Publications by authors named "Thomas J Stopka"

53 Publications

A Novel Imputation Approach for Sharing Protected Public Health Data.

Am J Public Health 2021 Sep 16:e1-e9. Epub 2021 Sep 16.

Elizabeth A. Erdman and Dana L. Bernson are with the Office of Population Health, Department of Public Health, the Commonwealth of Massachusetts, Boston. Leonard D. Young is with the Bureau of Health Professions Licensure, Department of Public Health, the Commonwealth of Massachusetts. Kenneth Chui is with the Department of Public Health and Community Medicine, Tufts University, Boston. Cici Bauer is with the Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston. Thomas J. Stopka is with Tufts Clinical and Translational Science Institute and the Department of Public Health and Community Medicine, Tufts University.

To develop an imputation method to produce estimates for suppressed values within a shared government administrative data set to facilitate accurate data sharing and statistical and spatial analyses. We developed an imputation approach that incorporated known features of suppressed Massachusetts surveillance data from 2011 to 2017 to predict missing values more precisely. Our methods for 35 de-identified opioid prescription data sets combined modified previous or next substitution followed by mean imputation and a count adjustment to estimate suppressed values before sharing. We modeled 4 methods and compared the results to baseline mean imputation. We assessed performance by comparing root mean squared error (RMSE), mean absolute error (MAE), and proportional variance between imputed and suppressed values. Our method outperformed mean imputation; we retained 46% of the suppressed value's proportional variance with better precision (22% lower RMSE and 26% lower MAE) than simple mean imputation. Our easy-to-implement imputation technique largely overcomes the adverse effects of low count value suppression with superior results to simple mean imputation. This novel method is generalizable to researchers sharing protected public health surveillance data. (. Published online ahead of print September 16, 2021: e1-e9. https://doi.org/10.2105/AJPH.2021.306432).
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http://dx.doi.org/10.2105/AJPH.2021.306432DOI Listing
September 2021

Prevalence and correlates of non-fatal overdose among people who use drugs: findings from rapid assessments in Massachusetts, 2017-2019.

Harm Reduct J 2021 Aug 30;18(1):93. Epub 2021 Aug 30.

Opioid Policy Research Collaborative, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA.

Background: People who experience non-fatal overdose (NFOD) are at high risk of subsequent overdose. With unprecedented increases in fentanyl in the US drug supply, many Massachusetts (MA) communities have seen a surge in opioid-related overdoses. The objective of this study was to determine factors associated with lifetime and past year NFOD in at-risk MA communities.

Methods: We conducted multiple rapid assessments among people who use drugs (PWUD) in eight MA communities using non-probability sampling (purposive, chain referral, respondent-driven) methods. We collected sociodemographic, substance use, overdose history, substance use treatment, and harm reduction services utilization data. We examined the prevalence of NFOD (lifetime and past year) and identified factors associated with NFOD through multivariable logistic regression analyses in a subset of 469 study participants between 2017 and 2019.

Results: The prevalence of lifetime and last year non-fatal opioid overdose was 62.5% and 36.9%, respectively. Many of the study participants reported heroin (64%) and fentanyl (45%) use during the 30 days preceding the survey. Nonprescription buprenorphine and fentanyl use were independently associated with higher odds of lifetime NFOD, while marijuana use was associated with lower odds of lifetime NFOD (p < 0.05). Injection as the route of administration, benzodiazepine, nonprescription buprenorphine, heroin, and fentanyl use were independently associated with higher odds, while methadone use was associated with lower odds of past year NFOD (p < 0.05).

Conclusion: We documented a high prevalence of past year and lifetime NFOD among PWUD in MA. Our findings provide indicators that can help inform interventions to prevent overdoses among PWUD, including overdose prevention, medication treatment, and naloxone distribution.
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http://dx.doi.org/10.1186/s12954-021-00538-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8404353PMC
August 2021

"Nobody Knows How You're Supposed to Interpret it: " End-user Perspectives on Prescription Drug Monitoring Program in Massachusetts.

J Addict Med 2021 Aug 19. Epub 2021 Aug 19.

Northeastern University, Boston, MA (MH, SS, LB, EC, AM, LB), Tufts University School of Medicine and Tufts Clinical and Translational Sciences Institute, Boston, MA (TJS), UCSD School of Medicine, La Jolla, CA (LB).

Objectives: America's overdose crisis spurred rapid expansion in the number and scope of prescription drug monitoring programs (PDMPs). As their public health impact remains contested, little is known about PDMP user experiences and perspectives. We explore perspectives of PDMP end-users in Massachusetts.

Methods: Between 2016 and 2017, we conducted semi-structured qualitative interviews on overdose crisis dynamics and PDMP experiences with a purposive sample of 18 stakeholders (prescribers, pharmacists, law enforcement, and public health regulators). Recordings were transcribed and double-coded using a grounded hermeneutic approach.

Results: Perspectives on prescription monitoring as an element of overdose crisis response differed across sectors, but narratives often critiqued PDMPs as poorly conceived to serve end-user needs. Respondents indicated that PDMP: (1) lacked clear orientation towards health promotion; (2) was not optimally configured or designed as a decision support tool, resulting in confusion over interpreting data to guide health care or law enforcement actions; and, (3) problematized communication and relationships between prescribers, pharmacists, and patients.

Conclusions: User insights must inform design, programmatic, and policy reform to maximize PDMP benefits while minimizing harm.
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http://dx.doi.org/10.1097/ADM.0000000000000901DOI Listing
August 2021

Why are some people reluctant to be vaccinated for COVID-19? A cross-sectional survey among U.S. Adults in May-June 2020.

Prev Med Rep 2021 Dec 14;24:101494. Epub 2021 Jul 14.

Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA.

Understanding reasons for COVID-19 vaccine hesitancy is necessary to ensure maximum uptake, needed for herd immunity. We conducted a cross-sectional online survey between May 29-June 20, 2020 among a national sample of U.S. adults ages 18 years and over to assess cognitive, attitudinal and normative beliefs associated with not intending to get a COVID-19 vaccine. Of 1219 respondents, 17.7% said that they would not get a vaccine and 24.2% were unsure. In multivariable analyses controlled for gender, age, income, education, religious affiliation, health insurance coverage, and political party affiliation, those who reported that they were unwilling be vaccinated (versus those who were willing) were less likely to agree that vaccines are safe/effective (Relative Risk Ratio (RRR): 0.45, 95% confidence interval (CI): 0.31, 0.66), that everyone has a responsibility to be vaccinated (RRR: 0.39, 95% CI: 0.30, 0.52), that public authorities should be able to mandate vaccination (RRR: 0.75, 95% CI: 0.58, 0.98), and more likely to believe that if everyone else were vaccinated they would not need a vaccine (RRR: 1.36, 95% CI: 1.04, 1.78). Our results suggest that health messages should emphasize the safety and efficacy of vaccines, as well as the fact that vaccinating oneself is important, even if the level of uptake in the community is high.
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http://dx.doi.org/10.1016/j.pmedr.2021.101494DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8277541PMC
December 2021

Understanding opioid overdose risk and response preparedness among people who use cocaine and other drugs: Mixed-methods findings from a large, multi-city study.

Subst Abus 2021 Jul 6:1-14. Epub 2021 Jul 6.

Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA.

Background: Fatal overdoses involving cocaine (powdered or crack) and fentanyl have increased nationally and in Massachusetts. It is unclear how overdose risk and preparedness to respond to an overdose differs by patterns of cocaine and opioid use. From 2017 to 2019, we conducted a nine-community mixed-methods study of Massachusetts residents who use drugs. Using survey data from 465 participants with past-month cocaine and/or opioid use, we examined global differences ( < 0.05) in overdose risk and response preparedness by patterns of cocaine and opioid use. Qualitative interviews ( = 172) contextualized survey findings. The majority of the sample (66%) used cocaine and opioids in the past month; 18.9% used opioids alone; 9.2% used cocaine and had no opioid use history; and 6.2% used cocaine and had an opioid use history. Relative to those with a current/past history of opioid use, significantly fewer of those with no opioid use history were aware of fentanyl in the drug supply, carried naloxone, and had received naloxone training. Qualitative interviews documented how people who use cocaine and have no history of opioid use are largely unprepared to recognize and respond to an overdose. Public health efforts are needed to increase fentanyl awareness and overdose prevention preparedness among people primarily using cocaine.
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http://dx.doi.org/10.1080/08897077.2021.1946893DOI Listing
July 2021

Women-centered drug treatment models for pregnant women with opioid use disorder: A scoping review.

Drug Alcohol Depend 2021 Sep 24;226:108855. Epub 2021 Jun 24.

Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA, 02111, United States. Electronic address:

Background: While there is a high unmet need for drug treatment services tailored to the needs of pregnant women, fewer than half of the opioid use disorder (OUD) treatment programs in the U.S. offer such services. We conducted a scoping review of the literature to identify women-centered drug treatment models that address access, coordination, and quality of care, and their facilitators and barriers.

Methods: We searched PubMed, EMBASE, PsycInfo, Sociology Database, Web of Science, CINAHL, EBSCO Open Dissertations, Health Services Research Projects in Progress, and relevant agency websites from 1990 to 2020. We included studies that evaluated multicomponent models of care that provided medication for OUD (MOUD) to pregnant women in the U.S.

Results: Of the 1,578 unduplicated articles screened, 26 articles met the inclusion criteria, which reported on 19 different studies and included 3,193 women. We identified seven different models of care and found that: (1) access was improved by co-locating various services for drug treatment and care, (2) coordination was enhanced by inter-professional collaboration, (3) quality was improved by treating pregnant patients in groups, and (4) stigmatization and criminalization of substance use during pregnancy was a significant barrier to care.

Conclusions: There is an urgent need to bolster patient-provider relationships that are built on trust, are free of stigma, and that empower patients to make their own decisions. Improved policies and regulations to reduce stigma around the use of opioids and MOUD are needed, so that pregnant women with OUD can access high quality care.
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http://dx.doi.org/10.1016/j.drugalcdep.2021.108855DOI Listing
September 2021

Locating the Risk: Using Participatory Mapping to Contextualize Perceived HIV Risk across Geography and Social Networks among Men Who Have Sex with Men in the Deep South.

J Sex Res 2021 Apr 7:1-8. Epub 2021 Apr 7.

Department of Psychiatry, Warren Alpert Medical School of Brown University.

HIV incidence among African American (AA) young men who have sex with men (YMSM) has remained stable even though they made up the largest number of new HIV diagnoses among men who have sex with men (MSM) in 2017. HIV spreads at increased rates in dense sexual networks. Identifying the location of risk behaviors "activity spaces" could inform geographically circumscribed HIV prevention interventions. Utilizing the modified social ecological model we completed five semi-structured focus groups incorporating a modified social mapping technique, based on Singer et al.'s approach. Participants included 27 AA YMSM. Focus groups explored how and where HIV transmission happens in Jackson, Mississippi. Result themes included: 1) location of sexual behaviors, 2) knowledge of geographic hotspots of HIV infection in Jackson, and 3) traveling to meet partners: at home and away. HIV transmission or "activity spaces" may be occurring outside identified HIV hot spots. Mixed geospatial and qualitative methods offered a comprehensive assessment of where HIV transmission occurs, and suggests that geographically circumscribed interventions may need to focus on where individuals living with HIV reside and in specific geographic locations where they engage in behaviors that raise their HIV acquisition risks.
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http://dx.doi.org/10.1080/00224499.2021.1906397DOI Listing
April 2021

Linking MATTERS: Barriers and Facilitators to Implementing Emergency Department-Initiated Buprenorphine-Naloxone in Patients with Opioid Use Disorder and Linkage to Long-Term Care.

Subst Use Misuse 2021 7;56(7):1045-1053. Epub 2021 Apr 7.

Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA.

Background: In March 2019, our health system launched a project called Linking MATTERS (edication for ddiction reatment linkage hrough mergency depatment) to initiate evidence-based treatment for opioid use disorder (OUD) with buprenorphine-naloxone (B/N) in our emergency departments and connect patients to our primary care sites to continue their addiction care. : Six months after project implementation, we conducted in-depth interviews with frontline providers ( = 14), including emergency physicians and hospitalists, recovery coaches, ED and outpatient nurses, and case managers. We used qualitative thematic analysis to identify barriers and facilitators to implementation and suggestions for improving the project. : We identified five salient themes: (1) provider trainings: mandated, rather than optional trainings, facilitated provider uptake; (2) provider attitudes: there was a growing recognition of addiction as a chronic, medical disease and the value of B/N in supporting patients' recovery, driven by a desire to make a difference in patients' lives; (3) patient engagement: frontline providers with lived experience of addiction who had designated time (such as recovery coaches) were optimally positioned to engage patients; (4) the linking mechanism: personal connections between ED and outpatient providers, rather than follow-up telephone calls, facilitated linkage; and (5) suggestions for improving the program, including: a physical space/bridge clinic to provide patient linkage, expansion of the recovery coach program, and standardized, evidence-based interdisciplinary trainings for all frontline providers. : The insights provided will support further program modifications. Healthcare systems should explore whether the components we identified warrant attention locally based on their unique infrastructure and culture.
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http://dx.doi.org/10.1080/10826084.2021.1906280DOI Listing
June 2021

Disparities in SARS-CoV-2 Testing in Massachusetts During the COVID-19 Pandemic.

JAMA Netw Open 2021 02 1;4(2):e2037067. Epub 2021 Feb 1.

Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamanetworkopen.2020.37067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7873783PMC
February 2021

Massachusetts Justice Community Opioid Innovation Network (MassJCOIN).

J Subst Abuse Treat 2021 09 8;128:108275. Epub 2021 Jan 8.

University of Massachusetts Medical School - Baystate, Springfield, MA, United States of America. Electronic address:

A major driver of the U.S. opioid crisis is limited access to effective medications for opioid use disorder (MOUD) that reduce overdose risks. Traditionally, jails and prisons in the U.S. have not initiated or maintained MOUD for incarcerated individuals with OUD prior to their return to the community, which places them at high risk for fatal overdose. A 2018 law (Chapter 208) made Massachusetts (MA) the first state to mandate that five county jails deliver all FDA-approved MOUDs (naltrexone [NTX], buprenorphine [BUP], and methadone). Chapter 208 established a 4-year pilot program to expand access to all FDA-approved forms of MOUD at five jails, with two more MA jails voluntarily joining this initiative. The law stipulates that MOUD be continued for individuals receiving it prior to detention and be initiated prior to release among sentenced individuals where appropriate. The jails must also facilitate continuation of MOUD in the community on release. The Massachusetts Justice Community Opioid Innovation Network (MassJCOIN) partnered with these seven diverse jails, the MA Department of Public Health, and community treatment providers to conduct a Type 1 hybrid effectiveness-implementation study of Chapter 208. We will: (1) Perform a longitudinal treatment outcome study among incarcerated individuals with OUD who receive NTX, BUP, methadone, or no MOUD in jail to examine postrelease MOUD initiation, engagement, and retention, as well as fatal and nonfatal opioid overdose and recidivism; (2) Conduct an implementation study to understand systemic and contextual factors that facilitate and impede delivery of MOUDs in jail and community care coordination, and strategies that optimize MOUD delivery in jail and for coordinating care with community partners; (3) Calculate the cost to the correctional system of implementing MOUD in jail, and conduct an economic evaluation from state policy-maker and societal perspectives to compare the value of MOUD prior to release from jail to no MOUD among matched controls. MassJCOIN made significant progress during its first six months until the COVID-19 pandemic began in March 2020. Participating jail sites restricted access for nonessential personnel, established other COVID-19 mitigation policies, and modified MOUD programming. MassJCOIN adapted research activities to this new reality in an effort to document and account for the impacts of COVID-19 in relation to each aim. The goal remains to produce findings with direct implications for policy and practice for OUD in criminal justice settings.
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http://dx.doi.org/10.1016/j.jsat.2021.108275DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8263807PMC
September 2021

SARS-CoV-2 Testing Disparities in Massachusetts.

medRxiv 2020 Nov 4. Epub 2020 Nov 4.

Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts (Dryden-Peterson, Velásquez, Lockman, Ojikutu); Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health (Dryden-Peterson, Lockman), Botswana Harvard AIDS Institute (Dryden-Peterson, Lockman), Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts (Velásquez, Ojikutu); Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts (Velásquez); Department of Public Health and Community Medicine, Tufts University School of Medicine (Stopka); Tufts Clinical and Translational Science Institute (Stopka); Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (Davey).

Objective: Early deficiencies in testing capacity contributed to poor control of transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In the context of marked improvement in SARS-CoV-2 testing infrastructure, we sought to examine the alignment of testing with epidemic intensity to mitigate subsequent waves of COVID-19 in Massachusetts.

Methods: We compiled publicly available weekly SARS-CoV-2 molecular testing data for period (May 27 to October 14, 2020) following the initial COVID-19 wave. We defined testing intensity as weekly SARS-CoV-2 tests performed per 100,000 population and used weekly test positivity (percent of tests positive) as a measure of epidemic intensity. We considered optimal alignment of testing resources to be matching community ranks of testing and positivity. In communities with a lower rank of testing than positivity in a given week, the testing gap was calculated as the additional tests required to achieve matching ranks. Multivariable Poisson modeling was utilized to assess for trends and association with community characteristics.

Results: During the observation period, 4,262,000 tests were reported in Massachusetts and the misalignment of testing with epidemic intensity increased. The weekly testing gap increased 9.0% per week (adjusted rate ratio [aRR]: 1.090, 95% confidence interval [CI]: 1.08-1.10). Increasing levels of community socioeconomic vulnerability (aRR: 1.35 per quartile increase, 95% CI: 1.23-1.50) and the highest quartile of minority and language vulnerability (aRR: 1.46, 95% CI 0.96-1.49) were associated with increased testing gaps, but the latter association was not statistically significant. Presence of large university student population (>10% of population) was associated with a marked decrease in testing gap (aRR 0.21, 95% CI: 0.12-0.38).

Conclusion: These analyses indicate that despite objectives to promote equity and enhance epidemic control in vulnerable communities, testing resources across Massachusetts have been disproportionally allocated to more affluent communities. Worsening structural inequities in access to SARS-CoV-2 testing increase the risk for another intense wave of COVID-19 in Massachusetts, particularly among vulnerable communities.
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http://dx.doi.org/10.1101/2020.11.02.20224469DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7654915PMC
November 2020

COVID-19 and People Who Use Drugs - A Commentary.

Health Behav Policy Rev 2020 Oct;7(5):489-497

Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, IL, United States.

Objective: People who use drugs (PWUD) face increased risk of exposure to COVID-19, but also elevated risk associated from injection drug use. We describe factors underlying their increased risk and identify mechanisms for reducing or minimizing rates of COVID-19 transmission and other health outcomes.

Methods: Our commentary draws upon empirical data, governmental and other reports, and field-based unpublished data from our own studies to inform our conclusion and recommendations.

Results: Co-morbid health conditions (eg, diabetes), structural challenges (eg, homelessness, criminal justice involvement), stigma (eg, social devaluation, discrediting), and syndemic clustering of of overdose, HCV, and HIV among PWUD are exacerbated by COVID-19.

Conclusions: Beyond the many challenges all people face to remain safe and healthy during the COVID-19 pandemic, PWUD face additional barriers to remaining safe not only from COVID-19 but from negative health outcomes associated with their living environments, socioeconomic positions, and injection drug use. Collaborative efforts among governmental agencies, health providers, SSPs, CBOs, and other agencies providing services to PWUD is essential to the development of programs and services to meet the many needs of PWUD, which have been particularly accentuated during the COVID-19 pandemic.
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http://dx.doi.org/10.14485/hbpr.7.5.11DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7595339PMC
October 2020

The HIV Care Continuum in Small Cities of Southern New England: Perspectives of People Living with HIV/AIDS, Public Health Experts, and HIV Service Providers.

AIDS Behav 2021 Mar 1;25(3):897-907. Epub 2020 Oct 1.

Department of Public Health & Community Medicine, Tufts University School of Medicine, Boston, MA, 02111, USA.

The HIV care continuum (HCC), comprised of five steps (screening, linkage to care, treatment initiation, retention, and viral suppression), is used to monitor treatment delivery to people living with HIV (PLWH). The HCC has primarily focused on large urban or metropolitan areas where the situation may differ from that in smaller cities. Three themes (i.e., knowledge, stigma, stability) that shaped HCC outcomes were identified from analysis of two qualitative studies involving HIV service providers, public health experts, and PLWH in smaller cities of southern New England. The findings suggest that enhancing HCC outcomes require a multiprong approach that targets both the individual and organizational levels and includes interventions to increase health literacy, staff communication skills, universal screening to assess patients' religiosity/spirituality and supplemental service needs. Interventions that further ensure patient confidentiality and the co-location and coordination of HIV and other healthcare services are particularly important in smaller cities.
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http://dx.doi.org/10.1007/s10461-020-03049-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7887013PMC
March 2021

Spatial epidemiology: An empirical framework for syndemics research.

Soc Sci Med 2020 Sep 10:113352. Epub 2020 Sep 10.

Department of Public Health and Community Medicine, Tufts University School of Medicine, USA. Electronic address:

Syndemics framework describes two or more co-occurring epidemics that synergistically interact with each other and the complex structural social forces that sustain them leading to excess disease burden. The term syndemic was first used to describe the interaction between substance abuse, violence, and AIDS by Merrill Singer. A broader range of syndemic studies has since emerged describing the framework's applicability to other public health scenarios. With syndemic theory garnering significant attention, the focus is shifting towards developing robust empirical analytical approaches. Unfortunately, the complex nature of the disease-disease interactions nested within several social contexts complicates empirical analyses. In answering the call to analyze syndemics at the population level, we propose the use of spatial epidemiology as an empirical framework for syndemics research. Spatial epidemiology, which typically relies on geographic information systems (GIS) and statistics, is a discipline that studies spatial variations to understand the geographic landscape and the risk environment within which disease epidemics occur. GIS maps provide visualization aids to investigate the spatial distribution of disease outcomes, the associated social factors, and environmental exposures. Analytical inference, such as estimation of disease risks and identification of spatial disease clusters, can provide a detailed statistical view of spatial distributions of diseases. Spatial and spatiotemporal models can help us to understand, measure, and analyze disease syndemics as well as the social, biological, and structural factors associated with them in space and time. In this paper, we present a background on syndemics and spatial epidemiological theory and practice. We then present a case study focused on the HIV and HCV syndemic in West Virginia to provide an example of the use of GIS and spatial analytical methods. The concepts described in this paper can be considered to enhance understanding and analysis of other syndemics for which space-time data are available.
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http://dx.doi.org/10.1016/j.socscimed.2020.113352DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7962030PMC
September 2020

Opioid initiation and injection transition in rural northern New England: A mixed-methods approach.

Drug Alcohol Depend 2020 12 30;217:108256. Epub 2020 Aug 30.

Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA, 02111, USA.

Background: In rural northern New England, located in the northeastern United States, the overdose epidemic has accelerated with the introduction of fentanyl. Opioid initiation and transition to opioid injection have been studied in urban settings. Little is known about opioid initiation and transition to injection drug use in rural northern New England.

Methods: This mixed-methods study characterized opioid use and drug injection in 11 rural counties in Massachusetts, Vermont, and New Hampshire between 2018 and 2019. People who use drugs completed audio computer-assisted self-interview surveys on substance use and risk behaviors (n = 589) and shared personal narratives through in-depth interviews (n = 22). The objective of the current study is to describe initiation of opioid use and drug injection in rural northern New England.

Results: Median age of first injection was 22 years (interquartile range 18-28 years). Key themes from in-depth interviews that led to initiating drug injection included normalization of drug use in families and communities, experiencing trauma, and abrupt discontinuation of an opioid prescription. Other factors that led to a transition to injecting included lower cost, increased effect/ rush, greater availability of heroin/ fentanyl, and faster relief of withdrawal symptoms with injection.

Conclusions: Trauma, normalization of drug use, over-prescribing of opioids, and abrupt discontinuation challenge people who use drugs in rural northern New England communities. Inadequate opioid tapering may increase transition to non-prescribed drug use. The extent and severity of traumatic experiences described highlights the importance of enhancing trauma-informed care in rural areas.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108256DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7769168PMC
December 2020

Touchpoints - Opportunities to predict and prevent opioid overdose: A cohort study.

Drug Alcohol Depend 2019 11 3;204:107537. Epub 2019 Sep 3.

Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02218, USA; Massachusetts Department of Public Health, 250 Washington Street, Boston, MA 02108, USA.

Background: Medical care, public health, and criminal justice systems encounters could serve as touchpoints to identify and intervene with individuals at high-risk of opioid overdose death. The relative risk of opioid overdose death and proportion of deaths that could be averted at such touchpoints are unknown.

Methods: We used 8 individually linked data sets from Massachusetts government agencies to perform a retrospective cohort study of Massachusetts residents ages 11 and older. For each month in 2014, we identified past 12-month exposure to 4 opioid prescription touchpoints (high dosage, benzodiazepine co-prescribing, multiple prescribers, or multiple pharmacies) and 4 critical encounter touchpoints (opioid detoxification, nonfatal opioid overdose, injection-related infection, and release from incarceration). The outcome was opioid overdose death. We calculated Standardized Mortality Ratios (SMRs) and Population Attributable Fractions (PAFs) associated with touchpoint exposure.

Results: The cohort consisted of 6,717,390 person-years of follow-up with 1315 opioid overdose deaths. We identified past 12-month exposure to any touchpoint in 2.7% of person-months and for 51.8% of opioid overdose deaths. Opioid overdose SMRs were 12.6 (95% CI: 11.1, 14.1) for opioid prescription and 68.4 (95% CI: 62.4, 74.5) for critical encounter touchpoints. Fatal opioid overdose PAFs were 0.19 (95% CI: 0.17, 0.21) for opioid prescription and 0.37 (95% CI: 0.34, 0.39) for critical encounter touchpoints.

Conclusions: Using public health data, we found eight candidate touchpoints were associated with increased risk of fatal opioid overdose, and collectively identified more than half of opioid overdose decedents. These touchpoints are potential targets for development of overdose prevention interventions.
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http://dx.doi.org/10.1016/j.drugalcdep.2019.06.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7020606PMC
November 2019

HCV treatment access among Latinxs who inject drugs: qualitative findings from Boston, Massachusetts, 2016.

Harm Reduct J 2019 07 9;16(1):44. Epub 2019 Jul 9.

Department of Public Health and Community Medicine, Clinical and Translational Sciences Institute, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA, 02111, USA.

Background: Compared with Caucasians, Latinxs with the hepatitis C virus (HCV) tend to initiate treatment less often, discontinue treatment, become infected younger, and have higher reinfection rates post-treatment. Little is known about HCV treatment experiences among Latinxs who inject drugs in the Northeastern USA. We assessed knowledge, attitudes, and perceptions tied to HCV, as well as HCV treatment readiness, and explored the overall HCV treatment experience of Latinx people who inject drugs (PWID) in Boston.

Methods: We conducted qualitative interviews with monolingual and bilingual Spanish-speaking Latinx PWID (n = 15) in Boston, Massachusetts, between 2015 and 2016. We used a thematic content analysis approach to code and analyze data to identify knowledge, attitudes, and experiences related to HCV treatment.

Results: We identified barriers and facilitators to HCV treatment. Six salient themes emerged from the data. For participants who had not initiated HCV treatment, lack of referral, fear of quitting drugs, and fear of relapse were perceived barriers. Trust in medical providers and a willingness to quit drugs were primary facilitators. Most participants had positive HCV treatment experiences, and several emphasized the need for outreach to Latinxs about the advantages of newer treatment options. Concerns about HCV reinfection were also notable.

Conclusions: We identified a range of experiences tied to HCV treatment among Latinx PWID. HCV care providers play a key role in determining treatment uptake, and more treatment information should be disseminated to Latinx PWID. Healthcare providers should capitalize on treatment facilitators by ensuring referrals to treatment and should continue to address perceived barriers.
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http://dx.doi.org/10.1186/s12954-019-0314-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6617637PMC
July 2019

The opioid epidemic in rural northern New England: An approach to epidemiologic, policy, and legal surveillance.

Prev Med 2019 11 31;128:105740. Epub 2019 May 31.

University of Massachusetts Medical School - Baystate, Springfield, MA, United States of America.

The opioid crisis presents substantial challenges to public health in New England's rural states, where access to pharmacotherapy for opioid use disorder (OUD), harm reduction, HIV and hepatitis C virus (HCV) services vary widely. We present an approach to characterizing the epidemiology, policy and resource environment for OUD and its consequences, with a focus on eleven rural counties in Massachusetts, New Hampshire and Vermont between 2014 and 2018. We developed health policy summaries and logic models to facilitate comparison of opioid epidemic-related polices across the three states that could influence the risk environment and access to services. We assessed sociodemographic factors, rates of overdose and infectious complications tied to OUD, and drive-time access to prevention and treatment resources. We developed GIS maps and conducted spatial analyses to assess the opioid crisis landscape. Through collaborative research, we assessed the potential impact of available resources to address the opioid crisis in rural New England. Vermont's comprehensive set of policies and practices for drug treatment and harm reduction appeared to be associated with the lowest fatal overdose rates. Franklin County, Massachusetts had good access to naloxone, drug treatment and SSPs, but relatively high overdose and HIV rates. New Hampshire had high proportions of uninsured community members, the highest overdose rates, no HCV surveillance data, and no local access to SSPs. This combination of factors appeared to place PWID in rural New Hampshire at elevated risk. Study results facilitated the development of vulnerability indicators, identification of locales for subsequent data collection, and public health interventions.
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http://dx.doi.org/10.1016/j.ypmed.2019.05.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6879818PMC
November 2019

Opioid overdose deaths and potentially inappropriate opioid prescribing practices (PIP): A spatial epidemiological study.

Int J Drug Policy 2019 06 11;68:37-45. Epub 2019 Apr 11.

Boston University School of Medicine/Boston Medical Center, Boston, MA, United States; RAND Corporation, Boston, MA, United States.

Introduction: Opioid overdose deaths quintupled in Massachusetts between 2000 and 2016. Potentially inappropriate opioid prescribing practices (PIP) are associated with increases in overdoses. The purpose of this study was to conduct spatial epidemiological analyses of novel comprehensively linked data to identify overdose and PIP hotspots.

Methods: Sixteen administrative datasets, including prescription monitoring, medical claims, vital statistics, and medical examiner data, covering >98% of Massachusetts residents between 2011-2015, were linked in 2017 to better investigate the opioid epidemic. PIP was defined by six measures: ≥100 morphine milligram equivalents (MMEs), co-prescription of benzodiazepines and opioids, cash purchases of opioid prescriptions, opioid prescriptions without a recorded pain diagnosis, and opioid prescriptions through multiple prescribers or pharmacies. Using spatial autocorrelation and cluster analyses, overdose and PIP hotspots were identified among 538 ZIP codes.

Results: More than half of the adult population (n = 3,143,817, ages 18 and older) were prescribed opioids. Nearly all ZIP codes showed increasing rates of overdose over time. Overdose clusters were identified in Worcester, Northampton, Lee/Tyringham, Wareham/Bourne, Lynn, and Revere/Chelsea (Getis-Ord Gi*; p < 0.05). Large PIP clusters for ≥100 MMEs and prescription without pain diagnosis were identified in Western Massachusetts; and smaller clusters for multiple prescribers in Nantucket, Berkshire, and Hampden Counties (p < 0.05). Co-prescriptions and cash payment clusters were localized and nearly identical (p < 0.05). Overlap in PIP and overdose clusters was identified in Cape Cod and Berkshire County. However, we also found contradictory patterns in overdose and PIP hotspots.

Conclusions: Overdose and PIP hotspots were identified, as well as regions where the two overlapped, and where they diverged. Results indicate that PIP clustering alone does not explain overdose clustering patterns. Our findings can inform public health policy decisions at the local level, which include a focus on PIP and misuse of heroin and fentanyl that aim to curb opioid overdoses.
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http://dx.doi.org/10.1016/j.drugpo.2019.03.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6685426PMC
June 2019

Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Mortality.

Ann Intern Med 2019 03;170(6):430-431

Clinical Addiction Research and Education Unit at Boston University School of Medicine and Boston Medical Center and Bureau of Substance Addiction Services, Massachusetts Department of Public Health, Boston, Massachusetts (A.Y.W.).

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http://dx.doi.org/10.7326/L18-0685DOI Listing
March 2019

Spatial Access and Willingness to Use Pre-Exposure Prophylaxis Among Black/African American Individuals in the United States: Cross-Sectional Survey.

JMIR Public Health Surveill 2019 Feb 4;5(1):e12405. Epub 2019 Feb 4.

Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, United States.

Background: Uptake of pre-exposure prophylaxis (PrEP) among black individuals in the United States is low and may be associated with the limited availability of clinics where PrEP is prescribed.

Objective: We aimed to determine the association between spatial access to clinics where PrEP is prescribed and willingness to use PrEP.

Methods: We identified locations of clinics where PrEP is prescribed from AIDSVu.org and calculated the density of PrEP clinics per 10,000 residents according to the ZIP code. Individual-level data were obtained from the 2016 National Survey on HIV in the Black Community. We used multilevel modelling to estimate the association between willingness to use PrEP and clinic density among participants with individual-level (HIV risk, age, gender, education, income, insurance, doctor visit, census region, urban/rural residence) and ZIP code-level (%poverty, %unemployed, %uninsured, %black population, and density of health care facilities) variables.

Results: All participants identified as black/African American. Of the 787 participants, 45% were men and 23% were found to be at high risk based on the self-reported behavioral characteristics. The mean age of the participants was 34 years (SD 9), 54% of participants resided in the South, and 26% were willing to use PrEP. More than one-third (38%) of the sample had to drive more than 1 hour to access a PrEP provider. Participants living in areas with higher PrEP clinic density were significantly more willing to use PrEP (one SD higher density of PrEP clinics per 10,000 population was associated with 16% higher willingness [adjusted prevalence ratio=1.16, 95% CI: 1.03-1.31]).

Conclusions: Willingness to use PrEP was associated with spatial availability of clinics where providers prescribe PrEP in this nationally representative sample of black African Americans.
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http://dx.doi.org/10.2196/12405DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6378549PMC
February 2019

Effect of Age on Opioid Prescribing, Overdose, and Mortality in Massachusetts, 2011 to 2015.

J Am Geriatr Soc 2019 01 24;67(1):128-132. Epub 2018 Nov 24.

School of Medicine, Tufts University, Boston, Massachusetts.

Objectives: To examine the effect of age on the likelihood of PIP of opioids and the effect of PIP on adverse outcomes.

Design: Retrospective cohort study.

Setting: Data from multiple state agencies in Massachusetts from 2011 to 2015.

Participants: Adult Massachusetts residents (N=3,078,163) who received at least one prescription opioid during the study period; approximately half (1,589,365) aged 50 and older.

Measurements: We measured exposure to 5 types of PIP: high-dose opioids, coprescription with benzodiazepines, multiple opioid prescribers, multiple opioid pharmacies, and continuous opioid therapy without a pain diagnosis. We examined 3 adverse outcomes: nonfatal opioid overdose, fatal opioid overdose, and all-cause mortality.

Results: The rate of any PIP increased with age, from 2% of individuals age 18 to 29 to 14% of those aged 50 and older. Older adults also had higher rates of exposure to 2 or more different types of PIP (40-49, 2.5%; 50-69, 5%; ≥70, 4%). Of covariates assessed, older age was the greatest predictor of PIP. In analyses stratified according to age, any PIP and specific types of PIP were associated with nonfatal overdose, fatal overdose, and all-cause mortality in younger and older adults.

Conclusion: Older adults are more likely to be exposed to PIP, which increases their risk of adverse events. Strategies to reduce exposure to PIP and to improve outcomes in those already exposed will be instrumental to addressing the opioid crisis in older adults. J Am Geriatr Soc 67:128-132, 2019.
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http://dx.doi.org/10.1111/jgs.15659DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6448572PMC
January 2019

'Hep C's like the common cold': understanding barriers along the HCV care continuum among young people who inject drugs.

Drug Alcohol Depend 2018 09 20;190:246-254. Epub 2018 Jul 20.

Tufts University School of Medicine, Department of Public Health and Community Medicine, 136 Harrison Avenue, Boston, MA 02186, USA. Electronic address:

Background: New highly effective medications are available to treat the hepatitis C virus (HCV). However, little is known about HCV treatment knowledge and readiness among young people who inject drugs (PWID), or factors that may contribute to treatment uptake and adherence in this treatment era.

Purpose: Using a framework for understanding healthcare utilization, we examined perspectives and experiences of young PWID tied to the HCV care continuum in Boston, Massachusetts, to inform future strategies.

Methods: We conducted 24 in-depth interviews with active and recent PWID aged 22-30 years living with HCV in Boston, February-August 2016. At the time of the interviews, no participants had been prescribed or had taken the new direct acting antivirals. We developed a codebook deductively from the interview guide and coded and analyzed the data into themes using a consensus-based process.

Results: The following five themes emerged, which captured PWID's knowledge of and experiences with HCV along the care continuum through social determinants of engagement in care, as well as illness level: (1) deservingness of HCV treatment and stigma, (2) dissatisfaction with provider interactions, (3) perceived lack of referral to treatment and care continuity, (4) disincentives around HCV treatment for PWID; and (5) perceived need for treatment. Young PWID living with HCV face unique barriers to HCV testing, counseling, and treatment.

Conclusion: Breakdowns in the HCV care continuum may have adverse effects on HCV-treatment readiness and willingness. Improved public health and practice approaches are needed to address these barriers to effectively engage young PWID in care.
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http://dx.doi.org/10.1016/j.drugalcdep.2018.06.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6367928PMC
September 2018

Food Insecurity, Morbidities, and Substance Use in Adults on Probation in Rhode Island.

J Urban Health 2018 08;95(4):564-575

The Miriam Hospital and the Alpert Medical School of Brown University, Box G-A1, Providence, Rhode Island, 02912, USA.

When individuals are on probation, they face challenges with securing employment and safe housing due to their criminal records, which may make food access problematic. Food insecurity is a construct used as a marker for food access that considers financial constraints and has been associated with poorer health and substance use. There is limited research on the extent of food insecurity and associated morbidities and substance use among adults on probation. We conducted a cross-sectional study in 2016, surveying 304 probationers in Rhode Island to determine whether food insecurity is associated with obesity, high blood pressure, depression, and substance use. Separate logistic regression models were used to determine the associations between food insecurity and obesity, high blood pressure, depression, and substance use. Food insecurity was experienced by 70% of our study population. The estimated prevalence of high blood pressure was significantly higher in our study sample compared to the general US population. Food insecurity was not associated with obesity, high blood pressure, or current drug use in this study sample. Food insecurity was independently associated with more than three times greater odds of being depressed (AOR 3.33, 95%CI 1.89, 5.86) and a nearly twofold greater odds of self-reporting a lower health status (AOR 1.91, 95%CI 1.18, 3.10) after adjusting for gender, race/ethnicity, age, income categories, and being homeless. Probationers were found to have a higher estimated prevalence of high blood pressure and food insecurity compared to the general population, which highlights the health disparities faced by this population. Our findings have important implications for future research and interventions to decrease the health burden not only on the individuals but their families and communities.
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http://dx.doi.org/10.1007/s11524-018-0290-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6095760PMC
August 2018

Potentially Inappropriate Opioid Prescribing, Overdose, and Mortality in Massachusetts, 2011-2015.

J Gen Intern Med 2018 09 14;33(9):1512-1519. Epub 2018 Jun 14.

Tufts University School of Medicine, Boston, MA, USA.

Background: Potentially inappropriate prescribing (PIP) may contribute to opioid overdose.

Objective: To examine the association between PIP and adverse events.

Design: Cohort study.

Participants: Three million seventy-eight thousand thirty-four individuals age ≥ 18, without disseminated cancer, who received prescription opioids between 2011 and 2015.

Main Measures: We defined PIP as (a) morphine equivalent dose ≥ 100 mg/day in ≥ 3 months; (b) overlapping opioid and benzodiazepine prescriptions in ≥ 3 months; (c) ≥ 4 opioid prescribers in any quarter; (d) ≥ 4 opioid-dispensing pharmacies in any quarter; (e) cash purchase of prescription opioids on ≥ 3 occasions; and (f) receipt of opioids in 3 consecutive months without a documented pain diagnosis. We used Cox proportional hazards models to identify PIP practices associated with non-fatal opioid overdose, fatal opioid overdose, and all-cause mortality, controlling for covariates.

Key Results: All six types of PIP were associated with higher adjusted hazard for all-cause mortality, four of six with non-fatal overdose, and five of six with fatal overdose. Lacking a documented pain diagnosis was associated with non-fatal overdose (adjusted hazard ratio [AHR] 2.21, 95% confidence interval [CI] 2.02-2.41), as was high-dose opioids (AHR 1.68, 95% CI 1.59-1.76). Co-prescription of benzodiazepines was associated with fatal overdose (AHR 4.23, 95% CI 3.85-4.65). High-dose opioids were associated with all-cause mortality (AHR 2.18, 95% CI 2.14-2.23), as was lacking a documented pain diagnosis (AHR 2.05, 95% CI 2.01-2.09). Compared to those who received opioids without PIP, the hazard for fatal opioid overdose with one, two, three, and ≥ four PIP subtypes were 4.24, 7.05, 10.28, and 12.99 (test of linear trend, p < 0.001).

Conclusions: PIP was associated with higher hazard for all-cause mortality, fatal overdose, and non-fatal overdose. Our study implies the possibility of creating a risk score incorporating multiple PIP subtypes, which could be displayed to prescribers in real time.
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http://dx.doi.org/10.1007/s11606-018-4532-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6109008PMC
September 2018

Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality: A Cohort Study.

Ann Intern Med 2018 08 19;169(3):137-145. Epub 2018 Jun 19.

Clinical Addiction Research and Education Unit at Boston University School of Medicine and Boston Medical Center and Bureau of Substance Addiction Services, Massachusetts Department of Public Health, Boston, Massachusetts (A.Y.W.).

Background: Opioid overdose survivors have an increased risk for death. Whether use of medications for opioid use disorder (MOUD) after overdose is associated with mortality is not known.

Objective: To identify MOUD use after opioid overdose and its association with all-cause and opioid-related mortality.

Design: Retrospective cohort study.

Setting: 7 individually linked data sets from Massachusetts government agencies.

Participants: 17 568 Massachusetts adults without cancer who survived an opioid overdose between 2012 and 2014.

Measurements: Three types of MOUD were examined: methadone maintenance treatment (MMT), buprenorphine, and naltrexone. Exposure to MOUD was identified at monthly intervals, and persons were considered exposed through the month after last receipt. A multivariable Cox proportional hazards model was used to examine MOUD as a monthly time-varying exposure variable to predict time to all-cause and opioid-related mortality.

Results: In the 12 months after a nonfatal overdose, 2040 persons (11%) enrolled in MMT for a median of 5 months (interquartile range, 2 to 9 months), 3022 persons (17%) received buprenorphine for a median of 4 months (interquartile range, 2 to 8 months), and 1099 persons (6%) received naltrexone for a median of 1 month (interquartile range, 1 to 2 months). Among the entire cohort, all-cause mortality was 4.7 deaths (95% CI, 4.4 to 5.0 deaths) per 100 person-years and opioid-related mortality was 2.1 deaths (CI, 1.9 to 2.4 deaths) per 100 person-years. Compared with no MOUD, MMT was associated with decreased all-cause mortality (adjusted hazard ratio [AHR], 0.47 [CI, 0.32 to 0.71]) and opioid-related mortality (AHR, 0.41 [CI, 0.24 to 0.70]). Buprenorphine was associated with decreased all-cause mortality (AHR, 0.63 [CI, 0.46 to 0.87]) and opioid-related mortality (AHR, 0.62 [CI, 0.41 to 0.92]). No associations between naltrexone and all-cause mortality (AHR, 1.44 [CI, 0.84 to 2.46]) or opioid-related mortality (AHR, 1.42 [CI, 0.73 to 2.79]) were identified.

Limitation: Few events among naltrexone recipients preclude confident conclusions.

Conclusion: A minority of opioid overdose survivors received MOUD. Buprenorphine and MMT were associated with reduced all-cause and opioid-related mortality.

Primary Funding Source: National Center for Advancing Translational Sciences of the National Institutes of Health.
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http://dx.doi.org/10.7326/M17-3107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6387681PMC
August 2018

Food acquisition methods and correlates of food insecurity in adults on probation in Rhode Island.

PLoS One 2018 8;13(6):e0198598. Epub 2018 Jun 8.

Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, United States of America.

Background: Individuals under community corrections supervision may be at increased risk for food insecurity because they face challenges similar to other marginalized populations, such as people experiencing housing instability or substance users. The prevalence of food insecurity and its correlates have not been studied in the community corrections population.

Methods: We conducted a cross-sectional study in 2016, surveying 304 probationers in Rhode Island to estimate the prevalence of food insecurity, identify food acquisition methods, and determine characteristics of groups most at-risk for food insecurity. We used chi-square and Fisher's exact tests to assess differences in sociodemographics and eating and food acquisition patterns, GIS to examine geospatial differences, and ordinal logistic regression to identify independent correlates across the four levels of food security.

Results: Nearly three-quarters (70.4%) of the participants experienced food insecurity, with almost half (48.0%) having very low food security. This is substantially higher than the general population within the state of Rhode Island, which reported a prevalence of 12.8% food insecurity with 6.1% very low food security in 2016. Participants with very low food security most often acquired lunch foods from convenience stores (and less likely from grocery stores) compared to the other three levels of food security. Participants did not differ significantly with regards to places for food acquisition related to breakfast or dinner meals based upon food security status. In adjusted models, being homeless (AOR 2.34, 95% CI: 1.31, 4.18) and depressed (AOR 3.12, 95% CI: 1.98, 4.91) were independently associated with a greater odds of being in a food insecure group. Compared to having help with meals none of the time, participants who reported having meal help all of the time (AOR 0.28, 95% CI: 0.12, 0.64), most of the time (AOR 0.31, 95% CI: 0.15, 0.61), and some of the time (AOR 0.54, 95% CI: 0.29, 0.98) had a lower odds of being in a food insecure group. Food insecure participants resided in different neighborhoods than food secure participants. The highest density of food insecure participants resided in census tracts with the lowest median incomes for the general population. The areas of highest density for each level of food security for our participants were in the census tracts with the lowest levels of full-time employment for the general population.

Conclusions: The prevalence of food insecurity and very low food security were markedly higher in our probation population compared to the general RI population. These findings suggest that access to food on a regular basis is a challenge for adults on probation. Depression and being homeless were independently associated with a greater odds of being in a food insecure group. In addition to intervening directly on food insecurity, developing interventions and policies that address the contributing factors of food insecurity, such as safe housing and treatment for depression, are critical.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0198598PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5993252PMC
January 2019

HIV Clustering in Mississippi: Spatial Epidemiological Study to Inform Implementation Science in the Deep South.

JMIR Public Health Surveill 2018 Apr 3;4(2):e35. Epub 2018 Apr 3.

School of Public Health, Brown University, Providence, RI, United States.

Background: In recent years, more than half of new HIV infections in the United States occur among African Americans in the Southeastern United States. Spatial epidemiological analyses can inform public health responses in the Deep South by identifying HIV hotspots and community-level factors associated with clustering.

Objective: The goal of this study was to identify and characterize HIV clusters in Mississippi through analysis of state-level HIV surveillance data.

Methods: We used a combination of spatial epidemiology and statistical modeling to identify and characterize HIV hotspots in Mississippi census tracts (n=658) from 2008 to 2014. We conducted spatial analyses of all HIV infections, infections among men who have sex with men (MSM), and infections among African Americans. Multivariable logistic regression analyses identified community-level sociodemographic factors associated with HIV hotspots considering all cases.

Results: There were HIV hotspots for the entire population, MSM, and African American MSM identified in the Mississippi Delta region, Southern Mississippi, and in greater Jackson, including surrounding rural counties (P<.05). In multivariable models for all HIV cases, HIV hotspots were significantly more likely to include urban census tracts (adjusted odds ratio [AOR] 2.01, 95% CI 1.20-3.37) and census tracts that had a higher proportion of African Americans (AOR 3.85, 95% CI 2.23-6.65). The HIV hotspots were less likely to include census tracts with residents who had less than a high school education (AOR 0.95, 95% CI 0.92-0.98), census tracts with residents belonging to two or more racial/ethnic groups (AOR 0.46, 95% CI 0.30-0.70), and census tracts that had a higher percentage of the population living below the poverty level (AOR 0.51, 95% CI 0.28-0.92).

Conclusions: We used spatial epidemiology and statistical modeling to identify and characterize HIV hotspots for the general population, MSM, and African Americans. HIV clusters concentrated in Jackson and the Mississippi Delta. African American race and urban location were positively associated with clusters, whereas having less than a high school education and having a higher percentage of the population living below the poverty level were negatively associated with clusters. Spatial epidemiological analyses can inform implementation science and public health response strategies, including improved HIV testing, targeted prevention and risk reduction education, and tailored preexposure prophylaxis to address HIV disparities in the South.
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http://dx.doi.org/10.2196/publichealth.8773DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5904450PMC
April 2018

Competing priorities that rival health in adults on probation in Rhode Island: substance use recovery, employment, housing, and food intake.

BMC Public Health 2018 02 27;18(1):289. Epub 2018 Feb 27.

Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA, 02111, USA.

Background: Individuals on probation experience economic disadvantage because their criminal records often prohibit gainful employment, which compromises their ability to access the basic components of wellbeing. Unemployment and underemployment have been studied as distinct phenomenon but no research has examined multiple determinants of health in aggregate or explored how these individuals prioritize each of these factors. This study identified and ranked competing priorities in adults on probation and qualitatively explored how these priorities impact health.

Methods: We conducted in-depth interviews in 2016 with 22 adults on probation in Rhode Island to determine priority rankings of basic needs. We used Maslow's hierarchy of needs theory and the literature to guide the priorities we pre-selected for probationers to rank. Within a thematic analysis framework, we used a modified ranking approach to identify the priorities chosen by participants and explored themes related to the top four ranked priorities.

Results: We found that probationers ranked substance use recovery, employment, housing, and food intake as the top four priorities. Probationers in recovery reported sobriety as the most important issue, a necessary basis to be able to address other aspects of life. Participants also articulated the interrelatedness of difficulties in securing employment, food, and housing; these represent stressors for themselves and their families, which negatively impact health. Participants ranked healthcare last and many reported underinsurance as an issue to accessing care.

Conclusions: Adults on probation are often faced with limited economic potential and support systems that consistently place them in high-risk environments with increased risk for recidivism. These findings emphasize the need for policies that address the barriers to securing gainful employment and safe housing. Interventions that reflect probationer priorities are necessary to begin to mitigate the health disparities in this population.
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http://dx.doi.org/10.1186/s12889-018-5201-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5828298PMC
February 2018

Sex work, injection drug use, and abscesses: Associations in women, but not men.

Drug Alcohol Depend 2018 04 20;185:293-297. Epub 2018 Feb 20.

Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, United States.

Background: Abscesses commonly occur among people who inject drugs (PWID). However, whether the risks are comparable between males and females, and the impact of sex work on abscess risk is unclear. The goal of this study was to examine the contemporary associations of gender and sex work with the risk of abscesses in PWID.

Methods: Combining data from two cross-sectional studies conducted in the Greater Boston Area with people at risk for HIV and hepatitis C virus (HCV), we used the following inclusion criteria: age 18-45 years and report of illicit or non-prescription drug injection within the 30 days prior to the survey. Information on demographics, injection-mediated risks, and sexual behaviors was collected using Audio Computer-Assisted Self-Interview Software. Multivariable logistic regressions were used to model associations.

Results: The study sample included 298 people including 30% were female. Females were more likely than men to report sex work (28% vs. 16%, p = .012) and abscess during their lifetime (55% vs. 37% p = .004). Among the females, engaging in sex work increased by >5-fold the odds of reporting abscesses [Adjusted odds ratio 5.42; 95% CI: 1.27, 23.10]. There was no association between sex work and abscesses among men.

Discussion: We found a female-specific association between sex work, injection drug use, and abscesses among PWID. Although the cross-sectional designs precluded causal inferences, longitudinal studies could enhance understanding of gender-associated risks for abscesses and inform the development of harm reduction interventions.
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http://dx.doi.org/10.1016/j.drugalcdep.2017.12.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5991097PMC
April 2018
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