Life Expectancy and Built Environments in the U.S.: A Multilevel Analysis.

INTRODUCTION: The purpose of this study is to examine the associations between built environments and life expectancy across a gradient of urbanicity in the U.S. METHODS: Census tract‒level estimates of life expectancy between 2010 and 2015, except for Maine and Wisconsin, from the U.S. Small-Area Life Expectancy Estimates Project were analyzed in 2022. Tract-level measures of the built environment included: food, alcohol, and tobacco outlets; walkability; park and green space; housing characteristics; and air pollution. Multilevel linear models for each of the 4 urbanicity types were fitted to evaluate the associations, adjusting for population and social characteristics. RESULTS: Old housing (built before 1979) and air pollution were important built environment predictors of life expectancy disparities across all gradients of urbanicity. Convenience stores were negatively associated with life expectancy in all urbanicity types. Healthy food options were a positive predictor of life expectancy only in high-density urban areas. Park accessibility was associated with increased life expectancy in all areas, except rural areas. Green space in neighborhoods was positively associated with life expectancy in urban areas but showed an opposite association in rural areas. CONCLUSIONS: After adjusting for key social characteristics, several built environment characteristics were salient risk factors for decreased life expectancy in the U.S., with some measures showing differential effects by urbanicity. Planning and policy efforts should be tailored to local contexts.

Measuring Population Health in a Large Integrated Health System to Guide Goal Setting and Resource Allocation: A Proof of Concept.

In integrated health care systems, techniques that identify successes and opportunities for targeted improvement are needed. The authors propose a new method for estimating population health that provides a more accurate and dynamic assessment of performance and priority setting. Member data from a large integrated health system (n = 96,246, 73.8% female, mean age = 44 ± 0.01 years) were used to develop a mechanistic mathematical simulation, representing the top causes of US mortality in 2014 and their associated risk factors. An age- and sex-matched US cohort served as comparator group. The simulation was recalibrated and retested for validity employing the outcome measure of 5-year mortality. The authors sought to estimate potential population health that could be gained by improving health risk factors in the study population. Potential gains were assessed using both average life years (LY) gained and average quality-adjusted life years (QALYs) gained. The simulation validated well compared to integrated health system data, producing an AUC (area under the curve) of 0.88 for 5-year mortality. Current population health was estimated as a life expectancy of 84.7 years or 69.2 QALYs. Comparing potential health gain in the US cohort to the Kaiser Permanente cohort, eliminating physical inactivity, unhealthy diet, smoking, and uncontrolled diabetes resulted in an increase of 1.5 vs. 1.3 LY, 1.1 vs. 0.8 LY, 0.5 vs. 0.2 LY, and 0.5 vs. 0.5 LY on average per person, respectively. Using mathematical simulations may inform efforts by integrated health systems to target resources most effectively, and may facilitate goal setting.

Addiction Research Training Programs: Four Case Studies and Recommendations for Evaluation.

: The presence of structured addiction research training programs helps to ensure that the scientific workforce includes well-trained, diverse scientists necessary to reduce the negative impact of alcohol, drug, and tobacco use disorders. Although the field has made significant progress in the development of standards for clinical training in addiction medicine, there remains significant room for improvement in the training of addiction researchers, and also opportunities to synergize across addiction research training programs. The purpose of this commentary is to describe 4 National Institutes of Health (NIH)-sponsored addiction research training programs, highlight critical components, and provide recommendations for more comprehensive and effective program evaluation. Moving forward, evaluation of addiction research training programs would be enhanced by the use of conceptual models to inform process and outcome evaluations, the application of innovative methods to ensure long-term data collection, the improvement of mentorship evaluation measures, and the integration of training methods from other fields of study. We encourage NIH and others in the field to be proactive in establishing core metrics for evaluation across programs. Furthermore, centralized tracking of NIH-funded addiction research trainees, analysis of aggregate data across programs, and innovative methods to effectively disseminate program materials and processes are recommended.

Accuracy of the Audio Computer Assisted Self Interview version of the Alcohol, Smoking and Substance Involvement Screening Test (ACASI ASSIST) for identifying unhealthy substance use and substance use disorders in primary care patients.

BACKGROUND: An Audio Computer-assisted Self Interview (ACASI) version of the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) could reduce barriers to substance use screening and assessment in primary care settings. This study evaluated the diagnostic accuracy of an ACASI ASSIST for identification of unhealthy substance use and substance use disorders (SUD). METHODS: 399 adult patients were consecutively recruited from an urban safety-net primary care clinic. ACASI ASSIST scores for tobacco, alcohol, marijuana, and cocaine were compared against reference standard measures to assess the instrument's diagnostic accuracy for identifying unhealthy use and SUD, first using empirically-derived optimal cutoffs, and second using the currently recommended ASSIST cutoffs. RESULTS: For identifying any unhealthy use, at the empirically-derived cutoffs the ACASI ASSIST had 93.6% sensitivity and 85.8% specificity (AUC=0.90) for tobacco, 85.9% sensitivity and 60.3% specificity (AUC=0.73), for alcohol in men, 100% sensitivity and 62.4% specificity (AUC=0.81) for alcohol in women, 94.6% sensitivity and 81.6% specificity (AUC=0.88) for marijuana, and 86.1% sensitivity, 84.0% specificity (AUC=0.85) for cocaine. For SUD, sensitivity ranged from 79% (for alcohol in males), to 100% (for tobacco), and specificity was 83% or higher (AUCs ranged 0.83-0.91). For substances other than tobacco, empirically-derived cutoff scores were lower than the standard cutoffs, and resulted in higher sensitivity and lower specificity for identifying unhealthy substance use. CONCLUSIONS: The ACASI ASSIST is a valid measure of unhealthy use and SUD for substances that are commonly used by primary care patients, and could facilitate effective and efficient screening for substance use in medical settings.

Validation of an audio computer-assisted self-interview (ACASI) version of the alcohol, smoking and substance involvement screening test (ASSIST) in primary care patients.

BACKGROUND AND AIMS: To address barriers to implementing the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in medical settings, we adapted the traditional interviewer-administered (IA) ASSIST to an audio-guided computer assisted self-interview (ACASI) format. This study sought to validate the ACASI ASSIST by estimating the concordance, correlation and agreement of scores generated using the ACASI versus the reference standard IA ASSIST. Secondary aims were to assess feasibility and compare ASSIST self-report to drug testing results. DESIGN: Participants completed the ACASI and IA ASSIST in a randomly assigned order, followed by drug testing. SETTING: Urban safety-net primary care clinic in New York City, USA. PARTICIPANTS: A total of 393 adult patients. MEASUREMENTS: Scores generated by the ACASI and IA ASSIST; drug testing results from saliva and hair samples. FINDINGS: Concordance between the ACASI and IA ASSIST in identifying moderate-high-risk use was 92-99% for each substance class. Correlation was excellent for global scores [intraclass correlation (ICC) = 0.937, confidence interval (CI) = 0.924-0.948] and for substance-specific scores for tobacco (ICC = 0.927, CI = 0.912-0.940), alcohol (ICC = 0.912, CI = 0.893-0.927) and illicit drugs (ICC = 0.854, CI = 0.854-0.900) and good for prescription drugs (ICC = 0.676, CI = 0.613-0.729). Ninety-four per cent of differences in global scores fell within anticipated limits of agreement. Among participants with a positive saliva test, 74% self-reported use on the ACASI ASSIST. The ACASI ASSIST required a median time of 3.7 minutes (range 0.7-15.4), and 21 (5.3%) participants requested assistance. CONCLUSIONS: The computer self-administered Alcohol, Smoking and Substance Involvement Screening Test appears to be a valid alternative to the interviewer-administered approach for identifying substance use in primary care patients.

A Brief Patient Self-administered Substance Use Screening Tool for Primary Care: Two-site Validation Study of the Substance Use Brief Screen (SUBS).

BACKGROUND: Substance use screening is widely encouraged in health care settings, but the lack of a screening approach that fits easily into clinical workflows has restricted its broad implementation. The Substance Use Brief Screen (SUBS) was developed as a brief, self-administered instrument to identify unhealthy use of tobacco, alcohol, illicit drugs, and prescription drugs. We evaluated the validity and test-retest reliability of the SUBS in adult primary care patients. METHODS: Adults aged 18-65 years were enrolled from urban safety net primary care clinics to self-administer the SUBS using touch-screen tablet computers for a test-retest reliability study (n = 54) and a 2-site validation study (n = 586). In the test-retest reliability study, the SUBS was administered twice within a 2-week period. In the validation study, the SUBS was compared with reference standard measures, including self-reported measures and oral fluid drug tests. We measured test-retest reliability and diagnostic accuracy of the SUBS for detection of unhealthy use and substance use disorder for tobacco, alcohol, and drugs (illicit and prescription drug misuse). RESULTS: Test-retest reliability was good or excellent for each substance class. For detection of unhealthy use, the SUBS had sensitivity and specificity of 97.8% (95% confidence interval [CI], 93.7-99.5) and 95.7% (95% CI, 92.4-97.8), respectively, for tobacco; and 85.2% (95% CI, 79.3-89.9) and 77.0% (95% CI, 72.6-81.1) for alcohol. For unhealthy use of illicit or prescription drugs, sensitivity was 82.5% (95% CI, 75.7-88.0) and specificity 91.1% (95% CI, 87.9-93.6). With respect to identifying a substance use disorder, the SUBS had sensitivity and specificity of 100.0% (95% CI, 92.7-100.0) and 72.1% (95% CI, 67.1-76.8) for tobacco; 93.5% (95% CI, 85.5-97.9) and 64.6% (95% CI, 60.2-68.7) for alcohol; and 85.7% (95% CI, 77.2-92.0) and 82.0% (95% CI, 78.2-85.3) for drugs. Analyses of area under the receiver operating curve (AUC) indicated good discrimination (AUC 0.74-0.97) for all substance classes. Assistance in completing the SUBS was requested by 11% of participants. CONCLUSIONS: The SUBS was feasible for self-administration and generated valid results in a diverse primary care patient population. The 4-item SUBS can be recommended for primary care settings that are seeking to implement substance use screening.

How patients understand the term "nonmedical use" of prescription drugs: insights from cognitive interviews.

BACKGROUND: With rising rates of prescription drug abuse and associated overdose deaths, there is great interest in having accurate and efficient screening tools that identify nonmedical use of prescription drugs in health care settings. The authors sought to gain a better understanding of how patients interpret questions about misuse of prescription drugs, with the goal of improving the accuracy and acceptability of instruments intended for use in primary care. METHODS: A total of 27 English-speaking adult patients were recruited from an urban safety net primary care clinic to complete a cognitive interview about a 4-item screening questionnaire for tobacco, alcohol, illicit drugs, and misuse of prescription drugs. Detailed field notes were analyzed for overall comprehension of the screening items on illicit drug use and prescription drug misuse, the accuracy with which participants classified drugs into these categories, and whether the screening response correctly captured the participant's substance use behavior. RESULTS: Based on initial responses to the screening items, 6 (22%) participants screened positive for past-year prescription drug misuse, and 8 (30%) for illicit drug use. The majority (26/27) of participants correctly interpreted the item on illicit drug use, and appropriately classified drugs in this category. Eleven (41%) participants had errors in their understanding of the prescription drug misuse item. The most common error was classifying use of medications without abuse potential as nonmedical use. All cases of misunderstanding the prescription drug misuse item occurred among participants who screened negative for illicit drug use. CONCLUSIONS: The results suggest that terminology used to describe misuse of prescription medications may be misunderstood by many primary care patients, particularly those who do not use illicit drugs. Failure to improve upon the language used to describe prescription drug misuse in screening questionnaires intended for use in medical settings could potentially lead to high rates of false-positive results.

Test-retest reliability of a self-administered Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in primary care patients.

The time required to conduct drug and alcohol screening has been a major barrier to its implementation in mainstream healthcare settings. Because patient self-administered tools are potentially more efficient, we translated the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) into an audio guided computer assisted self interview (ACASI) format. This study reports on the test-retest reliability of the ACASI ASSIST in an adult primary care population. Adult primary care patients completed the ACASI ASSIST, in English or Spanish, twice within a 1-4 week period. Among the 101 participants, there were no significant differences between test administrations in detecting moderate to high risk use for tobacco, alcohol, or any other drug class. Substance risk scores from the two administrations had excellent concordance (90-98%) and high correlation (ICC 0.90-0.97) for tobacco, alcohol, and drugs. The ACASI ASSIST has good test-retest reliability, and warrants additional study to evaluate its validity for detecting unhealthy substance use.

Estimating the prevalence of illicit opioid use in New York City using multiple data sources.

BACKGROUND: Despite concerns about its health and social consequences, little is known about the prevalence of illicit opioid use in New York City. Individuals who misuse heroin and prescription opioids are known to bear a disproportionate burden of morbidity and mortality. Service providers and public health authorities are challenged to provide appropriate interventions in the absence of basic knowledge about the size and characteristics of this population. While illicit drug users are underrepresented in population-based surveys, they may be identified in multiple administrative data sources. METHODS: We analyzed large datasets tracking hospital inpatient and emergency room admissions as well as drug treatment and detoxification services utilization. These were applied in combination with findings from a large general population survey and administrative records tracking prescriptions, drug overdose deaths, and correctional health services, to estimate the prevalence of heroin and non-medical prescription opioid use among New York City residents in 2006. These data were further applied to a descriptive analysis of opioid users entering drug treatment and hospital-based medical care. RESULTS: These data sources identified 126,681 cases of opioid use among New York City residents in 2006. After applying adjustment scenarios to account for potential overlap between data sources, we estimated over 92,000 individual opioid users. By contrast, just 21,600 opioid users initiated drug treatment in 2006. Opioid users represented 4 % of all individuals hospitalized, and over 44,000 hospitalizations during the calendar year. CONCLUSIONS: Our findings suggest that innovative approaches are needed to provide adequate services to this sizeable population of opioid users. Given the observed high rates of hospital services utilization, greater integration of drug services into medical settings could be one component of an effective approach to expanding both the scope and reach of health interventions for this population.

Training physician investigators in medicine and public health research.

OBJECTIVES: We have described and evaluated the impact of a unique fellowship program designed to train postdoctoral, physician fellows in research at the interface of medicine and public health. METHODS: We developed a rigorous curriculum in public health content and research methods and fostered linkages with research mentors and local public health agencies. Didactic training provided the foundation for fellows' mentored research initiatives, which addressed real-world challenges in advancing the health status of vulnerable urban populations. RESULTS: Two multidisciplinary cohorts (6 per cohort) completed this 2-year degree-granting program and engaged in diverse public health research initiatives on topics such as improving pediatric care outcomes through health literacy interventions, reducing hospital readmission rates among urban poor with multiple comorbidities, increasing cancer screening uptake, and broadening the reach of addiction screening and intervention. The majority of fellows (10/12) published their fellowship work and currently have a career focused in public health-related research or practice (9/12). CONCLUSIONS: A fellowship training program can prepare physician investigators for research careers that bridge the divide between medicine and public health.

Substance use prevalence and screening instrument comparisons in urban primary care.

Substance use screening in a primary care setting compared the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST version 3.0), Two-Item Conjoint Screen (TICS), National Institute on Alcohol Abuse and Alcoholism (NIAAA) daily limit single item, and electronic medical record (EMR). Among 236 consecutive adults, ASSIST moderate- to high-risk substance use prevalence was tobacco, 15.3%; alcohol, 8.5%; cannabis, 5.1%; cocaine, 2.5%; and opioids, 2.5%. Compared to ASSIST, a positive TICS was 45% (95% confidence interval [CI], 27-64%) sensitive, 99% (95-100%) specific; the NIAAA single-item screen was 80% (56-94%) sensitive, 87% (82-91%) specific. The NIAAA single item correlated closely with alcohol ASSIST. TICS and EMR were less sensitive for any nontobacco substance use.

Teaching physicians to address unhealthy alcohol use: a randomized controlled trial assessing the effect of a Web-based module on medical student performance.

BACKGROUND: The authors developed and evaluated an interactive, Web-based module to train medical students in screening and brief intervention (SBI) for unhealthy alcohol use. METHODS: First-year students were randomized to module versus lecture. Change in knowledge, attitudes, and confidence were compared. Performance was assessed by objective structured clinical examination (OSCE) and analyzed by intention to treat and treatment received. RESULTS: Of 141 consenting students, 64% (n = 90) completed an intervention (54% lecture vs. 70% Web assigned). Knowledge, confidence, and attitudes improved in both groups, with more improvement in Advise-Assist knowledge for Web students (14% vs. -3%, p = .003). Web students outperformed their lecture peers in both general communication (65% vs. 51% items well done, p = .004) and alcohol-specific tasks (54% vs. 41%, p = .021) on OSCE. Analysis by treatment received enhanced between-group differences. CONCLUSION: Use of a Web-based module to teach SBI is associated with greater knowledge gain and skills performance compared with a lecture covering similar content. The module provides an efficient means for training in this area.

Two-step tuberculin skin testing in drug users.

To assess the utility of booster testing and to identify factors associated with a positive booster test, two-step tuberculin testing was performed in drug users recruited from methadone treatment. Participants also received a standardized interview on demographics and testing for HIV and CD4+ lymphocyte count. Of 619 enrollees completing the protocol, 174 (28%) had a positive PPD and 24 of the remaining 445 (5%) had a positive booster test. On multivariate analysis, boosting was associated with older age (adjusted odds ratio [ORadj] 2.38/decade, 95% confidence interval [CI] 1.34-4.22), history of using crack cocaine (ORadj 2.61, 95% CI 1.10-6.18) and a history of working as a home health aide (ORadj 4.23, 95% CI 1.39-12.86). Two-step tuberculin skin testing increased the proportion of participants with latent tuberculosis infection from 22% to 25%. Given the effectiveness of chemoprophylaxis, booster testing should be considered when drug users are screened for tuberculosis infection.

Hepatitis C management by addiction medicine physicians: results from a national survey.

Drug users are disproportionately affected by hepatitis C virus (HCV), yet they face barriers to health care that place them at risk for levels of HCV-related care that are lower than those of nondrug users. Substance abuse treatment physicians may treat more HCV-infected persons than other generalist physicians, yet little is known about how such physicians facilitate HCV-related care. We conducted a nationwide survey of American Society of Addiction Medicine physicians (n = 320) to determine substance abuse physicians' HCV-related management practices and to describe factors associated with these practices. We found that substance abuse treatment physicians promote several elements of HCV-related care, including screening for HCV antibodies, recommending vaccinations against hepatitis A and B, and referring patients to subspecialists for HCV treatment. Substance abuse physicians who also provide primary medical or HIV-related care were most likely to facilitate HCV-related care. A significant minority of physicians were either providing HCV antiviral treatment or willing to provide HCV antiviral treatment.

The impact of barriers to hepatitis C virus treatment in recovering heroin users maintained on methadone.

Although most cases of hepatitis C virus (HCV) infection are associated with injection drug use, there are few data regarding the impact of putative barriers such as psychiatric disease and intercurrent drug use on HCV treatment outcomes. To define the impact of characteristics often cited as reasons for withholding HCV treatment, we studied HCV treatment in a real world sample of 76 recovering heroin users maintained on methadone. Overall, 21 (28%) had a sustained virological response and 18 (24%) discontinued treatment early. Although there was a modest decrement in response rates in patients reporting a preexisting psychiatric history (p = .01), neither intercurrent drug use nor short duration of pretreatment drug abstinence led to significant reductions in virological outcomes (p = .09 and p = .18, respectively.) We conclude that injection drug users can be safely and effectively treated for HCV despite multiple barriers to treatment when they are treated in a setting that can address their special needs.

Integrating services for injection drug users infected with hepatitis C virus with methadone maintenance treatment: challenges and opportunities.

Despite the high prevalence of hepatitis C virus (HCV) infection among drug users enrolled in methadone maintenance treatment programs, few drug users are being treated with combination therapy. The most significant barrier to treatment is lack of access to comprehensive HCV-related care. We describe a pilot program to integrate care for HCV infection with substance abuse treatment in a setting of maintenance treatment with methadone. This on-site, multidisciplinary model of care includes comprehensive screening and treatment for HCV infection, assessment of eligibility, counseling with regard to substance abuse, psychiatric services, HCV support groups, directly observed therapy, and enhanced linkages to a tertiary care system for diagnostic procedures. Our approach has led to high levels of adherence, with liver biopsy and substantial rates of initiation of antiviral therapy. Two cases illustrate the successful application of this model to patients with HCV infection complicated by active substance abuse and psychiatric comorbidity.

Factors associated with successful referral for clinical care of drug users with chronic hepatitis C who have or are at risk for HIV infection.

The objective of this study was to determine outcomes of referring drug users (DUs) with chronic hepatitis C for clinical evaluation and care. Two hundred twenty-eight persons with detectable hepatitis C virus RNA were given expedited referrals for evaluation and possible treatment of hepatitis C from a prospective study cohort of current and former opiate-addicted DUs. Four outcomes were analyzed: accepted referral, arrived for clinical evaluation, had liver biopsy, and received treatment. One hundred twenty-seven participants (56%) accepted referral, of whom 54 (43%) arrived for evaluation. Of these participants, 12 (22%) had liver biopsy, and 4 (7%) were treated. Multivariate logistic regression revealed that HIV-infected DUs were significantly less likely to accept referral (adjusted odds ratio [O(Radj)], 0.51; 95% confidence interval [CI], 0.30-0.88), and older participants were more likely to keep an appointment (O(Radj), 1.06/y; 95% CI, 1.00-1.12). Of HIV-seropositive participants, those with a history of injection were more likely to accept referral (O(Radj), 3.60; 95% CI, 1.08-11.96), and those with higher HIV load (O(Radj), 0.50/log10; 95% CI, 0.26-0.94) and Hispanic ethnicity (O(Radj), 0.26; 95% CI, 0.07-0.89) were less likely to keep an appointment. Despite expedited referrals for hepatitis C care, only a few participants received an evaluation, and even far fewer were treated. Because increasingly effective treatment is available, better methods are urgently needed to improve evaluation and treatment of HCV-infected DUs, including those coinfected with HIV.

Effectiveness of isoniazid treatment for latent tuberculosis infection among human immunodeficiency virus (HIV)-infected and HIV-uninfected injection drug users in methadone programs.

Injection drug users (IDUs) were heavily affected by the tuberculosis (TB) resurgence in New York City in the 1990s. We assessed the effectiveness of screening for latent TB infection in methadone users and of selective treatment with isoniazid. Risk for future TB was classified as low or high on the basis of tuberculin, anergy, and HIV test results. The cohort of 2212 IDUs was followed up for a median of 4.2 years; 25 IDUs, of whom 20 (80%) were infected with human immunodeficiency virus (HIV), developed TB. In an adjusted Cox proportional hazards model of high-risk IDUs, the risk of TB was associated with HIV infection (HR 10.3; 95% CI, 3.4-31.3); receipt of <6 months of isoniazid therapy (HR 7.6; 95% CI, 1.02-57.1); a CD4+ T lymphocyte count of <200 cells/mm3 (HR 6.6; 95% CI, 1.7-25.9); and tuberculin positivity (HR 4.0; 95% CI, 1.6-10.2). Treatment with isoniazid was beneficial in HIV-infected, tuberculin-positive IDUs.