Improving DEIB in Addiction Medicine Training Through Interdisciplinary Collaboration and Program Evaluation.

Developing a diverse Addiction Medicine (AM) workforce will improve medical and public health responses to the increasing health risks created by substance use disorders (SUDs). A workforce that embraces diversity, equity, inclusion, and belonging (DEIB) principles may foster novel responses to address the disparities in treatment and outcomes experienced by Black, Indigenous, and People of Color (BIPOC) who are impacted by SUDs. However, experiences of bias and discrimination in the workplace and a lack of exposure to addiction-related content in educational settings limit opportunities to develop and retain a diverse workforce. In this commentary, we describe the creation of the Inclusion, Diversity, and Equity in Addiction medicine, Addiction research, and Addiction health professions (IDEAAA) initiative, a strategy to foster diversity in the field of addiction through efforts targeting learners at different stages of the biomedical education pipeline. Now in its second year, the IDEAAA Program is focused on programmatic evaluation through a qualitative interview study of AM training programs to improve the understanding of experiences of participants who are self-identified members of underrepresented groups (URGs). Interdisciplinary programs with multi-faceted approaches are a strategy to improve DEIB in the AM workforce; IDEAAA's design and methods can inform other AM programs who have the desire to improve DEIB through novel approaches.

The mediating effect of health literacy on COVID-19 vaccine confidence among a diverse sample of urban adults in Boston and Chicago.

BACKGROUND: A high rate of COVID-19 vaccination is critical to reduce morbidity and mortality related to infection and to control the COVID-19 pandemic. Understanding the factors that influence vaccine confidence can inform policies and programs aimed at vaccine promotion. We examined the impact of health literacy on COVID-19 vaccine confidence among a diverse sample of adults living in two major metropolitan areas. METHODS: Questionnaire data from adults participating in an observational study conducted in Boston and Chicago from September 2018 through March 2021 were examined using path analyses to determine whether health literacy mediates the relationship between demographic variables and vaccine confidence, as measured by an adapted Vaccine Confidence Index (aVCI). RESULTS: Participants (N = 273) were on average 49 years old, 63 % female, 4 % non-Hispanic Asian, 25 % Hispanic, 30 % non-Hispanic white, and 40 % non-Hispanic Black. Using non-Hispanic white and other race as the reference category, Black race and Hispanic ethnicity were associated with lower aVCI (-0.76, 95 % CI -1.00 to -0.50; -0.52, 95 % CI -0.80 to -0.27, total effects from a model excluding other covariates). Lower education was also associated with lower aVCI (using college or more as the reference, -0.73 for 12th grade or less, 95 % CI -0.93 to -0.47; -0.73 for some college/associate's/technical degree, 95 % CI -1.05 to -0.39). Health literacy partially mediated these effects for Black and Hispanic participants and those with lower education (indirect effects -0.19 and -0.19 for Black race and Hispanic ethnicity; 0.27 for 12th grade or less; -0.15 for some college/associate's/technical degree). CONCLUSIONS: Lower levels of education, Black race, and Hispanic ethnicity were associated with lower scores on health literacy, which in turn were associated with lower vaccine confidence. Our findings suggest that efforts to improve health literacy may improve vaccine confidence, which in turn may improve vaccination rates and vaccine equity. CLINICAL TRIALS NUMBER: NCT03584490.

The risks of opioid treatment: Perspectives of primary care practitioners and patients from safety-net clinics.

BACKGROUND: Patients with a history of substance use are more likely than those without substance use to experience chronic noncancer pain (CNCP), to be prescribed opioids, and to experience opioid misuse or overdose. Primary care practitioners (PCPs) in safety-net settings care for low-income patients with CNCP and substance use, usually without specialist consultation. To inform communication related to opioid risk, we explored PCPs' and patients' perceptions of the risks of chronic opioid therapy. METHODS: We conducted semistructured interviews with 23 PCPs and 46 of their patients, who had a history of CNCP and substance use. We recruited from 6 safety-net health care settings in the San Francisco Bay Area. We transcribed interviews verbatim and analyzed transcripts using grounded theory methodology. RESULTS: (1) PCPs feared harming patients and the community by opioid prescribing. PCPs emphasized fear of opioid overdose. (2) Patients did not highlight concerns about the adverse health consequences of opioids, except for addiction. (3) Both patients and PCPs were concerned about PCPs' medicolegal risks related to opioid prescribing. (4) Patients reported feeling stigmatized by policies aimed at reducing opioid misuse. CONCLUSION: We identified differences in how clinicians and patients perceive opioid risk. To improve the informed consent process for opioid therapy, patients and PCPs need to have a shared understanding of the risks of opioids and engage in discussions that promote patient autonomy and safety. As clinics implement opioid prescribing policies, clinicians must develop effective communication strategies in order to educate patients about opioid risks and decrease patients' experiences of stigma and discrimination.

Factors associated with substance use in older homeless adults: Results from the HOPE HOME study.

BACKGROUND: The median age of the single adult homeless population is 50 and rising. Although the prevalence of substance use decreases as individuals age, older adults now have a higher prevalence of substance use than older adults did 10 years ago. Homeless individuals have a higher prevalence of substance use disorders than the general population. However, little is known about substance use in older homeless adults. METHODS: The objective of the study was to examine prevalence of and factors associated with substance use in a population-based sample (N = 350) of homeless individuals aged 50 and older in Oakland, California. Dependent variables included moderate or greater severity illicit drug symptoms (Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) score >3) and moderate or greater alcohol symptoms (Alcohol Use Disorders Identification Test (AUDIT) score >7). Independent variables included demographics, mental health problems, and negative life course events such as physical and sexual abuse, school expulsion, and onset of homelessness. RESULTS: Almost two thirds of participants, 64.6%, had moderate or greater severity symptoms for at least 1 illicit drug; 25.8% had moderate or greater severity alcohol symptoms. History of psychiatric hospitalization was associated with moderate or greater illicit drug symptoms (adjusted odds ratio [AOR] = 1.9, 1.0-3.6). The presence of major depressive symptoms was associated with moderate or greater severity alcohol symptoms (AOR = 1.8, 1.1-3.0). CONCLUSIONS: In this sample of older homeless adults, substance use is common. There is a need for substance use treatment programs, integrated with mental health services, which are targeted towards the needs of older homeless adults.

Management of obesity: a challenge for medical training and practice.

Health-care providers are in a unique position to encourage people to make healthy lifestyle choices. However, lifestyle modification counseling is a complex task, made even more so by the cultural and socioeconomic diversity of patient populations. The objective of this study is to evaluate the prevalence and predictors of attending and physician-in-training weight control counseling in an urban academic internal medicine clinic serving a unique low-income multiethnic high-risk population. In 2006, patients (n = 256) from the Associates in Internal Medicine clinic (Division of General Medicine at the New York Presbyterian Hospital, Columbia University Medical Center, New York, NY) were recruited and completed a questionnaire, which assessed demographic variables, health conditions, access to health-care services, physician weight control counseling, and weight loss attempts. Seventy-nine percent of subjects were either overweight or obese. Only 65% of obese subjects were advised to lose weight. Attending physicians were more likely than physicians-in-training to counsel subjects on weight control (P < 0.01). Factors that were significantly (P < 0.05) associated with different types of weight control counseling included obesity, cardiovascular disease (CVD) risk factors, female gender, nonblack race, college education, married status, and attending physician. Subjects advised to lose weight were more likely to report an attempt to lose weight (P < 0.01). Rates of weight control counseling among physicians are suboptimal, particularly among physicians-in-training. Training programs need to promote effective clinical obesity prevention and treatment strategies that address socioeconomic, linguistic, and cultural factors.