Giving Voice to Women with Substance Use Disorder: Findings from Expressive Writing About Trauma.

Background: Trauma exposure is a risk factor for substance use disorders (SUD) among women. This study explores written content from an expressive writing (EW) intervention conducted within a residential SUD program to examine themes across trauma experiences and characterize their deep insight into such experiences. Materials and Methods: This qualitative study is a secondary data analysis of written content of the first writing session from women (n = 44) randomized to an EW condition while in residential SUD treatment. Results: Nearly all participants (72.7% African American; mean age 37.3 years) reported a significant trauma event (93.2%) with an average of 3.7 types of trauma events (54.4% had a current posttraumatic stress disorder diagnosis). Four primary themes emerged: (1) trauma across the lifespan; (2) loss of safety; (3) altered self-concept; and (4) desire to move on. Most participants identified interpersonal trauma, especially at an early age, as well as parental neglect and physical and/or sexual violence. These themes indicate a pattern of interpersonal betrayal and paint a picture of trauma and the subsequent "rippling effect" such that the physical, mental, and emotional consequences were often as impactful as the event itself. However, there was also a desire to move on and gain a sense of normalcy. Conclusions: Findings highlight the importance of the written word and addressing underlying trauma in addiction treatment to facilitate healing and the woman's desire to move on.

OUD MEETS: A novel program to increase initiation of medications for opioid use disorder and improve outcomes for hospitalized patients being discharged to skilled nursing facilities.

INTRODUCTION: Rates of hospitalizations from medical complications of opioid use disorder (OUD) are rising and many of these patients require post-acute care at skilled nursing facilities (SNFs). However, access to medication for OUD (MOUD) at SNFs remains low and patients with OUD have high rates of patient-directed discharge (PDD) and hospital readmissions. METHODS: Opioid Use Disorder Medical Patient Engagement, Enrollment in treatment and Transitional Supports (OUD MEETS) program was a clinical pilot designed to increase initiation of buprenorphine and methadone for hospitalized patients with OUD requiring post-acute care. The program comprises a hospital partnership with two SNFs and two opioid treatment programs (OTPs) to improve recovery supports and access to MOUD for patients discharged to SNF. RESULTS: Between August 2019 and August 2020, study staff approached 49 hospitalized patients with OUD for participation in OUD MEETS. Twenty-eight of 30 eligible patients enrolled in the program and initiated buprenorphine or methadone. Twenty-seven (96 %) enrolled patients successfully completed hospital treatment. Twenty-three (85 %) patients successfully completed medical treatment at SNF. Thirteen (46 %) enrolled patients had confirmed linkage to OUD treatment post-SNF. One patient left the hospital (4 %) and four patients left SNF (15 %) via PDD. CONCLUSION: OUD MEETS demonstrates feasibility of hospital, SNF, and OTP partnership to integrate MOUD treatment into SNFs, with high rates of completion of medical treatment and low rates of PDD. Future research should find sustainable ways to improve access to MOUD at post-acute care facilities, including through regulatory and policy changes.

Stressful life events and transitions in problematic alcohol use involvement among US adults.

OBJECTIVE: We investigated the impact of stressful life events (SLEs) for males and females on transitions in problematic alcohol involvement, both progression and recovery, over a 3-year interval. METHOD: Participants of both Wave 1 (2001-2002) and Wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were stratified by sex (14,233 males and 19,550 females). Latent transition analysis estimated the impact of experiencing ≥3 SLE in the year preceding the Wave 1 interview on the probability of transitioning between three empirically-derived stages of alcohol involvement (patterns of alcohol use disorder [AUD] symptoms), across waves. Propensity score methods adjusted for confounding. RESULTS: For males, three or more SLEs were associated with progression from the moderate to the severe problem stage (odds ratio [OR] = 2.23, 95% confidence interval [CI] = 1.17, 4.26). Among those in the severe problem stage, SLEs negatively impacted recovery regardless of sex. Employment/Financial SLEs were associated with a higher odds of transition from the moderate to the no problem stage (OR = 1.60, 95% CI = 1.03, 2.46) and lower odds of transitions from the severe to the moderate problem stage (OR = 0.40, 95% CI = 0.16, 0.99) among males, and from the severe to the no problem stage (OR = 0.26, 95% CI = 0.07, 0.88) among females. CONCLUSION: Stressful life events appear to affect transitions in alcohol involvement over time among those who already have alcohol problems, rather than impacting a transition among those without AUD problems.

Treating Perioperative and Acute Pain in Patients on Buprenorphine: Narrative Literature Review and Practice Recommendations.

Opioid use disorder (OUD), a leading cause of morbidity and mortality in the USA, can be effectively treated with buprenorphine. However, the same pharmacologic properties (e.g., high affinity, partial agonism, long half-life) that make it ideal as a treatment for OUD often cause concern among clinicians that buprenorphine will prevent effective management of acute pain with full agonist opioid analgesics. Because of this concern, many patients are asked to stop buprenorphine preoperatively or at the onset of acute pain, placing them at high risk for both relapse and a difficult transition back to buprenorphine after acute pain has resolved. The purpose of this review is to summarize the existing literature for acute pain and perioperative management in patients treated with buprenorphine for OUD and to provide practical management recommendations for generalist practitioners based on evidence and clinical experience. In short, evidence suggests that sufficient analgesia can be achieved with maintenance of buprenorphine and use of both opioid and non-opioid analgesic options for breakthrough pain. We recommend that clinicians (1) continue buprenorphine in the perioperative or acute pain period for patients with OUD; (2) use a multi-modal analgesic approach; (3) pay attention to care coordination and discharge planning when making an analgesic plan for patients with OUD treated with buprenorphine; and (4) use an individualized approach founded upon shared decision-making. Clinical examples involving mild and severe pain are discussed to highlight important management principles.

Adverse childhood experiences (ACEs) and transitions in stages of alcohol involvement among US adults: Progression and regression.

BACKGROUND: Adverse childhood experiences (ACEs) are associated with a number of medical comorbidities. However, there is a paucity of data on the role ACEs play in transitions in stages of alcohol involvement. OBJECTIVE: To examine the association between ACEs and transitions in alcohol problems progression and regression between No Problems, Moderate Problems and Severe Problems stages. PARTICIPANTS AND SETTING: Data from 14,363 male and 19,774 female participants in Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). METHODS: We used latent transition analysis (LTA) with propensity score adjustment to estimate the odds of transitioning across stages of alcohol involvement, between waves, based on the number of types of ACEs experienced. We hypothesized that ACEs would be associated with increased risk of progression and decreased risk of regression. RESULTS: ACEs were associated with progression to higher alcohol involvement stages, with greatest likelihood of progression from No Problems to Severe Problems for those reporting ≥3 ACEs (males: aOR = 4.78 [CI (1.84-12.44)]; females: aOR = 3.81 [CI (1.69-8.57)]). ACEs were also associated with decreased odds of regression to less problematic alcohol involvement stages, with some distinctive patterns of associations in males and in females. CONCLUSIONS: This study suggests that ACEs impact transitions in alcohol involvement in both males and females, affecting both progression and regression. The association is magnified for those with multiple types of ACE exposures. These results highlight the need for prevention, early identification and intervention to mitigate the risks associated with childhood maltreatment.

Correlates of alcohol use disorder pharmacotherapy receipt in medically insured patients.

BACKGROUND: Alcohol use disorder is a highly prevalent disease with multiple medications available for treatment. The overall prevalence of patients receiving pharmacotherapy is believed to be low and the characteristics and comorbidities that affect receipt are not well-established. METHODS: We created a dataset from Truven Health Analytics MarketScan Commercial Claims and Encounters Database of patients with an outpatient encounter for alcohol abuse or dependence in 2014. We subsequently identified patient characteristics, comorbid medical, psychiatric, or substance use disorders, as well as encounter provider specialties and, using multivariable logistic regression, assessed which variables correlated with increased or decreased receipt of pharmacotherapy for alcohol use disorder for this population. RESULTS: In our dataset of 123,355 patients, patient receipt of pharmacotherapy for alcohol use disorder was 3.3 %, and 9.3 % when restricted to the former diagnosis of alcohol dependence only. Male sex, younger age, alcohol-related liver disease, and cannabis use disorders correlated with decreased receipt whereas comorbid major depressive disorders and anxiety disorders correlated with increased receipt. Compared to patients seen by psychiatrists, those seen by primary medical doctors had a lower odds of receiving pharmacotherapy. CONCLUSIONS: Pharmacotherapy for alcohol use disorder is an underutilized treatment modality with a low prevalence of prescription in insured individuals. Patients with specific characteristics and comorbidities are less likely to receive this treatment and greater focus on these patients and in the primary care setting can allow for increased prescribing of these medications.

Current tobacco use, nicotine dependence, and transitions across stages of alcohol involvement: A latent transition analysis approach.

OBJECTIVES: This study aims to examine the (a) probability of transition between stages of alcohol involvement and (b) influence of tobacco use and nicotine dependence on transitions. METHODS: Data came from Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Latent transition analysis estimated the probability of transitioning between stages of alcohol involvement across waves and the impact of tobacco use and nicotine dependence at Wave 1 on transitions. RESULTS: Males reporting current tobacco use but no dependence at Wave 1 were more likely to progress from No Problems to Moderate Problems (adjusted odds ratio [aOR] = 1.79; 95% confidence interval [CI] [1.44, 2.22]) and from No Problems to Severe Problems (aOR = 2.44; 95% CI [1.25, 4.77]) than nontobacco users. Females reporting current tobacco use but no dependence were more likely to progress from No Problems to Moderate Problems (aOR = 2.00; 95% CI [1.37, 2.94]) and from No Problems to Severe Problems (aOR = 2.87; 95% CI [1.34, 6.13]). Females reporting current tobacco use and dependence were more likely than females not using tobacco to transition from Moderate to No Problems (aOR = 2.10; 95% CI [1.04, 4.22]). CONCLUSIONS: Results suggest that tobacco use is a preceding correlate of progression in alcohol involvement among males and females. Among females, tobacco use and nicotine dependence are also related to alcohol involvement recovery.

Evaluation of the Brief Alcohol Withdrawal Scale Protocol at an Academic Medical Center.

OBJECTIVES: The standard of care for treatment of alcohol withdrawal is symptom-triggered dosing of benzodiazepines using a withdrawal scale. Abbreviated scales are desired for clinician efficiency. The objective of this study was to evaluate the use of the 5-item Brief Alcohol Withdrawal Scale (BAWS) protocol. METHODS: This single-center, retrospective, observational, cohort study assessed patients ordered the BAWS protocol between August 1, 2016 and July 31, 2017. Data were collected on benzodiazepine exposure, duration of treatment, withdrawal severity, agitation, over-sedation, and delirium while being treated for alcohol withdrawal. Comparisons were made to analyze predetermined patient subgroups. RESULTS: Seven hundred ninety-nine patients were initiated on the BAWS protocol. Patients received a median (IQR) of 0 (0-4) lorazepam equivalents (LEs) and were on the BAWS protocol for a median (IQR) of 44.9 (22.4-77.2) hours. Of the patients that received benzodiazepines while on the BAWS protocol, a median (IQR) of 4 (2-11) LEs were given. Seventeen (2.1%) patients had severe withdrawal. Days of agitation, over-sedation, and delirium were minimal, with the median (IQR) of 0 (0-0). Few patients received adjunctive medications for symptom management. Intensive care unit (ICU) patients had more severe withdrawal than non-ICU patients, but received the same cumulative benzodiazepine dose. CONCLUSIONS: Most patients on the BAWS protocol received little-to-no benzodiazepines; severe withdrawal, agitation, delirium, or over-sedation were uncommon. This is the first evaluation of the BAWS protocol on a diverse population of hospitalized patients.

Information and Communication Technologies Interest, Access, and Use: Cross-Sectional Survey of a Community Sample of Urban, Predominantly Black Women.

BACKGROUND: Information and communication technologies (ICT) offer the potential for delivering health care interventions to low socioeconomic populations who often face barriers in accessing health care. However, most studies on ICT for health education and interventions have been conducted in clinical settings. OBJECTIVE: The aim of this study was to examine access to and use of mobile phones and computers, as well as interest in, using ICT for receipt of behavioral health information among a community sample of urban, predominately black, women with low socioeconomic status. METHODS: Participants (N=220) were recruited from hair salons and social service centers and completed audio-computer assisted self-interviews. RESULTS: The majority of the participants (212/220, 96.3%) reported use of a cell phone at least weekly, of which 89.1% (189/212) used smartphones and 62.3% (137/220) reported computer use at least weekly. Of the women included in the study, 51.9% (107/206) reported using a cell phone and 39.4% (74/188) reported using a computer to access health and/or safety information at least weekly. Approximately half of the women expressed an interest in receiving information about stress management (51%-56%) or alcohol and health (45%-46%) via ICT. Smartphone ownership was associated with younger age (odds ratio [OR] 0.92, 95% CI 0.87-0.97) and employment (OR 5.12, 95% CI 1.05-24.95). Accessing health and safety information weekly by phone was associated with younger age (OR 0.96, 95% CI 0.94-0.99) and inversely associated with higher income (OR 0.42, 95% CI 0.20-0.92). CONCLUSIONS: Our findings suggest that ICT use, particularly smartphone use, is pervasive among predominantly black women with low socioeconomic status in urban, nonclinical settings. These results show that ICT is a promising modality for delivering health information to this population. Further exploration of the acceptability, feasibility, and effectiveness of using ICT to disseminate behavioral health education and intervention is warranted.

Transitions through stages of alcohol involvement: The potential role of mood disorders.

INTRODUCTION: Although prior clinical and population-based studies have demonstrated comorbidity between mood and alcohol use disorders (AUD), there is a paucity of research assessing whether mood disorders predict transition across stages of alcohol involvement. METHOD: Hypothesizing that mood disorders predict transition across sex-specific alcohol involvement stages, we used prospective data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative survey of US adults, which included male (n = 14,564) and female (n = 20,089) participants surveyed in 2001-2 and re-interviewed in 2004-5. Latent class (LCA) and latent transition analyses (LTA) were used to assess patterns of alcohol involvement in the US and the association of lifetime mood disorders at baseline with transition across stages of alcohol involvement during follow-up. RESULTS: A three-class model of AUD criteria was identified (No problems, Moderate problems and Severe problems) for both sexes. Positive cross-sectional associations between mood disorder and problem classes of alcohol involvement were found among both sexes, as were positive longitudinal associations. Propensity score adjustment mitigated the associations of baseline mood disorder with progressive transition for both sexes. However, among females, baseline mood disorder was consistently associated with reduction in remission from Severe to Moderate alcohol problems (aOR = 0.30, CI = 0.09-0.99, p = .048) over time. DISCUSSION: Our study provides evidence that mood disorders impact transition through stages of alcohol involvement and are most strongly associated with hindering remission among females. Findings advance our understanding of these comorbid relationships and have clinical implications for ongoing assessment of drinking patterns among individuals with mood disorders.

Associations of Drug Use, Violence, and Depressive Symptoms with Sexual Risk Behaviors Among Women with Alcohol Misuse.

BACKGROUND: Alcohol misuse is associated with increased human immunodeficiency virus sexual risk behaviors by women. Drug use, intimate partner violence (IPV), and depressive symptoms frequently co-occur, are well-recognized alcohol misuse comorbidities, and may interact to increase risk behaviors. Using a syndemic framework we examined associations between drug use, IPV, and depressive symptoms and sexual risk behaviors by 400 women with alcohol misuse attending an urban sexually transmitted infections clinic. METHODS: Participants completed computer-assisted interviews querying drug use, IPV, and depressive symptoms and sexual risk behavior outcomes-unprotected sex under the influence of alcohol, sex for drugs/money, and number of lifetime sexual partners. We used multivariable analysis to estimate prevalence ratios (PR) for independent and joint associations between drug use, IPV, and depressive symptoms and our outcomes. To investigate synergy between risk factors we calculated the relative excess prevalence owing to interaction for all variable combinations. RESULTS: In multivariable analysis, drug use, IPV, and depressive symptoms alone and in combination were associated with higher prevalence/count of risk behaviors compared with women with alcohol misuse alone. The greatest prevalence/count occurred when all three were present (unprotected sex under the influence of alcohol [PR, 2.6; 95% confidence interval, 1.3-4.9]), sex for money or drugs [PR, 2.6; 95% confidence interval, 1.7-4.2], and number of lifetime partners [PR, 3.2; 95% confidence interval, 1.9-5.2]). Drug use, IPV, and depressive symptoms did not interact synergistically to increase sexual risk behavior prevalence. CONCLUSIONS: A higher prevalence of sexual risk behaviors by women with alcohol misuse combined with drug use, IPV, and depressive symptoms supports the need for alcohol interventions addressing these additional comorbidities.

Change in Medical Student Attitudes Toward Patients with Substance Use Disorders After Course Exposure.

OBJECTIVE: Negative physician attitudes toward patients with substance use disorders (SUD) pose a significant barrier to treatment. This study tests the overall and intra-individual change in attitudes of second year medical students after exposure to a 15 hour SUD course. METHODS: Two cohorts of second year medical students (2014 and 2015) responded to an anonymous 13-item previously published survey exploring personal views regarding patients with SUD using a four-point Likert scale. Students were surveyed one day before and up to one month after course completion. Survey items were grouped into the following categories: treatment optimism/confidence in intervention, moralism, and stereotyping. The Wilcoxon nonparametric signed-rank test (α=0.05) was used to compare the pre- and post- survey responses. RESULTS: In 2014 and 2015 respectively, 118 and 120 students participated in the SUD course with pre- and post-response rates of 89.0% and 75.4% in 2014 and 95.8% and 97.5% in 2015. Of the 13 survey questions, paired responses to eight questions showed a statistically significant positive change in attitudes with a medium (d = 0.5) to large effect size (d = 0.8). Items focused on treatment optimism and confidence in treatment intervention reflected a positive attitude change, as did items associated with stereotyping and moralism. CONCLUSIONS: These results support the hypothesis that exposure to a course on SUD was associated with positive change in medical students' attitudes toward patients with SUD.

Marijuana use and HIV treatment outcomes among PWH receiving care at an urban HIV clinic.

BACKGROUND: While marijuana use is prevalent among persons with HIV (PWH), few studies have examined the relationship between marijuana use and HIV treatment outcomes independent of alcohol and other drug use. METHODS: We conducted a prospective cohort study to examine the relationships between frequency of marijuana use and antiretroviral therapy (ART) adherence and viral suppression in patients enrolled in the Johns Hopkins HIV Clinical Cohort between September 2013 through November 2015 (N=1377). We categorized marijuana use as no use, none in the last 3months, monthly use or less, weekly/daily. Our outcomes of interest were use of ART, ≥90 ART adherence, and viral suppression (HIV1-RNA<200 copies). We conducted multivariable analyses to examine associations between the frequency of marijuana use and our treatment outcomes, using generalized estimating equations to account for repeated measures. Other independent variables of interest included alcohol use, other drug use, and depressive symptoms. Analyses were adjusted for age, race, sex and HIV acquisition risk factor. RESULTS: In multivariable analyses we found no statistically significant association between frequency of marijuana use and our treatment outcomes. Alcohol use, other drug use and depressive symptoms were associated with lower odds of ART adherence and viral suppression. CONCLUSIONS: In this sample of PWH in care, frequency of marijuana use independent of other substance use does not appear to be associated with negative HIV treatment outcomes. Our results indicate that unlike alcohol, other substances and depression, marijuana use may not be a barrier to the effective treatment of HIV.

Perceptions of Neighborhood Mediate the Relationship Between PTSD Symptoms and Coping in a Neighborhood-Matched Substance-Using Sample.

OBJECTIVES: People with substance use problems living in neighborhoods with high levels of disorder are disproportionately likely to experience trauma and develop PTSD symptoms. We sought to evaluate the relationships between objective neighborhood disorder, perceptions of neighborhood, and the use of maladaptive coping behaviors among both non-substance-using and substance-using participants with and without PTSD symptoms. METHODS: Participants (255 non-drug users [NDUs], 168 marijuana and/or alcohol users [MAUs], and 273 opioid and/or stimulant users) completed the Addiction Severity Index, PTSD Checklist-Civilian Version, The COPE Inventory, and the Perceived Neighborhood Scale. The Neighborhood Inventory for Environmental Typology (NIfETy) was used to objectively assess neighborhood disorder at participants' home addresses. Regression modeling was used to assess within-group predictors of PTSD and test for mediation in the relationships between PTSD, perceptions of neighborhood, and coping behaviors. RESULTS: In NDUs, lower sense of community partially mediated the relationship between PTSD symptoms and using mental disengagement to cope. In MAUs, higher levels of perceived crime partially mediated the individual relationships between PTSD symptoms and using mental disengagement, focusing on and venting emotions, and using substances to cope. Opioid and/or stimulant users with PTSD symptoms reported using higher levels of mental disengagement, focusing on and venting emotions, and substances to cope and perceived a higher degree of crime; no mediation was inferred. CONCLUSION: Perceptions of community and crime may be more predictive of PTSD symptoms than objectively measured neighborhood disorder. These perceptions partially mediate the relationship between maladaptive coping behaviors and PTSD symptoms.

Development and implementation of an alcohol withdrawal protocol using a 5-item scale, the Brief Alcohol Withdrawal Scale (BAWS).

BACKGROUND: The standard of care for management of alcohol withdrawal is symptom-triggered treatment using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar). Many items of this 10-question scale rely on subjective assessments of withdrawal symptoms, making it time-consuming and cumbersome to use. Therefore, there is interest in shorter and more objective methods to assess alcohol withdrawal symptoms. METHODS: A 6-item withdrawal scale developed at another institution was piloted. Based on comparison with the CIWA-Ar, this was adapted into a 5-item scale named the Brief Alcohol Withdrawal Scale (BAWS). The BAWS was compared with the CIWA-Ar and a withdrawal protocol utilizing the BAWS was developed. The new protocol was implemented on an inpatient unit dedicated to treating substance withdrawal. Data was collected on the first 3 months of implementation and compared with the 3 months prior to that. RESULTS: A BAWS score of 3 or more predicted CIWA-Ar score ≥8 with a sensitivity of 85.3% and specificity of 65.8%. The demographics of the patients in the 2 time periods were similar: the mean age was 45.9; 70.6% were male; 30.9% received concurrent treatment for opioid withdrawal; and 14.2% were receiving methadone maintenance. During the BAWS phase, patients received significantly less diazepam (mean dose 81.4 vs. 60.3 mg, P < .001). There was no significant difference in length of stay. No patients experienced a seizure, delirium, or required transfer to a higher level of care during any of the 664 admissions in either phase. CONCLUSIONS: This simple protocol utilizing a 5-item withdrawal scale performed well in this setting. Its use in other settings, particularly with patients with concurrent medical illnesses or more severe withdrawal, needs to be explored further.

Family history of alcoholism is related to increased D2 /D3 receptor binding potential: a marker of resilience or risk?

The aim of this study was to examine the relationship between family history of alcohol use disorder and striatal dopamine using positron emission tomography imaging. Participants were 84 healthy, 18- to 30-year-old, social drinkers recruited via fliers and newspaper advertisements. At assessment, participants completed measures of lifetime personal and family substance use and psychiatric symptoms. Participants underwent two consecutive positron emission tomography scans using the D2 /D3 dopamine receptor radioligand [11 C]raclopride. Scans were preceded by intravenous saline and amphetamine 0.3 mg/kg, providing measures of baseline [11 C]raclopride binding potential (BPND ) and change in [11 C]raclopride (ΔBPND ). Subjective ratings of stimulant drug effects were collected during scans. Subjects were classified as family history positive (FHP) if they reported any first-degree relative with alcohol use disorder (AUD) and family history negative (FHN) if no first-degree relatives had history of AUD. Participants were predominantly White (69.0 percent) and male (62.1 percent). Baseline [11 C]raclopride BPND was generally higher in FHP compared with FHN subjects across striatal subdivisions. There were no differences in ΔBPND across regions. Negative subjective drug effects were more pronounced in FHP than in FHN subjects. While FHN subjects evidenced the expected positive relationship between ΔBPND and positive subjective drug effects, this relationship was disrupted in FHP subjects. There are key differences in dopamine status and subjective stimulant drug experiences as a function of family AUD history. These findings have important implications for understanding risk for AUD development in FHP offspring.

The Association Between Changes in Alcohol Use and Changes in Antiretroviral Therapy Adherence and Viral Suppression Among Women Living with HIV.

Heavy alcohol use has adverse effects in women with HIV. We examined the association between changes in alcohol use (measured with Timeline Followback) and changes in antiretroviral therapy adherence (medication possession ratio) and viral suppression (HIV RNA), measured over 6-month intervals. Among women who were (1) non-adherent or not virologically suppressed and (2) infrequent binge drinkers or non-heavy drinkers at baseline, increasing drinking was significantly associated with lower odds of subsequently improving adherence or viral suppression (OR of becoming adherent of 0.90 in infrequent binge drinkers; OR of becoming suppressed of 0.81 and 0.75 in infrequent binge drinkers and non-heavy drinkers, respectively). Our findings suggest that for these women, increasing drinking may be a barrier to achieving viral suppression. Addressing this barrier by integrating proactive alcohol counseling strategies into routine HIV care may be key to improving viral suppression rates among women retained in HIV care.

Lifetime Cocaine and Opiate Use and Chronic Kidney Disease.

BACKGROUND: More than 50% of American adolescents and adults report having used illicit drugs in their lifetime. We examined the association of lifetime opiate and cocaine use with reduced kidney function, albuminuria and rapid kidney function decline among urban-dwelling adults. METHODS: Our prospective cohort included 2,286 Healthy Aging in Neighborhoods of Diversity across the Life Span study participants who were community-dwelling adults residing in Baltimore, MD. The predictive variables were lifetime opiate and cocaine use, defined as use of opiates or crack/cocaine ≥5 times. Outcomes included prevalent reduced estimated glomerular filtration rate (eGFR; <60 ml/min/1.73 m2 by Chronic Kidney Disease (CKD)-Epidemiology Collaboration), albuminuria (albumin-to-creatinine ratio >30 mg/g, n = 1,652) and rapid kidney function decline (>3 ml/min/1.73 m2 per year over a median of 4.7 years, n = 1,660). RESULTS: Participants' mean age was 48 years, 15% reported opiate use, and 22% reported cocaine use. A total of 115 (5.0%) participants had reduced eGFR, 190 (11.5%) had albuminuria and 230 (13.8%) experienced rapid decline in kidney function. In adjusted logistic regression analyses, both substances were associated with greater odds of reduced eGFR (OR 2.71, 95% CI 1.50-4.89 for opiates; OR 1.40, 95% CI 0.87-2.24 for cocaine). Both substances were associated with greater odds of albuminuria (OR 1.20, 95% CI 0.83-1.73 for opiates; OR 1.80, 95% CI 1.29-2.51 for cocaine). Neither substance was associated with the rapid decline of kidney function. CONCLUSIONS: Lifetime opiate and cocaine use was associated with prevalent reduced eGFR and albuminuria, yet not with rapid kidney function decline. The use of opiate and cocaine may be an important risk factor for CKD in urban populations.

Internal medicine resident knowledge, attitudes, and barriers to naloxone prescription in hospital and clinic settings.

BACKGROUND: The United States is facing an epidemic of opioid use and misuse leading to historically high rates of overdose. Community-based overdose education and naloxone distribution has effectively trained lay bystanders to recognize signs of overdose and administer naloxone for reversal. There has been a movement to encourage physicians to prescribe naloxone to all patients at risk of overdose; however, the rate of physician prescribing remains low. This study aims to describe resident knowledge of overdose risk assessment, naloxone prescribing practices, attitudes related to naloxone, and barriers to overdose prevention and naloxone prescription. METHODS: The HOPE (Hospital-based Overdose Prevention and Education) Initiative is an educational campaign to teach internal medicine residents to assess overdose risk, provide risk reduction counseling, and prescribe naloxone. As part of a needs assessment, internal medicine residents at an academic medical center in Baltimore, Maryland, were surveyed in 2015. Data were collected anonymously using Qualtrics. RESULTS: Ninety-seven residents participated. Residents were overwhelmingly aware of naloxone (80%) and endorsed a willingness to prescribe (90%). Yet despite a high proportion of residents reporting patients in their panels at increased overdose risk (79%), few had prescribed naloxone (15%). Residents were willing to discuss overdose prevention strategies, although only a minority reported doing so (47%). The most common barriers to naloxone prescribing were related to knowledge gaps in how to prescribe and how to assess risk of overdose and identify candidates for naloxone (52% reporting low confidence in ability to identify patients who are at risk). CONCLUSIONS: Medicine residents are aware of naloxone and willing to prescribe it to at-risk patients. Due to decreased applied knowledge and limited self-efficacy, few residents have prescribed naloxone in the past. In order to improve rates of physician prescribing, initiatives must help physicians better assess risk of overdose and improve prescribing self-efficacy.