Journal: JAMA Network Open, 2023, doi:10.1001/jamanetworkopen.2022.55101
Authors: Elizabeth M. Magnan, Daniel J. Tancredi, Guibo Xing, Alicia Agnoli, Anthony Jerant & Joshua J. Fenton
Abstract:
Importance: Opioid tapering has been associated with negative consequences, such as increased overdoses and mental health needs. Tapering could also alter use of health care services and worsen care of comorbid conditions through disruption in primary care.
Objective: To evaluate tapering of stable long-term opioid therapy (LTOT) and subsequent health care service use and chronic condition care.
Design, Setting, and Participants: A retrospective cohort study was conducted from January 1, 2008, to December 31, 2019. Data analysis was performed from July 9, 2020, to December 9, 2022. Data from the Optum Labs Data Warehouse, which contains deidentified retrospective administrative claims data and linked electronic health record data for commercial and Medicare Advantage enrollees, were used. Adults aged 18 years or older prescribed stable doses of LTOT at 50 morphine milligram equivalents or more per day during a 12-month baseline period were included, including subcohorts with hypertension or diabetes.
Exposures: Opioid tapering, with 15% or more relative reduction in mean daily dose in 6 overlapping periods during 6 months.
Main Outcomes and Measures: Emergency department visits, hospitalizations, primary care and specialist visits, antihypertensive or antiglycemic medication adherence, and blood pressure and hemoglobin A1c levels during up to 12 months’ follow-up. Covariates included sociodemographic characteristics, comorbidities, health care use, and chronic condition control.
Results: Among 113 604 patients (60 764 [53.5%] women; mean [SD] age, 58.1 [11.8] years) prescribed LTOT, 41 207 had hypertension and 23 335 had diabetes; in all cohorts, approximately half were women, and half were aged 50 to 65 years. In the overall cohort, tapering was associated with more emergency department visits (adjusted incidence rate ratio [aIRR], 1.19; 95% CI, 1.16-1.21) and hospitalizations (aIRR, 1.16; 95% CI, 1.12-1.20), with similar magnitude associations in the hypertension and diabetes subcohorts. Tapering was associated with fewer primary care visits in the overall cohort (aIRR, 0.95; 95% CI, 0.94-0.96) and hypertension subcohort (aIRR, 0.98; 95% CI, 0.97-0.99). For the hypertension or diabetes subcohorts, tapering was associated with reduced medication adherence (hypertension: aIRR, 0.60; 95% CI, 0.59-0.62; diabetes: aIRR, 0.69; 95% CI, 0.67-0.71) and small increases in diastolic blood pressure and hemoglobin A1c level.
Conclusions and Relevance: In this cohort study of patients prescribed LTOT, opioid tapering was associated with more emergency department visits and hospitalizations, fewer primary care visits, and reduced antihypertensive and antidiabetic medication adherence. These outcomes may represent unintended negative consequences of opioid tapering for policy makers and clinicians to consider.
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Journal: BMC Public Health, 2023, doi: 10.1186/s12889-023-15108-w
Authors: Olivia Baker, Chevaughn Wellington, Carolina R. Price, DeShana Tracey, Lindsay Powell, Sara Loffredo, Silvia Moscariello & Jaimie P. Meyer
Abstract:
Background: People returning to communities from prison or jail face stressors related to securing housing, including discrimination, restrictions based on prior felony convictions, and limited economic and social resources. Existing housing programs can effectively reduce housing instability but often do not fully address the needs of people involved in the criminal justice system experiencing homelessness who often have co-occurring chronic medical issues, and psychiatric and substance use disorders.
Methods: Project CHANGE is an ongoing program to deliver person-centered, integrated care and services to individuals involved with the criminal justice system and experiencing homelessness. Applying a Screening, Brief Intervention, (Referral to) Treatment framework, a comprehensive needs assessment is followed by delivery of intensive housing and vocational case management; and psychiatric, substance use, and medical services in a single location by an interdisciplinary team. Participants are followed with study interviews for 12 months. The current analysis was designed to assess the baseline characteristics and needs of the sample population, and the intensity of contact required for integrated service delivery.
Results: Between November 2019 and September 2021, 86 participants were enrolled, of whom 64% had been released from prison/jail in the past 6 months; the remainder were on parole, probation, or intensive pretrial supervision. Participants were unstably housed (64%) or residing outdoors (26.7%) or in a shelter (24.4%). Most participants had high medical need and frequent healthcare engagement through outpatient and emergency department visits. Most participants were at-risk for clinical depression, and half were diagnosed with anxiety, dissociative, stress-related, somatoform, and other non-psychotic psychiatric disorders. Over 12-month follow-up, the interdisciplinary team made over 500 contact encounters, over half of which resulted in direct services provided, including obtaining vital documents for homelessness verification, housing applications, and employment coaching.
Conclusion: Navigation of services can be particularly challenging for individuals experiencing criminal justice involvement, homelessness, and co-occurring medical, psychiatric, and substance use issues, which can be addressed holistically in an integrated service model. Integrated service delivery was time-, resource-, and staffing-intensive, and challenged by the COVID-19 pandemic, requiring innovative solutions to sustain participant engagement.
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Journal: Frontiers in Psychiatry, 2023, doi: 10.3389/fpsyt.2022.1055481
Authors: Rosemary T. Smith & Staci A. Gruber
Abstract: The majority of states have fully legalized the use of medical cannabis (MC), and nearly all other states allow limited access to cannabidiol (CBD), a non-intoxicating constituent of cannabis often touted for a range of therapeutic indications. Further, the Agricultural Improvement Act of 2018 legalized hemp-derived products in all 50 states; typically high in CBD, these products are derived from cannabis varieties containing ≤0.3% delta-9-tetrahydrocannabinol (THC) by weight. The recent “green rush” has resulted in a striking increase in cannabis use among patients and consumers who often use a wide variety of novel product types, each with a unique blend of cannabinoid constituents. Importantly, however, several cannabinoids have the potential to cause drug-drug interactions (DDI) with other medications, primarily due to their involvement with the hepatic cytochrome P450 (CYP450) system. This article examines the potential for individual cannabinoids, particularly CBD, to interact with the hepatic metabolic system, which is concerning given its involvement in the metabolism of commonly-prescribed medications. CBD and other cannabinoids are metabolized extensively by the CYP450 system, and also inhibit many of these enzymes, potentially leading to variable serum levels of other medications, as well as variable levels of cannabinoids when other medications modify the system. As access and interest in cannabinoid-based products continues to increase, critical questions remain unanswered regarding their safety. The complex relationship between cannabinoids and the hepatic metabolic system, including common potential DDI resulting from cannabinoid exposure, are explored along with the clinical significance of these potential interactions and monitoring or mitigation strategies
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Journal: Harm Reduction Journal, 2023, doi: 10.1186/s12954-023-00742-9
Authors: Mercy Ude, Czarina N. Behrends, Shea Kelly, Bruce R. Schackman, Allan Clear, Rebecca Goldberg, Kitty Gelberg & Shashi N. Kapadia
Abstract:
Background: Syringe service programs (SSPs) deliver critical harm reduction services to people who inject drugs (PWID). Some SSPs in New York State received enhanced funding to provide additional services to combat opioid overdose fatalities. These SSPs, known as Drug User Health Hubs, provide buprenorphine for the treatment of opioid use disorder and other health-related services in addition to their syringe services. While the COVID-19 pandemic posed widespread challenges to the delivery of health services nationwide, the effect of the pandemic on SSPs uniquely impacts PWID. This study examines the impact of COVID-19 on service delivery of Drug User Health Hubs and stand-alone SSPs in New York State.
Methods: Between July 2020 and September 2020, we performed eleven semi-structured virtual interviews with staff from three Health Hub SSPs and three stand-alone SSPs. The interviews explored the effect of the COVID-19 pandemic on SSPs and their clients as well as the changes implemented in response. Interviews were recorded and transcribed. We performed content analysis to identify emerging themes from the data.
Results: Due to the COVID-19 pandemic, some SSPs temporarily shut down while others limited their hours of operation. SSPs modified their service delivery to maintain syringe services and naloxone distribution over other services such as STI and HCV testing. They virtualized components of their services, including telemedicine for the provision of buprenorphine. While SSPs found virtualization to be important for maintaining their services, it negatively impacted the intimate nature of client interactions. Participants also described the impact of the pandemic on the well-being of PWID, including isolation, worsened mental health challenges, and increased drug overdoses.
Conclusions: In response to the COVID-19 pandemic, SSPs demonstrated innovation, adaptability, and togetherness. Despite the challenges posed by the pandemic, SSPs continued to be key players in maintaining access to sterile supplies, buprenorphine, and other services for PWID. In addition to adapting to COVID-19 restrictions, they also responded to the dynamic needs of their clients. Sustainable funding and recognition of the critical role of SSPs in supporting PWID can help to improve outcomes for PWID.
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Journal: Frontiers in Cellular and Infection Microbiology, 2023, doi: 10.3389/fcimb.2022.1051272
Authors: Danielle S. Sopovski, Jing Han, Marla Stevens-Riley, Qiang Wang, Bruce D. Erickson, Berk Oktem, Michelle Vanlandingham, Cassandra L. Taylor & Steven L. Foley
Abstract:
Introduction: There are concerns about microorganisms present on cannabis materials used in clinical settings by individuals whose health status is already compromised and are likely more susceptible to opportunistic infections from microbial populations present on the materials. Most concerning is administration by inhalation where cannabis plant material is heated in a vaporizer, aerosolized, and inhaled to receive the bioactive ingredients. Heating to high temperatures is known to kill microorganisms including bacteria and fungi; however, microbial death is dependent upon exposure time and temperature. It is unknown whether the heating of cannabis at temperatures and times designated by a commercial vaporizer utilized in clinical settings will significantly decrease the microbial loads in cannabis plant material.
Methods: To assess this question, bulk cannabis plant material supplied by National Institute on Drug Abuse (NIDA) was used to assess the impact of heating by a commercial vaporizer. Initial method development studies using a cannabis placebo spiked with Escherichia coli were performed to optimize culture and recovery parameters. Subsequent studies were carried out using the cannabis placebo, low delta-9 tetrahydrocannabinol (THC) potency and high THC potency cannabis materials exposed to either no heat or heating for 30 or 70 seconds at 190°C. Phosphate-buffered saline was added to the samples and the samples agitated to suspend the microorganism. Microbial growth after no heat or heating was evaluated by plating on growth media and determining the total aerobic microbial counts and total yeast and mold counts.
Results and Discussion: Overall, while there were trends of reductions in microbial counts with heating, these reductions were not statistically significant, indicating that heating using standard vaporization parameters of 70 seconds at 190°C may not eliminate the existing microbial bioburden, including any opportunistic pathogens. When cultured organisms were identified by DNA sequence analyses, several fungal and bacterial taxa were detected in the different products that have been associated with opportunistic infections or allergic reactions including Enterobacteriaceae, Staphylococcus, Pseudomonas, and Aspergillus.
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