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Access to new syringes can reduce the risk of HIV and hepatitis C transmission, skin and soft tissue infections, and infectious endocarditis for people who inject drugs (PWID). Syringe service programs (SSPs) and other harm reduction programs are a good source of syringes. However, they are sometimes not accessible due to limited hours, geographic barriers, and other factors. In this perspective, we argue that when PWID faces barriers to syringes physicians and other providers should prescribe, and pharmacists should dispense, syringes to decrease health risks associated with syringe re-use. This strategy is endorsed by professional organizations and is legally permissible in most states. Such prescribing has numerous benefits, including insurance coverage of the cost of syringes and the sense of legitimacy conveyed by a prescription. We discuss these benefits as well as the legality of prescribing and dispensing syringes and address practical considerations such as type of syringe, quantity, and relevant diagnostic codes, if required. In the face of an unprecedented overdose crisis with many associated health harms, we also make the case for advocacy to change state and federal laws to make access to prescribed syringes uniform, smooth, and universal as part of a suite of harm reduction efforts.
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Overdose de Drogas , Usuários de Drogas , Infecções por HIV , Abuso de Substâncias por Via Intravenosa , Humanos , Abuso de Substâncias por Via Intravenosa/complicações , Abuso de Substâncias por Via Intravenosa/epidemiologia , Redução do Dano , Overdose de Drogas/epidemiologia , Overdose de Drogas/prevenção & controle , Atenção Primária à Saúde , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controleRESUMO
BACKGROUND: Bias pervades every aspect of healthcare including admissions, perpetuating the lack of diversity in the healthcare workforce. Admissions interviews may be a time when applicants to health profession education programs experience discrimination. METHODS: Between January and June 2021 we invited US and Canadian applicants to health profession education programs to complete a survey including the Everyday Discrimination Scale, adapted to ascertain experiences of discrimination during admissions interviews. We used chi-square tests and multivariable logistic regression to determine associations between identity factors and positive responses. RESULTS: Of 1115 respondents, 281 (25.2%) reported discrimination in the interview process. Individuals with lower socioeconomic status (OR: 1.78, 95% CI [1.26, 2.52], p = 0.001) and non-native English speakers (OR: 1.76, 95% CI [1.08, 2.87], p = 0.02) were significantly more likely to experience discrimination. Half of those experiencing discrimination (139, or 49.6%) did nothing in response, though 44 (15.7%) reported the incident anonymously and 10 (3.6%) reported directly to the institution where it happened. CONCLUSIONS: Reports of discrimination are common among HPE applicants. Reforms at the interviewer- (e.g. avoiding questions about family planning) and institution-level (e.g. presenting institutional efforts to promote health equity) are needed to decrease the incidence and mitigate the impact of such events.
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Promoção da Saúde , Internato e Residência , Humanos , Canadá , Escolas para Profissionais de Saúde , Ocupações em SaúdeRESUMO
PURPOSE: Existing frameworks to address instances of microaggressions and discrimination in the clinical environment have largely been developed for faculty and resident physicians, creating a lack of resources for medical students. METHODS: We implemented a workshop to prepare pre-clinical medical/dental students to recognize and respond to microaggressions. Participants in three cohorts from 2018 to 2020 completed pre- and post-workshop surveys assessing the prevalence of exposure to clinical microaggressions and the workshop's effect on mitigating commonly perceived barriers to addressing microaggressions. RESULTS: Of 461 first-year medical and dental students who participated, 321 (69.6%) provided survey responses. Over 80% of students reported experiencing microaggressions, with women and URM students over-represented. After the workshop, participants reported significant reductions in barriers to addressing microaggressions and discrimination, including recognizing incidents, uncertainty of what to say or do, lack of allies, lack of familiarity with institutional policies, and uncertainty of clinical relevance. The workshop was similarly effective in-person and virtual formats. CONCLUSIONS: Most medical/dental student respondents reported experiencing microaggressions in the clinical setting, particularly female and URM students. Our workshop mitigated most perceived challenges to responding to microaggressions. Future interventions across institutions should continue to equip students with the tools they need to address and respond to microaggressions.
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Educação Médica , Estudantes de Medicina , Feminino , Humanos , Microagressão , Inquéritos e QuestionáriosRESUMO
OBJECTIVES: This study explores knowledge and utilization of, barriers to, and preferences for harm reduction services among street-involved young adults (YA) in Boston, Massachusetts. METHODS: This cross-sectional survey of YA encountered between November and December 2019 by a longstanding outreach program for street-involved YA. We report descriptive statistics on participant-reported substance use, knowledge and utilization of harm reduction strategies, barriers to harm reduction services and treatment, and preferences for harm reduction service delivery. RESULTS: The 52 YA surveyed were on average 21.4 years old; 63.5% were male, and 44.2% were Black. Participants reported high past-week marijuana (80.8%) and alcohol (51.9%) use, and 15.4% endorsed opioid use and using needles to inject drugs in the past six months. Fifteen (28.8%) YA had heard of "harm reduction", and 17.3% reported participating in harm reduction services. The most common barriers to substance use disorder treatment were waitlists and cost. Participants suggested that harm reduction programs offer peer support (59.6%) and provide a variety of services including pre-exposure prophylaxis (42.3%) and sexually transmitted infection testing (61.5%) at flexible times and in different languages, including Spanish (61.5%) and Portuguese (17.3%). CONCLUSIONS: There is need for comprehensive, YA-oriented harm reduction outreach geared toward marginalized YA and developed with YA input to reduce barriers, address gaps in awareness and knowledge of harm reduction, and make programs more relevant and inviting to YA.
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Transtornos Relacionados ao Uso de Opioides , Abuso de Substâncias por Via Intravenosa , Adulto , Boston , Estudos Transversais , Feminino , Redução do Dano , Humanos , Masculino , Massachusetts , Adulto JovemRESUMO
BACKGROUND: Recent evidence suggests that the practice of combining opioid use with non-opioid substances is common, though little is known about this phenomenon and how best to address it. Methods: We recruited adults in Boston, Massachusetts, with recent opioid use. We conducted semi-structured interviews to explore the practice of combining non-opioid substances with opioids and analyzed transcripts to identify themes. Results: Twenty-nine individuals completed interviews. Combining other substances with opioids was a well-known practice: "that's what we call the cocktail." Participants reported the use of clonidine, gabapentin, benzodiazepines, promethazine, amphetamine salts, quetiapine, barbiturates, cough and cold medications, as well as alcohol and candy in combination with opioids. Participants reported purchasing these substances on the street, stealing them, or getting them from a prescriber. Augmenting the opioid high was a common reason for combining substances. Importantly, participants also reported combining substances to treat psychiatric symptoms. Individuals commonly reported learning about combining substances "from people on the street" but also reported learning from the internet and television. Perceived benefits outweighed safety concerns. Participants also felt that using over-the-counter or prescription medications would be safe. Conclusions: Combining a variety of substances with opioids is common and driven by diverse motives. Clinicians caring for opioid-involved patients should consider screening for concurrent use of other substances and discussing the risks of this practice.
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Transtornos Relacionados ao Uso de Opioides , Medicamentos sob Prescrição , Adulto , Bebidas Alcoólicas , Analgésicos Opioides/efeitos adversos , Benzodiazepinas , Humanos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológicoAssuntos
Betacoronavirus , Infecções por Coronavirus , Abastecimento de Alimentos/economia , Equidade em Saúde , Política de Saúde , Pandemias , Pneumonia Viral , COVID-19 , Abastecimento de Alimentos/legislação & jurisprudência , Humanos , Seguro/legislação & jurisprudência , SARS-CoV-2 , Desemprego , Estados UnidosAssuntos
Participação da Comunidade/estatística & dados numéricos , Equidade em Saúde/estatística & dados numéricos , Grupos Raciais/estatística & dados numéricos , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Pesquisa Participativa Baseada na Comunidade , Política de Saúde , Humanos , Determinantes Sociais da Saúde , Transtornos Relacionados ao Uso de Substâncias/prevenção & controle , Estados UnidosRESUMO
A lattice model for continuum percolation by cylindrical rods is generalized to account for inhomogeneities in the volume fraction that are indicative of particle clustering or aggregation. The percolation threshold is evaluated from a formalism that uses two different categories of occupied sites (denoting particles) with different occupation probabilities that represent large and small local volume fractions. Our modeling framework enables independent variations in (i) the strength of the correlation that adjacent particles experience high (or low) effective volume fractions, (ii) the disparity between the macroscopically averaged volume fraction and (say) the volume fraction characterizing the regions with high effective particle concentrations, and (iii) the overall proportion of particles that are located in regions with either high or low volume fraction. Calculations performed for monodisperse cylinders show that enhancement in each of the above factors leads to reduction in the macroscopically averaged volume fraction at the percolation threshold.
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OBJECTIVES: To examine whether traffic-light labeling and choice architecture interventions improved dietary choices among students at a northeastern US university. METHODS: In 6 cafeterias at Harvard University, in Cambridge, Massachusetts, we implemented a 7-week intervention including traffic-light labeling (red: least nutrient rich; yellow: nutrient neutral; green: most nutrient rich), choice architecture (how choices are presented to consumers), and "healthy-plate" tray stickers. During the 2014-2015 academic year, 2 cafeterias received all interventions, 2 received choice architecture only, and 2 were controls. We analyzed sales for 6 weeks before and 7 weeks during interventions. Using interrupted time-series analyses, we measured changes in red, yellow, and green items served. We collected 1329 surveys to capture perceptions of labeling. RESULTS: Among 2.6 million portions served throughout the study, we found no significant changes in red (-0.8% change/week; P = .2) or green (+1.1% change/week; P = .4) items served at intervention sites compared with controls. In surveys, 58% of students reported using traffic-light labels at least a few times per week, and 73% wanted them to continue. CONCLUSIONS: Although many students reported using traffic-light labels regularly and wanted interventions to continue, cafeteria interventions did not demonstrate clear improvements in dietary quality.
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Comportamento de Escolha , Dieta , Rotulagem de Alimentos/estatística & dados numéricos , Serviços de Alimentação/estatística & dados numéricos , Feminino , Preferências Alimentares/psicologia , Comportamentos Relacionados com a Saúde , Humanos , Masculino , Massachusetts , Inquéritos e Questionários , Universidades , Adulto JovemRESUMO
OBJECTIVE: To determine the relationship between household chaos and substance use, sexual activity, and violence-related risk behaviors in adolescents. STUDY DESIGN: We analyzed cross-sectional data among 929 high-school students in Los Angeles who completed a 90-minute interview that assessed health behaviors and household chaos with the 14-question Chaos, Hubbub, and Order Scale (CHAOS). Using the generalized estimating equation and adjusting for personal, parental, and family covariates, we examined associations of CHAOS score with substance use, sexual activity, and violent behavior outcome variables. We also examined the role of depression and school engagement as mediators. RESULTS: Mean (SD) age of the 929 students was 16.4 (1.3) years, 516 (55%) were female, and 780 (84%) were Latino. After adjustment, compared with students with CHAOS score 0, those students with the greatest scores (5-14) had ORs of 3.1 (95% CI 1.1-8.7) for smoking, 2.6 (95% CI 1.6-4.4) for drinking, 6.1 (95% CI 1.8-21) for substance use at school, and 1.9 (95% CI 1.1-3.3) for fighting in the past 12 months. Associations between CHAOS score and sexual risk and other violent behaviors were not significant. Depression and school engagement attenuated the associations. CONCLUSIONS: In this group of adolescents, greatest CHAOS score was associated with increased odds of risky health behaviors, with depression and school engagement as potential mediators. In the future, CHAOS score could be measured to assess risk for such behaviors or be a target for intervention to reduce chances of engaging in these behaviors.
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Comportamento do Adolescente/psicologia , Comportamentos Relacionados com a Saúde , Assunção de Riscos , Estudantes/psicologia , Adolescente , Estudos Transversais , Feminino , Humanos , Los Angeles , Masculino , Fatores de Risco , Instituições AcadêmicasRESUMO
A model is developed for percolation in polydisperse systems of oriented cylinders that integrates excluded volume arguments with an analogy to site percolation on a modified Bethe lattice. Results from this treatment are presented for the volume fraction at the percolation threshold (denoted Ïc) as a function of the degree of polydispersity, mixture composition, and degree of orientational ordering. For monodisperse systems, Ïc is found to be a monotonically increasing function of the traditional orientational order parameter that quantifies degree of alignment. The presence of a fraction of isotropically oriented rods of small aspect ratio is shown to lower the percolation threshold for systems in which the longer rods are strongly aligned.
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The percolation threshold for polydisperse systems of (i) isotropically oriented, and (ii) perfectly aligned, circular disks is calculated within an analogy to a lattice model. Our results are expressed in terms of moments of the distribution function over the disk radii, and they closely resemble findings obtained from an integral equation approach. The threshold is found to be quite sensitive to polydispersity in the disk radii and, for monodisperse systems, to approach a plateau for large values of the aspect ratio (thickness to diameter ratio). A similar plateau is found for disks with perfectly nematic orientational order, for which the percolation threshold always exceeds that for identical systems of disks that are oriented isotropically.
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The adolescent and young adult (AYA) population has experienced an increase in both emergency room visits and deaths related to substance use. However, AYA are less likely to engage in existing addiction treatment infrastructure. A youth-specific mobile harm reduction program has the potential to reduce substance-related morbidity and mortality including infections, overdose, and death. Launched in 2019, the Community Care in Reach AYA pilot program seeks to address the difference in patterns of substance use between AYA and adults. The results of this evaluation suggest the importance of a youth-oriented program in increasing AYA engagement with harm reduction.
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Redução do Dano , Transtornos Relacionados ao Uso de Substâncias , Humanos , Adolescente , Adulto Jovem , Transtornos Relacionados ao Uso de Substâncias/prevenção & controle , Masculino , Feminino , Projetos Piloto , Adulto , Avaliação de Programas e Projetos de Saúde , TelemedicinaRESUMO
Opioid overdose deaths continue to increase in the US. Recent data show disproportionately high and increasing overdose death rates among Black, Latine, and Indigenous individuals, and people experiencing homelessness. Medications for opioid use disorder (MOUD) can be lifesaving; however, only a fraction of eligible individuals receive them. Our goal was to describe our experience promoting equitable MOUD access using a mobile delivery model. We implemented a mobile MOUD unit aiming to improve equitable access in Brockton, a racially diverse, medium-sized city in Massachusetts. Brockton has a relatively high opioid overdose death rate with increasingly disproportionate death rates among Black residents. Brockton Neighborhood Health Center (BNHC), a community health center, provides brick-and-mortar MOUD access. Through the Communities That HEAL intervention as part of the HEALing Communities Study (HCS), Brockton convened a community coalition with the aim of selecting evidence-based practices to decrease overdose deaths. BNHC leadership and coalition members recognized that traditional brick-and-mortar treatment locations were inaccessible to marginalized populations, and that a mobile program could increase MOUD access. In September 2021, with support from the HCS coalition, BNHC launched its mobile initiative - Community Care-in-Reach® - to bring low-threshold buprenorphine, harm reduction, and preventive care to high-risk populations. During implementation, the team encountered several challenges including: securing local buy-in; navigating a complex licensure process; maintaining operations throughout the COVID-19 pandemic; and finally, planning for sustainability. In two years of operation, the mobile team cared for 297 unique patients during 1,286 total visits. More than one-third (36%) of patients received buprenorphine prescriptions. In contrast to BNHC's brick-and-mortar clinics, patients with OUD seen on the mobile unit were more representative of historically marginalized racial and ethnic groups, and people experiencing homelessness, evidencing improved, equitable addiction care access for these historically disadvantaged populations. Offering varied services on the mobile unit, such as wound care, syringe and safer smoking supplies, naloxone, and other basic medical care, was a key engagement strategy. This on-demand mobile model helped redress systemic disadvantages in access to addiction treatment and harm reduction services, reaching diverse individuals to offer lifesaving MOUD at a time of inequitable increases in overdose deaths.
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Redução do Dano , Unidades Móveis de Saúde , Transtornos Relacionados ao Uso de Opioides , Humanos , Massachusetts , COVID-19 , Feminino , Masculino , Adulto , Acessibilidade aos Serviços de Saúde , Buprenorfina/uso terapêutico , Overdose de Opiáceos , Centros Comunitários de Saúde , Overdose de Drogas/prevenção & controle , Overdose de Drogas/mortalidadeRESUMO
The number of people experiencing homelessness in tent encampments in the US has increased significantly. Citing concerns over health and safety, many cities have pursued highly visible encampment removals. In January 2022, a major tent encampment in Boston, Massachusetts, was cleared using a unique approach: Most encampment residents were placed in transitional harm reduction housing. We conducted interviews between July 2022 and February 2023 with thirty former encampment residents to explore how the encampment clearing affected their health and sense of safety. We also explored participants' perspectives on harm reduction housing. Of those interviewed, fourteen people had been placed in such housing. Among those not placed, the encampment clearing tended to exacerbate health and safety concerns, especially those related to mental health conditions and risk for violence. Among people successfully placed, harm reduction housing improved health and safety and allowed participants to make meaningful progress toward long-term goals such as addiction recovery, management of chronic health conditions, and permanent housing. Our findings suggest that encampments can have safety-promoting characteristics, but if encampment removal is pursued, offering harm reduction housing after removal can be beneficial.
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Comportamento Aditivo , Pessoas Mal Alojadas , Transtornos Mentais , Humanos , Habitação , CidadesRESUMO
Importance: Transitions in insurance coverage may be associated with worse health care outcomes. Little is known about insurance stability for individuals with opioid use disorder (OUD). Objective: To examine insurance transitions among adults with newly diagnosed OUD in the 12 months after diagnosis. Design, Setting, and Participants: Longitudinal cohort study using data from the Massachusetts Public Health Data Warehouse. The cohort includes adults aged 18 to 63 years diagnosed with incident OUD between July 1, 2014, and December 31, 2014, who were enrolled in commercial insurance or Medicaid at diagnosis; individuals diagnosed after 2014 were excluded from the main analyses due to changes in the reporting of insurance claims. Data were analyzed from November 10, 2022, to May 6, 2024. Exposure: Insurance type at time of diagnosis (commercial and Medicaid). Main Outcomes and Measures: The primary outcome was the cumulative incidence of insurance transitions in the 12 months after diagnosis. Logistic regression models were used to generate estimated probabilities of insurance transitions by insurance type and diagnosis for several characteristics including age, race and ethnicity, and whether an individual started medication for OUD (MOUD) within 30 days after diagnosis. Results: There were 20â¯768 individuals with newly diagnosed OUD between July 1, 2014, and December 31, 2014. Most individuals with newly diagnosed OUD were covered by Medicaid (75.4%). Those with newly diagnosed OUD were primarily male (67% in commercial insurance, 61.8% in Medicaid). In the 12 months following OUD diagnosis, 30.4% of individuals experienced an insurance transition, with adjusted models demonstrating higher transition rates among those starting with Medicaid (31.3%; 95% CI, 30.5%-32.0%) compared with commercial insurance (27.9%; 95% CI, 26.6%-29.1%). The probability of insurance transitions was generally higher for younger individuals than older individuals irrespective of insurance type, although there were notable differences by race and ethnicity. Conclusions and Relevance: This study found that nearly 1 in 3 individuals experience insurance transitions in the 12 months after OUD diagnosis. Insurance transitions may represent an important yet underrecognized factor in OUD treatment outcomes.
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Cobertura do Seguro , Seguro Saúde , Medicaid , Transtornos Relacionados ao Uso de Opioides , Humanos , Adulto , Masculino , Feminino , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Pessoa de Meia-Idade , Cobertura do Seguro/estatística & dados numéricos , Estudos Longitudinais , Estados Unidos/epidemiologia , Adolescente , Massachusetts/epidemiologia , Medicaid/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Adulto JovemRESUMO
BACKGROUND: Medications for Opioid Use Disorder (MOUD) are lifesaving, but <20 % of individuals in the US who could benefit receive them. As part of the NIH-supported HEALing Communities Study (HCS), coalitions in several communities in Massachusetts and Ohio implemented mobile MOUD programs to overcome barriers to MOUD receipt. We defined mobile MOUD programs as units that provide same-day access to MOUD at remote sites. We aimed to (1) document the design and organizational structure of mobile programs providing same-day or next-day MOUD, and (2) explore the barriers and facilitators to implementation as well as the successes and challenges of ongoing operation. METHODS: Program staff from five programs in two states (n = 11) participated in semi-structured interviews. Two authors conducted thematic analysis of the transcripts based on the domains of the social-ecological model and the semi-structured interview guide. RESULTS: Mobile MOUD units sought to improve immediate access to MOUD ("Our answer is pretty much always, 'Yes, we'll get you started right here, right now,'"), advance equity ("making sure that we have staff who speak other languages, who are on the unit and have some resources that are in different languages,"), and decrease opioid overdose deaths. Salient program characteristics included diverse staff, including staff with lived experience of substance use ("She just had that personal knowledge of where we should be going"). Mobile units offered harm reduction services, broad medical services (in particular, wound care), and connection to transportation programs and incorporated consistency in service provision and telemedicine access. Implementation facilitators included trusting relationships with partner organizations (particularly pharmacies and correctional facilities), nuanced understanding of local politics, advertising, protocol flexibility, and on-unit prescriber hours. Barriers included unclear licensing requirements, staffing shortages and competing priorities for staff, funding challenges due to inconsistency in grant funding and low reimbursement ("It's not really possible that billing in and of itself is going to be able to sustain it"), and community stigma toward addiction services generally. CONCLUSIONS: Despite organizational, community, and policy barriers, participants described mobile MOUD units as an innovative way to expand access to life-saving medications, promote equity in MOUD treatment, and overcome stigma.