8 parts per million at week 12 (primary outcome); carbon monoxide (CO)-verified abstinence, cigarettes/day, incident Axis I psychiatric illness, suicidal ideation or serious adverse events (SAEs) at weeks 2, 4, 8, 12 or 24 (secondary outcomes).

Findings: Baseline demographic, smoking and clinical factors were similar between groups. Retention at 24 weeks was 90%. Subjects receiving varenicline were more likely than those receiving placebo to achieve abstinence (10.5 versus 0%, P = 0.03; effect size 10.5%, 95% confidence interval (CI) = 4.4-19.3%) and to reduce smoking (median five versus two cigarettes/day, P < 0.001) at 12 weeks. These effects were not maintained after drug treatment ceased. Incident psychiatric illness (OR= 0.84, 95% CI = 0.16, 4.4) and suicidality [odds ratio (OR) = 0.88, 95% CI 0.2, 3.9] were not different between groups. There were no psychiatric or cardiac SAEs.

Conclusions: Varenicline can aid short-term smoking abstinence in methadone-maintained smokers.
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http://dx.doi.org/10.1111/add.12631DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4300953PMC
September 2014

Low incidence of adverse events following varenicline initiation among opioid dependent smokers with comorbid psychiatric illness.

Drug Alcohol Depend 2013 Sep 17;132(1-2):47-52. Epub 2013 Jan 17.

Department of Medicine, Albert Einstein College of Medicine, Bronx, NY 10467, USA.

Background: Most drug treatment patients smoke cigarettes, yet few data exist on the prevalence and outcomes of varenicline treatment among smokers with comorbid substance use and psychiatric disorders.

Methods: We reviewed all patient charts of opioid-dependent smokers prescribed varenicline between May 2006 and December 2009 in two urban methadone clinics that also provide on-site medical and psychiatric care. We assessed prevalence, adverse events, and effectiveness of varenicline treatment in this cohort.

Results: We identified 575 smokers among 690 patients (83.3%), and assessed 82 courses of varenicline treatment prescribed to 70 smokers. Both cardiovascular risk factors and psychiatric illness were highly prevalent among those prescribed varenicline: hypertension, 51%; hyperlipidemia, 23%; diabetes, 20%; depression, 53%; anxiety, 30%; psychotic disorders, 10%; bipolar disorder, 8.6%. Of 82 varenicline courses, nine (11%) were discontinued due to adverse events and two due to depressive symptoms. One patient initiated new psychiatric medications within six months of initiating varenicline, but did not discontinue varenicline. There were no reports of suicidal ideation, agitation prompting clinical intervention, or psychiatric hospitalization. There were no incident cardiac or vascular events within six months of varenicline prescription. Some (8.6%) varenicline-treated smokers quit smoking, and cessation was significantly associated with varenicline treatment duration.

Conclusions: Despite substantial comorbidity, opioid-dependent smokers receiving integrated substance abuse, medical and psychiatric care had few documented adverse events with varenicline treatment. Methadone patients will likely experience little harm and a great deal of benefit from treatment with varenicline for smoking cessation.
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http://dx.doi.org/10.1016/j.drugalcdep.2012.12.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3762456PMC
September 2013

Medicinal and recreational marijuana use among HIV-infected women in the Women's Interagency HIV Study (WIHS) cohort, 1994-2010.

J Acquir Immune Defic Syndr 2012 Dec;61(5):618-26

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.

Background: Despite the major benefits of effective antiretroviral therapy on HIV-related survival, there is an ongoing need to help alleviate medication side effects related to antiretroviral therapy use. Initial studies suggest that marijuana use may reduce HIV-related symptoms, but medical marijuana use among HIV-infected individuals has not been well described.

Methods: The authors evaluated trends in marijuana use and reported motivations for use among 2776 HIV-infected women in the Women's Interagency HIV Study between October 1994 and March 2010. Predictors of any and daily marijuana use were explored in multivariate logistic regression models clustered by person using generalized estimating equation. In 2009, participants were asked if their marijuana use was medical, "meaning prescribed by a doctor," or recreational, or both.

Results: Over the 16 years of this study, the prevalence of current marijuana use decreased significantly from 21% to 14%. In contrast, daily marijuana use almost doubled from 3.3% to 6.1% of all women and from 18% to 51% of current marijuana users. Relaxation, appetite improvement, reduction of HIV-related symptoms, and social use were reported as common reasons for marijuana use. In 2009, most marijuana users reported either purely medicinal use (26%) or both medicinal and recreational usage (29%). Daily marijuana use was associated with higher CD4 cell count, quality of life, and older age. Demographic characteristics and risk behaviors were associated with current marijuana use overall but were not predictors of daily use.

Conclusions: This study suggests that both recreational and medicinal marijuana use are relatively common among HIV-infected women in the United States.
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http://dx.doi.org/10.1097/QAI.0b013e318273ab3aDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3508315PMC
December 2012

Increased risk of mortality and readmission among patients discharged against medical advice.

Am J Med 2012 Jun 17;125(6):594-602. Epub 2012 Apr 17.

Department of Medicine, Division of Hospital Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA.

Background: Approximately 500,000 patients are discharged from US hospitals against medical advice annually, but the associated risks are unknown.

Methods: We examined 148,810 discharges from an urban, academic health system between July 1, 2002 and June 30, 2008. Of these, 3544 (2.4%) were discharged against medical advice, and 80,536 (54.1%) were discharged home. We excluded inpatient deaths, transfers to other hospitals or nursing facilities or discharges with home care. Using adjusted and propensity score-matched analyses, we compared 30-day mortality, 30-day readmission, and length of stay between discharges against medical advice and planned discharges.

Results: Discharge against medical advice was associated with higher mortality than planned discharge, after adjustment (odds ratio [OR](adj) 2.05; 95% confidence interval [CI], 1.48-2.86), and in propensity-matched analysis (OR(matched) 2.46; 95% CI, 1.29-4.68). Discharge against medical advice also was associated with higher 30-day readmission after adjustment (OR(adj) 1.84; 95% CI, 1.69-2.01), and in propensity-matched analysis (OR(matched) 1.65; 95% CI, 1.46-1.87). Finally, discharges against medical advice had shorter lengths of stay than matched planned discharges (3.37 vs 4.16 days, P <.001).

Conclusions: Discharge against medical advice is associated with increased risk for mortality and readmission. In addition, discharges against medical advice have shorter lengths of stay than matched planned discharges, suggesting that the increased risks associated with discharge against medical advice are attributable to premature discharge.
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http://dx.doi.org/10.1016/j.amjmed.2011.12.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3372411PMC
June 2012

Impact of adherence counseling dose on antiretroviral adherence and HIV viral load among HIV-infected methadone maintained drug users.

AIDS Care 2012 24;24(7):828-35. Epub 2012 Jan 24.

University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, NJ, USA.

Adherence counseling can improve antiretroviral adherence and related health outcomes in HIV-infected individuals. However, little is known about how much counseling is necessary to achieve clinically significant effects. We investigated antiretroviral adherence and HIV viral load relative to the number of hours of adherence counseling received by 60 HIV-infected drug users participating in a trial of directly observed antiretroviral therapy delivered in methadone clinics. Our adherence counseling intervention combined motivational interviewing and cognitive-behavioral counseling, was designed to include six 30 minute individual counseling sessions with unlimited "booster" sessions, and was offered to all participants in the parent trial. We found that, among those who participated in adherence counseling, dose of counseling had a significant positive relationship with antiretroviral adherence measured after the conclusion of counseling. Specifically, a liner mixed-effects model revealed that each additional hour of counseling was significantly associated with a 20% increase in post-counseling adherence. However, the number of cumulative adherence counseling hours was not significantly associated with HIV viral load, also measured after the conclusion of counseling. Our findings suggest that more intensive adherence counseling interventions may have a greater impact on antiretroviral adherence than less intensive interventions; however, it remains unknown how much counseling is required to impact HIV viral load.
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http://dx.doi.org/10.1080/09540121.2011.644231DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3380183PMC
October 2012

Directly observed antiretroviral therapy eliminates adverse effects of active drug use on adherence.

Drug Alcohol Depend 2012 Jan 31;120(1-3):174-80. Epub 2011 Aug 31.

Department of Medicine (Division of General Internal Medicine), Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY 10467, United States.

Background: The impact of adherence enhancing interventions on the relationship between active drug use and adherence is largely unknown.

Methods: We conducted a 24-week randomized controlled trial of antiretroviral directly observed therapy (DOT) vs. treatment as usual (TAU) among HIV-infected methadone patients. Our outcome measure was pill count antiretroviral adherence, and our major independent variables were treatment arm (DOT vs. TAU) and active drug use (opiates, cocaine, or both opiates and cocaine). We defined any drug use as ≥ 1 positive urine toxicology result, and frequent drug use as ≥ 50% tested urines positive. We used mixed-effects linear models to evaluate associations between adherence and drug use, and included a treatment arm-by-drug use interaction term to evaluate whether DOT moderates associations between drug use and adherence.

Results: 39 participants were randomized to DOT and 38 to TAU. We observed significant associations between adherence and active drug use, but these were limited to TAU participants. Adherence was worse in TAU participants with any opiate use than in TAU participants without (63% vs. 75%, p<0.01); and worse among those with any polysubstance (both opiate and cocaine) use than without (60% vs. 73%, p=0.01). We also observed significant decreases in adherence among TAU participants with frequent opiate or frequent polysubstance use, compared to no drug use. Among DOT participants, active drug use was not associated with worse adherence.

Conclusions: Active opiate or polysubstance use decreases antiretroviral adherence, but the negative impact of drug use on adherence is eliminated by antiretroviral DOT.
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http://dx.doi.org/10.1016/j.drugalcdep.2011.07.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3245772PMC
January 2012

Review: the need for smoking cessation among HIV-positive smokers.

AIDS Educ Prev 2009 Jun;21(3 Suppl):14-27

Department of Medicine, Division of General Internal Medicine, Montefiore Medical Center, 111 East 210 thSt. Bronx, NY 10467, USA.

Most HIV-positive persons in the U.S. smoke cigarettes. Despite substantial clinical advances in HIV care in the era of highly active antiretroviral therapy (HAART), HIV-positive persons are at high risk of tobacco-related disease and death. HIV-positive persons have complex social, economic, psychiatric, and medical needs that may impact smoking behavior and response to smoking cessation interventions, but there is a dearth of research on smoking cessation interventions tailored to HIV-positive persons. HIV care providers should treat tobacco use with the array of evidence-based smoking cessation treatments available, updating their clinical practice as new data emerge. This article reviews the literature on the health consequences of tobacco use in HIV-positive persons, the treatment of tobacco dependence, and the research to date on smoking cessation interventions in HIV-positive persons, and it presents recommendations for future research and intervention.
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http://dx.doi.org/10.1521/aeap.2009.21.3_supp.14DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2704483PMC
June 2009

Successful treatment of chronic hepatitis C with pegylated interferon in combination with ribavirin in a methadone maintenance treatment program.

J Subst Abuse Treat 2009 Jul 28;37(1):32-40. Epub 2008 Nov 28.

Division of General Internal Medicine, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York 10467, USA.

Injection drug users constitute 60% of the more than 4 million people in the United States with hepatitis C virus (HCV), including many methadone maintenance patients. Few data exist describing clinical outcomes for patients receiving HCV treatment on-site in methadone maintenance settings. In this retrospective study, we describe clinical outcomes for 73 patients receiving HCV treatment on-site in a methadone maintenance treatment program. Fifty-five percent of patients achieved end-of-treatment response, and 45% achieved sustained viral response. These treatment response rates are nearly equivalent to previously published HCV treatment response rates, despite high prevalences of ongoing drug use (49%), psychiatric comorbidity (67%), and HIV coinfection (32%). These data show that on-site HCV treatment with pegylated interferon and ribavirin is effective in methadone-maintained patients, many of whom are active drug users, psychiatrically ill, or HIV coinfected, and that methadone maintenance treatment programs represent an opportunity to safely treat chronic hepatitis C.
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http://dx.doi.org/10.1016/j.jsat.2008.09.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2692471PMC
July 2009
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