Toward safer opioid prescribing: effects of the TOWER intervention on HIV care providers.

ABSTRACTRates of opioid use disorder and associated deaths remain alarmingly high. Measures to address the epidemic have included reductions in opioid prescribing, in part guided by the Centers for Disease Control Opioid Prescribing Guideline (CDCG). While reductions in over-prescribing have occurred, these measures have also resulted in decreased access and adverse outcomes for some stable opioid-treated chronic pain patients. The TOWard SafER Opioid Prescribing (TOWER) intervention was designed to support HIV primary care providers in use of the CDCG and in decision-making and patient-provider communication regarding safe opioid prescribing. Eleven HIV primary care providers and 40 of their patients were randomized into intervention and control groups. Transcripts from 21 patient visits were analyzed, focusing on opioid and pain-related communications. Findings from this research indicate greater alignment with the CDCG among visits carried out with providers in the TOWER intervention group. However, control group visits were notably consistent with guideline recommendations in several key areas. Differences observed between the intervention and control group visits demonstrate intervention strengths, as well as areas where additional work needs to be done to ensure prescribing and communication consistent with the CDCG.

Using Public Deliberation to Set Priorities: The Case of COVID-19 Vaccine Access in New York City.

CONTEXT: The COVID-19 pandemic has resulted in a record number of deaths in the United States and tremendous economic and personal strain. During 2020, in anticipation of a vaccine to slow the spread of disease, local and state governments in the United States developed plans for vaccine prioritization, given a limited initial supply. Recognizing the challenges inherent in prioritization, the New York City (NYC) health department sought guidance from members of the public about the fairest approach to early-stage vaccine distribution. OBJECTIVE: To solicit recommendations from NYC residents on priorities regarding vaccine access for essential worker occupations, considering risk factors and preferred approaches to fairness. IMPLEMENTATION: Five public deliberations were conducted with NYC residents (N = 91). Participants heard presentations on the COVID-19 vaccine, the local distribution of illness and death, and approaches to fairness in the context of deliberating on priorities for 6 essential worker occupations and 4 risk factors. Discussions were transcribed, and transcriptions were coded and analyzed using preidentified and emergent themes. Pre- and post-surveys, focused on factors relevant to prioritization, were administered during each public deliberation. RESULTS: Recommendations for prioritization emphasized risk of severe morbidity and mortality, and work and neighborhood conditions with fewer protections (eg, in-person work, exposure to many people). Participants prioritized elementary schoolteachers, grocery store workers, and bus drivers, underlying health conditions, and neighborhood of residence. Participants focused on equity, recognizing that those at highest risk were largely low-income populations of color and individuals living in low-resourced neighborhoods. CONCLUSIONS: Participants' focus on equity, and acknowledgment of racial and ethnic disparities, revealed a nuanced understanding of the broader determinants of health. Recommendations reinforced the NYC health department's approach to vaccine distribution. PUBLIC HEALTH IMPLICATIONS: Results from these public deliberations confirmed community support for approaches prioritizing health equity, recognizing both societal and personal factors affecting vulnerability to poor health.

Patient recommendations for opioid prescribing in the context of HIV care: findings from a set of public deliberations.

It is widely acknowledged that the growing opioid epidemic and associated increase in overdose deaths necessitates a reexamination of processes and procedures related to an opioid prescription for the treatment of chronic pain. However, the perspectives of patients, including those at the highest risk for opioid-related harms, are largely missing from this reexamination. To partially address the gap, we conducted a pair of one-day public deliberations on opioid prescribing in the context of HIV care. Results included recommendations and perspectives from people living with HIV that detail how providers can best assess patient needs, communicate regarding opioids, and reduce the risk of misuse. Participants emphasized the importance of building trust with patients and taking an extensive patient history prior to making decisions about whether to initiate or end an opioid prescription. This trust - together with an understanding of the origin of a patient's pain, history of drug use and other therapies tried - was perceived as essential to effective monitoring and pain management, as well as promotion of positive health outcomes. Ensuring that such patient perspectives are incorporated into the operationalization of guidelines for safe opioid prescribing may help to improve outcomes and quality of care for people living with HIV.

Community Priorities for Hospital-Based Prevention Initiatives: Results From a Deliberating Public.

CONTEXT: Internal revenue service provisions require not-for-profit hospitals to provide "community benefit." In addition, the Affordable Care Act requires these hospitals to conduct community health needs assessments that involve appropriate stakeholders. These requirements signal government interest in creating opportunities for developing programs that are well tailored and responsive to the needs of the communities served. Gaining meaningful input from residents is a critical aspect of these processes. OBJECTIVE: To implement public deliberations that explore local resident priorities for use of a hospital's community benefit resources to prevent chronic disease. METHODS: Public deliberation is a method of community engagement that can provide guidance to decision makers on value-laden issues when technical solutions alone are inadequate to provide direction or set priorities. Three deliberations featuring presentations by experts and discussions among participants were convened with a cross section of residents in Brooklyn, New York. Participants were asked whether new hospital initiatives should prioritize: clinical prevention, community-based interventions, or action on broader policies affecting population health. Pre- and postsurveys, as well as qualitative methods, were used to assess knowledge and attitudes. RESULTS: Postdeliberation, participants had significant changes in knowledge, particularly on the impact of education on health. Participants prioritized community-based and policy interventions over expanding clinical prevention capacity. CONCLUSIONS: Public deliberation offers a method to probe informed constituent views of how a hospital can best promote its community's health. Informed local residents felt that hospitals should frame health-promoting activities more broadly than is current practice. Not-for-profit hospitals gain significant tax advantages. Increased insurance rates suggest that some hospitals will experience savings in uncompensated care that can be used to promote health more broadly. Vetting priorities for the use of new resources with informed community members can be accomplished through public deliberation. These results suggest community support for nonclinical approaches to disease prevention.

Making Oneself "Fit": Community Perspectives on Disaggregated Race and Ethnicity Data Collection and Reporting in Healthcare Settings.

Patient race/ethnicity data collection in most U.S. health systems abide by federal standards, determined by the federal Office of Management and Budget. Yet, decades of research show that reliance on these categories alone limits understanding of within-group health disparities, systematically erasing key groups from health data. Because granular race/ethnicity data is complex and patients may be hesitant to disclose this personal information, it is important for health leaders to consider community perspectives when making decisions about race/ethnicity data procedures. As such, this study uses community focus groups to understand: (1) how individuals representing different racial/ethnic identities perceive the collection of race/ethnicity in healthcare settings; (2) differences in opinions between disaggregated race/ethnicity data collection instruments and those using federal standards; and (3) recommended practices for collecting race/ethnicity from patients. Participants self-selected into 13 focus groups and one key informant interview based on the race/ethnicity with which they most closely identified. Audio recordings from these groups were transcribed and evaluated using thematic content analysis. Among the 83 total participants in this study, there was a strong preference for more flexible and specific options for self-identifying race/ethnicity in healthcare settings. Participants also felt comfortable disclosing granular race/ethnicity to health providers but expressed discomfort with disclosing this information for other purposes. Recommendations for healthcare leaders include ensuring patients receive detailed communication about race/ethnicity data use and purpose, allowing multiple category selection, keeping the list of disaggregated response options short so as to not overwhelm patients, and providing a free text option to ensure inclusivity.

Toward Safer Opioid Prescribing in HIV care (TOWER): a mixed-methods, cluster-randomized trial.

BACKGROUND: The 2016 U.S. Centers for Disease Control Opioid Prescribing Guideline (CDC Guideline) is currently being revised amid concern that it may be harmful to people with chronic pain on long-term opioid therapy (CP-LTOT). However, a methodology to faithfully implement the CDC guideline, measure prescriber adherence, and systematically test its effect on patient and public health outcomes is lacking. We developed and tested a CDC Guideline implementation strategy (termed TOWER), focusing on an outpatient HIV-focused primary care setting. METHODS: TOWER was developed in a stakeholder-engaged, multi-step iterative process within an Information, Motivation and Behavioral Skills (IMB) framework of behavior change. TOWER consists of: 1) a patient-facing opioid management app (OM-App); 2) a progress note template (OM-Note) to guide the office visit; and 3) a primary care provider (PCP) training. TOWER was evaluated in a 9-month, randomized-controlled trial of HIV-PCPs (N = 11) and their patients with HIV and CP-LTOT (N = 40). The primary outcome was CDC Guideline adherence based on electronic health record (EHR) documentation and measured by the validated Safer Opioid Prescribing Evaluation Tool (SOPET). Qualitative data including one-on-one PCP interviews were collected. We also piloted patient-reported outcome measures (PROMs) reflective of domains identified as important by stakeholders (pain intensity and function; mood; substance use; medication use and adherence; relationship with provider; stigma and discrimination). RESULTS: PCPs randomized to TOWER were 48% more CDC Guideline adherent (p < 0.0001) with significant improvements in use of: non-pharmacologic treatments, functional treatment goals, opioid agreements, prescription drug monitoring programs (PDMPs), opioid benefit/harm assessment, and naloxone prescribing. Qualitative data demonstrated high levels of confidence in conducting these care processes among intervention providers, and that OM-Note supported these efforts while experience with OM-App was mixed. There were no intervention-associated safety concerns (defined as worsening of any of the PROMs). CONCLUSIONS: CDC-guideline adherence can be promoted and measured, and is not associated with worsening of outcomes for people with HIV receiving LTOT for CP. Future work would be needed to document scalability of these results and to determine whether CDC-guideline adherence results in a positive effect on public health. Trial registration https://clinicaltrials.gov/ct2/show/NCT03669939 . Registration date: 9/13/2018.

Decreasing risk among HIV patients on opioid therapy for chronic pain: Development of the TOWER intervention for HIV care providers.

Many people with HIV (PWH) experience chronic pain that limits daily function and quality of life. PWH with chronic pain have commonly been prescribed opioids, sometimes for many years, and it is unclear if and how the management of these legacy patients should change in light of the current US opioid epidemic. Guidelines, such as the Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain (CDCG), provide recommendations for the management of such patients but have yet to be translated into easily implementable interventions; there is also a lack of strong evidence that adhering to these recommendations improves patient outcomes such as amount of opioid use and pain levels. Herein we describe the development and preliminary testing of a theory-based intervention, called TOWER (TOWard SafER Opioid Prescribing), designed to support HIV primary care providers in CDCG-adherent opioid prescribing practices with PWH who are already prescribed opioids for chronic pain. TOWER incorporates the content of the CDCG into the theoretical and operational framework of the Information Motivation and Behavioral Skills (IMB) model of health-related behavior. The development process included elicitation research and incorporation of feedback from providers and PWH; testing is being conducted via an adaptive feasibility clinical trial. The results of this process will form the basis of a large, well-powered clinical trial to test the effectiveness of TOWER in promoting CDCG-adherent opioid prescribing practices and improving outcomes for PWH with chronic pain.

Power Up for Health-Participants' Perspectives on an Adaptation of the National Diabetes Prevention Program to Engage Men.

The National Diabetes Prevention Program (NDPP) has been effectively translated to various community and clinical settings; however, regardless of setting, enrollment among men and lower-income populations is low. This study presents participant perspectives on Power Up for Health, a novel NDPP pilot adaption for men residing in low-income communities in New York City. We conducted nine interviews and one focus group with seven participants after the program ended. Interview and focus group participants had positive perceptions of the program and described the all-male aspect of the program and its reliance on male coaches as major strengths. Men felt the all-male adaptation allowed for more open, in-depth conversations on eating habits, weight loss, body image, and masculinity. Participants also reported increased knowledge and changes to their dietary and physical activity habits. Recommendations for improving the program included making the sessions more interactive by, for example, adding exercise or healthy cooking demonstrations. Overall, findings from the pilot suggest this NDPP adaptation was acceptable to men and facilitated behavior change and unique discussions that would likely not have occurred in a mixed-gender NDPP implementation.

Translation of the National Diabetes Prevention Program to Engage Men in Disadvantaged Neighborhoods in New York City: A Description of Power Up for Health.

The Diabetes Prevention Program (DPP) landmark randomized trial demonstrated that participants with prediabetes could reduce their risk for type 2 diabetes by 58% if they achieved 5%-7% weight loss through healthy eating and increasing physical activity. The National DPP (NDPP) is a group intervention based on the DPP and has been widely disseminated by the Centers for Disease Control and Prevention (CDC) and many healthcare institutions. While data show that the program is effective in diverse populations, enrollment among men from low-income and minority communities is low. Thus, the study piloted a novel adaptation focused on men living in disadvantaged neighborhoods. The study approach to adaptation and implementation used characteristics of participatory research, including input from an expert panel of African American and Latino leaders, ongoing consultation with an Advisory Panel, and focus groups with members of the target population. Discussions with these groups focused on male perspectives regarding health promotion and barriers and facilitators to participation in health programming for men. There was general agreement when reviewing ongoing pilot program implementation that the adapted program should have male-only groups with male coaches, as the Advisory Panel had originally suggested. The pilot programs were implemented at five New York City Department of Parks and Recreation sites in Harlem, the Bronx, and Brooklyn in 2015-2016.

Power Up for Health: Pilot Study Outcomes of a Diabetes Prevention Program for Men from Disadvantaged Neighborhoods.

There is a significant evidence base for the Diabetes Prevention Program, a lifestyle intervention to prevent onset of type 2 diabetes among high-risk individuals; however, translation of this intervention for men has been challenging. This report presents outcomes of the pilot study of an adapted 16-week diabetes prevention program entitled " Power Up for Health." The study goal was to better engage men of color with prediabetes from disadvantaged neighborhoods of New York City. It was implemented at five different recreation centers located in predominantly low-income neighborhoods across New York City. The curriculum was facilitated by male lifestyle coaches only; one group was conducted in Spanish. Primary outcome was weight loss from baseline to 16 weeks. Other measures included lifestyle activities, depressive symptoms, and self-reported health status. Men ( N = 47) were screened by telephone. Of the 29 eligible men who began the program, 25 attended at least 4 sessions (52% non-Latino Black, 32% Latino, mean age 51.7 ± SD 9.9 years, mean body mass index 35 ± SD 6.9 kg/m2). End of program outcomes ( n = 23) varied by site and included a mean weight loss of 3.8% (9.7 lbs); 3 of the 5 sites had a mean weight loss of 5.6%, meeting the national goal of 5%-7%. Men ( n = 23) attended a mean of 11.6 of 16 sessions. Improvement in depressive symptoms, healthy eating and exercise, and health status were also seen. While recruitment was challenging with many lessons learned, the adapted men's diabetes prevention program shows promise of success for participants and their coaches.

Illicit drug use and HIV risk in the Dominican Republic: tourism areas create drug use opportunities.

While the Caribbean has the second highest global human immunodeficiency virus (HIV) prevalence, insufficient attention has been paid to contributing factors of the region's elevated risk. Largely neglected is the potential role of drugs in shaping the Caribbean HIV/acquired immune deficiency syndrome epidemic. Caribbean studies have almost exclusively focused on drug transportation and seldom acknowledged local user economies and drug-related health and social welfare consequences. While tourism is consistently implicated within the Caribbean HIV epidemic, less is known about the intersection of drugs and tourism. Tourism areas represent distinct ecologies of risk often characterised by sex work, alcohol consumption and population mixing between lower and higher risk groups. Limited understanding of availability and usage of drugs in countries such as the Dominican Republic (DR), the Caribbean country with the greatest tourist rates, presents barriers to HIV prevention. This study addresses this gap by conducting in-depth interviews with 30 drug users in Sosúa, a major sex tourism destination of the DR. A two-step qualitative data analysis process was utilised and interview transcripts were systematically coded using a well-defined thematic codebook. Results suggest three themes: (1) local demand shifts drug routes to tourism areas, (2) drugs shape local economies and (3) drug use facilitates HIV risk behaviours in tourism areas.