Maya Vijayaraghavan

Primary Care Providers’ Judgments of Opioid Analgesic Misuse in a Community-Based Cohort of HIV-Infected Indigent Adults

BACKGROUNDPrimary care providers (PCPs) must balance treatment of chronic non-cancer pain with opioid analgesics with concerns about opioid misuse.OBJECTIVEWe co-enrolled community-based indigent adults and their PCPs to determine PCPs’ accuracy of estimating opioid analgesic misuse and illicit substance use.DESIGNPatient-provider dyad study.PARTICIPANTSHIV-infected, community-based indigent adults (‘patients’) and their PCPs.MAIN MEASURESUsing structured interviews, we queried patients on use and misuse of opioid analgesics and illicit substances. PCPs completed patient- and provider-specific questionnaires. We calculated the sensitivity, specificity, and measures of agreement between PCPs’ judgments and patients’ reports of opioid misuse and illicit substance use. We examined factors associated with PCPs’ thinking that their patients had misused opioid analgesics and determined factors associated with patients’ misuse.KEY RESULTSWe had 105 patient-provider dyads. Of the patients, 21 had misused opioids and 45 had used illicit substances in the past year. The sensitivity of PCPs’ judgments of opioid analgesic misuse was 61.9% and specificity, 53.6% (Kappa score 0.09, p = 0.10). The sensitivity of PCPs’ judgments of illicit substance use was 71.1% and specificity, 66.7% (Kappa score 0.37, p <0.001). PCPs were more likely to think that younger patients (Adjusted odds ratio (AOR) 0.89, 95% CI 0.84-0.97), African American patients (AOR 2.53, 95% CI 1.05-6.07) and those who had used illicit substances in the past year (AOR 3.33, 95% CI 1.35-8.20) had misused opioids. Younger (AOR 0.94, 95% CI 0.86-1.02) and African American (AOR 0.71, 95% CI 0.25-1.97) patients were not more likely to report misuse, whereas persons who had used illicit substances were (AOR 3.01, 95% CI 1.04-8.76).CONCLUSIONPCPs’ impressions of misuse were discordant with patients’ self-reports of opioid analgesic misuse. PCPs incorrectly used age and race as predictors of misuse in this high-risk cohort.

The Association Between Housing Instability, Food Insecurity, and Diabetes Self-Efficacy in Low-Income Adults

Limited data exist on whether structural factors associated with poverty such as inadequate housing and food insecurity affect diabetes care. In a sample of low-income participants with diabetes (N=711), we sought to determine if housing instability was associated with lower diabetes self-efficacy, and whether this relationship was mediated by food insecurity. We ordered housing from most to least stable. We observed a linear decrease in diabetes self-efficacy as housing instability increased (p<.01). After adjusting for age, sex, race/ethnicity, and alcohol or substance use, adults lacking a usual place to stay had lower self-efficacy than those who owned their own home (ß-coefficient -0.94, 95% CI -1.88, -0.01). Food insecurity mediated the association between housing instability and diabetes self-efficacy (ß-coefficient -0.64, 95% CI -1.57, 0.31). Our findings suggest that inadequate access to food lowers self-efficacy among adults with diabetes, and supports provision of food to unstably housed adults as part of diabetes care.

The Effectiveness of Cigarette Price and Smoke-Free Homes on Low-Income Smokers in the United States

OBJECTIVES We examined the effectiveness of state cigarette price and smoke-free homes on smoking behaviors of low-income and high-income populations in the United States. METHODS We used the 2006-2007 Tobacco Use Supplement to the Current Population Survey. The primary outcomes were average daily cigarette consumption and successful quitting. We used multivariable regression to examine the association of cigarette price and smoke-free home policies on these outcomes. RESULTS High state cigarette price (pack price ≥ 

Health, Access to Health Care, and Health Care use Among Homeless Women with a History of Intimate Partner Violence

4.50) was associated with lower consumption across all income levels. Although low-income individuals were least likely to adopt smoke-free homes, those who adopted them had consumption levels and successful quit rates that were similar to those among higher-income individuals. In multivariable analysis, both policies were independently associated with lower consumption, but only smoke-free homes were associated with sustained cessation at 90 days. CONCLUSIONS High cigarette prices and especially smoke-free homes have the potential to reduce smoking behaviors among low-income individuals. Interventions are needed to increase adoption of smoke-free homes among low-income populations to increase cessation rates and prevent relapse.

Disparities in undiagnosed diabetes among United States-Mexico border populations

Among a sample of sheltered homeless women, we examined health, access to health care, and health care use overall and among the subgroup of participants with and without intimate partner violence (IPV). We recruited homeless women from a random sampling of shelters in New York City, and queried them on health, access to health care and health care use. Using multivariable logistic regression, we determined whether IPV was associated with past-year use of emergency, primary care and outpatient mental health services. Of the 329 participants, 31.6% reported one or more cardiovascular risk factors, 32.2% one or more sexually transmitted infections, and 32.2% any psychiatric condition. Three-fourths (73.5%) had health insurance. Health care use varied: 55.4% used emergency, 48.9% primary care, and 75.9% outpatient mental health services in the past year. Across all participants, 44.7% reported IPV. Participants with IPV compared to those without were more likely to report medical and psychiatric conditions, and be insured. Participants with IPV reported using emergency (64.4%) more than primary care (55.5%) services. History of IPV was independently associated with use of emergency (Adjusted odds ratio (AOR) 1.7, 95% CI 1.0–2.7), but not primary care (AOR 1.5, 95% CI 0.9–2.6) or outpatient mental health services (AOR 1.9, 95% CI 0.9–4.1). Across the whole sample and among the subgroup with IPV, participants used emergency more than primary care services despite being relatively highly insured. Identifying and eliminating non-financial barriers to primary care may increase reliance on primary care among this high-risk group.

Opioid analgesic misuse in a community-based cohort of hiv-infected indigent adults

OBJECTIVE To compare the prevalence of undiagnosed diabetes among populations with diabetes living on the United States (U.S.)-Mexico border, examine explanations for differences between groups, and investigate differences in metabolic outcomes by diagnosis status. METHODS Data come from the U.S.-Mexico Border Diabetes Prevention and Control Project survey (2001-2002), which used a stratified, multistage design. The sample included 603 adults (18 years or older) with diabetes. Undiagnosed diabetes was defined as a fasting plasma glucose (FPG) value of ≥ 126 mg/dL and no report of diagnosis. Logistic regression was used to compare the odds of being undiagnosed among border populations with diabetes. Metabolic outcomes included FPG, glycosylated hemoglobin, and mean arterial blood pressure. RESULTS One in four adults with diabetes (25.9%) living on the U.S.-Mexico border was undiagnosed. Mexicans (43.8%) and Mexican immigrants (39.0%) with diabetes were significantly more likely to be undiagnosed than were U.S.-born Hispanics (15.0%; P < 0.05 for either comparison) or non-Hispanic whites (6.6%; P < 0.001 for either comparison). Mexicans were more likely to be undiagnosed than were all U.S. adults (14.7%; P < 0.001) with diabetes. Significant differences in the likelihood of being undiagnosed remained between all groups with diabetes after adjustment for sociodemographic and healthcare-related covariates, with the exception of that between Mexicans and U.S.-born Hispanics. Worse metabolic control and potentially greater benefits of diagnosis for control were observed for Mexicans in particular compared with U.S. groups with undiagnosed diabetes. CONCLUSIONS Efforts to improve diabetes diagnosis should concentrate on Mexican and Mexican immigrant populations on the U.S.-Mexico border.

Differential use of other tobacco products among current and former cigarette smokers by income level

Author(s): Vijayaraghavan, Maya; Penko, Joanne; Bangsberg, David R; Miaskowski, Christine; Kushel, Margot B

Non-medical use of non-opioid psychotherapeutic medications in a community-based cohort of HIV-infected indigent adults

With the declining sales of cigarettes, the tobacco industry has been promoting other forms of combustible and smokeless tobacco to current and former cigarette smokers. Exposure to the promotion of tobacco products has been shown to vary by income level. We combined the 2006 through 2011 National Surveys on Drug Use and Health to compare the prevalence and patterns of other tobacco use (cigar, snuff, and chewing tobacco) between current and former cigarette smokers by income level. Other tobacco use was minimal among females and among male non-smokers. Approximately a third of both current and former male cigarette smokers reported past-year other tobacco use. Overall, current smokers were more likely than former smokers to have used cigars (adjusted odds ratio (AOR) 1.69, 95% CI 1.50-1.92) or snuff (AOR 1.14, 95% CI 1.01-1.28) in the past year. The association of smoking status with other tobacco use differed by income level (interaction term p-value<0.001). Among lower income groups, current smokers were more likely to use cigars and snuff compared to former smokers. Among the highest income group, former smokers were just as likely to use smokeless tobacco as current smokers. The differing patterns of use of other tobacco between current and former smokers by income level highlight a need for studies to understand the motivations for the use of these products and their role in smoking cessation.

A Qualitative Examination of Smoke-Free Policies and Electronic Cigarettes Among Sheltered Homeless Adults.

BACKGROUND Non-opioid psychotherapeutic medications significantly increase the risk of opioid overdose-related deaths. We prospectively followed HIV-infected indigent adults sampled from the community to examine rates of and factors associated with non-medical use of benzodiazepines, muscle relaxants, and prescription stimulants. METHODS We interviewed participants quarterly for 2 years about alcohol and illicit substance use; depression; use of prescribed opioid analgesics, benzodiazepines and muscle relaxants; opioid analgesic misuse; and non-medical use (i.e., use without a prescription) of benzodiazepines, muscle relaxants, and prescription stimulants. Using mixed-effects multivariate logistic regression, we determined factors associated with non-medical use of benzodiazepines, muscle relaxants, and prescription stimulants. RESULTS Among the 296 participants at enrollment, 52.0% reported taking opioid analgesics that had been prescribed, 17.9% took benzodiazepines that had been prescribed, and 8.1% took muscle relaxants that had been prescribed. Over the 2-year study interval, 53.4% reported prescription opioid misuse, 25.3% reported non-medical use of benzodiazepines, 11.5% reported non-medical use of muscle relaxants, and 6.1% reported non-medical use of prescription stimulants. In multivariable analysis, opioid analgesic misuse in the past 90 days was associated with non-medical use of benzodiazepines, muscle relaxants, and prescription stimulants during the same time interval. Illicit substance use and depression were not associated with non-medical use of these medications. CONCLUSIONS Prescription opioid analgesic misuse is associated with non-medical use of other psychotherapeutic medications. Health care providers should monitor for non-medical use of a broad array of psychoactive medications among high-risk populations to minimize harm.

Tobacco Cessation Behaviors Among Older Homeless Adults: Results From the HOPE HOME Study

Purpose. To examine attitudes toward smoke-free policies and perceptions of e-cigarette use among homeless adults. Approach. A cross-sectional qualitative study was conducted. Setting. Study setting comprised seven transitional homeless shelters with indoor smoke-free policies in San Diego County; facilities differed in outdoor restrictions on smoking. Participants. Sixty-six current or former smokers were the study participants. Method. Participants completed a questionnaire on smoking behaviors, perceived antitobacco norms, and attitudes toward smoke-free policies, and attended a focus group interview that explored these topics. We used a directed content analysis approach to analyze the focus group transcripts. Results. Clients in facilities with outdoor restrictions on smoking had stronger perceived antitobacco norms than those in facilities without such restrictions. We identified the following major themes: attitudes toward smoke-free policies, the use of e-cigarettes, the addictive potential of cigarettes, vulnerability to tobacco industry marketing, and interest in smoking cessation. The consensus was that smoke-free policies were important because they limited secondhand smoke exposure to nonsmokers and children. All were curious about e-cigarettes, particularly if they could be smoked in areas where smoking was prohibited and/or used as a cessation aid. Conclusion. In this study of homeless adults, there was strong support for indoor and outdoor smoke-free policies. However, misperceptions that e-cigarettes could be used indoors could threaten antitobacco norms, highlighting opportunities to educate about the potential risks of e-cigarette use among homeless individuals.