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1.
Anthropol Med ; 28(2): 223-238, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34058932

RESUMO

Opioids, a set of potent pain medications, have numerous known deleterious side effects, ranging from constipation to respiratory depression and death, and yet they are routinely prescribed and administered in biomedical settings. Situated against the backdrop of the US opioid epidemic, this paper examines how the iatrogenic and inadvertent harms and complications caused by opioid administration in clinical settings are experienced by clinicians as forms of moral injury. 'Moral injury' describes a moral agent's experience of perpetrating or being unable to prevent events that are at odds with their moral beliefs and social expectations. This concept powerfully extends Illich's notion of clinical iatrogenesis, which refers to harms experienced by patients; instead, 'moral injury' indexes forms of harm that extend beyond patients to those providing them care. Using an analytic auto-ethnographic approach based on more than a decade of clinical practice in urban hospitals in the Midwestern and Northeastern United States, the authors describe interactions with patients on opioids whose treatment trajectories are fraught with iatrogenic complications, and explore how biomedical institutions and systems further harm vulnerable patients who receive and are addicted to opioids. Though anxious to avoid harming their patients, clinicians are disempowered by hierarchical systems of medical decision-making, which hinder their ability to always act in what they feel are the patient's best interests. This paper highlights the emotional/affective distress and ambivalence experienced by physicians when making decisions about whether to administer or prescribe opioids. Ultimately, the paper demonstrates how iatrogenesis and moral injury are concomitantly produced through cascades of decision-making and local health systems, rather than individual clinical decisions alone.


Assuntos
Analgésicos Opioides , Doença Iatrogênica/etnologia , Epidemia de Opioides , Transtornos Relacionados ao Uso de Opioides/etnologia , Idoso , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Antropologia Médica , Tomada de Decisão Clínica , Humanos , Masculino , Pessoa de Meia-Idade , Relações Médico-Paciente , Estados Unidos/etnologia
2.
Anthropol Med ; 28(2): 239-254, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34190020

RESUMO

This paper explores how poor health outcomes in the HIV/AIDS and opioid epidemics in the United States are undergirded by iatrogenesis. Data are drawn from two projects in Southern California: one among men who have sex with men (MSM) engaging with pre-exposure prophylaxis to HIV (PrEP) and the other in a public hospital system encountering patients with chronic pain and opioid use disorder (OUD). Ethnographic evidence demonstrates how efforts to minimize risk via PrEP and opioid prescription regulation paradoxically generate new forms of risk. Biomedical risk management paradigms engaged across the paper's two ethnographic field sites hinge on the production and governance of deserving patienthood, which is defined by providers and experienced by patients through moral judgments about risk underlying both increased surveillance and abandonment. This paper argues that the logic of deservingness disconnects clinical evaluations of risk from patients' lived, intersectional experiences of race, class, gender, and sexuality. This paper's analysis thus re-locates patients in the context of broader historical and sociopolitical trajectories to highlight how notions of clinical risk designed to protect patients can in fact imperil them. Misalignment between official, clinical constructions of risk and the embodied experience of risk borne by patients produces iatrogenesis.


Assuntos
Atitude do Pessoal de Saúde/etnologia , Infecções por HIV , Doença Iatrogênica/etnologia , Epidemia de Opioides , Transtornos Relacionados ao Uso de Opioides , Antropologia Médica , Fármacos Anti-HIV/uso terapêutico , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/etnologia , Homossexualidade Masculina , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/etnologia , Transtornos Relacionados ao Uso de Opioides/terapia , Profilaxia Pré-Exposição , Gestão de Riscos , Estados Unidos
3.
Med Care ; 59(5): 393-401, 2021 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-33734194

RESUMO

AIM: The aim of this study was to characterize quality of buprenorphine care for opioid use disorder (OUD) by quantifying buprenorphine initiation, engagement, and maintenance for individuals in a large, diverse, real-world cohort in the United States. DESIGN: This was a retrospective cohort analysis. SETTING: OUD treatment in the outpatient setting. PARTICIPANTS: A total of 45,210 commercially insured and Medicare Advantage (MA) enrollees 18 years or older in the OptumLabs Data Warehouse with an index diagnosis of OUD between January 1, 2018 and December 31, 2018. INTERVENTIONS: Treatment with buprenorphine. MEASUREMENTS: We calculated 6 measures of buprenorphine treatment quality. We conducted survival analyses to characterize treatment duration and logistic regressions to evaluate the association between clinical and sociodemographic characteristics and quality. FINDINGS: Of 45,210 eligible individuals with OUD, ∼1 in 10 (n=4600, 10.2%) initiated buprenorphine within 365 days following diagnosis (Measure #1) and 2850 individuals (6.3%) initiated buprenorphine within 14 days of diagnosis (Measure #2). Of individuals initiating treatment within 14 days of diagnosis, 1769 (62.1%) had 2 or more buprenorphine claims within 34 days of initiation (Measure #3). Of the 4600 individuals who received buprenorphine, 2300 (50.0%) were maintained in care with 180 days or more of covered buprenorphine treatment during 365 days after diagnosis (Measure #4). Finally, of the 4600 individuals who received buprenorphine, 2543 (55.3%) did not fill any other concurrent opioid analgesic (Measure #5) and 2951 (64.2%) did not fill any concurrent benzodiazepine (Measure #6). Quality was generally lower for individuals with MA compared with commercial coverage and among Hispanic and Black adults compared with White adults. CONCLUSION: Widespread gaps exist in quality of buprenorphine treatment initiation, engagement, and maintenance among commercially insured and MA enrollees with OUD.


Assuntos
Analgésicos Opioides/uso terapêutico , Buprenorfina/uso terapêutico , Seguro Saúde/estatística & dados numéricos , Medicare Part C/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides , Setor Privado , Qualidade da Assistência à Saúde , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/etnologia , Estudos Retrospectivos , Estados Unidos
4.
Med Anthropol Q ; 35(2): 159-189, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33715229

RESUMO

Opioid abuse is an increasingly global phenomenon. Rather than assuming it to be a uniformly global or neoliberal pathology, how might we better understand comparative and locally specific dimensions of opioid addiction? Working with neighborhoods as a unit of analysis, this article analyzes the striking differences between patterns of addiction and violence in two proximate and seemingly similar urban poor neighborhoods in Delhi, India. Rather than global or national etiologies, I suggest that an attention to sharp ecological variation within epidemics challenges social scientists to offer more fine-grained diagnostics. Using a combination of quantitative and ethnographic methods, I show how heroin addiction and collective violence might be understood as expressions of what Durkheim called "suicido-genetic currents." I suggest the idea of varying currents as an alternative to the sociology of neighborhood "effects" in understanding significant differences in patterns of self-harm and injury across demographically similar localities.


Assuntos
Transtornos Relacionados ao Uso de Opioides , Características de Residência , Violência/etnologia , Adulto , Antropologia Médica , Feminino , Infecções por HIV , Humanos , Índia/etnologia , Masculino , Transtornos Relacionados ao Uso de Opioides/etnologia , Transtornos Relacionados ao Uso de Opioides/mortalidade , População Urbana
5.
Am J Public Health ; 111(5): 896-906, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33734839

RESUMO

Failed by mainstream medical institutions, 1970s revolutionaries of color sought to take health care into their own hands. A lesser-known phenomenon was their use of acupuncture. In 1970, an alliance of Black, Latinx, and White members at Lincoln Detox, a drug treatment program in the South Bronx area of New York City, learned of acupuncture as an alternative to methadone. In Oakland, California, Tolbert Small, MD, used acupuncture for pain management following his exposure to the practice as part of a 1972 Black Panther Party delegation to China. Unaware of one another then, the Lincoln team and Small were similarly driven to "serve the people, body and soul." They enacted "toolkit care,"-self-assembled, essential community care-in response to dire situations such as the intensifying drug crisis. These stories challenge the traditional American history of acupuncture and contribute innovations to and far beyond the addiction field by presenting a holistic model of prevention and care. They advance a nuanced definition of integrative medicine as one that combines medical and social practices, and their legacies are currently carried out by thousands of health care practitioners globally.


Assuntos
Terapia por Acupuntura/métodos , Transtornos Relacionados ao Uso de Opioides/etnologia , Transtornos Relacionados ao Uso de Opioides/terapia , Humanos , Grupos Minoritários , Cidade de Nova Iorque/epidemiologia , Fatores Socioeconômicos
6.
Drug Alcohol Depend ; 221: 108588, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33639569

RESUMO

OBJECTIVE: To characterize racial/ethnic differences in past-year prescription opioid misuse and heroin use. METHODS: Data on 1,117,086 individuals age 12 and older were from the 1999-2018 National Survey on Drug Use and Health. We compared relative prevalences across 6 racial/ethnic groups for prescription opioid misuse analyses and 4 racial/ethnic groups for heroin analyses. Unadjusted and gender- and age-adjusted prevalences are reported for 5 time periods (1999-2002, 2003-2006, 2007-2010, 2011-2014, 2015-2018). Survey-weighted Poisson regression models with robust variance were used to estimate risk ratios by race/ethnicity and to test for time trends. RESULTS: Prescription opioid misuse was significantly higher among non-Hispanic White individuals than among Black, Hispanic, and Asian individuals across all time periods, yet was highest among Native American individuals in every time period. The relative difference between White and both Hispanic and Asian individuals significantly widened over time, whereas the gap between Black and White individuals significantly decreased. Early in the study period, heroin use was highest among Black and Hispanic individuals. Heroin use among White individuals first surpassed all other groups in 2007-2010 and continued to steadily increase, more than doubling from 1999-2002 to 2015-2018. CONCLUSIONS: While heroin use has risen among all racial/ethnic groups, the demographics of heroin use have changed significantly in the past two decades such that prevalence is now highest among White individuals. Opioid prevention and treatment initiatives should both be informed by the changing demographics of heroin use and seek to reduce opioid-related harms and expand treatment access equitably for all racial/ethnic groups.


Assuntos
Heroína , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Adulto , Afro-Americanos/estatística & dados numéricos , Analgésicos Opioides , Criança , Grupos Étnicos/estatística & dados numéricos , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Hispano-Americanos/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/etnologia , Prevalência , Inquéritos e Questionários , Estados Unidos/epidemiologia
7.
Health Serv Res ; 56(2): 310-322, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33395731

RESUMO

OBJECTIVE: To examine individual- and community-level factors associated with racial/ethnic differences in individuals' opioid prescription use. DATA SOURCES: Outpatient opioid prescription utilization and demographic, socioeconomic, and health characteristics from a nationally representative sample of the US noninstitutionalized civilian population obtained from 2013-2016 Medical Expenditure Panel Survey (MEPS) data and combined with 2012-2016 American Community Survey data and 2015 Health Area Resources File data. STUDY DESIGN: We use the Oaxaca-Blinder decomposition method to disaggregate racial/ethnic differences in prescription opioid utilization into differences explained by underlying predisposing, enabling and need characteristics, and unexplained differences. DATA COLLECTION/EXTRACTION METHODS: We use restricted-use geographic identifiers to supplement the MEPS data with information on community characteristics and local health care resources. PRINCIPAL FINDINGS: The average annual rate of any outpatient opioid prescription use was higher for non-Hispanic whites (15.8%; standard errors [SE]: 0.3) than for non-Hispanic blacks and Hispanics by 1.4 percentage points (SE: 0.5) and 6.2 percentage points (SE: 0.4), respectively. The smaller difference between non-Hispanic blacks and whites is not explained by the differences in the risk factors, while almost all the difference between Hispanics and non-Hispanic whites can be explained by the differences in the means of the risk factors. The differences in the prevalence of pain, the rate of being United States-born, and the racial/ethnic composition of the community explain 2.4 (SE: 0.2), 1.4 (SE: 0.3), and 1.9 (SE: 0.4) percentage-point differences, respectively. Pain prevalence explains the difference regardless of opioid potency, while foreign-born status and community racial/ethnic composition explain the difference in higher-potency opioid utilization only. CONCLUSIONS: This study underscores the importance of accounting for both individual and community characteristics when investigating patterns in opioid use. Our results could assist policy makers in tailoring strategies to promote safer and more effective pain management based on individual and community characteristics.


Assuntos
Analgésicos Opioides/administração & dosagem , Transtornos Relacionados ao Uso de Opioides/etnologia , Dor/tratamento farmacológico , Dor/etnologia , Determinantes Sociais da Saúde/etnologia , Adolescente , Adulto , Analgésicos Opioides/uso terapêutico , Grupos de Populações Continentais , Grupos Étnicos , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Características de Residência , Fatores de Risco , Fatores Socioeconômicos , Estados Unidos , Adulto Jovem
8.
JAMA ; 325(2): 146-155, 2021 01 12.
Artigo em Inglês | MEDLINE | ID: mdl-33433576

RESUMO

Importance: Substantial increases in both neonatal abstinence syndrome (NAS) and maternal opioid use disorder have been observed through 2014. Objective: To examine national and state variation in NAS and maternal opioid-related diagnoses (MOD) rates in 2017 and to describe national and state changes since 2010 in the US, which included expanded MOD codes (opioid use disorder plus long-term and unspecified use) implemented in International Classification of Disease, 10th Revision, Clinical Modification. Design, Setting, and Participants: Repeated cross-sectional analysis of the 2010 to 2017 Healthcare Cost and Utilization Project's National Inpatient Sample and State Inpatient Databases, an all-payer compendium of hospital discharge records from community nonrehabilitation hospitals in 47 states and the District of Columbia. Exposures: State and year. Main Outcomes and Measures: NAS rate per 1000 birth hospitalizations and MOD rate per 1000 delivery hospitalizations. Results: In 2017, there were 751 037 birth hospitalizations and 748 239 delivery hospitalizations in the national sample; 5375 newborns had NAS and 6065 women had MOD documented in the discharge record. Mean gestational age was 38.4 weeks and mean maternal age was 28.8 years. From 2010 to 2017, the estimated NAS rate significantly increased by 3.3 per 1000 birth hospitalizations (95% CI, 2.5-4.1), from 4.0 (95% CI, 3.3-4.7) to 7.3 (95% CI, 6.8-7.7). The estimated MOD rate significantly increased by 4.6 per 1000 delivery hospitalizations (95% CI, 3.9-5.4), from 3.5 (95% CI, 3.0-4.1) to 8.2 (95% CI, 7.7-8.7). Larger increases for MOD vs NAS rates occurred with new International Classification of Disease, 10th Revision, Clinical Modification codes in 2016. From a census of 47 state databases in 2017, NAS rates ranged from 1.3 per 1000 birth hospitalizations in Nebraska to 53.5 per 1000 birth hospitalizations in West Virginia, with Maine (31.4), Vermont (29.4), Delaware (24.2), and Kentucky (23.9) also exceeding 20 per 1000 birth hospitalizations, while MOD rates ranged from 1.7 per 1000 delivery hospitalizations in Nebraska to 47.3 per 1000 delivery hospitalizations in Vermont, with West Virginia (40.1), Maine (37.8), Delaware (24.3), and Kentucky (23.4) also exceeding 20 per 1000 delivery hospitalizations. From 2010 to 2017, NAS and MOD rates increased significantly for all states except Nebraska and Vermont, which only had MOD increases. Conclusions and Relevance: In the US from 2010 to 2017, estimated rates of NAS and MOD significantly increased nationally and for the majority of states, with notable state-level variation.


Assuntos
Síndrome de Abstinência Neonatal/epidemiologia , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Complicações na Gravidez/epidemiologia , Adolescente , Adulto , Estudos Transversais , Bases de Dados Factuais , Feminino , Custos de Cuidados de Saúde , Humanos , Recém-Nascido , Tempo de Internação/economia , Tempo de Internação/estatística & dados numéricos , Síndrome de Abstinência Neonatal/economia , Transtornos Relacionados ao Uso de Opioides/etnologia , Gravidez , Complicações na Gravidez/etnologia , Estados Unidos/epidemiologia , Adulto Jovem
9.
Med Anthropol ; 40(3): 228-240, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-32886015

RESUMO

The opioid epidemic in the United States is often portrayed as leading to a "pendulum swing" from indiscriminate prescribing toward appropriate use. This portrayal imagines rational-ethical physicians trying to resist irrational-manipulative patients and pharmaceutical companies. Drawing on an ethnography of pain management in U.S. hospital and clinic settings, I suggest instead that chronic pain generates a constantly renewed "emergency affect," a mutual experience for providers and patients that polarizes decisions toward either medication escalation or patient abandonment. Understanding this "emergency affect" can help provide a path forward through the opioid epidemic to embrace the discomfort of pain management.


Assuntos
Analgésicos Opioides , Dor Crônica/tratamento farmacológico , Manejo da Dor/métodos , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Antropologia Médica , Humanos , Narração , Transtornos Relacionados ao Uso de Opioides/etnologia , Manejo da Dor/psicologia , Médicos/psicologia , Padrões de Prática Médica , Estados Unidos
10.
Can Fam Physician ; 66(12): 907-912, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33334959

RESUMO

OBJECTIVE: To assess for long-term positive effects of buprenorphine treatment (BT) on opioid use disorder (OUD) at a Nishnawbe Aski Nation high school clinic. DESIGN: Postgraduation telephone survey of high school students between March 2017 and January 2018. SETTING: Dennis Franklin Cromarty High School in Thunder Bay, Ont. PARTICIPANTS: All 44 students who had received BT in the high school clinic during its operation from 2011 to 2013 were eligible to participate. MAIN OUTCOME MEASURES: Current substance use, BT status, and social and employment status. RESULTS: Thirty-eight of the 44 students who had received BT in the high school clinic were located and approached; 32 consented to participate in the survey. A descriptive analysis of the surveyed indicators was undertaken. Almost two-thirds (n = 20, 62.5%) of the cohort had graduated from high school, more than one-third (n = 12, 37.5%) were employed full time, and most (n = 29, 90.6%) rated their health as "good" or "OK." A greater percentage of participants who continued taking BT after high school (n = 19, 61.3%) were employed full time (n = 8, 42.1% vs n = 4, 33.3%) and were abstinent from alcohol (n = 12, 63.2% vs n = 4, 33.3%). Participants still taking BT were significantly more likely to have obtained addiction counseling in the past year than those participants not in treatment (n = 9, 47.4% vs n = 1, 8.3%; P = .0464). CONCLUSION: The study results suggest that offering OUD treatment to youth in the form of BT in a high school clinic might be an effective strategy for promoting positive long-term health and social outcomes. Clinical treatment guidelines currently recommend long-term opioid agonist treatment as the treatment of choice for OUD in the general population; they should consider adding youth to the population that might also benefit.


Assuntos
Buprenorfina/uso terapêutico , Canadenses Indígenas/psicologia , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Estudantes/psicologia , Adolescente , Criança , Aconselhamento , Feminino , Humanos , Masculino , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/etnologia , Avaliação de Programas e Projetos de Saúde , Instituições Acadêmicas , Resultado do Tratamento
11.
Spine (Phila Pa 1976) ; 45(15): 1062-1066, 2020 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-32675613

RESUMO

STUDY DESIGN: Retrospective cross-sectional study. OBJECTIVES: The aim of this study was to examine whether there are racial and ethnic disparities in opioid use for back pain treatment. In addition, we examine whether physical therapy reduces opioid use. SUMMARY OF BACKGROUND DATA: Back pain is a common health problem that affects most adults in their lifetime. Opioid and physical therapy are commonly used to treat back pain. While evidence indicates that there are substantial disparities in the receipt of opioids by race and ethnicity in opioid use in the United States, it remains unclear whether these disparities in opioid use exist in the treatment of back pain. METHODS: Cross-sectional analysis of the 2010-2012 Medical Expenditures Panel Survey and logistic regression of a sample of about 4000 adults with back pain. RESULTS: Logistic regression models showed statistically significant differences in opioids receipt by race among adult patients with back pain. Compared to White patients, Asian and Hispanic patients are less likely to be prescribed opioids. On the other hand, Black patients and patients of other race are more likely to receive an opioid prescription to treat their back pain even after accounting for socioeconomic status, health insurance status, and general health status. Additionally, patients who receive physical therapy treatment are less likely to be prescribed opioids. CONCLUSION: These findings suggest that there are racial disparities in the use of opioids and physical therapy may reduce opioid prescription use to treat back pain. These disparities may be contributing to disparities in back pain recovery and long-term health disparities in general. LEVEL OF EVIDENCE: 2.


Assuntos
Analgésicos Opioides/uso terapêutico , Dor nas Costas/tratamento farmacológico , Dor nas Costas/etnologia , Grupos de Populações Continentais/etnologia , Grupos Étnicos , Disparidades em Assistência à Saúde/etnologia , Adulto , Analgésicos Opioides/efeitos adversos , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Transtornos Relacionados ao Uso de Opioides/etnologia , Manejo da Dor/métodos , Estudos Retrospectivos , Classe Social , Estados Unidos/etnologia
12.
J Ment Health Policy Econ ; 23(1): 19-25, 2020 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-32458814

RESUMO

BACKGROUND: Research has documented a low rate of opioid use disorder (OUD) treatment utilization among individuals involved in the criminal justice system. However, racial disparities in sources of payment for OUD treatment have not been examined in the existing literature. AIM OF THE STUDY: Although substance use disorder (SUD) treatment is relatively rare for all criminal justice system involved racial-groups, previous research has indicated that, among individuals with SUD, members of racial minority groups receive treatment at lower rates than their non-Hispanic White counterparts. Given the alarming rise of OUD in the US and the association between source of payment and utilization of health care services, this study seeks to quantify racial disparities in sources of payment for OUD treatment among individuals with criminal justice involvement. METHOD: Using data from the 2008-2016 National Survey of Drug Use and Health (NSDUH), this study analyzes data on non-incarcerated individuals with OUD who have had any criminal justice involvement in the previous 12 months. An extension of the Blinder-Oaxaca decomposition method for non-linear models is implemented to determine the extent that differences in OUD treatment utilization across non-Hispanic Blacks and non-Hispanic Whites are explained by observed and measurable characteristics and/or unobserved factors. RESULTS: Results indicate that non-Hispanic Whites are more likely to have their OUD treatment paid by a court (10%) relative to non-Hispanic Blacks (4.0%). Black-White differences in measurable factors explain 87% of the disparity, while the rest is attributed to unobserved factors. Non-Hispanic Blacks are more likely to have their OUD treatment paid by public insurance (77% vs 36%) than non-Hispanic Whites and only 72% of this disparity can be explained by observed characteristics. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Our findings indicate racial disparities in sources of payment for OUD treatment among the criminal justice-involved population. Expansion of health insurance coverage and access to substance use disorder treatments would be beneficial for reducing health care disparities. IMPLICATIONS FOR HEALTH POLICY: Equitable treatment options in the criminal justice system that incentivize OUD treatment availability may help address racial disparities in sources of payment among the criminal justice-involved population with OUD. IMPLICATIONS FOR FURTHER RESEARCH: Future research should focus on understanding the main factors driving the court's treatment decisions among the criminal justice system involved individuals.


Assuntos
Crime/estatística & dados numéricos , Disparidades em Assistência à Saúde/etnologia , Serviços de Saúde Mental/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/reabilitação , Adulto , Afro-Americanos/estatística & dados numéricos , Grupos de Populações Continentais , Crime/etnologia , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Pesquisas sobre Serviços de Saúde , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde/estatística & dados numéricos , Hispano-Americanos/estatística & dados numéricos , Humanos , Masculino , Transtornos Relacionados ao Uso de Opioides/etnologia , Fatores Socioeconômicos , Estados Unidos/epidemiologia , Adulto Jovem
13.
JAMA Netw Open ; 3(4): e203711, 2020 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-32320038

RESUMO

Importance: Treatment with methadone or buprenorphine is the current standard of care for opioid use disorder. Given the paucity of research identifying which patients will respond best to which medication, both medications should be accessible to all patients so that patients can determine which works best for them. However, given differences in the historical contexts of their initial implementation, access to each of these medications may vary along racial/ethnic lines. Objective: To examine the extent to which capacity to provide methadone and buprenorphine vary with measures of racial/ethnic segregation. Design, Setting, and Participants: This cross-sectional study included all counties and county-equivalent divisions in the US in 2016. Data on racial/ethnic population distribution were derived from the American Community Survey, and data on locations of facilities providing methadone and buprenorphine were obtained from Substance Abuse and Mental Health Services Administration databases. Data were analyzed from August 22, 2018, to September 11, 2019. Exposures: Two county-level measures of racial/ethnic segregation, including dissimilarity (representing the proportion of African American or Hispanic/Latino residents who would need to move census tracts to achieve a uniform spatial distribution of the population by race/ethnicity) and interaction (representing the probability that an African American or Hispanic/Latino resident will interact with a white resident and vice versa, assuming random mixing across census tracts). Main Outcomes and Measures: County-level capacity to provide methadone or buprenorphine, defined as the number of facilities providing a medication per 100 000 population. Results: Among 3142 US counties, there were 1698 facilities providing methadone (0.6 facilities per 100 000 population) and 18 868 facilities providing buprenorphine (5.9 facilities per 100 000 population). Each 1% decrease in probability of interaction of an African American resident with a white resident was associated with 0.6 more facilities providing methadone per 100 000 population. Similarly, each 1% decrease in probability of interaction of a Hispanic/Latino resident with a white resident was associated with 0.3 more facilities providing methadone per 100 000 population. Each 1% decrease in the probability of interaction of a white resident with an African American resident was associated with 8.17 more facilities providing buprenorphine per 100 000 population. Similarly, each 1% decrease in the probability of interaction of a white resident with a Hispanic/Latino resident was associated with 1.61 more facilities providing buprenorphine per 100 000 population. Conclusions and Relevance: These findings suggest that the racial/ethnic composition of a community was associated with which medications residents would likely be able to access when seeking treatment for opioid use disorder. Reforms to existing regulations governing the provisions of these medications are needed to ensure that both medications are equally accessible to all.


Assuntos
Buprenorfina/uso terapêutico , Metadona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Segregação Social , Adulto , Estudos Transversais , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Masculino , Transtornos Relacionados ao Uso de Opioides/etnologia , Fatores Raciais , Análise Espacial , Inquéritos e Questionários , Estados Unidos/epidemiologia
14.
Drug Alcohol Depend ; 209: 107952, 2020 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-32172130

RESUMO

BACKGROUND: Mental health diagnoses (MHD) are common among those with opioid use disorders (OUD). Methadone/buprenorphine are effective medication-assisted treatment (MAT) strategies; however, treatment receipt is low among those with dual MHDs. Medicaid expansions have broadly increased access to OUD and mental health services over time, but MAT uptake may vary depending on multiple factors, including MHD status, state Medicaid expansion decisions, and race/ethnicity and gender. Examining clinical and policy approaches to promoting MAT uptake may improve services among marginalized groups. METHODS: MAT treatment discharges were identified using the Treatment Episodes Dataset-Discharges (TEDS-D; 2014-2017) (n = 1,400,808). We used multivariate logistic regression to model MAT receipt using interactions and adjusted for several potential confounders. RESULTS: Nearly one-third of OUD treatment discharges received MAT. Dual MHDs in both expansion and non-expansion states were positively associated with MAT uptake over time. Dual MHDs were negatively associated with MAT receipt only among American Indian/Alaska Native women residing in Medicaid expansion states (aOR = 0.58, 95 % CI = 0.52-0.66, p < 0.0001). CONCLUSION: Disparities in MAT utilization are nuanced and vary widely depending on dual MHD status, Medicaid expansion, and race/ethnicity/gender. Medicaid is beneficial but not a universal treatment panacea. Clinical decisions to initiate MAT are dependent on multiple factors and should be tailored to meet the needs of high-risk, historically disadvantaged clients.


Assuntos
Medicaid/tendências , Transtornos Mentais/tratamento farmacológico , Transtornos Mentais/etnologia , Tratamento de Substituição de Opiáceos/tendências , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/etnologia , Adolescente , Adulto , Analgésicos Opioides/uso terapêutico , Buprenorfina/uso terapêutico , Grupos de Populações Continentais , Diagnóstico Duplo (Psiquiatria)/tendências , Grupos Étnicos , Feminino , Previsões , Humanos , Masculino , Transtornos Mentais/diagnóstico , Metadona/uso terapêutico , Pessoa de Meia-Idade , Tratamento de Substituição de Opiáceos/métodos , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Fatores Sexuais , Estados Unidos/epidemiologia , Adulto Jovem
15.
J Psychoactive Drugs ; 52(2): 186-194, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32005084

RESUMO

Medication-assisted therapy (MAT) for opioid use disorders is an effective treatment strategy. Racial/ethnic and gender disparities in MAT utilization have been documented, but less is known about disparities in MAT outcomes. We used the Treatment Episodes Dataset-Discharges (TEDS-D; 2015- 2017) to identify outpatient treatment episodes with heroin or illicit opioids indicated at admission (n = 232,547). We used multivariate logistic regression to model the association between MAT and a reduction in opioid use between treatment admission and discharge. We explored moderation by race/ethnicity and gender by including an interaction term. We identified a strong moderating effect of race/ethnicity and gender. American Indian/Alaska Native (AI/AN) women demonstrated the strongest association between MAT (versus no MAT) and a reduction in opioid use (aOR = 6.05, 95% CI = 4.81- 7.61), while White men demonstrated the weakest association (aOR = 2.78, CI = 2.70- 2.87). Our findings could inform changes in clinical MAT settings that are based on harm reduction and the incremental transition from illicit opioids to medication-assistance among a diverse opioid use disorder population.


Assuntos
Tratamento de Substituição de Opiáceos/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/etnologia , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Pacientes Ambulatoriais/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Adolescente , Adulto , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores Sexuais , Estados Unidos/etnologia , Adulto Jovem
16.
BMC Psychiatry ; 20(1): 41, 2020 01 31.
Artigo em Inglês | MEDLINE | ID: mdl-32005204

RESUMO

BACKGROUND: Genome Wide Association Studies (GWAS) have been conducted to identify genes and pathways involved in development of opioid use disorder. This study extends the first GWAS of substance use disorder (SUD) patients from the United Arab Emirates (UAE) by stratifying the study group based on opioid use, which is the most common substance of use in this cohort. METHODS: The GWAS cohort consisted of 512 (262 case, 250 controls) male participants from the UAE. The samples were genotyped using the Illumina Omni5 Exome system. Data was stratified according to opioid use using PLINK. Haplotype analysis was conducted using Haploview 4.2. RESULTS: Two main associations were identified in this study. Firstly, two SNPs on chromosome 7 were associated with opioid use disorder, rs118129027 (p-value = 1.23 × 10 - 8) and rs74477937 (p-value = 1.48 × 10 - 8). This has been reported in Alblooshi et al. (Am J Med Genet B Neuropsychiatr Genet 180(1):68-79, 2019). Secondly, haplotypes on chromosome 2 which mapped to the KIAA1211L locus were identified in association with opioid use. Five SNPs in high linkage disequilibrium (LD) (rs2280142, rs6542837, rs12712037, rs10175560, rs11900524) were arranged into haplotypes. Two haplotypes GAGCG and AGTTA were associated with opioid use disorders (p-value 3.26 × 10- 8 and 7.16 × 10- 7, respectively). CONCLUSION: This is the first GWAS to identify candidate genes associated with opioid use disorder in participants from the UAE. The lack of other genetic data of Arabian descent opioid use patients has hindered replication of the findings. Nevertheless, the outcomes implicate new pathways in opioid use disorder that requires further research to assess the role of the identified genes in the development of opioid use disorder.


Assuntos
Estudo de Associação Genômica Ampla , Proteínas dos Microfilamentos/genética , Transtornos Relacionados ao Uso de Opioides , Cromossomos Humanos Par 2 , Predisposição Genética para Doença/genética , Genótipo , Haplótipos , Humanos , Masculino , Transtornos Relacionados ao Uso de Opioides/etnologia , Transtornos Relacionados ao Uso de Opioides/genética , Polimorfismo de Nucleotídeo Único/genética , Emirados Árabes Unidos
17.
Drug Alcohol Depend ; 206: 107736, 2020 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-31765857

RESUMO

BACKGROUND: American Indian (AI) youth have disproportionately high rates of both heroin and other opioid misuse and recently have seen a large increase in negative outcomes due to opioid misuse. To address the dearth of research on within-group risk factors for heroin and other opioid misuse in AI adolescents, the goal of the present study is to explore the influence of peer, family, and school factors on opioid use among AI youth. METHODS: Participants (n = 3498, 49.5 % female, Mage = 14.8) were drawn from a large school-based sample of AI youth living on or near reservations, across six geographic regions, between 2009 and 2013. Participants completed a self-report questionnaire regarding substance use and related factors. Multilevel logistic regression was utilized to examine the role of peer, family, and school-related factors on past-month and lifetime heroin and other opioid misuse. RESULTS: Greater peer substance use (OR = 1.14, p<0.001), lower family disapproval of use (OR = .98, p = 0.01), and lower school performance (OR = .90, p = 0.01) were associated with greater likelihood of lifetime opioid misuse. Greater peer substance use (OR = 1.05, p<0.001) and lower family disapproval of use (OR = .99, p = 0.04) were associated with greater likelihood of past month opioid misuse. Greater peer substance use was the only variable significantly related to greater likelihood of lifetime (OR = 1.15, p<0.001) or past month heroin use (OR = 1.02, p = 0.047). CONCLUSIONS: Findings highlight the need for interventions and offer potential factors to consider in developing interventions for heroin and/or other opioid misuse among AI adolescents.


Assuntos
Comportamento do Adolescente/etnologia , Comportamento do Adolescente/psicologia , Índios Norte-Americanos/etnologia , Índios Norte-Americanos/psicologia , Transtornos Relacionados ao Uso de Opioides/etnologia , Transtornos Relacionados ao Uso de Opioides/psicologia , Adolescente , Analgésicos Opioides/efeitos adversos , Criança , Feminino , Humanos , Masculino , Transtornos Relacionados ao Uso de Opioides/terapia , Grupo Associado , Fatores de Proteção , Fatores de Risco , Autorrelato , Inquéritos e Questionários , Adulto Jovem
18.
Hisp Health Care Int ; 18(1): 40-43, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31747797

RESUMO

Opioid addiction is a public health concern. Opioid overdose death rates account for one third to a half of all global substance-related deaths. Opioid mortality rates increased nearly fivefold in the United States between 1999 and 2016. Recent research has found health care disparities in the United States among minority populations with opioid use disorder, particularly Hispanics. Current literature also suggests that a number of social and cultural factors, including the stigma linked to mental illness and treatment in the Hispanic culture, may further negatively contribute to the problem. This brief report pays close attention to the opioid epidemic in the United States and addresses issues related to the crisis among Hispanics. Recommendations for clinical practice, research, and health care policy are also discussed.


Assuntos
Analgésicos Opioides , Comportamento Aditivo/etnologia , Hispano-Americanos/psicologia , Epidemia de Opioides , Transtornos Relacionados ao Uso de Opioides/etnologia , Disparidades em Assistência à Saúde , Humanos , Saúde Mental , Grupos Minoritários , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/etnologia , Estados Unidos/epidemiologia
19.
Drug Alcohol Depend ; 205: 107664, 2019 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-31707272

RESUMO

BACKGROUND: Research on adolescent heroin use has focused on national surveillance, access, prevalence of use, and overdose deaths, however, to our knowledge, no study has examined local-level differences in the prevalence of adolescent heroin use in the context of nonmedical prescription opioid (NMPO) use. This study characterizes heroin and NMPO use among US high school students in select urban areas by sex and race/ethnicity. METHODS: Data are from 21 urban school districts that participate in CDC's Local Youth Risk Behavior Surveillance System. We describe 2017 prevalence estimates (and 95 % confidence intervals) of lifetime heroin and NMPO use among youth stratified by sex and race/ethnicity (i.e., White, Black, Hispanic/Latino). RESULTS: The highest estimates of heroin use were in Baltimore, MD (7.6 %), Shelby County, TN (6.3 %), and Duval County, FL (6.1 %), whereas NMPO use was highest in Duval County, FL (18.1 %), Cleveland, OH (18.0 %), and Shelby County, TN (16.8 %). Heroin use was higher among boys than girls, especially among Hispanic/Latino boys in Duval County (12.3 %) and Black boys in Baltimore (10.9 %). NMPO use was highest among Hispanic/Latino girls (21.3 %) and White girls (19.9 %) in Duval County. DISCUSSION: While some cities and subpopulations with high levels of adolescent heroin use also had elevated levels of NMPO use, others did not, illustrating the complexities of this opioid epidemic.


Assuntos
Heroína , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Vigilância da População , Estudantes/estatística & dados numéricos , População Urbana/estatística & dados numéricos , Adolescente , Afro-Americanos/estatística & dados numéricos , Baltimore/epidemiologia , Grupos Étnicos/estatística & dados numéricos , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Hispano-Americanos/estatística & dados numéricos , Humanos , Masculino , Transtornos Relacionados ao Uso de Opioides/etnologia , Prevalência , Assunção de Riscos , Instituições Acadêmicas/estatística & dados numéricos , Tennessee/epidemiologia
20.
Drug Alcohol Depend ; 204: 107547, 2019 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-31536877

RESUMO

BACKGROUND: Death from fentanyl-related overdose is now a leading cause of mortality among US adults. We sought to characterize fentanyl preference among street-based people who use drugs (PWUD). METHODS: Cross-sectional surveys were administered to PWUD (N = 308) who illicitly used heroin or prescription opioids in the prior six months. Recruitment occurred in 2017 in three US east coast cities with high overdose mortality: Baltimore, Boston, and Providence. Our main outcome was preference for fentanyl (yes/no); exposures included sociodemographics, drug use, and overdose history. Pearson's χ2, Shapiro-Wilk-Mann rank-sum tests, and tiered log-binomial regression determined sociodemographic and exposure-related factors associated with fentanyl preference. RESULTS: Preference for nonmedical use of fentanyl was reported by 27% (n = 83) of the sample. Fentanyl preference was associated with non-Hispanic white race (adjusted risk ratio (ARR) = 1.68, 95% confidence interval (CI):1.18-2.40), daily illicit drug use (aRR = 2.2, CI:1.71-2.87), and overdose ≥1 year ago (aRR = 1.33, CI:1.18-1.50). Age (in decades; aRR = 0.77, CI:0.61-0.98) and overdose <1 year ago (aRR = 0.92, CI:0.87-0.97) were associated with a decreased likelihood of preference. In our model excluding sociodemographics, initiating opioid use with non-prescribed opioids was associated with fentanyl preference (aRR = 1.48, CI:1.26-1.73). CONCLUSION: In three cities with high levels of opioid use and overdose, a quarter of street based PWUD reported preferring fentanyl. An opioid use age cohort effect and disproportionate access to prescription opioids by race could be contributing to preference. Frequency of opioid use, not route of administration, was associated with preference. Our data demonstrate the need to consider preferences for fentanyl when targeting services and interventions for PWUD.


Assuntos
Usuários de Drogas/psicologia , Fentanila/análise , Drogas Ilícitas/análise , Transtornos Relacionados ao Uso de Opioides/psicologia , Preferência do Paciente/psicologia , Adolescente , Adulto , Baltimore , Boston , Estudos Transversais , Overdose de Drogas/etnologia , Overdose de Drogas/mortalidade , Grupo com Ancestrais do Continente Europeu/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/etnologia , Transtornos Relacionados ao Uso de Opioides/mortalidade , Preferência do Paciente/etnologia , Prescrições/estatística & dados numéricos , Rhode Island , Inquéritos e Questionários , Adulto Jovem
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