Looking for the uninsured in Massachusetts? Check opioid dependent persons seeking detoxification.

BACKGROUND: We examined the rate of uninsurance among persons seeking detoxification at a large drug treatment program in Massachusetts in 2013, five years after insurance mandates. METHODS: We interviewed three hundred and forty opioid dependent persons admitted for inpatient detoxification in Fall River, Massachusetts. Potential predictors of self-reported insurance status included age, gender, ethnicity, employment, homelessness, years of education, current legal status, and self-perceived health status. RESULTS: Participants mean age was 32 years, 71% were male, and 87% were non-Hispanic Caucasian. Twenty-three percent were uninsured. In the multivariate model, the odds of being uninsured was positively associated with years of education (OR=1.22, 95% CI=1.03; 1.46, p<.05), higher among males than females (OR=2.63, 95% CI=1.33; 5.20, p<.01), and inversely associated with age (OR=0.94, 95% CI=0.90; 0.98, p<.01). CONCLUSION: Opioid dependent persons recruited from a detoxification program in Massachusetts are uninsured at rates far above the state average. With the arrival of the Affordable Care Act, drug treatment programs in Massachusetts and nationally will be important sites to target to expand health coverage.

Varenicline for smoking cessation among methadone-maintained smokers: a randomized clinical trial.

BACKGROUND: With smoking rates far exceeding the general population, methadone-maintained (MMT) opiate-dependent smokers experience high rates of tobacco-related health consequences. Previous treatment studies have used nicotine replacement and produced low quit rates. METHODS: We test, using a three-group randomized design, the efficacy of varenicline versus placebo, in comparison with nicotine replacement therapy (NRT) that combines nicotine patch prescription plus ad libitum nicotine rescue, for smoking cessation. We recruited methadone-maintained smokers from nine treatment centers in southern New England and provided six months of treatment, and a minimal behavioral intervention at baseline (NCI's 5A's). Outcomes included carbon monoxide (CO) confirmed 7-day point smoking cessation prevalence at 6 months and self-reported change in mean cigarettes per day. RESULTS: The 315 participants had a mean age of 40, with 50% male and 79% non-Hispanic White, smoked an average of 19.6 (± 10.4) cigarettes/day, and had a mean daily methadone dose of 109 mg. Intent-to-treat analyses, with missing considered to be smoking, showed the rate of CO-confirmed 7-day abstinence at 6-months was 5.4% overall, with varenicline 3.7% compared to placebo 2.2%, and NRT 8.3% (p>.05). Adherence rates during the 7-days immediately prior to 6-month assessment were 34.2% in varenicline, 34.4% in placebo, and 48.8% in NRT. Between baseline and 6-months there was an overall self-reported mean reduction of 8.3 cigarettes/day. CONCLUSION: Varenicline did not increase quit rates over placebo. Smoking cessation rates in methadone-maintained smokers are low and novel treatment strategies are required.

Adequacy of testing, empiric treatment, and referral for adult male emergency department patients with possible chlamydia and/or gonorrhoea urethritis.

This study evaluated the adequacy of testing, empiric treatment and referral for further evaluation of adult male emergency department (ED) patients with possible chlamydia and/or gonorrhoea urethritis. Of 968 adult male ED patients, 84% were tested for chlamydia and gonorrhoea, 16% for HIV and 27% for syphilis; 92% received empiric treatment for chlamydia and gonorrhoea and 71% were referred for further evaluation; of those tested, 29% were infected with chlamydia, gonorrhoea or both; and 3% of those tested had a positive syphilis test. The results of logistic regression modelling indicated that testing, treatment and referral were not related to a history of sexual contact with someone known to have a sexually transmitted disease or to the patient's ultimate diagnosis of a laboratory-confirmed infection. Compliance with Centers for Disease Control and Prevention (CDC) recommendations for chlamydia and gonorrhoea testing and treatment regimens was high, but was poor for HIV testing. More explicit guidance from CDC regarding syphilis testing and referral for further evaluation is needed.

Relationship quality among HIV patients and their caregivers.

Despite the increasing attention to caregivers of HIV patients, no previous study has systematically investigated the effects of the relationship quality between an HIV patient and their caregiver. The present study assessed 176 dyads consisting of an HIV-infected patient and their self-identified 'caregiver'. Relationship quality was measured by the Family Assessment Device (FAD). Dependent measures included the Beck Depression Inventory, SF-36 Physical Functioning Scale, Caregiver Strain Index and 4-day HIV treatment adherence. A substantial proportion of HIV patient-caregiver dyads reported difficulties in their relationships (17-66% depending upon FAD scale). The level of relationship difficulties was not strongly related to the type of patient-caregiver relationship. However, the quality of the HIV patient-caregiver relationship was significantly associated (p<0.05) with caregiver depression and burden as well as HIV patient depression, physical functioning and HIV medication adherence, even when the potential effects of length of HIV infection and social support were controlled. These results suggest that relationship quality is impaired in many patient-caregiver dyads and is uniquely associated with levels of depression, caregiver burden and treatment adherence.

Sexual risk for hepatitis B virus infection among hepatitis C virus-negative heroin and cocaine users.

Hepatitis C virus (HCV) and hepatitis B virus (HBV) are highly prevalent, often co-occurring infections among drug users. We examined HBV prevalence and risk behaviour patterns among a group of HCV-negative heroin and/or cocaine users in order to understand HBV risk and prevention opportunities among this unique group. Of 164 people enrolled, 44% had injected drugs. Overall, 24% of participants tested positive for exposure to HBV; drug injectors (28%) were only slightly and not significantly (P=0.287) more likely to test positive than those who had never injected drugs (21%). HBV exposure was significantly associated with multiple indicators of greater sex risk. HBV status was not associated with any demographic characteristic, but participants who reported longer duration of cocaine use were significantly less likely to test positive to exposure for HBV. It appears that HBV risk among HCV-negative drug users in this cohort is primarily due to sexual behaviour.

Alcohol use and sexual risk taking among hazardously drinking drug injectors who attend needle exchange.

BACKGROUND: To determine if sex-risk days are also alcohol use days for active injection drug users. METHODS: Cross-sectional interview of 187 active injection drug users who scored positively (> or =8) on the Alcohol Use Disorders Identification Test who were recruited between February 1998 and October 1999 from a needle exchange program in Providence, Rhode Island. A sex-risk day was defined as "vaginal sex, anal sex or oral sex without a condom," measured by using a 30 day timeline follow-back procedure. RESULTS: The sample was 64% male and 87% white, and 85% met DSM-IV criteria for alcohol abuse/dependence. Of the total days analyzed (n = 5610), 19% were sex-risk days; on 52% of these days drinking also occurred. By using a generalized estimating equation model to cluster by subject, alcohol use was associated with sex-risk days (odds ratio, 1.76; 95% confidence interval, 1.35-2.29; p < 0.001), when we controlled for gender, age, race, education, cocaine use, injection frequency, exchanging sex for money or drugs, number of sexual partners, and perceived sexual risk of acquiring human immunodeficiency virus from partners. CONCLUSIONS: Alcohol use is associated with sex risk-taking behavior among injection drug users. A substantial majority of participants reported using alcohol before or during sexual relations, which temporally links alcohol use with human immunodeficiency virus injection risk.

Transportation and retention in outpatient drug abuse treatment programs.

To determine whether certain types of transportation assistance improve outpatient treatment retention beyond thresholds shown to have therapeutic benefits, we analyzed data from 1,144 clients in 22 outpatient methadone maintenance (OMM) programs and 2,031 clients in 22 outpatient drug-free (ODF) programs in the Drug Abuse Treatment Outcomes Study (DATOS), a national, 12-month, longitudinal study of drug abuse treatment programs. Directors' surveys provided information about provision of car, van, or contracted transportation services or individual vouchers/payment for public transportation. Chart-abstracted treatment retention was dichotomized at 365 days for OMM and 90 days for ODF. Separate multivariate hierarchical linear models revealed that provision of car, van, or contracted transportation services improved treatment retention beyond these thresholds for both OMM and ODF, but individual vouchers or payment for public transportation did not. Future research should validate whether car, van, or contracted transportation services improve retention and other treatment outcomes in outpatient drug abuse treatment.

Effects of drug abuse and mental disorders on use and type of antiretroviral therapy in HIV-infected persons.

OBJECTIVE: To distinguish the effects of drug abuse, mental disorders, and problem drinking on antiretroviral therapy (ART) and highly active ART (HAART) use. DESIGN: Prospective population-based probability sample of 2,267 (representing 213,308) HIV-infected persons in care in the United States in early 1996. MEASUREMENTS: Self-reported ART from first (January 1997-July 1997) to second (August 1997-January 1998) follow-up interviews. Drug abuse/dependence, severity of abuse, alcohol use, and probable mental disorders assessed in the first follow-up interview. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) estimated from weighted models for 1) receipt of any ART, and 2) receipt of HAART among those on ART. RESULTS: Of our study population, ART was reported by 90% and HAART by 61%. Over one third had a probable mental disorder and nearly half had abused any drugs, but drug dependence (9%) or severe abuse (10%) was infrequent. Any ART was less likely for persons with dysthymia (AOR, 0.74; CI, 0.58 to 0.95) but only before adjustment for drug abuse. After full adjustment with mental health and drug abuse variables, any ART was less likely for drug dependence (AOR, 0.58; CI, 0.34 to 0.97), severe drug abuse (AOR, 0.52; CI, 0.32 to 0.87), and HIV risk from injection drug use (AOR, 0.55; CI, 0.39 to 0.79). Among drug users on ART, only mental health treatment was associated with HAART (AOR, 1.57; CI, 1.11 to 2.08). CONCLUSIONS: Drug abuse-related factors were greater barriers to ART use in this national sample than mental disorders but once on ART, these factors were unrelated to type of therapy.

Screening for cervical cancer in HIV-infected women receiving care in the United States.

OBJECTIVE: We examined the sociodemographic, clinical and provider factors associated with screening for cervical cancer among HIV-infected women. METHODS: We studied a national sample representing 43,490 women receiving treatment of HIV infection who completed first follow-up surveys of the HIV Cost and Service Utilization Study (HCSUS). All women were asked, "In the past 12 months, have you had a Pap test?" Women reporting an abnormal Pap test result were asked whether they had been told antibiotics could cure abnormal cells, and whether they were scheduled for another Pap test or for a colposcopy within 3 months. RESULTS: Of the population represented, 81% had had a Pap test in the past 12 months. Women who reported having a gynecologist and primary care physician at the same clinical site were almost twice as likely (odds ratio, 1.9; 95% confidence interval, 1.3-3.0) as other women to report Pap testing. Among women who reported abnormal Pap test results and were not told antibiotics could cure abnormal cells, 95% were scheduled for a repeat Pap test or colposcopy, but 15% of the women had not received their repeat Pap test or colposcopy. CONCLUSION: Although Pap test rates and appropriate referral for abnormal findings were high among HIV-tested women, many women with initially abnormal Pap test results did not actually receive follow-up Pap testing or colposcopy. Providing gynecologic care at the same site as primary HIV care would likely improve delivery of needed gynecologic care for women.

The clinical relevance of microbiologic testing: a comparative analysis of microbiologic samples secured from the same sites and cultured in two independent laboratories.

A field study using five different private periodontal practices was conducted; it compared two microbiologic culture samples simultaneously secured from the same sites within 23 individual patients and submitted for bacterial identification and antibiotic sensitivity testing to two separate laboratories. The results from the two laboratories were often different. In no instance did both laboratories agree on the presence of identical bacterial species. When only bacteria above threshold levels were compared, agreement was found in only nine of 23 cases. When examining antibiotic sensitivity, using 100% kill of all tested pathogens as the ideal, agreement between the two laboratories was poor. The laboratories agreed on the use of amoxicillin 17% of the time, tetracycline 26% of the time, and metronidazole 48% of the time. The use of amoxicillin and metronidazole in combination yielded a 78% agreement when the results of both laboratories were combined. It would appear from the data that the empirical use of amoxicillin-metronidazole combination therapy may be more clinically sound and cost effective than culturing and antibiotic selection based on the results of culture from any single microbiologic testing laboratory.

Social relationships and intravenous drug use among methadone maintenance patients.

This study examined the extent to which social relationships were associated with continued injection drug use and needle sharing among 252 methadone maintenance patients. Logistic regression analyses indicated that drug use was highest among persons who had a substance using live-in partner and among those with more drug-using social relationships. Among injectors, whites and those who had more people present during IV drug use were more likely to share needles, while those with more emotional support were less likely to do so. These findings suggest that personal relationships strongly influence continued injection drug use and that methadone programs should help patients develop social networks of non-users.

Injection drug users: hospital care and charges.

Injection drug users have high rates of hospital use, however, the specific contribution of injection-related infections to hospitalization has never been determined. After reviewing 92 consecutive admissions of HIV-negative injection drug users to Rhode Island Hospital in 1998, we found that 49% were related to infections and an additional 24% were due to the biological effects of the injected drug. Admissions that were for injection-related infections were significantly more costly than other admissions of injection drug users ($13958 vs. $7906). We conclude that considerable savings may result from preventative care of this population, including instruction in skin-cleaning techniques.

Interest in smoking cessation among injection drug users.

We describe the degree of nicotine addiction and readiness to quit smoking among people with a history of injection drug use, comparing those in a methadone maintenance treatment program (MMTP) with active illicit drug injectors in a needle exchange program (NEP). Interview data were collected from 452 persons in Providence, RI, from July 1997 to March 1998. Ninety-one percent (91%) of the population currently smoked cigarettes. Smokers were more likely to be female and from an NEP. Higher nicotine dependence by the Fagerstrom Test for Nicotine Dependence was found in Caucasians, those with a Methadone dose greater than 80 mg per day, those with less than high school education, and those with active alcohol abuse. Those more likely to be contemplating smoking cessation in the next six months were those from MMTP, older than 35, and without alcohol abuse. Although smoking cessation counseling should be offered to all smokers, interventions directed towards older individuals enrolled in MMTP may target the group most interested in smoking cessation.

Validation of the screening strategy in the NIAAA "Physicians' Guide to Helping Patients with Alcohol Problems".

OBJECTIVE: This study was undertaken to determine the diagnostic test characteristics of the alcohol screening strategy recommended in the National Institute on Alcoholism and Alcohol Abuse (NIAAA) "Physicians' Guide to Helping Patients with Alcohol Problems." METHOD: A research interview was performed on patients who presented to one urban emergency department (N = 395; 61% women). It asked three alcohol consumption questions, the CAGE questionnaire, and about past alcohol problems. The NIAAA-recommended screen was considered positive for alcohol consumption in excess of 14 drinks per week or 4 drinks per occasion for men, or 7 drinks per week or 3 drinks per occasion for women, or a CAGE score of 1 or greater. A sample of patients (n = 250) received the Composite International Diagnostic Interview substance abuse module, a gold standard interview, to determine lifetime or prior 12-month alcohol abuse or dependence; results were adjusted for verification bias. RESULTS: The prevalence of lifetime:alcohol abuse or dependence was 13%, for which the NIAAA strategy was 81% sensitive and 80% specific. The prevalence of alcohol abuse or dependence in the prior 12 months was 10%, for which the strategy was 83% sensitive and 84% specific. Its positive likelihood ratio exceeded that of the CAGE, augmented CAGE or consumption questions alone, and its negative likelihood ratio was the lowest. CONCLUSIONS: The screening strategy combining alcohol consumption and CAGE questions recommended in the NIAAA "Physicians' Guide" is valid, and has superior test characteristics compared to the CAGE alone, in this predominantly black (86%) emergency department population. Its brevity and simple interpretation recommend wider dissemination of the NIAAA "Physicians' Guide," although future research should examine its test characteristics in other clinical settings and with other populations.

Needle exchange program attendance and injection risk in Providence, Rhode Island.

Needle sharing has long been recognized as a primary route of HIV infection. However, recent research has shown that HIV antibody is also detectable in injection supplies other than needles. In this study we tested frequency of attendance at a Providence, Rhode Island, needle exchange program (NEP) as a correlate of injection risk indicators including not just sharing needles but also sharing cookers, sharing cotton filters, cleaning the skin before injecting, and using bleach as a needle disinfectant. Results showed that drug users who attended the NEP less frequently were more likely to report needle sharing, less likely to report always cleaning their skin, and more likely to report sharing cookers. The Providence NEP is one at which alcohol swabs and cookers are distributed along with clean needles. Our results suggest that NEPs represent a valuable and underexploited opportunity to promote risk reduction efforts beyond the avoidance of needle sharing. NEPs should be distributing risk reduction supplies in addition to clean needles and should adopt strategies (e.g., outreach and more days/hours of operation) to encourage frequent attendance.

Linkage to medical services in the Drug Abuse Treatment Outcome Study.

BACKGROUND: An episode of substance abuse treatment is an opportunity to link substance-abusing patients to medical care at a time when management of medical problems might stabilize recovery and long-term health. However, little is known about the ability of organizational linkage mechanisms to facilitate the delivery of medical care to this population. OBJECTIVES: The goal of this study was to examine whether organizational linkage mechanisms facilitate medical service utilization in drug abuse treatment programs. RESEARCH DESIGN: This was a prospective secondary analysis of the Drug Abuse Treatment Outcome Study, a national longitudinal study of drug abuse treatment programs and their patients from 1991 to 1993. Hierarchical linear models evaluated the effect of on-site delivery, formal and informal referral, case management emphasis, and transportation on the log-transformed number of medical visits at the 1-month in-treatment patient interview. MEASURES: Program directors' surveys provided organizational information, including the linkage mechanism used to deliver medical care. Patients reported the number of medical visits during the first month of drug abuse treatment. RESULTS: Exclusive on-site delivery increased medical utilization during the first month of drug abuse treatment (beta estimate, 0.22; standard error [SE], 0.06; P <0.001). Transportation services also increased 1-month medical utilization (beta estimate, 0.13; SE, 0.03; P <0.001). CONCLUSIONS: Exclusive on-site delivery of medical services increased drug abuse treatment patients' utilization of medical services in the first month of treatment. Transportation assistance warrants strong policy consideration as a facilitator of medical service delivery. Future research should clarify whether program-level linkage to medical services improves the patient-level outcomes of drug abuse treatment.

Adverse drinking consequences among alcohol abusing intravenous drug users.

BACKGROUND: Heavy alcohol use is common among out-of-treatment injection drug users (IDUs); however, the relationship between alcohol and drug use behaviors in codependent populations is not well understood. Our specific objectives were (1) to describe the psychometric properties of the Drinker Inventory of Consequences (DrInC) in a sample of active IDUs, and (2) to compare DrInC scores of active IDUs with those reported for the alcohol treatment seeking sample on which the instrument was developed. METHODS: Interview data were collected from 187 active IDUs who scored positively (> or = 8) on the Alcohol Use Disorders Identification Test, who were recruited from a Providence, RI, needle exchange program (1998-1999). DrInC total and subscale scores for the 159 (85%) participants who met DSM-IV criteria for alcohol abuse/dependence were analyzed. Six-month follow-up data were used to estimate test-retest reliability. RESULTS: The DrInC total scale exhibited high internal consistency and test-retest reliability. With the exception of adverse physical consequences, reliability estimates for DrInC subscales were good to very good. These data indicate higher subscale redundancy than reported for the development sample. Active IDUs had significantly higher adverse impulse control consequences than the alcohol treatment seeking population on which the instrument was developed. CONCLUSIONS: The DrInC exhibits desirable psychometric properties for assessing adverse drinking consequences in active IDU populations. IDUs who met DSM-IV criteria for alcohol abuse/dependence reported overall levels of adverse drinking consequences comparable with non-IDU alcohol treatment populations but were more likely to exhibit adverse impulse control consequences.

Evolution of depressive symptoms in human immunodeficiency virus-infected patients entering primary care.

Our purpose was to examine among HIV-infected patients a) characteristics associated with depressive symptoms at initial primary care presentation and b) factors associated with improvement in depressive symptoms. We interviewed HIV-infected patients at initial presentation and reassessed them 6 months later. At baseline and follow-up, we collected data on depressive symptoms (CES-D) and other characteristics. Using multiple linear regression, we examined associations between CES-D score and baseline variables. We used multiple logistic regression to examine factors associated with improvement in depressive symptoms. Seventy-one percent of the baseline sample (N = 203) scored above the threshold considered indicative of depression. At 6 months, 36% of the subjects who were followed improved in depressive symptoms. Higher baseline CES-D scores, improvements in HIV-related symptoms, and joining a support group were associated with improvement. Depressive symptoms in this urban HIV-infected population were highly prevalent. It is essential to screen, identify, and treat depression among patients entering care for HIV disease. Encouragement in joining support groups is a reasonable component of a strategy for addressing this common condition.

Understanding delay to medical care for HIV infection: the long-term non-presenter.

OBJECTIVE: To examine delayed presentation for HIV testing and primary care in the second decade of the AIDS epidemic. DESIGN: Cohort study in two urban hospitals in the USA between February 1994 and April 1996. METHODS: A total of 203 consecutive outpatients on initial HIV primary care presentation were interviewed about sociodemographic characteristics, alcohol and drug use, social support, sexual practices, HIV testing, awareness of possible HIV infection, and CD4 cell count. MAIN OUTCOME MEASURE: Duration of delay to medical presentation in years based on CD4 cell count, factors independently associated with low CD4 cell counts, frequency of awareness of HIV risk before testing. RESULTS: The estimated mean duration between acquiring HIV infection and initial presentation to primary care was 8.1 years (95% CI 7.5, 8.6) based on our cohort's median initial CD4 cell count of 280/microl. Male sex, older age, and no jail time were associated with lower CD4 cell counts; 34% reported not being aware that they were at risk of HIV before testing. Heterosexual intercourse as a risk behavior for HIV was the most statistically significant factor for personal unawareness of HIV risk. Of those who acknowledged awareness, the mean time between awareness of HIV risk and testing was 2.5 years (median 1.0 year). CONCLUSION: In the pre-highly active antiretroviral therapy era, HIV-infected patients frequently initiated primary medical care years after initial infection, at a time of advanced immunosuppression. Over one-third of HIV-infected patients were not cognisant of their HIV risk before testing, a condition significantly associated with heterosexual intercourse as the only HIV risk behavior.