Treatment Initiation, Substance Use Trajectories, and the Social Determinants of Health in Persons Living With HIV Seeking Medication for Opioid Use Disorder.

BACKGROUND: People living with HIV and opioid use disorder (OUD) are disproportionally affected by adverse socio-structural exposures negatively affecting health, which have shown inconsistent associations with uptake of medications for OUD (MOUD). This study aimed to determine whether social determinants of health (SDOH) were associated with MOUD uptake and trajectories of substance use in a clinical trial of people seeking treatment. METHODS: Data are from a 2018 to 2019 randomized trial comparing the effectiveness of different MOUD to achieve viral suppression among people living with HIV and OUD. SDOH were defined by variables mapping to Healthy People 2030 domains: education (Education Access and Quality), income (Economic Stability), homelessness (Neighborhood and Built Environment), criminal justice involvement (Social and Community Context), and recent SUD care (Health Care Access and Quality). Associations between SDOH and MOUD initiation were assessed with Cox proportional hazards models, and SDOH and substance use over time with generalized estimating equation models. RESULTS: Participants (N = 114) averaged 47 years old, 63% were male, 56% were Black, and 12% Hispanic. Participants reported an average of 2.3 out of 5 positive SDOH indicators (SD = 1.2). Stable housing was the most commonly reported SDOH (61%), followed by no recent criminal justice involvement (59%), having a high-school level education or greater (56%), income stability (45%), and recent SUD care (13%). Each additional favorable SDOH was associated with a 25% increase in the likelihood of MOUD initiation during the study period [adjusted HR = 1.25, 95% CI = (1.01, 1.55), P = .044]. Positive SDOH were also associated with a decrease in the odds of baseline opioid use and a greater reduction in opioid use during subsequent weeks of the study (P < .001 for a joint test of baseline and slope differences). CONCLUSIONS: Positive social determinants of health, in aggregate, may increase the likelihood of MOUD treatment initiation among people living with HIV and OUD.

Urban-Rural Differences in Mental and Physical Health among Primary Care Patients with Multiple Chronic Conditions: A Secondary Analysis from a Randomized Clinical Trial.

PURPOSE: Rural health disparities are largely attributable to access to healthcare, socioeconomic status, and health behaviors. Little is known about the persistence of these disparities when differences in access to care are eliminated. We sought to investigate urban-rural differences in physical and mental health in primary care patients with demonstrated access to primary care. METHODS: We obtained cross-sectional survey responses from a multicenter randomized controlled trial on 2726 adult primary care patients with multiple chronic medical or behavioral conditions from 42 primary care practices in 13 states. Study outcomes include measures of mental health including: The Patient-Reported Outcomes Measurement Information System (PROMIS-29®), General Anxiety Disorder-7 (GAD-7), and Patient Health Questionnaire-9 (PHQ-9), as well as physical health including: the PROMIS-29® and the Duke Activity Status Index (DASI). Urban-rural residence was indicated by census-tract Rural Urban Commuting Areas of the participant's home address. Differences in mental and physical health outcomes attributable to rurality were assessed using multilevel models with a random intercept for census-tract. RESULTS: After adjustment for demographic and neighborhood characteristics, urban residents had significantly worse generalized anxiety disorder (GAD-7) (ß = 0.7; 95% CI = 0.1, 1.3; p = 0.027), depression (PHQ-9) (ß = 0.7; 95% CI = 0.1, 1.4; p = 0.024), and functional capacity (DASI) (ß = -0.4; 95% CI = -0.5, -0.2; p < 0.001) compared to rural residents. Urban residents also had significantly worse anxiety and depression as measured by the PROMIS-29® compared to their rural counterparts. There were no urban-rural differences in the other PROMIS-29® subdomains. CONCLUSIONS: Among adults with demonstrated access to care and multiple diagnosed chronic conditions, rural residents had better mental health and functional capacity than their urban counterparts. This finding is not consistent with prior research documenting rural health disparities and should be confirmed.

Peer-based Retention Of people who Use Drugs in Rural Research (PROUD-R2): a multisite, randomised, 12-month trial to compare efficacy of standard versus peer-based approaches to retain rural people who use drugs in research.

INTRODUCTION: Rural communities bear a disproportionate share of the opioid and methamphetamine use disorder epidemics. Yet, rural people who use drugs (PWUD) are rarely included in trials testing new drug use prevention and treatment strategies. Numerous barriers impede rural PWUD trial engagement and advancing research methods to better retain rural PWUD in clinical trials is needed. This paper describes the Peer-based Retention Of people who Use Drugs in Rural Research (PROUD-R2) study protocol to test the effectiveness of a peer-driven intervention to improve study retention among rural PWUD. METHODS AND ANALYSIS: The PROUD-R2 study is being implemented in 21 rural counties in three states (Kentucky, Ohio and Oregon). People who are 18 years or older, reside in the study area and either used opioids or injected any drug to get high in the past 30 days are eligible for study inclusion. Participants are allocated in a 1:1 ratio to two arms, stratified by site to assure balance at each geographical location. The trial compares the effectiveness of two retention strategies. Participants randomised to the control arm provide detailed contact information and receive standard retention outreach by study staff (ie, contacts for locator information updates, appointment reminders). Participants randomised to the intervention arm are asked to recruit a 'study buddy' in addition to receiving standard retention outreach. Study buddies are invited to participate in a video training and instructed to remind their intervention participant of follow-up appointments and encourage retention. Assessments are completed by intervention, control and study buddy participants at 6 and 12 months after enrolment. ETHICS AND DISSEMINATION: The protocol was approved by a central Institutional Review Board (University of Utah). Results of the study will be disseminated in academic conferences and peer-reviewed journals, online and print media, and in meetings with community stakeholders. TRIAL REGISTRATION NUMBER: NCT03885024.

Associations between fentanyl use and initiation, persistence, and retention on medications for opioid use disorder among people living with uncontrolled HIV disease.

BACKGROUND: Associations between fentanyl use and initiation and retention on medications for opioid use disorder (MOUD) are poorly understood. METHODS: Data were from a multisite clinical trial comparing extended-release naltrexone (XR-NTX) with treatment as usual (TAU; buprenorphine or methadone) to achieve HIV viral suppression among people with OUD and uncontrolled HIV disease. The exposure of interest was fentanyl use, as measured by urine drug screening. Outcomes were time to MOUD initiation, defined as date of first injection of XR-NTX, buprenorphine prescription, or methadone administration; MOUD persistence, the total number of injections, prescriptions, or administrations received over 24 weeks; and MOUD retention, having an injection, prescription, or administration during weeks 20-24. RESULTS: Participants (N = 111) averaged 47 years old and 62% were male. Just over half (57%) were Black and 13% were Hispanic. Sixty-four percent of participants tested positive for fentanyl at baseline. Participants with baseline fentanyl positivity were 11 times less likely to initiate XR-NTX than those negative for fentanyl (aHR = 0.09, 95% CI 0.03-0.24, p < .001), but there was no evidence that fentanyl use impacted the likelihood of TAU initiation (aHR = 1.50, 0.67-3.36, p = .323). Baseline fentanyl use was not associated with persistence or retention on any MOUD. CONCLUSIONS: Fentanyl use was a substantial barrier to XR-NTX initiation for the treatment of OUD in persons with uncontrolled HIV infection. There was no evidence that fentanyl use impacted partial/full agonist initiation and, once initiated, retention on any MOUD.