Faculty Bibliography

PURPOSE/OBJECTIVE:To assess cross-population linkages in HIV/AIDS epidemics, we tested the hypothesis that the number of newly diagnosed AIDS cases among Black people who inject drugs (PWID) was positively related to the natural log of the rate of newly diagnosed HIV infections among Black non-PWID heterosexuals in 84 large U.S. metropolitan statistical areas (MSAs) in 2008-2016. METHODS:We estimated a multilevel model centering the time-varying continuous exposures at baseline between the independent (Black PWID AIDS rates) and dependent (HIV diagnoses rate among Black heterosexuals) variables. RESULTS:At MSA level, baseline (standardized β = 0.12) Black PWID AIDS rates and change in these rates over time (standardized β = 0.11) were positively associated with the log of new HIV diagnoses rates among Black heterosexuals. Thus, MSAs with Black PWID AIDS rates that were 1 standard deviation= higher at baseline also had rates of newly diagnosed HIV infections among Black non-PWID heterosexuals that were 10.3% higher. A 1 standard deviation increase in independent variable over time corresponded to a 7.8% increase in dependent variable. CONCLUSIONS:Black PWID AIDS rates may predict HIV rates among non-PWID Black heterosexuals. Effective HIV programming may be predicated, in part, on addressing intertwining of HIV epidemics across populations.

BACKGROUND:The COVID-19 pandemic poses significant challenges to people with opioid use disorder (OUD). As localities enforce lockdowns and pass emergency OUD treatment regulations, questions arise about how these changes will affect access and retention in care. In this study, we explore the influence of COVID-19 on access to, experiences with, and motivations for OUD treatment through a qualitative analysis of public discussion forums on Reddit. METHODS:We collected data from Reddit, a free and international online platform dedicated to public discussions and user-generated content. We extracted 1000 of the most recent posts uploaded between March 5th and May 13th, 2020 from each of the two most popular opioid subreddits "r/Opiates" and "r/OpiatesRecovery" (total 2000). We reviewed posts for relevance to COVID-19 and opioid use and coded content using a hybrid inductive-deductive approach. Thematic analysis identified common themes related to study questions of interest. RESULTS:Of 2000 posts reviewed, 300 (15%) discussed topics related to the intersection of opioid use and COVID-19. Five major themes related to OUD treatment were identified: Concern about closure of OUD treatment services; transition to telehealth and virtual care; methadone treatment requirements and increased exposure to COVID-19; reactions to changing regulations on medications for OUD; and influences of the pandemic on treatment motivation and progress. CONCLUSION/CONCLUSIONS:In the face of unprecedented challenges due to COVID-19, reactions of Reddit opioid forum users ranged from increased distress in accessing and sustaining treatment, to encouragement surrounding new modes of treatment and opportunities to engage in care. New and less restrictive avenues for treatment were welcomed by many, but questions remain about how new norms and policy changes will be sustained beyond this pandemic and impact OUD treatment access and outcomes long-term.

BACKGROUND:The COVID-19 pandemic is creating severe issues for healthcare and broad social structures, exposing societal vulnerabilities. Among the populations affected by COVID-19 are people engaged in substance use, such as people who smoke; vape (e-cigarette use); use opioids, cannabis, alcohol, or psychoactive prescription drugs; or have a substance use disorder (SUD). Monitoring substance use and SUD during the pandemic is essential, as people who engage in substance use or present with SUD are at greater risk for COVID-19, and the economic and social changes resulting from the pandemic may aggravate SUD. There have been several reviews focused on COVID-19 in relation to substance use and SUD. Reviews generally did not consider on a large range of substance use variants or SUDs. We plan a scoping review that seeks to fill gaps in our current understanding of substance use and SUD, in the COVID-19 era. METHODS:A scoping review focused on substance use and SUD, in relation to COVID-19, will be conducted. We will search (from January 2020 onwards) Cumulative Index to Nursing and Allied Health Literature, Africa-Wide Information, Web of Science Core Collection, Embase, Global Health, WHO Global Literature on Coronavirus Disease Database, WHO Global Index Medicus, PsycINFO, PubMed, Middle Eastern Central Asian Studies, CINAHL Complete, and Sociological Abstracts. Grey literature will be identified using Disaster Lit, Google Scholar, HSRProj, governmental websites, and clinical trials registries (e.g., ClinicalTrial.gov , World Health Organization, International Clinical Trials Registry Platform and International Standard Randomized Con-trolled Trial Number registry). Study selection will conform to Joanna Briggs Institute Reviewers' Manual 2015 Methodology for JBI Scoping Reviews. Only English language, original studies investigating substance use and SUD, in relation to COVID-19 in all populations and settings, will be considered for inclusion. Two reviewers will independently screen all citations, full-text articles, and abstract data. A narrative summary of findings will be conducted. Data analysis will involve quantitative (e.g., frequencies) and qualitative (e.g., content and thematic analysis) methods. DISCUSSION:Original research is urgently needed to mitigate the risks of COVID-19 on substance use and SUD. The planned scoping review will help to address this gap. SYSTEMATIC REVIEW REGISTRATION:Open Science Framework (osf/io/tzgm5).

PURPOSE/OBJECTIVE:Individuals with poor physical and mental health may face elevated risk for suicide, particularly suicide by firearm. METHODS:This retrospective cohort study used statewide, longitudinally-linked ED patient record and mortality data to examine 12-month incidence of firearm suicide among emergency department (ED) patients presenting with a range of physical health problems. Participants included all residents presenting to a California ED in 2009-2013 with nonfatal visits for somatic diagnoses hypothesized to increase suicide risk, including myocardial infarction, congestive heart failure, cerebrovascular disease, chronic obstructive pulmonary disease, diabetes, cancer, back pain, headache, joint disorder, and injuries. For each patient diagnostic group, we calculated rates of firearm suicide per 100,000 person-years and standardized mortality ratios (SMRs) relative to the demographically matched California population. RESULTS:Firearm suicide rates per 100,000 person-years ranged from 9.6 (among patients presenting with unintentional injury) to 55.1 (patients with cancer diagnoses), with SMRs from 1.48 to 7.45 (all p<0.05). SMRs for patients with cardiovascular conditions ranged from 2.45 to 5.10. Males and older individuals had higher firearm suicide rates, and there was substantial between-group variability in the proportion of suicide decedents who used a firearm. CONCLUSIONS:ED patients presenting with deliberate self-harm injuries, substance use, and cancer were especially at risk for firearm suicide. To avoid missed suicide-prevention opportunities, EDs should implement evidence-based suicide interventions as a best practice for their patients.

OBJECTIVES:The rapid increase in opioid overdose and opioid use disorder (OUD) over the past 20 years is a complex problem associated with significant economic costs for healthcare systems and society. Simulation models have been developed to capture and identify ways to manage this complexity and to evaluate the potential costs of different strategies to reduce overdoses and OUD. A review of simulation-based economic evaluations is warranted to fully characterize this set of literature. METHODS:A systematic review of simulation-based economic evaluation (SBEE) studies in opioid research was initiated by searches in PubMed, EMBASE, and EbscoHOST. Extraction of a predefined set of items and a quality assessment were performed for each study. RESULTS:The screening process resulted in 23 SBEE studies ranging by year of publication from 1999 to 2019. Methodological quality of the cost analyses was moderately high. The most frequently evaluated strategies were methadone and buprenorphine maintenance treatments; the only harm reduction strategy explored was naloxone distribution. These strategies were consistently found to be cost-effective, especially naloxone distribution and methadone maintenance. Prevention strategies were limited to abuse-deterrent opioid formulations. Less than half (39%) of analyses adopted a societal perspective in their estimation of costs and effects from an opioid-related intervention. Prevention strategies and studies' accounting for patient and physician preference, changing costs, or result stratification were largely ignored in these SBEEs. CONCLUSION:The review shows consistently favorable cost analysis findings for naloxone distribution strategies and opioid agonist treatments and identifies major gaps for future research.

Drug use involves social interactions. Therefore, norms in the proximal environment of people who inject drugs (PWID) can favor behaviors that may result in HIV transmission. This work aimed at studying drug injection-related norms and their potential association with risky behaviors among PWID in Athens, Greece, in the context of economic recession and political activism that followed the fiscal crisis and soon after a recent HIV outbreak had leveled off. The Transmission Reduction Intervention Project (TRIP) was a social network-based approach (June 2013 to July 2015) that involved two groups of PWID seeds-with recent HIV infection and with long-term HIV infection and one control group of HIV-negative PWID. Network contacts of seeds were also enrolled. TRIP participants answered a questionnaire that included items on injection-related norms and behaviors. TRIP recruited 320 PWID (HIV positive, 44.4%). TRIP participants, especially those without HIV, often recalled or perceived as normative among their partners and in their networks some behaviors that can lead to HIV transmission. TRIP participants who recalled that they were encouraged by their regular drug partners to use an unclean syringe were almost twice as likely to report that they share syringes [odds ratio (OR) = 2.03; 95% confidence interval (CI) = 1.86-2.21], or give syringes to someone else (OR = 1.70; 95% CI = 1.42-2.04) as those who did not recall such an encouragement. Associations were modified by HIV status. HIV negatives, who were reportedly encouraged to share nonsyringe injecting equipment, were almost 4.5 times as likely to share that material as HIV-negative participants who were not encouraged (OR = 4.59, 95% CI = 4.12-5.11). Further research is needed on the multiple determinants (social, economic, and political) of norms in the social environments of PWID. Since peer norms are associated with risky behaviors, interventions should be developed to encourage norms and peer pressure against the sharing of injection equipment.

PURPOSE/OBJECTIVE:The challenges of producing adequate estimates of HIV prevalence among men who have sex with men (MSM) are well known. No one, to our knowledge, has published annual estimates of HIV prevalence among MSM over an extended period and across a wide range of geographic areas. METHODS:This article applies multilevel modeling to data integrated from numerous sources to estimate and validate trajectories of HIV prevalence among MSM from 1992 to 2013 for 86 of the largest metropolitan statistical areas in the United States. RESULTS:Our estimates indicate that HIV prevalence among MSM increased, from an across-metropolitan statistical area mean of 11% in 1992 to 20% in 2013 (S.D. = 3.5%). Our estimates by racial/ethnic subgroups of MSM suggest higher mean HIV prevalence among black and Hispanic/Latino MSM than among white MSM across all years and geographic regions. CONCLUSIONS:The increases found in HIV prevalence among all MSM are likely primarily attributable to decreases in mortality and perhaps also to increasing HIV incidence among racial/ethnic minority MSM. Future research is needed to confirm this. If true, health care initiatives should focus on targeted HIV prevention efforts among racial/ethnic minority MSM and on training providers to address cross-cutting health challenges of increased longevity among HIV-positive MSM.

BACKGROUND:American Indians and Alaska Natives (AI/ANs) are disproportionately affected by the opioid overdose crisis. Treatment with medications for opioid use disorder (MOUD) can significantly reduce overdose risk, but no national studies to date have reported on the extent to which AI/ANs access these treatments overall and in relation to other groups. METHODS:The current study used two national databases - the 2018 National Survey on Substance Abuse Treatment Services and the 2017 Treatment Episode Dataset - to estimate the extent to which MOUD is available and used among AI/ANs across the U.S. RESULTS:We found that facilities serving AI/ANs (N = 1,532) offered some MOUD at similar rates as other facilities (N = 13,277) (39.6 vs. 40.6 %, p = 0.435) but were less likely to offer the standard of care with buprenorphine or methadone maintenance (22.4 % vs. 27.6 %, p < 0.001). AI/AN clients in specialty treatment (N = 8,136) exhibited slightly higher MOUD use (40.0 % vs. 38.6 %, p = 0.009) relative to other race groups (N = 673,938). AI/AN clients were also more likely to exhibit greater prescription opioid use and methamphetamine co-use relative to other groups. AI/AN clients in the South (aOR:0.23[95 %CI: 0.19-0.28] or referred by criminal justice sources (aOR:0.13[95 %CI: 0.11-0.16] were least likely to receive MOUD. CONCLUSIONS:We conclude that most AI/ANs in specialty treatment do not receive medications for opioid use disorder, and that rates of MOUD use are similar to those of other race groups. Efforts to expand MOUD among AI/ANs that are localized and cater to unique characteristics of this population are gravely needed.