Mance E. Buttram

Resilience, Syndemic Factors, and Serosorting Behaviors Among HIV-Positive and HIV-Negative Substance-Using MSM

Serosorting is commonly employed by MSM to reduce HIV risk. We hypothesize that MSM perceive serosorting to be effective, and that serosorting is predicted by resilience and inversely related to syndemic characteristics. Surveys included 504 substance-using MSM. Logistic regression models examined syndemic and resilience predictors of serosorting, separately by serostatus. For HIV-positive men, positive coping behaviors (P = .015) and coping self-efficacy (P = .014) predicted higher odds, and cognitive escape behaviors (P = .003) lower odds, of serosorting. For HIV-negative men, social engagement (P = .03) and coping self-efficacy (P = .01) predicted higher odds, and severe mental distress (P = .001), victimization history (P = .007) and cognitive escape behaviors (P = .006) lower odds, of serosorting. HIV-negative serosorters reported lower perceptions of risk for infection than non-serosorters (P < .000). Although high risk HIV-negative men may perceive serosorting to be effective, their high rates of UAI and partner change render this an ineffective risk reduction approach. Relevant public health messages are urgently needed.

Risk and Protective Factors Associated With Gay Neighborhood Residence

Using a sample of 482 ethnically diverse current substance using men who have sex with men who reported recent unprotected anal intercourse, this study compared health risk behaviors—substance use and sexual HIV risk—and one health protective factor—prosocial activities—between men who live in a gay neighborhood and those who do not. Data are drawn from comprehensive health and social risk assessments administered in South Florida. In a multivariate logistic regression model, methamphetamine use, high rates of receptive unprotected anal intercourse, and lower levels of prosocial engagement were found to be risk factors associated with gay neighborhood residence. Compared with living elsewhere, gay neighborhood residence appeared to be protective against cocaine use and substance dependence. Implications of the findings for prevention interventions are discussed, as is the need for further research regarding decisions about neighborhood residence and how neighborhood risk and protective factors emerge and are sustained.

Interview as intervention: The case of young adult multidrug users in the club scene

This paper reports on changes in substance use and substance dependence symptoms-without intervention-among young adult multidrug users in the club scene, ages 18-29, (N = 444) who participated in a natural history study. Computer-assisted personal interviews at baseline and 6-, 12-, and 18-month follow-ups included well-tested measures of substance use and dependence. Changes in substance dependence symptoms and drug use frequencies were calculated using Cohens d statistic. Mean age was 22; 40% were female; 58% were Hispanic, 17% White, and 21% Black. At 18-month follow-up assessment, participants reported significantly fewer days of cocaine (d = -.85 at 18 months), ecstasy (d = -.93), benzodiazepine (d = -.82), and prescription opioid (d = -.81) use, as well as reduced substance dependence symptoms (d = -.42). These results, together with data from focus groups with completers, suggest that comprehensive health and social risk assessments may have quite strong intervention effects among young adult multidrug users.

Vulnerable infected populations and street markets for ARVs: Potential implications for PrEP rollout in the USA

Widespread diversion of antiretroviral (ARV) medications to illicit markets has recently been documented among indigent patients in South Florida. The recent approval of ARVs for pre-exposure prophylaxis (PrEP) has the potential to broaden these illicit markets, as high-risk individuals seek ARVs without a prescription or medical supervision. Nonadherence among diverters and unsupervised use of ARVs for treatment or PrEP increase risks of treatment failure, drug resistance, and disease transmission. We report the scope of ARV diversion among substance-using men who have sex with men in South Florida. Structured interviews (N = 515) queried demographics, HIV status, mental distress, substance dependence, and sexual risks. HIV-positive participants answered questions about medical care, treatment, and ARV adherence and diversion. Median age was 39. Of 46.4% who were HIV-positive, 79.1% were prescribed ARVs. Of these, 27% reported selling/trading ARVs. Reasons for diversion were sharing/trading with friends, sale/trade for money/drugs, and sale/trade of unused medications. ARV diverters, compared to nondiverters, were more likely to be substance dependent (74.5% vs. 58.7%, p = 0.046) and have traded sex for money/drugs (60.8% vs. 32.6%, p < 0.001), and less likely to be adherent to ARVs (54.9% vs. 73.9%, p = 0.012). ARV diversion should be a particular concern in communities of high-risk men who have sex with men as uninfected men in such communities are likely to benefit most from PrEP but unlikely to have access to PrEP and necessary ancillary services through the health-care system. The implications of diversion for increased risks of treatment failure, disease transmission, and PrEP failure should be carefully considered in developing policy and behavioral supports to scaling up treatment as prevention and PrEP.

Sustained reduction of diversion and abuse after introduction of an abuse deterrent formulation of extended release oxycodone

BACKGROUND The development of abuse deterrent formulations is one strategy for reducing prescription opioid misuse and abuse. A putative abuse deterrent formulation of oxycodone extended release (OxyContin®) was introduced in 2010. Early reports demonstrated reduced abuse and diversion, however, an analysis of social media found 32 feasible methods to circumvent the abuse deterrent mechanism. We measured trends of diversion, abuse and street price of OxyContin to assess the durability of the initial reduction in abuse. METHODS Data from the Poison Center Program, Drug Diversion Program, Opioid Treatment Program, Survey of Key Informant Patients Program and StreetRx program of the Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS®) System were used. The average quarterly rates of abuse and diversion for OxyContin were compared from before reformulation to the rate in second quarter 2015. Rates were adjusted for population using US Census data and drug availability. RESULTS OxyContin abuse and diversion declined significantly each quarter after reformulation and persisted for 5 years. The rate of abuse of other opioid analgesics increased initially and then decreased, but to lesser extent than OxyContin. Abuse through both oral and non-oral routes of self-administration declined following the reformulation. The geometric mean difference in the street price of reformulated OxyContin was 36% lower than the reformulated product in the year after reformulation. DISCUSSION Despite methods to circumvent the abuse deterrent mechanism, abuse and diversion of OxyContin decreased promptly following the introduction of a crush- and solubility- resistant formulation and continued to decrease over the subsequent 5 years.

A mixed methods study of health and social disparities among substance-using African American/Black men who have sex with men

African American/Black men who have sex with men (MSM) in the USA experience health and social disparities at greater rates than MSM of other races/ethnicities, including HIV infection and substance use. This mixed methods paper presents: (1) a quantitative examination of health and social disparities among a sample of substance-using African American/Black MSM (N = 108) compared to Caucasian/White MSM (N = 250) and (2) in-depth qualitative data from a subsample of African American/Black MSM (N = 21) in order to contextualize the quantitative data. Findings indicate that compared to Caucasian/White MSM, African American/Black MSM experienced a wide range of health and social disparities including: substance use and dependence; buying, trading or selling sex; educational attainment; employment; homelessness; identifying as gay; HIV status; arrest history; social support; and satisfaction with one’s living situation. Qualitative data suggests that structural interventions that address homophobia and the social environment would be likely to mitigate many of the health and social disparities experienced by African American/Black MSM.

Resilience and syndemic risk factors among African-American female sex workers

Research on street-based female sex workers documents a multitude of problems faced by these women, such as substance use, HIV risk, mental health problems, victimization, and homelessness. The presence of problems such as these is understood as a syndemic, or co-occurrence of two or more risk factors that act synergistically to create an excess burden of disease. However, the syndemic framework has not previously incorporated the examination of resilience to understand what protective factors enable female sex workers to cope with syndemic risk. Using 562 baseline interviews from street-based African-American female sex workers enrolled in a randomized intervention trial, this study is the first to investigate expressions of resilience among this vulnerable population. Specifically, these analyses examine high levels of resilience, as measured by personal mastery, in order to understand the contributions of syndemic risk factors and protective factors on the expression of resilience. In bivariate logistic regression models, women with high resilience reported significantly higher odds of high school education, greater access to transportation, and more social support, in addition to lower odds of foster care history, homelessness, substance dependence, severe mental distress, victimization, and HIV risk. In the multivariate model, higher odds of high school education and increased social support, in addition to lower odds of mental distress and HIV risk remained associated with high resilience. The findings suggest specific targets for intervention to assist female sex workers in coping with syndemic risk factors and achieving better health outcomes. These include the prioritizing of education and training opportunities and the enhancement of social support.

Under treatment of pain: a prescription for opioid misuse among the elderly?

OBJECTIVE To examine the demographic, physical, and mental health characteristics; current drug use patterns; motivations for use; and diversion sources among elderly prescription opioid misusers. DESIGN Mixed methods design. SETTING Research field offices, or senior or community center offices in South Florida. SUBJECTS Individuals aged 60 and over reporting past 90-day prescription medication misuse; only prescription opioid misusers (N = 88) were included in the final analysis. METHODS The Global Appraisal of Individual Needs was the main survey instrument. A subsample of elderly reporting substantial prescription drug misuse were chosen for the in-depth interview (N = 30). RESULTS The mean age was 63.3. Fifty percent reported ever being admitted to a drug treatment program; several endorsed recent illicit drug use: powder cocaine and/or crack (35.2%), marijuana (30.7%), heroin (14.8%). The majority reported past year severe physical pain and discomfort (86.4%), and misuse of their primary opioid for pain (80.7%); over half (52.3%) obtained their primary opioid from their regular doctor. Qualitative data highlight the misuse of prescription opioids due to untreated or undertreated pain. Participants with primary opioid misuse for pain had over 12 times higher odds of obtaining the medication from their regular doctor (odds ratio [OR] = 12.22, P = 0.002) and had lower odds of using a dealer (OR = 0.20, P = 0.005). CONCLUSIONS Findings suggest that this group of elderly participants often misuse their own prescriptions for pain management. This study highlights the need to educate prescribing professionals on appropriate pain management for older adults while still being sensitive to issues of substance abuse and dependence.

Benzodiazepine Dependence among Young Adult Participants in the Club Scene Who Use Drugs

ABSTRACT Young adults ages 18–29 report the highest rates of benzodiazepine (BZD) misuse in the United States. The majority of club drug users are also in this age group, and BZD misuse is prevalent among participants in club scenes. This article examines BZD dependence and its correlates among young adult participants in the electronic dance music (EDM) culture in Miami, Florida, who use drugs. Structured interviews were with men and women (N = 356) ages 18 to 29 who reported regular attendance at EDM venues and recent use of both club drugs and BZDs. Prevalences of BZD-related problems were 12.6% for BZD dependence, 21.1% BZD abuse, and 24.2% BZD abuse and/or dependence. In a multivariate logistic regression model, younger age (OR 0.85; 95% CI 0.76, 0.96), severe mental distress (OR 8.30; 95% CI 3.07, 22.49), daily marijuana use (OR 2.10; 95% CI 1.03, 4.27), and heavy opioid use (OR 2.33; 95% CI 1.12, 4.83) were associated with BZD dependence. BZD dependence was higher in this sample than in other populations described in the literature. The links between BZD dependence, overdose history, and heavy opioid misuse are especially worrisome among this young sample. Recommendations for intervention and research are discussed.

Characteristics associated with group sex participation among men and women in the club drug scene

This study examined the demographics, substance use and sexual risk behaviours associated with group sex (GS) participation among a sample of club drug users (n=498) in Miami. Men (n=128; 46.3%) and women (n=75; 33.7%) reported histories of GS. Group sex participation among men and women was associated with heroin and injection drug use, trading or selling sex, and sex while high, compared with no GS participation. Moreover, among men, GS was associated with buying sex and sex with an injection drug user; among women, GS was associated with substance dependence, a history of sexually transmissible infections and crack cocaine use, compared with no GS participation.