"I'm on the Right Path": Exploring 1-Month Retention in a Homeless-Tailored Outpatient-Based Opioid Treatment Program.

BACKGROUND: Homeless-tailored office-based opioid treatment (OBOT) programs have been developed to address the ongoing opioid overdose crisis, which disproportionately affects people experiencing homelessness. The objective of this study was to evaluate the facilitators of and barriers to retention in a homeless-tailored OBOT program. METHODS: We performed in-depth qualitative interviews with 24 homeless-experienced adults who newly enrolled in Boston Health Care for the Homeless Program's OBOT program from January 6, 2022 through January 5, 2023. We purposively sampled participants based on whether they were retained at 1 month (n = 12) or not (n = 12). We used an abductive analytic process, applying codes to the interview transcripts from an a priori analytic framework based on the Behavioral Model for Vulnerable Populations and supplementing with emergent codes as needed. We compared themes by participants' 1-month retention status to explore facilitators of and barriers to retention in OBOT care. RESULTS: The average age was 41.9 years, 29.2% were female, 20.8% were Black, 58.3% were White, and 33.0% were Hispanic. Facilitators of retention common to many participants included the clinic experience, low-threshold model, clinic staff, and provision of comprehensive care. Among participants who were retained at 1-month, personal motivation, use of extended-release buprenorphine, and adequate buprenorphine efficacy were additional facilitators. Barriers to retention common to many participants included the clinic's surrounding environment, competing subsistence difficulties, and transportation difficulty. Among participants who were not retained at 1-month, opioid use severity, drug use in social networks, and inadequate buprenorphine efficacy represented additional barriers. CONCLUSIONS: We identified several common determinants of OBOT retention among our homeless-experienced participants as well as some facilitators and barriers that differed by 1-month retention status. These divergent factors represent potential points of intervention to promote retention in homeless-tailored OBOT programs.

Mortality by Age, Gender, and Race and Ethnicity in People Experiencing Homelessness in Boston, Massachusetts.

Importance: People experiencing homelessness (PEH) face disproportionately high mortality rates compared with the general population, but few studies have examined mortality in this population by age, gender, and race and ethnicity. Objective: To evaluate all-cause and cause-specific mortality in a large cohort of PEH by age, gender, and race and ethnicity. Design, Setting, and Participants: An observational cohort study was conducted from January 1, 2003, to December 31, 2018. All analyses were performed between March 16, 2021, and May 12, 2022. A cohort of adults (age ≥18 years) seen at the Boston Health Care for the Homeless Program (BHCHP), a large federally funded Health Care for the Homeless organization in Boston, Massachusetts, from January 1, 2003, to December 31, 2017, was linked to Massachusetts death occurrence files spanning January 1, 2003, to December 31, 2018. Main Outcomes and Measures: Age-, gender-, and race and ethnicity-stratified all-cause and cause-specific mortality rates were examined and compared with rates in the urban Northeast US population using mortality rate ratios (RRs). Results: Among the 60 092 adults included in the cohort with a median follow-up of 8.6 (IQR, 5.1-12.5) years, 7130 deaths occurred. The mean (SD) age at death was 53.7 (13.1) years; 77.5% of decedents were men, 21.0% Black, 10.0% Hispanic/Latinx, and 61.5% White. The all-cause mortality rate was 1639.7 deaths per 100 000 person-years among men and 830 deaths per 100 000 person-years among women. The all-cause mortality rate was highest among White men aged 65 to 79 years (4245.4 deaths per 100 000 person-years). Drug overdose was a leading cause of death across age, gender, and race and ethnicity groups, while suicide uniquely affected young PEH and HIV infection and homicide uniquely affected Black and Hispanic/Latinx PEH. Conclusions and Relevance: In this large cohort study of PEH, all-cause and cause-specific mortality varied by age, gender, and race and ethnicity. Tailored interventions focusing on those at elevated risk for certain causes of death are essential for reducing mortality disparities across homeless-experienced groups.

Health Care Utilization among Homeless-Experienced Adults Who Were Seen by a Mobile Addiction Health Clinic in Boston, Massachusetts: A Quasi-Experimental Study.

Background: Mobile health clinics improve access to care for marginalized individuals who are disengaged from the healthcare system. This study evaluated the association between a mobile addiction health clinic and health care utilization among people experiencing homelessness. Methods: Using Medicaid claims data, we evaluated adults who were seen by a mobile addiction health clinic in Boston, Massachusetts from 1/16/18-1/15/19 relative to a propensity score matched control cohort. We evaluated both cohorts from four years before to one year after the index visit date with the mobile clinic. The primary outcome was the number of outpatient visits; secondary outcomes were the number of hospitalizations and emergency department (ED) visits. We used Poisson regression to compare changes in outcomes from before to after the index date in a quasi-experimental design. Results: 138 adults were seen by the mobile clinic during the observation period; 29.7% were female, 16.7% were Black, 8.0% Hispanic, 68.1% White, and the mean age was 40.4 years. The mean number of mobile clinic encounters was 3.1. The yearly mean number of outpatient visits increased from 11.5 to 12.1 (p = 0.43; pdiff-in-diff = 0.15), the number of hospitalizations increased from 2.2 to 3.0 (p = 0.04; pdiff-in-diff = 0.87), and the number of ED visits increased from 5.4 to 6.5 (p = 0.04; pdiff-in-diff = 0.40). Conclusions: The mobile addiction health clinic was not associated with statistically significant changes in health care utilization in the first year. Further research in larger samples using a broader set of outcomes is needed to quantify the benefits of this innovative care delivery model.

Mortality Trends Among Adults Experiencing Homelessness in Boston, Massachusetts From 2003 to 2018.

This cohort study involves assessing causes of death among people experiencing homelessness in Boston from 2003 to 2018.

Drug Overdose Mortality Among People Experiencing Homelessness, 2003 to 2018.

Importance: Despite high rates of drug overdose death among people experiencing homelessness, patterns in drug overdose mortality, including the types of drugs implicated in overdose deaths, remain understudied in this population. Objective: To describe the patterns in drug overdose mortality among a large cohort of people experiencing homelessness in Boston vs the general adult population of Massachusetts and to evaluate the types of drugs implicated in overdose deaths over a continuous 16-year period of observation. Design, Setting, and Participants: This cohort study analyzed adults aged 18 years or older who received care at Boston Health Care for the Homeless Program (BHCHP) between January 1, 2003, and December 31, 2017. Individuals were followed up from the date of their initial BHCHP encounter during the study period until the date of death or December 31, 2018. Data were analyzed from December 1, 2020, to June 6, 2021. Main Outcomes and Measures: Drug overdose deaths and the types of drugs involved in each overdose death were ascertained by linking the BHCHP cohort to the Massachusetts Department of Public Health death records. Results: In this cohort of 60 092 adults experiencing homelessness (mean [SD] age at entry, 40.4 [13.1] years; 38 084 men [63.4%]), 7130 individuals died by the end of the study period. A total of 1727 individuals (24.2%) died of a drug overdose. Of the drug overdose decedents, 456 were female (26.4%), 194 were Black (11.2%), 202 were Latinx (11.7%), and 1185 were White (68.6%) individuals, and the mean (SD) age at death was 43.7 (10.8) years. The age- and sex-standardized drug overdose mortality rate in the BHCHP cohort was 278.9 (95% CI, 266.1-292.3) deaths per 100 000 person-years, which was 12 times higher than the Massachusetts adult population. Opioids were involved in 91.0% of all drug overdose deaths. Between 2013 and 2018, the synthetic opioid mortality rate increased from 21.6 to 327.0 deaths per 100 000 person-years. Between 2004 and 2018, the opioid-only overdose mortality rate decreased from 117.2 to 102.4 deaths per 100 000 person-years, whereas the opioid-involved polysubstance mortality rate increased from 44.0 to 237.8 deaths per 100 000 person-years. Among opioid-involved polysubstance overdose deaths, cocaine-plus-opioid was the most common substance combination implicated throughout the study period, with Black individuals having the highest proportion of cocaine-plus-opioid involvement in death (0.72 vs 0.62 in Latinx and 0.53 in White individuals; P < .001). Conclusions and Relevance: In this cohort study of people experiencing homelessness, drug overdose accounted for 1 in 4 deaths, with synthetic opioid and polysubstance involvement becoming predominant contributors to mortality in recent years. These findings emphasize the importance of increasing access to evidence-based opioid overdose prevention strategies and opioid use disorder treatment among people experiencing homelessness, while highlighting the need to address both intentional and unintentional polysubstance use in this population.

Experience with a Mobile Addiction Program among People Experiencing Homelessness.

A mobile addiction-focused outreach program designed to improve access to care for people experiencing homelessness was implemented in response to the opioid overdose crisis. This innovative program was readily accepted among participants and can inform the development of similar programs delivering addiction-focused care to people experiencing homelessness elsewhere.

High Inpatient Health Care Utilization and Charges Associated With Injection Drug Use-Related Infections: A Cohort Study, 2012-2015.

Our study describes the characteristics of patients hospitalized with injection drug use-related infection over a multiyear period in a region highly impacted by the opioid epidemic. Intensive health care needs were common in this young cohort, including high rates of readmission, high hospitalization costs, and prolonged lengths of stay.

Office-Based Addiction Treatment Retention and Mortality Among People Experiencing Homelessness.

Importance: People experiencing homelessness have been disproportionately affected by the opioid overdose crisis. To mitigate morbidity and mortality, several office-based addiction treatment (OBAT) programs designed for this population have been established across the US, but studies have not yet evaluated their outcomes. Objective: To evaluate treatment retention and mortality in an OBAT program designed specifically for individuals experiencing homelessness with opioid use disorder (OUD). Design, Setting, and Participants: A retrospective cohort study was conducted in the Boston Health Care for the Homeless Program (BHCHP). Participants included all adult patients (N = 1467) who had 1 or more OBAT program encounter at BHCHP from January 1 through December 31, 2018. Data analysis was conducted from January 13 to December 14, 2020. Exposures: Sociodemographic, clinical, and addiction treatment-related characteristics were abstracted from the BHCHP electronic health record. Main Outcomes and Measures: The primary outcome was all-cause mortality, identified by linkage to the Massachusetts Department of Public Health vital records. Multivariable Cox proportional hazards regression analyses were performed to evaluate baseline and time-varying variables associated with all-cause mortality. Secondary addiction treatment-related outcomes were abstracted from the electronic health record and included (1) BHCHP OBAT program retention, (2) buprenorphine continuation and adherence verified by toxicology testing, and (3) opioid abstinence verified by toxicology testing. Results: Of 1467 patients in the cohort, 1046 were men (71.3%) and 731 (49.8%) were non-Hispanic White; mean (SD) age was 42.2 (10.6) years. Continuous retention in the OBAT program was 45.2% at 1 month, 21.7% at 6 months, and 11.3% at 12 months. Continuous buprenorphine adherence was 41.5% at 1 month, 17.6% at 6 months, and 10.2% at 12 months, and continuous opioid abstinence was 28.3% at 1 month, 6.1% at 6 months, and 2.9% at 12 months. The all-cause mortality rate was 29.0 deaths per 1000 person-years, with 51.8% dying from drug overdose. Past-month OBAT program attendance was associated with lower mortality risk (adjusted hazard ratio, 0.34; 95% CI, 0.21-0.55). Conclusions and Relevance: Mortality rates were high in this cohort of addiction treatment-seeking homeless and unstably housed individuals with OUD. Although continuous OBAT program retention was low, past-month attendance in care was associated with reduced mortality risk. Future work should examine interventions to promote increased OBAT attendance to mitigate morbidity and mortality in this vulnerable population.

Societal Biases, Institutional Discrimination, and Trends in Opioid Use in the USA.

History has demonstrated cyclical trends in opioid use in the USA, alternating between high rates of prescribing driven by compassion and marketing and restrictive prescribing driven by stigma and fear of precipitating addiction and other harms. Two under-recognized yet powerful forces driving these trends are societal biases against individuals who use and are addicted to drugs, as well as a recognized social determinant of health, institutional discrimination. In the context of these influential forces, which are often based on racist and classist ideologies, we examine the history of opioid use in the USA from the 1800s when the vast majority of those addicted to opioids were middle- to upper-class women to the present-day white-washed narrative of the opioid crisis. As the demographics of those affected by opioid use and addiction has started to shift from white communities to communities of color, we cannot allow the preliminary success observed in white communities to obscure rising mortality rates from opioids in black and Latinx communities. To do so, we highlight ways to prevent racist and classist ideologies from further shaping responses towards opioid use. It is important to acknowledge the long history that has influenced responses to opioid use in the USA and take active steps towards promoting a sense of compassion towards all individuals who use and those who are addicted to drugs.

Disparities in United States hospitalizations for serious infections in patients with and without opioid use disorder: A nationwide observational study.

BACKGROUND: Patients with opioid use disorder (OUD) who are hospitalized for serious infections requiring prolonged intravenous antibiotics may face barriers to discharge, which could prolong hospital length of stay (LOS) and increase financial burden. We investigated differences in LOS, discharge disposition, and charges between hospitalizations for serious infections in patients with and without OUD. METHODS AND FINDINGS: We utilized the 2016 National Inpatient Sample-a nationally representative database of all discharges from US acute care hospitals. The population of interest was all hospitalizations for infective endocarditis, epidural abscess, septic arthritis, or osteomyelitis. The exposure was OUD, and the primary outcome was LOS until discharge, assessed by using a competing risks analysis to estimate adjusted hazard ratios (aHRs). Adjusted odds ratio (aOR) of discharge disposition and adjusted differences in hospital charges were also reported. Of 95,470 estimated hospitalizations for serious infections (infective endocarditis, epidural abscess, septic arthritis, and osteomyelitis), the mean age was 49 years and 35% were female. 46% had Medicare (government-based insurance coverage for people age 65+ years), and 70% were non-Hispanic white. After adjustment for potential confounders, OUD was associated with a lower probability of discharge at any given LOS (aHR 0.61; 95% CI 0.59-0.63; p < 0.001). OUD was also associated with lower odds of discharge to home (aOR 0.38; 95% CI 0.33-0.43; p < 0.001) and higher odds of discharge to a post-acute care facility (aOR 1.85; 95% CI 1.57-2.17; p < 0.001) or patient-directed discharge (also referred to as "discharge against medical advice") (aOR 3.47; 95% CI 2.80-4.29; p < 0.001). There was no significant difference in average total hospital charges, though daily hospital charges were significantly lower for patients with OUD. Limitations include the potential for unmeasured confounders and the use of billing codes to identify cohorts. CONCLUSIONS: Our findings suggest that among hospitalizations for some serious infections, those involving patients with OUD were associated with longer LOS, higher odds of discharge to post-acute care facilities or patient-directed discharge, and similar total hospital charges, despite lower daily charges. These findings highlight opportunities to improve care for patients with OUD hospitalized with serious infections, and to reduce the growing associated costs.

Baseline Factors Associated with Mortality in Patients Who Engaged in Buprenorphine Treatment for Opioid Use Disorder: a Cohort Study.

BACKGROUND: Opioid agonist therapy (OAT) has been shown to reduce mortality in patients with opioid use disorder (OUD), yet mortality in individuals receiving OAT remains higher than in an age- and gender-matched population. OBJECTIVE: To identify baseline risk factors in patients who engaged in buprenorphine treatment that are associated with this elevated risk of death. DESIGN: We performed a retrospective cohort study from January 1, 2007, to December 31, 2018, using a centralized clinical data registry within a multi-hospital health system in Boston, MA, USA. PARTICIPANTS: All adult patients who had ≥ 2 consecutive encounters with sublingual buprenorphine on the active medication list from January 1, 2007, to December 31, 2018. MAIN MEASURES: We abstracted several sociodemographic, clinical, and healthcare use characteristics from the clinical data registry. The primary outcome was all-cause mortality and the secondary outcome was opioid overdose-related mortality. We performed multivariable cox regression to identify baseline characteristics independently associated with these outcomes. KEY RESULTS: Of 5948 patients in the cohort, the majority were white (80.7%) and male (59.7%), with a mean age of 38.2 years. The all-cause mortality rate was 24.0 deaths per 1000 person-years. Baseline characteristics independently associated with an increased hazard of all-cause mortality included homelessness (adjusted hazard ratio [aHR] = 1.39; 95% confidence interval [CI] = 1.09, 1.78), an opioid on the active medication list (aHR = 1.28; 95% CI = 1.08, 1.52), and entry into the cohort during an inpatient hospitalization (aHR = 1.43; 95% CI = 1.18, 1.73). Homelessness was also associated with an increased hazard of opioid overdose-related mortality (aHR = 1.77; 95% CI = 1.25, 2.50). CONCLUSIONS: We identified several novel and potentially modifiable predictors of mortality among patients engaging in buprenorphine treatment who remain at an increased risk of death compared with the general population. Understanding these risk factors can assist healthcare providers in risk stratification and inform the design of targeted interventions to improve outcomes in a high-risk patient population.

Smoking status and quit behaviors among health center patients with substance use disorders: A national study.

BACKGROUND: Despite a high prevalence of smoking among individuals with substance use disorders, tobacco dependence in this vulnerable population is undertreated. METHODS: We analyzed data from 5592 adult (≥18 years old) respondents to the 2014 Health Center Patient Survey, a nationally representative cross-sectional survey of individuals who receive care at U.S. Federally Qualified Health Centers. We evaluated self-reported smoking status, smoking-related quit behaviors (having quit, wanting or attempting to quit in the past year, and planning to quit in the next 6 months), and receipt of advice to quit smoking among participants with and without alcohol use disorder (AUD) and drug use disorder (DUD). RESULTS: Current smoking was common among individuals with AUD (64.3%) and DUD (55.0%). Few patients with AUD or DUD had quit smoking (16.7% and 24.0%, respectively). Smokers with AUD had higher odds of wanting to quit smoking in the past year (adjusted odds ratio = 2.88; 95% confidence interval = 1.19, 7.05), but were not more likely to have made a past-year quit attempt. DUD was not significantly associated with smoking-related quit behaviors. Smokers with AUD or DUD, as well as those who engaged in treatment for AUD or DUD, did not differ significantly from other smokers in receipt of advice to quit smoking. CONCLUSIONS: Smokers with AUD and DUD were unlikely to have quit smoking despite interest in quitting. Our findings suggest a need for individualized tobacco treatment approaches in patients with AUD and DUD and missed opportunities to provide tobacco cessation counseling during addiction treatment.