Faculty Bibliography

The positive effects of increased diversity and inclusion in scientific research and practice are well documented. In this issue, DeVilbiss et al. (Am J Epidemiol. 2020;189(10):998-1010) present findings from a survey used to collect information to characterize diversity among epidemiologists and perceptions of inclusion in the epidemiologic profession. They capture identity across a range of personal characteristics, including race, gender, socioeconomic background, sexual orientation, religion, and political leaning. In this commentary, we assert that the inclusion of political leaning as an axis of identity alongside the others undermines the larger project of promoting diversity and inclusion in the profession and is symptomatic of the movement for "ideological diversity" in higher education. We identify why political leaning is not an appropriate metric of diversity and detail why prioritizing ideological diversity counterintuitively can work against equity building initiatives. As an alternative to ideological diversity, we propose that epidemiologists take up an existing framework for research and practice that centers the voices and perspectives of historically marginalized populations in epidemiologic work.

BACKGROUND:In August 2010, extended-release OxyContin® products, including oxycodone 80 mg, were reformulated and released as abuse-deterrent medications. This paper describes changes in individual prescription filling patterns that followed the reformulation of oxycodone 80 mg. METHODS:Using New York State prescription monitoring program data, we conducted a retrospective analysis of a cohort of New York City residents who had filled at least three consecutive prescriptions for oxycodone 80 mg immediately prior to the reformulation. We classified cohort members into one of three groups (continuers, switchers, and discontinuers) based on prescription filling patterns post-reformulation. Descriptive analyses were conducted to identify prevalence of filling patterns. Differences in median morphine milligram equivalents (MME) pre- and post-reformulation were compared using the Wilcoxon signed-rank sum test. Analyses were completed in 2018. RESULTS:A cohort of 4,098 New York City residents filled continuous prescriptions for oxycodone 80 mg immediately prior to reformulation. Post-reformulation, 14% of the cohort discontinued filling opioid analgesic prescriptions; 46% continued to fill prescriptions for oxycodone 80 mg; and 40% switched to a different opioid analgesic, most commonly oxycodone 30 mg. Post-reformulation, the median MME dose decreased significantly among all three groups: 45 mg among continuers, 150 mg among switchers, and 360 mg among discontinuers. CONCLUSION:Post-reformulation, more than half the cohort changed their filling patterns. Following reformulation, median MME dose decreased significantly among the cohort. We hypothesize that the dramatic decrease in MME dose prompted many to transition to heroin in order to avoid severe withdrawal.

This study evaluates racial differences in opioid overdose deaths in New York City for 2017.

Relay, a peer-delivered response to nonfatal opioid overdoses, provides overdose prevention education, naloxone, support, and linkage to care to opioid overdose survivors for 90 days after an overdose event. From June 2017 to December 2018, Relay operated in seven New York City emergency departments and enrolled 649 of the 876 eligible individuals seen (74%). Preliminary data show high engagement, primarily among individuals not touched by harm reduction or naloxone distribution networks. Relay is a novel and replicable response to the opioid epidemic.

There is consensus in the scientific literature that the opioid agonist medications methadone and buprenorphine are the most effective treatments for opioid use disorder. Despite increasing opioid overdose deaths in the United States, these medications remain substantially underutilized. For no other medical conditions for which an effective treatment exists is that treatment used so infrequently. In this commentary, we discuss the potential role of stigma in the underutilization of these opioid agonist medications for addiction treatment. We outline stigma toward medications for addiction treatment and suggest that structural and policy barriers to methadone and buprenorphine may contribute to this stigma. We offer pragmatic public health solutions to reduce stigma and expand access to these effective treatments.

BACKGROUND:Rates of overdose death in New York City (NYC) increased 26% from 2000 to 2015, with a notable decrease in rate from 2006 to 2010. Beginning in 2016, the synthetic opioid fentanyl entered the NYC illicit drug market and has been associated with large increases in overdose death. This study assessed NYC trends in opioid-involved overdose death prior to fentanyl to understand the contribution of specific opioids and inform overdose prevention strategies. METHODS:Data were derived from death certificates linked to postmortem toxicology testing. We stratified cases into three mutually exclusive groups: (1) heroin without opioid analgesics (OAs); (2) OAs without heroin; and (3) the combination of heroin and OAs. We calculated mortality rates by year, and compared rates by the demographic characteristics age, sex, and race/ethnicity. Joinpoint regression identified junctures in trends between 2000 and 2015. RESULTS:Rates of overdose death involving heroin without OAs decreased from 2006 to 2010, then increased from 2010 to 2015 among males, persons age 15 to 54, and Blacks and Whites. Rates of overdose death involving OAs with and without heroin increased from 2000 to 2015 across all demographic subgroups. CONCLUSIONS:The identified trends in overdose death are suggestive of demographic shifts in drug use. In particular, the tamper-resistant reformulation of oxycodone 80 mg may have increased the use of heroin among primary OA users. Notably, older adults may have had established heroin use practices prior to the proliferation of OAs and thus may have been less likely to modify drug use practices.

Latinas comprise the largest racial/ethnic group of trans women (male-to-female transgender people) in New York City, where HIV seroprevalence among trans Latinas has been found to be as high as 49%. Despite this population's high risk of HIV, little is known about resilience among trans Latinas that may provide protective health factors. Six focus groups and one in-depth interview were conducted with 34 low-income trans/gender-variant people of colour who attended transgender support groups at harm reduction programmes in New York City. This paper reports on data from 13 participants who identified as immigrant trans Latinas. Focus groups were coded and analysed using thematic qualitative methods. The majority of immigrants were undocumented but reported having robust social support. Unique characteristics of immigrant trans Latinas included alternative kinship structures and sources of income. Social creativity was used to develop achievable ways in which to improve their health outcomes. Resilience was evident in informal kinship dynamics, formal support groups, gender-transition, educational access and skills training and substance use reduction. Individual-level resilience increased as a result of strong community-level resilience.

A cohort of frequently incarcerated individuals in the New York City jail system was identified through "hot spotting" analysis. This group demonstrated higher levels of substance use, mental illness, and homelessness than the general jail population, and was typically incarcerated on minor criminal charges. To understand this population better, in-depth interviews (n = 20) were conducted at three Rikers Island correctional facilities with people who had entered the jail system at least 18 times in a six-year period. Findings showed that life circumstances, chronic homelessness, mental illness, and substance use resulted in repeated institutionalization across multiple settings. Participants described an "institutional circuit" that promoted a state of permanent instability characterized by rotating involvement with custodial institutions. Exiting the institutional circuit requires the ability to navigate complex bureaucratic systems; however, without structural reorganization in social service delivery and an emphasis on permanent housing, participants in this group are unlikely to break the cycle.

BACKGROUND:As the prevalence of opioid analgesic (OA) misuse and associated harms have increased in the United States, the prevalence of heroin use and rates of unintentional overdose have concurrently risen. Research has begun to identify connections between OA misuse and heroin use, although this relationship remains under explored. The present study explores the context of heroin initiation among persons with histories of OA misuse in New York City. METHODS:In-depth interviews were conducted with 31 individuals with histories of OA misuse who initiated heroin use within the past five years. Data were collected between August 2013 and January 2015. All participants' OA misuse temporally preceded their heroin use. Interviews were coded and analyzed utilizing thematic qualitative methods. RESULTS:Participants ranged in age from 18 to 44 years; 25 identified as male and 30 identified as non-Hispanic white and heterosexual. All participants had stable housing at the time of interview and all were high school graduates. Participants described several key points of transition along their trajectories from OA misuse to heroin initiation: dual- to single-entity OAs; oral to intranasal OA administration; and the development of physical opioid dependence. Participants described the breaking down of heroin-related stigma across social networks as new drug use permeated social groups. CONCLUSION/CONCLUSIONS:Several points of transition were identified in participants' trajectories from OA misuse to heroin initiation. In particular the development of physical dependence was a critical factor as existing heroin stigma was rapidly overcome in the face of opioid withdrawal. The relatively short time to heroin initiation documented among new user groups serves as an added challenge to the development of interventions.