Expanding access to nurse-managed medication for opioid use disorder.

BACKGROUND: Advanced practice registered nurses (APRNs) are increasingly caring for individuals with opioid use disorder. Advances have been made to increase APRN education, outreach, and prescribing privileges, but as demand for medication for opioid use disorder (MOUD) grows, evidence suggests that policy and care barriers inhibit the ability of APRNs to support MOUD. PURPOSE: This paper highlights the significant challenges of expanding access to buprenorphine prescribing by APRNs. FINDINGS: Barriers and recommendations were derived from the culmination of literature review, expert consensus discussions among a diverse stakeholder panel including patient representatives, and feedback from community webinars with care providers. DISCUSSION: We provide an overview of existing care barriers, promising practices, and proposed recommendations to enhance the care of individuals and communities with opioid use disorder.

Homeless women's service use, barriers, and motivation for participating in substance use treatment.

BACKGROUND: Homeless women are at high risk for substance use disorder (SUD), and are a growing proportion of the homeless population. However, homeless women experience barriers to engaging in substance use services. OBJECTIVES: Among homeless women with SUD, to explore service use, motivation to change, service barriers, and willingness to have substance use and mental health problems addressed in primary health care. METHODS: Women with SUD were sampled from 11 Health Care for the Homeless (HCH) primary care clinics in 9 states, yielding 241 with either an alcohol or drug use disorder who then completed questions about SUD services. RESULTS: Over 60% of women with dual alcohol and drug use disorders used some type of SUD service in the past year, while 52% with a drug only disorder, and 44% with an alcohol only disorder used services. The most mentioned barrier to service use was depression, but cost, wait time, where to find treatment, and facilities located too far away, were also frequently noted. A large proportion across all groups indicated high motivation for treatment and willingness to discuss their SUD in a primary care setting. CONCLUSION: There are continued barriers to SUD service use for homeless women despite high motivation for treatment, and willingness to be asked about SUD and mental health problems in primary care. HCH primary care sites should more systematically ask about SUD and mental health issues and address women's expressed need for support groups and alternative therapies to more holistically address their SUD needs.

Prevalence and predictors of substance use disorders among homeless women seeking primary care: An 11 site survey.

BACKGROUND AND OBJECTIVES: Homeless women have shown high rates of substance use disorders (SUD), but many studies are more than a decade old, limited in geographic location, or focus only on women living outdoors or in shelters. The purpose of this study was to obtain a more current and representative sample of homeless women and the prevalence and predictors of substance use disorders among women seeking primary care at Health Care for the Homeless clinics across the US. METHODS: Eleven Health Care for the Homeless (HCH) clinics in nine states contributed proportionally to a sample of n = 780 female patients who completed a self-administered survey including demographics, housing history, health, mental health, and drug and alcohol use. RESULTS: Compared to the general population of women, rates were four times higher for an alcohol use disorder, and 12 times higher for a drug use disorder. DISCUSSION AND CONCLUSIONS: The findings indicate a significant need for SUD services, with an equally high need for mental health services. In addition, high rates of victimization and use of tobacco, and overall poor health status, indicate overall health disparities. SCIENTIFIC SIGNIFICANCE: Addressing barriers to full integration of substance use and mental health services, such as improving screening, reimbursement, clinician training, and addressing biases about motivation of this population to engage in treatment, are necessary to improve the health of women seeking care in HCH settings. (Am J Addict 2017;26:680-688).

Civil Legal Services and Medical-Legal Partnerships Needed by the Homeless Population: A National Survey.

OBJECTIVES: To examine civil legal needs among people experiencing homelessness and the extent to which medical-legal partnerships exist in homeless service sites, which promote the integration of civil legal aid professionals into health care settings. METHODS: We surveyed a national sample of 48 homeless service sites across 26 states in November 2015. The survey asked about needs, attitudes, and practices related to civil legal issues, including medical-legal partnerships. RESULTS: More than 90% of the homeless service sites reported that their patients experienced at least 1 civil legal issue, particularly around housing, employment, health insurance, and disability benefits. However, only half of all sites reported screening patients for civil legal issues, and only 10% had a medical-legal partnership. The large majority of sites reported interest in receiving training on screening for civil legal issues and developing medical-legal partnerships. CONCLUSIONS: There is great need and potential to deploy civil legal services in health settings to serve unstably housed populations. Training homeless service providers how to screen for civil legal issues and how to develop medical-legal partnerships would better equip them to provide comprehensive care.

Preliminary efficacy of group medical nutrition therapy and motivational interviewing among obese African American women with type 2 diabetes: a pilot study.

OBJECTIVE: To assess the efficacy and acceptability of a group medical nutritional therapy (MNT) intervention, using motivational interviewing (MI). RESEARCH DESIGN & METHOD: African American (AA) women with type 2 diabetes (T2D) participated in five, certified diabetes educator/dietitian-facilitated intervention sessions targeting carbohydrate, fat, and fruit/vegetable intake and management. Motivation-based activities centered on exploration of dietary ambivalence and the relationships between diet and personal strengths. Repeated pre- and post-intervention, psychosocial, dietary self-care, and clinical outcomes were collected and analyzed using generalized least squares regression. An acceptability assessment was administered after intervention. RESULTS: Participants (n = 24) were mostly of middle age (mean age 50.8 ± 6.3) with an average BMI of 39 ± 6.5. Compared to a gradual pre-intervention loss of HbA1c control and confidence in choosing restaurant foods, a significant post-intervention improvement in HbA1c (P = 0.03) and a near significant (P = 0.06) increase in confidence in choosing restaurant foods were observed with both returning to pre-intervention levels. 100% reported that they would recommend the study to other AA women with type 2 diabetes. CONCLUSION: The results support the potential efficacy of a group MNT/MI intervention in improving glycemic control and dietary self-care-related confidence in overweight/obese AA women with type 2 diabetes.

Exploring the experiences of violence among individuals who are homeless using a consumer-led approach.

Homelessness increases vulnerability to violence victimization; however, the precise factors associated with victimization and injury are not clearly understood. Thus, this study explores the prevalence of and characteristics associated with violence victimization among homeless individuals by surveying approximately 500 individuals experiencing homelessness in 5 cities across the United States. Our findings reveal that nearly one-half of our sample reported experiencing violence and that prolonged duration of homelessness (greater than 2 years) and being older increased the risk of experiencing a violent attack. In addition, increased length of homelessness and female gender predicted experiencing rape. Women were also significantly more likely to know one's perpetrator and experience continued suffering after a violent attack. We conclude that certain subpopulations within the homeless population are at an increased risk for victimization and, subsequently, require added protective services; implications for health care and policy recommendations are also discussed.

Identifying US veterans who access services from health care for the homeless clinics.

Research on veterans experiencing homelessness is predominantly focused on the US Department of Veterans Affairs setting, despite the fact that substantial numbers receive services from Health Care for the Homeless (HCH) clinics. We explored how HCH clinics identified veteran patients through a survey of administrators (49% response rate). The majority (98%) identified veterans but used varied language and approaches. Implementing a streamlined, culturally competent identification process is vital to collecting accurate data, connecting veterans with benefits, and informing treatment plans.

Health status and health care experiences among homeless patients in federally supported health centers: findings from the 2009 patient survey.

OBJECTIVE: To examine health status and health care experiences of homeless patients in health centers and to compare them with their nonhomeless counterparts. DATA SOURCES/STUDY SETTING: Nationally representative data from the 2009 Health Center Patient Survey. STUDY DESIGN: Cross-sectional analyses were limited to adults (n = 2,683). We compared sociodemographic characteristics, health conditions, access to health care, and utilization of services among homeless and nonhomeless patients. We also examined the independent effect of homelessness on health care access and utilization, as well as factors that influenced homeless patients' health care experiences. DATA COLLECTION: Computer-assisted personal interviews were conducted with health center patients. PRINCIPAL FINDINGS: Homeless patients had worse health status-lifetime burden of chronic conditions, mental health problems, and substance use problems-compared with housed respondents. In adjusted analyses, homeless patients had twice the odds as housed patients of having unmet medical care needs in the past year (OR = 1.98, 95 percent CI: 1.24-3.16) and twice the odds of having an ED visit in the past year (OR = 2.00, 95 percent CI: 1.37-2.92). CONCLUSIONS: There is an ongoing need to focus on the health issues that disproportionately affect homeless populations. Among health center patients, homelessness is an independent risk factor for unmet medical needs and ED use.

Noninvasive bioluminescence imaging of normal and spontaneously transformed prostate tissue in mice.

Several transgenic mouse models of prostate cancer have been developed recently that are able to recapitulate many key biological features of the human condition. It would, therefore, be desirable to employ these models to test the efficacy of new therapeutics before clinical trial; however, the variable onset and non-visible nature of prostate tumor development limit their use for such applications. We now report the generation of a transgenic reporter mouse that should obviate these limitations by enabling noninvasive in vivo bioluminescence imaging of normal and spontaneously transformed prostate tissue in the mouse. We used an 11-kb fragment of the human prostate-specific antigen (PSA) promoter to achieve specific and robust expression of firefly luciferase in the prostate glands of transgenic mice. Ex vivo bioluminescence imaging and in situ hybridization analysis confirmed that luciferase expression was restricted to the epithelium in all four lobes of the prostate. We also show that PSA-Luc mice exhibit decreased but readily detectable levels of in vivo bioluminescence over extended time periods following androgen ablation. These results suggest that this reporter should enable in vivo imaging of both androgen-dependent and androgen-independent prostate tumor models. As proof-of-principle, we show that we could noninvasively image SV40 T antigen-induced prostate tumorigenesis in mice with PSA-Luc. Furthermore, we show that our noninvasive imaging strategy can be successfully used to image tumor response to androgen ablation in transgenic mice and, as a result, that we can rapidly identify individual animals capable of sustaining tumor growth in the absence of androgen.

Bioluminescent human breast cancer cell lines that permit rapid and sensitive in vivo detection of mammary tumors and multiple metastases in immune deficient mice.

INTRODUCTION: Our goal was to generate xenograft mouse models of human breast cancer based on luciferase-expressing MDA-MB-231 tumor cells that would provide rapid mammary tumor growth; produce metastasis to clinically relevant tissues such as lymph nodes, lung, and bone; and permit sensitive in vivo detection of both primary and secondary tumor sites by bioluminescent imaging. METHOD: Two clonal cell sublines of human MDA-MB-231 cells that stably expressed firefly luciferase were isolated following transfection of the parental cells with luciferase cDNA. Each subline was passaged once or twice in vivo to enhance primary tumor growth and to increase metastasis. The resulting luciferase-expressing D3H1 and D3H2LN cells were analyzed for long-term bioluminescent stability, primary tumor growth, and distal metastasis to lymph nodes, lungs, bone and soft tissues by bioluminescent imaging. Cells were injected into the mammary fat pad of nude and nude-beige mice or were delivered systemically via intracardiac injection. Metastasis was also evaluated by ex vivo imaging and histologic analysis postmortem. RESULTS: The D3H1 and D3H2LN cell lines exhibited long-term stable luciferase expression for up to 4-6 months of accumulative tumor growth time in vivo. Bioluminescent imaging quantified primary mammary fat pad tumor development and detected early spontaneous lymph node metastasis in vivo. Increased frequency of spontaneous lymph node metastasis was observed with D3H2LN tumors as compared with D3H1 tumors. With postmortem ex vivo imaging, we detected additional lung micrometastasis in mice with D3H2LN mammary tumors. Subsequent histologic evaluation of tissue sections from lymph nodes and lung lobes confirmed spontaneous tumor metastasis at these sites. Following intracardiac injection of the MDA-MB-231-luc tumor cells, early metastasis to skeletal tissues, lymph nodes, brain and various visceral organs was detected. Weekly in vivo imaging data permitted longitudinal analysis of metastasis at multiple sites simultaneously. Ex vivo imaging data from sampled tissues verified both skeletal and multiple soft tissue tumor metastasis. CONCLUSION: This study characterized two new bioluminescent MDA-MB-231-luc human breast carcinoma cell lines with enhanced tumor growth and widespread metastasis in mice. Their application to current xenograft models of breast cancer offers rapid and highly sensitive detection options for preclinical assessment of anticancer therapies in vivo.

Imaging of bioluminescent LNCaP-luc-M6 tumors: a new animal model for the study of metastatic human prostate cancer.

BACKGROUND: Animal experiments examining hormone-sensitive metastatic prostate cancer using the human LNCaP cell line have been limited to endpoint analyses. To permit longitudinal studies, we generated a luciferase-expressing cell line and used bioluminescent imaging (BLI) to non-invasively monitor the in vivo growth of primary LNCaP tumors and metastasis. METHODS: LNCaP.FGC cells were transfected to constitutively express firefly luciferase. LNCaP-luc-M6 cells were tested for bioluminescent signal intensity and hormone responsiveness in vitro. The cells were implanted in subcutaneous and orthotopic sites in SCID-bg mice and imaged over time. RESULTS: The LNCaP-luc-M6 cells formed subcutaneous and orthotopic tumors in SCID-bg mice, and nearly all tumor-bearing animals developed pulmonary metastases. Early detection and temporal growth of primary tumors and metastatic lesions was successfully monitored by BLI. CONCLUSIONS: The LNCaP-luc-M6 cell line is a bioluminescent, hormone-sensitive prostate cancer cell line applicable for BLI studies to non-invasively monitor subcutaneous and orthotopic prostate tumor growth and metastasis in vivo.

Bioluminescent imaging (BLI) to improve and refine traditional murine models of tumor growth and metastasis.

Bioluminescent imaging (BLI) permits sensitive in vivo detection and quantification of cells specifically engineered to emit visible light. Three stable human tumor cell lines engineered to express luciferase were assessed for their tumorigenicity in subcutaneous, intravenous and spontaneous metastasis models. Bioluminescent PC-3M-luc-C6 human prostate cancer cells were implanted subcutaneously into SCID-beige mice and were monitored for tumor growth and response to 5-FU and mitomycin C treatments. Progressive tumor development and inhibition/regression following drug treatment were observed and quantified in vivo using BLI. Imaging data correlated to standard external caliper measurements of tumor volume, but bioluminescent data permitted earlier detection of tumor growth. In a lung colonization model, bioluminescent A549-luc-C8 human lung cancer cells were injected intravenously and lung metastases were monitored in vivo by whole animal imaging. Anesthetized mice were imaged weekly allowing a temporal assessment of in vivo lung tumor growth. This longitudinal study design permitted an accurate, real-time evaluation of tumor burden in the same animals over time. End-point bioluminescence measured in vivo correlated to total lung weight at necropsy. For a spontaneous metastatic tumor model, bioluminescent HT-29-luc-D6 human colon cancer cells implanted subcutaneously produced metastases to lung and lymph nodes in SCID-beige mice. Both primary tumors and micrometastases were detected by BLI in vivo. Ex vivo imaging of excised lung lobes and lymph nodes confirmed the in vivo signals and indicated a slightly higher frequency of metastasis in some mice. Levels of bioluminescence from in vivo and ex vivo images corresponded to the frequency and size of metastatic lesions in lungs and lymph nodes as subsequently confirmed by histology. In summary, BLI provided rapid, non-invasive monitoring of tumor growth and regression in animals. Its application to traditional oncology animal models offers quantitative and sensitive analysis of tumor growth and metastasis. The ability to temporally assess tumor development and responses to drug therapies in vivo also improves upon current standard animal models that are based on single end point data.

In vivo monitoring of tumor relapse and metastasis using bioluminescent PC-3M-luc-C6 cells in murine models of human prostate cancer.

We used the bioluminescent human prostate carcinoma cell line PC-3M-luc-C6 to non-invasively monitor in vivo growth and response of tumors and metastasis before, during and after treatments. Our goal was to determine the utility of a luciferase-based prostate cancer animal model to specifically assess tumor and metastatic recurrence in vivo following chemotherapy. Bioluminescent PC-3M-luc-C6 cells, constitutively expressing luciferase, were implanted into the prostate or under the skin of mice for primary tumor assessment. Cells were also injected into the left ventricle of the heart as an experimental metastasis model. Weekly serial in vivo images were taken of anesthetized mice that were untreated or treated with 5-fluorouracil or mitomycin C. Ex vivo imaging and/or histology was used to confirm and localize metastatic lesions in various tissues initially detected by images in vivo. Our in vivo data detected and quantified early inhibition of subcutaneous and orthotopic prostate tumors in mice as well as significant tumor regrowth post-treatment. Local and distal metastasis was observed within seven days following intracardiac injection of PC-3M-luc-C6 cells. Differential drug responses and metastatic tumor relapse patterns were distinguished over time by in vivo imaging depending on the metastatic site. The longitudinal evaluation of bioluminescent tumor and metastatic development within the same cohorts of animals permitted sensitive and quantitative assessment of both primary and metastatic prostate tumor response and recurrence in vivo.