Interest in Electronic Cigarettes for Smoking Cessation Among Adults With Opioid Use Disorder in Buprenorphine Treatment: A Mixed-Methods Investigation.

INTRODUCTION: Individuals in treatment for opioid use disorder (OUD) have high smoking rates and limited success with Food and Drug Administration (FDA)-approved cessation aids, suggesting need for novel approaches. Electronic cigarettes (e-cigarettes) might benefit this population, but e-cigarettes' acceptability for tobacco reduction or cessation among smokers in OUD treatment is not known. METHODS: A cross-sectional mixed-methods study of 222 adults in OUD treatment with buprenorphine in the Boston, Massachusetts metropolitan area was conducted in 2020. We used quantitative and qualitative data to investigate individuals' experience with and interest in e-cigarettes and other methods for smoking cessation and assessed factors associated with interest in e-cigarette use. RESULTS: One hundred sixty (72%) of the 222 participants were past 30-day cigarette smokers. They most frequently reported having ever used nicotine replacement therapy (NRT; 83%) and e-cigarettes (71%) for smoking cessation and most often indicated interest in using NRT (71%) and e-cigarettes (44%) for future smoking cessation. In multiple logistic regression analysis, interest in using e-cigarettes for future smoking cessation was independently associated with having ever used e-cigarettes for smoking cessation, current e-cigarette use, and perceiving e-cigarettes to be less harmful than cigarettes (ps < .05). In qualitative data, many current vapers/former smokers reported that e-cigarettes had been helpful for quitting cigarettes. For current smokers who currently or formerly vaped, frequently reported challenges in switching to e-cigarettes were concerns about replacing one addiction with another and e-cigarettes not adequately substituting for cigarettes. CONCLUSIONS: E-cigarettes had a moderate level of acceptability for smoking cessation among cigarette smokers in OUD treatment. More research is warranted to test the efficacy of this approach. IMPLICATIONS: Individuals in treatment for opioid use disorder (OUD) have high smoking rates and limited success with existing smoking cessation tools, suggesting a need for novel cessation treatment approaches. In this mixed-methods study of individuals receiving medication treatment for OUD with buprenorphine in Massachusetts in 2020, we found a moderate level of acceptability of e-cigarettes for smoking cessation.

Prevalence of Cannabis Use and Cannabis Route of Administration among Massachusetts Adults in Buprenorphine Treatment for Opioid Use Disorder.

BACKGROUND: Recent prevalence estimates of cannabis use among individuals receiving medication treatment for OUD (MOUD) are lacking, and no study has characterized cannabis route of administration (cROA) in this population. These knowledge gaps are relevant because cannabis' effects and health outcomes vary by cROA and the availability and perceptions of cROA (e.g., vaping devices) are changing. METHODS: The Vaping In Buprenorphine-treated patients Evaluation (VIBE) cross-sectional survey assessed the prevalence and correlates of cannabis use and cROA among adults receiving buprenorphine MOUD from 02/20 to 07/20 at five community health centers in Massachusetts, a state with legal recreational and medical cannabis use. RESULTS: Among the 92/222 (41%) respondents reporting past 30-day cannabis use, smoking was the most common cROA (75%), followed by vaping (38%), and eating (26%). Smoking was more often used as a single cROA vs. in combination others (p = 0.01), whereas vaping, eating, and dabbing were more often used in combination with another cROA (all p < 0.05). Of the 39% of participants reporting multiple cROA, smoking and vaping (61%), and smoking and eating (50%), were the most prevalent combinations. Nonwhite race (vs. white) and current cigarette smoking (vs. no nicotine use) were associated with past 30-day cannabis use in multiple logistic regression. CONCLUSIONS: Prevalence of past 30-day cannabis use among individuals receiving buprenorphine MOUD in Massachusetts in 2020 was nearly double the prevalence of cannabis use in Massachusetts' adult general population in 2019 (21%). Our data are consistent with state and national data showing smoking as the most common cROA.

Perceptions of E-cigarettes among adults in treatment for opioid use disorder.

Background: Individuals with opioid use disorder (OUD) have a high prevalence of smoking and limited success quitting smoking with existing tools. There is ongoing debate about whether electronic cigarettes (e-cigarettes) may be a viable harm reduction strategy. We sought to determine the potential acceptability of e-cigarettes for cigarette harm reduction among individuals receiving medication treatment for opioid use disorder (MOUD) with buprenorphine. Among individuals receiving MOUD we investigated health harm perceptions of cigarettes, nicotine e-cigarettes, and nicotine replacement therapy (NRT), and perceptions of the helpfulness of e-cigarettes and NRT for quitting cigarettes. Methods: Cross-sectional telephone survey conducted among adults in buprenorphine treatment at five community health centers in the Boston, MA metropolitan area from February to July 2020. Results: 93% and 63% of participants rated cigarettes and e-cigarettes, respectively, as very or extremely harmful to health, and 62% rated NRT as not to slightly harmful to health. Over half (58%) rated cigarettes as more harmful than e-cigarettes; 65% and 83% perceived e-cigarettes and NRT, respectively, to be helpful for reducing/quitting cigarette use. In bivariate analyses, nicotine e-cigarette users, compared to nonusers, perceived e-cigarettes to be less harmful to health and more often rated e-cigarettes as helpful for reducing/quitting cigarette use (both p<0.05). Conclusions: This study suggests that Massachusetts patients receiving MOUD with buprenorphine have concerns about the health harms of e-cigarettes yet rate them as helpful tools for reducing or quitting cigarette smoking. Future research is needed to test the efficacy of e-cigarettes for cigarette harm reduction.

Higher Marijuana use among Young Adults Persists Even during Pregnancy.

Background: Marijuana is linked to adverse pregnancy health effects, yet limited data exist regarding demographic and regional differences in marijuana use during pregnancy. Objective: To determine the prevalence of prenatal marijuana use among reproductive-age women and assess regional and age-related differences. Methods: This study secondarily analyzed cross-sectional, population-based Pregnancy Risk Assessment Monitoring System data from states querying about marijuana use. It included 10,350 women with live births in 2009-2011. Primary outcome was "any use of marijuana" during pregnancy. Logistic regression analysis examined associations between marijuana use, age, and other socio demographic characteristics. Results: In all states, marijuana use during pregnancy was more likely in adolescent and young adults (AYA; <25 years) than older mothers: Alaska, prevalence rate ratio (PRR), 2.07 (95% confidence interval [CI], 1.5-2.6); Hawaii, PRR, 1.55 (95% CI, 1.2-1.9); Vermont, PRR, 2.44 (95% CI, 1.9-2.9). Regression analyses, controlling for other demographic characteristics, showed that age <25 was associated with higher odds of marijuana use in Alaska (adjusted odds ratio [aOR], 2.24 [95% CI, 1.9-2.5]) and Vermont (aOR, 1.74 [95% CI, 1.5-1.9]). Smoking cigarettes during pregnancy was associated with higher odds of concomitant marijuana use in Alaska (aOR, (P<0.05)) and Vermont (aOR, 1.2 (P<0.05)). Conclusions: AYA reported higher marijuana use rates during pregnancy than older women. Cigarette use during pregnancy was associated with marijuana use. Additional research, examining national marijuana use patterns and maternal and child health outcomes in the context of evolving marijuana policies, is warranted.

Perceived risk, attitudes, and behavior of cigarette smokers and nicotine vapers receiving buprenorphine treatment for opioid use disorder during the COVID-19 pandemic.

BACKGROUND: Cigarette smoking may increase the risk of COVID-19 complications, reinforcing the urgency of smoking cessation in populations with high smoking prevalence such as individuals with opioid use disorder (OUD). Whether the COVID-19 pandemic has altered perceptions, motivation to quit, or tobacco use among cigarette smokers and nicotine e-cigarette vapers with OUD is unknown. METHODS: A telephone survey was conducted in March-July 2020 of current cigarette smokers or nicotine vapers with OUD who were stable on buprenorphine treatment at five Boston (MA) area community health centers. The survey assessed respondents' perceived risk of COVID-19 due to smoking or vaping, interest in quitting, quit attempts and change in tobacco consumption during the pandemic. RESULTS: 222/520 patients (43 %) completed the survey, and 145 were asked questions related to COVID-19. Of these, 61 % smoked cigarettes only, 13 % vaped nicotine only, and 26 % were dual users. Nearly 80 % of participants believed that smoking and vaping increased their risk of COVID-19 infection or complications. Smokers with this belief reported an increased interest in quitting (AOR 4.6, 95 % CI:1.7-12.4). Overall, 49 % of smokers and 42 % of vapers reported increased interest in quitting due to the pandemic; 24 % and 20 %, respectively, reported attempting to quit since the pandemic. However, 35 % of smokers and 27 % of vapers reported increasing smoking and vaping, respectively, during the pandemic. CONCLUSIONS: Most patients with OUD believed that smoking and vaping increased their vulnerability to COVID-19, half reported increased interest in quitting, but others reported increasing smoking and vaping during the COVID-19 pandemic.

Improving LARC Access for Urban Adolescents and Young Adults in the Pediatric Primary Care Setting.

The objective of this quality improvement study was to assess the feasibility, acceptability, and impact of integrating long-acting reversible contraceptive (LARC) delivery services into an academic pediatric primary care practice. Adolescent medicine providers in Baltimore, Maryland, were trained in LARC placement with gynecology providers integrated to offer onsite LARC placement and procedural support. Referrals, appointments, and contraceptive method choice/receipt were tabulated. Of 212 individuals referred for LARC consultations, 104 attended appointments. LARC placement at the initial referral increased from year 1 (N = 1) to year 2 (N = 42; P < .01). Adolescent medicine providers placed more LARCs in year 2 (N = 34) than year 1 (N = 0; P < .01). Patients aged 18 to 24 years were less likely to have a LARC placed than those aged 13 to 17 years (unadjusted odds ratio = 0.47 [0.26-0.86]). In conclusion, provider training and service integration of LARC services within a pediatric practice is feasible, acceptable, and increases LARC access and placement.

The role of spirituality in diabetes self-management in an urban, underserved population: a qualitative exploratory study.

BACKGROUND: Although many studies examine motivators for diabetes self-management, few explore the role spirituality plays in this disease, especially in low-income urban populations. METHODS: This qualitative, focus group study elicits thoughts of diabetic patients regarding spirituality in diabetes self-care, at an urban primary care practice in Rhode Island. Focus group discussions were audiotaped, transcribed verbatim, and analyzed using the immersion/crystallization technique. RESULTS: Themes included: significant impact of diabetes on daily life; fear and family as prominent self-care motivators; relationships with self, others, nature and the divine as major sources of hope and strength. Patients varied considerably regarding the role spirituality played in their illness, ranging from minimal to profound impact. All appeared comfortable discussing spirituality within the context of strength and hope. CONCLUSION: Patients in this urban, underserved population are willing to discuss spirituality related to their diabetes care. They vary in the role spirituality plays in their illness experience.

Ability of an information mastery curriculum to improve residents' skills and attitudes.

BACKGROUND AND OBJECTIVES: Teaching evidence-based medicine is becoming more frequent in family medicine residency education, as is the teaching of information mastery, which is using techniques to answer clinical questions at the point of care and to keep up with changes in medical knowledge. The goal of this study was to determine the effect of an integrated curriculum of information mastery on residents' evidence-based medicine knowledge and skills as well as their confidence at critically appraising medical literature and using evidence to inform clinical decisions. METHODS: We used a before-after study in a single residency over 5 years. Residents completed the Fresno Test of Evidence-based Medicine and an attitude questionnaire at the start of the curriculum and then again before graduation. The integrated curriculum consisted of intensive instruction over the course of 1 month (30 hours), followed by a longitudinal series of ongoing conferences, integrated into the teaching of clinical content. Teaching was also integrated into day-to-day clinical activities via precepting interactions. RESULTS: Twenty-three residents completed the study. Modified Fresno Test scores significantly improved from 104.0 to 121.5. Using a pass/fail approach, nine residents (40.1%) passed the test at the start of training, increasing to 17 (73.4%) at the end of the intervention. Confidence in critical appraisal scores increased from an average 17.90 (95% CI=16.55--19.25) to 21.10 (95% CI=19.49--22.71), out of a possible score of 25. Confidence scores were significantly lower in residents who did not pass the posttest (18.5 versus 21.9). Attitudes regarding confidence in the use of evidence and a decreased reliance on experts were also improved following the curriculum. CONCLUSIONS: A curriculum of information mastery, integrated across the greater curriculum, improved trainees' evidence-based medicine knowledge and skills and attitude toward using evidence to inform clinical decision making.

Implications of new hypertension guidelines in the United States.

The American Heart Association released a scientific statement based on available clinical trials and expert opinion in 2007 for the treatment of hypertension to prevent coronary artery disease. These guidelines recommend more aggressive control of blood pressure (BP <130/80 mm Hg) among those at high risk for coronary artery disease, individuals with diabetes mellitus, chronic kidney disease, coronary artery disease or coronary artery disease risk equivalent, or a 10-year Framingham risk score ≥10%. Based on newer clinical trial data, the 2011 American College of Cardiology Foundation/American Heart Association (AHA) hypertension guidelines for the elderly recommend a less aggressive approach of <145/90 mm Hg in those over the age of 80 years. We estimated the burden of uncontrolled BP among those at an increased risk of coronary artery disease using the both the 2007 AHA and the 2011 American College of Cardiology Foundation/AHA hypertension guidelines. We used a cross-sectional analysis of National Health and Nutrition Examination Survey 2005-2008 participants. Participants were 10198 adults aged 18 to 85 years. Using the 2011 American College of Cardiology Foundation/AHA hypertension guidelines (≥140/90 mm Hg), 72 million Americans (35%) have hypertension. Using the 2007 AHA guidelines, an additional 7 million American adults (5%) have elevated BP requiring treatment, for a total of 79 million adults (40%). Although individuals at a higher risk for coronary artery disease are more likely to be aware of their hypertension and to be taking antihypertension medication, they are less likely to have their BP under control. Additional efforts are needed in the treatment of elevated BP, especially among individuals with an increased risk of coronary artery disease.

Implications of new hypertension guidelines in the United States.

The American Heart Association Task Force released a scientific statement in 2007 for the treatment of hypertension in the prevention of coronary artery disease (CAD). These guidelines recommend more aggressive control of blood pressure (BP) among those at high risk for CAD: individuals with diabetes mellitus, chronic kidney disease, cardiovascular disease, congestive heart failure, or a 10-year Framingham risk score ≥10%. These individuals are advised to maintain a BP <130/80 mm Hg. We estimated the burden of uncontrolled BP among those at an increased risk of CAD using the updated task force guidelines. We used a cross-sectional analysis of National Health and Nutrition Examination Survey 2005-2008 participants. Participants were 24 989 adults aged 18 to 85 years. Using the old definition of hypertension (>140/90 mm Hg), 98 million (21%) Americans have hypertension. Using the updated guidelines, an additional 52 million (11%) American adults now have elevated BP requiring treatment, for a total of 150 million adults (32%). Adults with diabetes mellitus have the greatest population burden of uncontrolled BP (50.6 million), followed by adults with chronic kidney disease (43.7 million) and cardiovascular disease (43.3 million). Although individuals at a higher risk for CAD are more likely to be aware of their hypertension and to be taking antihypertension medication, they are less likely to have their BP under control. Additional efforts are needed in the treatment of elevated BP, especially among individuals with an increased risk of CAD.