The North American opioid epidemic: current challenges and a call for treatment as prevention

Abstract There is a need for creative, public health-oriented solutions to the increasingly intractable problems associated with the North American opioid epidemic. This epidemic is a fundamentally continental problem, as routes of migration, drug demand, and drug exchange link the USA with Mexico and Canada. The challenges faced throughout North America include entrenched prescribing practices of opioid medications, high costs and low availability of medication-assisted treatment (MAT), and policy approaches that present substantial barriers to care. We advocate for the scale up of a low-threshold treatment model for MAT that incorporates the best practices in addiction treatment. Such a model would remove barriers to care through widespread treatment availability and affordability and also a policy of decriminalization. Given that MAT reduces the frequency of drug injecting among opioid injectors, this treatment model should also be guided by an understanding of the socially communicable nature of injection drug use, such that increasing MAT availability may also prevent the spread of injecting practices to individuals at risk of transitions from non-injection to injection drug use. To that end, the “Treatment as Prevention” model employed to respond to the individual- and population-level risks for HIV/AIDS prevention could be adapted to efforts to halt the North American opioid epidemic

Outpatient clinic visits during heat waves: findings from a large family medicine clinical database

Introduction:The purpose of this study was to determine whether heat waves are associated with increased frequency of clinic visits for ICD-9 codes of illnesses traditionally associated with heat waves. Methods:During 4 years of family medicine clinic data between 2012 and 2016, we identified six heat wave events in San Diego County. For each heat wave event, we selected a control period in the same season that was twice as long. Scheduling a visit on a heat wave day (versus a non-heat wave day) was the primary predictor, and receiving a primary ICD-9 disease code related to heat waves was the outcome. Analyses were adjusted for age, gender, race/ethnicity and marital status. Results:Of the 5448 visits across the heat wave and control periods, 6.4% of visits (n = 346) were for heat wave-related diagnoses. Scheduling a visit on heat wave day was not associated with receiving a heat wave-related ICD code as compared with the control period (adjusted odds ratio: 1.35; 95% confidence interval: 0.86-1.36; P = 0.51). Discussion:We show that in a relatively large and demographically diverse population, patients who schedule appointments during heat waves are not being more frequently seen for diagnoses typically associated with heat waves in the acute setting. Given that heat waves are increasing in frequency due to climate change, there is an opportunity to increase utilization of primary care clinics during heat waves

Relation Between Calcified Atherosclerosis in the Renal Arteries and Kidney Function (from the Multi-Ethnic Study of Atherosclerosis)

Renal artery calcium (RAC) has been shown to be associated with higher odds of hypertension (HTN). The purpose of this study was to determine if the presence and extent of RAC is associated with renal function. We analyzed cross-sectional data from the Multi-Ethnic Study of Atherosclerosis (MESA). A subsample of 1,226 participants underwent computed tomography of the abdomen and also had venous blood samples measured for kidney function. RAC was the primary predictor variable and the following measures of kidney function were the outcome variables: estimated glomerular filtration rate (eGFR), urinary albumin-to-creatinine ratio (UACR), and chronic kidney disease (CKD) stage. The analyses were adjusted for age, gender, race, height, visceral fat, dyslipidemia, diabetes, cigarette smoking, hypertension, interleukin-6 and abdominal aortic calcium (AAC). The average age of this cohort was 66.1 years (SD 9.7), 44.8% (549 of 1,226) were men, and nearly 30% had RAC >0. Compared with those with no RAC, those with RAC >0 were significantly older but not different by gender or race. After adjustment for age, gender, and race, those with RAC >0 had significantly higher visceral fat, were more likely to have dyslipidemia, diabetes, and hypertension, had a higher interleukin-6, and a higher prevalence of AAC >0. The mean eGFR and UACR among those without RAC were 80 ml/min/1.73 m2 and 21 mg/g, whereas these values were 78 ml/min/1.73 m2 and 55 mg/g among those with RAC. In fully adjusted multivariable linear regression models, the presence of RAC was associated with a lower eGFR (β = -2.21, p = 0.06) but not with UACR (β = 0.02, p = 0.79). In fully adjusted ordinal logistic regression, RAC as a continuous variable was associated with increased odds of being in a worse CKD category (odds ratio 1.14, p = 0.05). When measured by eGFR and CKD stage, there is a modest relation between RAC and kidney function. Further studies might involve clinical trials to assess the role of intensive cardiovascular disease risk factor management in patients with subclinical RAC to determine if this may prevent or delay the development and progression of CKD

Another Person Was Going to Do It: The Provision of Injection Drug Use Initiation Assistance in a High-Risk U.S.-Mexico Border Region.

Background: Persons who inject drugs (PWID) play a key role in assisting others initiation into injection drug use (IDU). We aimed to explore the pathways and socio-structural contexts for this phenomenon in Tijuana, Mexico, a border setting marked by a large PWID population with limited access to health and social services. Methods: Preventing Injecting by Modifying Existing Responses (PRIMER) is a multi-cohort study assessing socio-structural factors associated with PWID assisting others into initiating IDU. Semi-structured qualitative interviews in Tijuana included participants ≥18 years old, who reported IDU within the month prior to cohort enrollment and ever initiating others into IDU. Purposive sampling ensured a range of drug use experiences and behaviors related to injection initiation assistance. Thematic analysis was used to develop recurring and significant data categories. Results: Twenty-one participants were interviewed (8 women, 13 men). Broadly, participants considered public injection to increase curiosity about IDU. Many considered transitioning into IDU as inevitable. Emergent themes included providing assistance to mitigate overdose risk and to protect initiates from being taken advantage of by others. Participants described reluctance in engaging in this process. For some, access to resources (e.g., shared drugs or a monetary fee) was a motivator to initiate others. Conclusion: In Tijuana, public injection and a lack of harm reduction services are perceived to fuel the incidence of IDU initiation and to incentivize PWID to assist in injection initiation. IDU prevention efforts should address structural factors driving PWID participation in IDU initiation while including PWID in their development and implementation

“Another Person Was Going to Do It”:The Provision of Injection Drug Use Initiation Assistance in a High-Risk U.S.–Mexico Border Region

Background: Persons who inject drugs (PWID) play a key role in assisting others' initiation into injection drug use (IDU). We aimed to explore the pathways and socio-structural contexts for this phenomenon in Tijuana, Mexico, a border setting marked by a large PWID population with limited access to health and social services. Methods: Preventing Injecting by Modifying Existing Responses (PRIMER) is a multi-cohort study assessing socio-structural factors associated with PWID assisting others into initiating IDU. Semi-structured qualitative interviews in Tijuana included participants ≥18 years old, who reported IDU within the month prior to cohort enrollment and ever initiating others into IDU. Purposive sampling ensured a range of drug use experiences and behaviors related to injection initiation assistance. Thematic analysis was used to develop recurring and significant data categories. Results: Twenty-one participants were interviewed (8 women, 13 men). Broadly, participants considered public injection to increase curiosity about IDU. Many considered transitioning into IDU as inevitable. Emergent themes included providing assistance to mitigate overdose risk and to protect initiates from being taken advantage of by others. Participants described reluctance in engaging in this process. For some, access to resources (e.g., shared drugs or a monetary fee) was a motivator to initiate others. Conclusion: In Tijuana, public injection and a lack of harm reduction services are perceived to fuel the incidence of IDU initiation and to incentivize PWID to assist in injection initiation. IDU prevention efforts should address structural factors driving PWID participation in IDU initiation while including PWID in their development and implementation

History of medication-assisted treatment and its association with initiating others into injection drug use in San Diego, CA.

BackgroundMedication-assisted treatment (MAT) remains the gold standard for the treatment of opioid use disorder. MAT also reduces the frequency of injecting among people who inject drugs (PWID). Relatedly, data suggest that PWID play a key role in the initiation of others into drug injecting by exposing injecting practices to injection-naïve drug users. Our primary objective was to test whether a history of MAT enrollment is associated with a reduced odds of PWID providing injection initiation assistance.MethodsPreventing Injecting by Modifying Existing Responses (PRIMER; NIDA DP2-DA040256-01), is a multi-site cohort study assessing the impact of socio-structural factors on the risk that PWID provide injection initiation assistance. Data were drawn from a participating cohort of PWID in San Diego, CA. The primary outcome was reporting ever providing injection initiation assistance; the primary predictor was reporting ever being enrolled in MAT. Logistic regression was used to model associations between MAT enrollment and ever initiating others into injecting while adjusting for potential confounders.ResultsParticipants (n = 354) were predominantly male (n = 249, 70%). Thirty-eight percent (n = 135) of participants reported ever initiating others into injection drug use. In multivariate analysis, participants who reported a history of MAT enrollment had significantly decreased odds of ever providing injection initiation assistance (Adjusted Odds Ratio [AOR]: 0.62, 95% Confidence Interval [CI]: 0.39-0.99).ConclusionsThese preliminary findings suggest an association between MAT enrollment and a lower odds that male PWID report providing injection initiation assistance to injection-naïve drug users. Further research is needed to identify the pathways by which MAT enrollment may impact the risk that PWID initiate others into drug injecting

Heat, Disparities, and Health Outcomes in San Diego County's Diverse Climate Zones.

Climate variability and change are issues of growing public health importance. Numerous studies have documented risks of extreme heat on human health in different locations around the world. Strategies to prevent heat-related morbidity and reduce disparities are possible but require improved knowledge of health outcomes during hot days at a small-scale level as important within-city variability in local weather conditions, socio-demographic composition, and access to air conditioning (AC) may exist. We analyzed hospitalization data for three unique climate regions of San Diego County alongside temperature data spanning 14 years to quantify the health impact of ambient air temperature at varying exceedance threshold levels. Within San Diego, coastal residents were more sensitive to heat than inland residents. At the coast, we detected a health impact at lower temperatures compared to inland locations for multiple disease categories including heat illness, dehydration, acute renal failure, and respiratory disease. Within the milder coastal region where access to AC is not prevalent, heat-related morbidity was higher in the subset of zip codes where AC saturation is lowest. We detected a 14.6% increase (95% confidence interval [4.5%, 24.6%]) in hospitalizations during hot weather in comparison to colder days in coastal locations where AC is less common, while no significant impact was observed in areas with higher AC saturation. Disparities in AC ownership were associated with income, race/ethnicity, and homeownership. Given that heat waves are expected to increase with climate change, understanding health impacts of heat and the role of acclimation is critical for improving outcomes in the future