Primary preventive health care among injection drug users, other sustained drug users, and non-users

Barriers and facilitators to primary care engagement for people who inject drugs: A systematic review

INTRODUCTION

People who inject drugs (PWID) have a greater burden of multimorbid chronic diseases than the general population. However, little attention has been paid to the engagement in primary care for services related specifically to injection drug use and management of underlying chronic comorbid diseases for this population. This systematic review identified facilitators and barriers to healthcare engagement in the primary care setting among PWID.

DESIGN AND METHODS

Studies were identified by a literature search of PubMed, CINAHL, and EMBASE, and by searching the references of retrieved articles. Studies were included if they measured active injection drug use, and outcomes related to primary care engagement characterized by: diagnosis of a health condition, linkage or retention in care, health condition-related outcomes, and reported patient-provider relationship.

RESULTS

Twenty-three articles were included. Using the behavioral model, factors within predisposing, enabling, need, and health behavior domains were identified. Having co-located services and a positive patient-provider relationship were among the strongest factors associated with healthcare utilization and engagement while active injection drug use was associated with decreased engagement.

CONCLUSIONS

To our knowledge, this is the only review of evidence that has examined factors related to primary care engagement for people who inject drugs. Most articles were observational studies utilizing descriptive designs. Although the assessment of the evidence was primarily rated 'Good', this review identifies a significant need to improve our understanding of primary care engagement for PWID. Future research and intervention strategies should consider these findings to better integrate the holistic care needs of PWID into primary care to reduce morbidity and mortality associated with injection drug use and chronic disease.

CLINICAL RELEVANCE

Primary care engagement is important for preventative care, early diagnosis of disease, and management of chronic diseases, including addressing problems of substance use. This review highlights factors nurses can utilize to facilitate primary care engagement of PWID.

Awareness, perception and utilization of a mobile health clinic by people who use drugs

INTRODUCTION

People who use drugs (PWUD) face a multitude of barriers to accessing healthcare and other services. Mobile health clinics (MHC) are an innovative, cost-effective health care delivery approach that increases healthcare access to vulnerable populations and medically underserved areas. There is limited understanding, however, of how PWUD perceive and experience MHCs.

METHODS

Semi-structured interviews were conducted with 31 PWUD - 16 who had received care (clients) on an MHC (The Spot) and 15 who had not (non-clients) - to explore their perceptions and utilization of an MHC partnered with a mobile syringe services program in Baltimore, Maryland. Data analysis of the text was conducted using an iterative thematic constant comparison process informed by grounded theory.

RESULTS

Clients and non-clients, once aware of the MHC, had positive perceptions of The Spot and its benefits for their individual health as well as for the wellbeing of their community. These sentiments among clients were largely driven by access to low-barrier buprenorphine and service delivery without stigma around drug use. However, lack of general awareness of the spot and specific service offering were barriers to its use among non-clients.

DISCUSSION

MHCs provide an important opportunity to engage PWUD in healthcare and to expand buprenorphine use; however, even with accessibility near where PWUD access injection equipment, barriers to its use remain. Peer dissemination may be able to facilitate program information sharing and recruitment.KEY MESSAGESPeople who use drugs perceive a mobile health clinic in their neighbourhood as a benefit to their communities and themselves by improving access to healthcare services, providing access to low-threshold buprenorphine dispensation, and offering services without drug use stigma.People who use drugs learned about a mobile health clinic in their neighbourhood largely through word-of-mouth. As a result, people received limited information about the mobile health clinic services creating a barrier to its use.

A community-based study of abscess self-treatment and barriers to medical care among people who inject drugs in the United States

Skin and soft tissue infections (SSTIs) are the most common medical complication of injection drug use in the United States, though little work has been done assessing SSTI treatment among people who inject drugs (PWID). We examined past-3-month abscess characteristics, treatment utilization, and barriers to medical treatment among N = 494 community-recruited PWID. We used descriptive statistics to determine the frequencies of self-treatment and medical treatment for their most recent past-3-month abscess as well as barriers to seeking medical treatment. We then used bivariate and multivariate logistic regression to identify factors associated with having an abscess in the past 3 months. Overall, 67% of participating PWID ever had an abscess and 23% had one in the past 3 months. Only 29% got medical treatment for their most recent abscess whereas 79% self-treated. Methods for self-treatment included pressing the pus out (81%), applying a hot compress (79%), and applying hydrogen peroxide (67%). Most (91%) self-treated abscesses healed without further intervention. Barriers to medical treatment included long wait times (56%), being afraid to go (49%), and not wanting to be identified as a PWID (46%). Factors associated independently with having an abscess in the past 3 months were injecting purposely into muscle tissue (adjusted odds ratio [AOR] = 2.64), having difficulty finding a vein (AOR = 2.08), and sharing injection preparation equipment (AOR = 1.74). Our findings emphasize the importance of expanding community-based access to SSTI education and treatment services, particularly at syringe service programs where PWID may be more comfortable seeking resources.

Receipt of preventive health services and current cannabis users

Substance use is associated with greater barriers and reduced access to care. Little research, however, has examined the relationship between cannabis use and receipt of preventive health services. Using data from the 2017 Behavioral Risk Factor Surveillance System, we examined the association between current cannabis use and receipt of 12 preventive health services, adjusting for sociodemographic characteristics and access to care. In analyses that adjusted for sociodemographic factors and access to care, participants with current cannabis use had lower odds of being vaccinated for influenza (AOR = 0.67, 95% CI = 0.54-0.83) and higher odds of ever receiving HPV vaccination (AOR = 1.77, 95% CI = 1.06-2.96) and HIV screening (AOR = 2.34, 95% CI = 1.88-2.92) compared with those without cannabis use. Among the 12 preventive services examined, we found three differences in receipt of preventive services by cannabis use status. Cannabis use does not appear to be associated with significant underuse of preventive services.

Maternal risk factors associated with inadequate testing and loss to follow-up in infants with perinatal hepatitis C virus exposure

OBJECTIVES

Inadequate testing (IT) and follow-up in infants with perinatal hepatitis C virus (HCV) exposure are challenging. We sought to identify maternal clinical and demographic risk factors that are associated with inadequate testing (IT) and follow-up of perinatally HCV-exposed infants.

METHODS

In a retrospective cohort study spanning a period of 23 years, medical records of HCV-infected women and their perinatally exposed infants were reviewed for maternal characteristics that could be associated with their infants' IT and loss to follow-up.

RESULTS

A total of 27% (108/407) of HCV-exposed infants were adequately tested (AT) for HCV perinatal transmission. Among AT infants, HCV transmission rate was 11% (12/108). History of maternal intravenous drug use (IVDU) was significantly higher in IT vs. AT infants [88% (193/218) vs. 76% (70/92); p = 0.005]. The percentage of mothers on methadone maintenance treatment during pregnancy was higher in AT vs. IT infants [53% (35/66) vs. 34% (65/186); p = 0.010]. The percentage of mothers with HCV medical care was higher among AT than IT infants [54% (56/102) vs. 41% (106/255); p = 0.022].

CONCLUSIONS

Infants born to HCV-infected mothers have suboptimal testing, possibly leading to an underestimation of the rate of HCV vertical transmission. Infants of mothers receiving HCV medical care and methadone treatment have improved testing. Infants of HCV-positive mothers with history of IVDU have lower rates of testing. Screening HCV-infected pregnant women for history of IVDU and linking them to drug treatment programs, and HCV medical care may improve testing and follow-up in their infants.

"Health Is on the Back Burner:" Multilevel Barriers and Facilitators to Primary Care Among People Who Inject Drugs

BACKGROUND

The estimated 2.2 million people who inject drugs (PWID) in the USA experience significant gaps in preventive healthcare and a high burden of infectious, psychiatric, and other chronic diseases. Many PWID rely on emergency medical services, which are costly and not designed to deliver preventive services, manage chronic conditions, or address social needs.

OBJECTIVE

The objective of this study was to explore barriers and facilitators to primary care utilization from the perspectives of PWID in New England, a region highly affected by the overdose crisis.

DESIGN

Participants completed semi-structured qualitative interviews exploring substance use and healthcare utilization patterns.

PARTICIPANTS

We recruited 78 PWID through community-based organizations (e.g., syringe service programs) in 16 urban and non-urban communities throughout Massachusetts and Rhode Island.

APPROACH

Thematic analysis identified barriers and facilitators to primary care utilization at the individual, interpersonal, and systemic levels.

KEY RESULTS

Among 78 PWID, 48 described recent primary care experiences; 33 had positive experiences and 15 described negative experiences involving discrimination or mistrust. Individual-level barriers to primary care utilization included perceived lack of need and competing priorities (e.g., avoiding opioid withdrawal, securing shelter beds). Interpersonal-level barriers included stigma and perceived low quality of care for PWID. Systemic-level barriers included difficulty navigating healthcare systems, inadequate transportation, long wait times, and frequent provider turnover. Participants with positive primary care experiences explained how appointment reminders, flexible hours, addiction medicine-trained providers, case management services, and transportation support facilitated primary care utilization and satisfaction.

CONCLUSIONS

Findings regarding the multilevel barriers and facilitators to accessing primary care among PWID identify potential targets for programmatic interventions to improve primary care utilization in this population. Based on these findings, we make recommendations for improving the engagement of PWID in primary care as a means to advance individual and public health outcomes.

Providing reproductive health services for women who inject drugs: a pilot program

Background

Needle syringe programs (NSPs), a proven harm reduction strategy for people who inject drugs, frequently offer limited healthcare services for their clients. Women who inject drugs face multiple barriers to accessing reproductive health care in traditional settings: personal histories of trauma, judgmental treatment from providers, and competing demands on their time. Our aim was to implement patient-centered reproductive healthcare services at a Seattle NSP.

Methods

We interviewed clients and staff of an NSP in Seattle and staff of other community-based organizations serving women who inject drugs, then used the Consolidated Framework for Implementation Research to code transcripts deductively. Based on our qualitative work, we implemented reproductive health care at the NSP program 1 day per week. We evaluated the implementation by surveying staff and clients and auditing charts over a 9-month period.

Results

Clients and staff (N = 15 for clients, N = 13 for staff) noted a high unmet need for trauma-informed, accessible reproductive health care. We successfully implemented reproductive health care services including short- and long-acting contraception, sexually transmitted disease testing, and cervical cancer screening. Survey data was limited but demonstrated client satisfaction with services.

Conclusions

Integrating reproductive health care into an NSP’s clinical services is feasible and can be a source of low-barrier preventive care for women unable to seek gynecologic care elsewhere.

The Survivor: A Clinical Case of Tetanus in a Non-Immunized, Parenteral Drug User, Former Female Convict with HIV and HCV

Tetanus is a serious and potentially fatal systemic disease, caused by the bacterium Clostridium tetani. It is estimated that 1 million cases occur worldwide annually. Immunization programs have drastically decreased tetanus in developed countries, and the sporadic cases have been linked to injecting drug users (IDUs), immunosuppressed individuals, or those older than 65 without complete vaccination. Regrettably, it is still endemic in under-developed countries. In Spain, an average of 10 cases are notified each year, especially affecting those older than 65. The present article describes a case of a 48-year-old Spanish woman, an ex-convict and IDU with infection antecedents of Human Immunodeficiency Virus (HIV) and Hepatitis C (HCV), who was admitted to the Emergency Department of a University Hospital with cervical rigidity and trismus. In a few hours, a neurological and respiratory deterioration was observed, resulting in admittance to the intensive care unit under the suspicion of a generalized tetanus infection. The treatment included hemodynamic support and respiratory therapy, antibiotics, muscle relaxants, sedatives, and tetanus immunoglobulin. Her stay in the ICU lasted 47 days. The clinical suspicion, the antecedents of risk, and the verification of the vaccination records should provide early guidance for diagnostics and the establishment of a treatment in these cases.

Dental caries and periodontal disease among people who use drugs: a systematic review and meta-analysis

BACKGROUND

The aim of our study was to perform a systematic review of the literature and meta-analysis in order to investigate relationship between drug use and oral health.

METHODS

We searched for studies in English published before July 1, 2019 on PsycINFO, PubMed, SciELO, Scopus, and Web of Science. We assessed the relationship between drug use (methamphetamines, heroin; opiates; crack, cocaine and cannabis as dependent variables) and reported tooth loss, periodontal disease, or decayed, missing, and filled teeth index as an independent variable. The data were analyzed using Stata 12.0 software.

RESULTS

We initially identified 1836 potential articles (with 1100 duplicates) and screened the remaining 736 titles and abstracts, comprising 54 studies. In the next step, we evaluated the full-texts; 44 studies were excluded, accordingly. In total, we included 10 publications in the meta-analysis. Drug type was associated with periodontal disease (OR 1.44; 95% CI 0.8-2.6) and pooled estimates showed that type of drug used increased the odds of the number of decayed, missed and filled teeth (DMFT) (OR 4.11; 95% CI 2.07-8.15) respectively.

CONCLUSIONS

The analytical challenges of segregating the impact of individual drug types on oral health diseases mean that investigations on the direct relationship between oral health status and drug use are limited. Developing programs to improve potential confounding with various substances and addressing the dental health needs of people who use drugs is vital if we are to improve their overall quality of life.

Recurrent Necrotizing Soft Tissue Infections with Atypical Pathogens after Injection Drug Abuse: Another Manifestation of the Opioid Crisis

Background: The United States is in the midst of an opioid crisis. Injection drug use is a major risk factor for necrotizing soft tissue infections (NSTI) by introducing bacteria into the soft tissues. Repetitive infection and atypical pathogens may be tangible manifestations of the opioid crisis. Methods: We describe recidivism in two cases of NSTI involving opioid abuse and atypical pathogens at a single institution and review pertinent international literature. Results: Repetitive NSTI is rare. Patients with chronic injection drug use, however, may be at particular risk of repetitive NSTI and infections with atypical organisms. Conclusions: Care providers must have a heightened awareness of infections with atypical pathogens and risk of repetitive infection in patients with injection drug use. Aggressive surgical management and antibiotic coverage tailored to culture and susceptibility data are necessary for a successful short-term outcome. A successful long-term outcome mandates identification and management of co-existent behavioral health issues.

The Affordable Care Act and Changes in Insurance Coverage and Source of Health Care among High-risk Rural, Substance-using, Female Offenders Transitioning to the Community

PURPOSE

This study examines health care coverage and health care among rural, drug-involved female offenders under the Affordable Care Act (ACA) compared with pre-ACA and whether being insured is associated with having a usual source of care.

METHODS

This study involved random selection, screening, and face-to-face interviews with drug-using women in three rural Appalachian jails. Analyses focused on participants who had completed a three-month follow-up interview after release from jail (N=371).

RESULTS

Analyses indicated that women released after ACA implementation were more likely than those released pre-implementation to be insured. A multivariate logistic regression model showed that being insured was significantly related to having a usual health care source during community re-entry.

CONCLUSIONS

Results demonstrate the benefits of the ACA, signaling important implications for public health in rural communities and the criminal justice system, including targeting underserved groups during incarceration and providing information about and resources for health care enrollment.

Addictive behaviors and healthcare renunciation for economic reasons in a French population-based sample

BACKGROUND

Healthcare renunciation for economic reasons is a major health concern, but it has been scarcely investigated among drug users, even if drug users constitute a vulnerable population in need of medical care. This study investigated associations of healthcare renunciation for economic reasons and addictive behaviors (alcohol, tobacco, cannabis, illicit drug use, and gambling) in a population-based sample of adults living in France, a country with universal health coverage.

METHODS

Data were collected using the 2014 Health Barometer, a French cross-sectional survey conducted among a random representative sample of the general population aged 18-64 (n=12,852). Measures included healthcare renunciation, substance use (alcohol, tobacco, cannabis, and other illicit drugs) and gambling. Experimental/recreational and heavy/chronic use were assessed. Logistic regressions were used to test the relationship between healthcare renunciation and addictive behaviors, controlling for relevant covariates.

RESULTS

A total of 25% of the participants had renounced care at least once in the previous twelve months. Most variables of drug use were significantly associated with increased healthcare renunciation. This was the case for heavy/hazardous use and experimental/recreational use. Regular gambling was not associated with healthcare renunciation, but disordered gambling was.

CONCLUSION

This study showed that addictive behaviors, including substance use and gambling, were part of the burden of vulnerability of people who forgo care. Therefore, drug use and gambling patterns should be a focus in the development of policies to reduce health inequalities, not only for heavy and chronic drug users.

"They treated me like crap and I know it was because I was Native": The healthcare experiences of Aboriginal peoples living in Vancouver's inner city

There is growing evidence that Aboriginal peoples often experience healthcare inequalities due to racism. However, research exploring the healthcare experiences of Aboriginal peoples who use illicit substances is limited, and research rarely accounts for how multiple accounts of stigma intersect and contribute to the experiences of marginalized populations. Our research aimed to explore the healthcare experiences of Aboriginal peoples who use illicit drugs and or illicit alcohol (APWUID/A) living in Vancouver's inner city. Using Indigenous methodologies, a community research team comprised of APWUID/A led the study design, data collection and analysis. Peer-facilitated talking circles explored community members' experiences accessing healthcare services and patient-provider encounters. Using an intersectionality framework, our research demonstrated how healthcare inequalities among Aboriginal peoples are perpetuated by systemic racism and discrimination. Stigmatizing racial stereotypes were perceived to negatively influence individual attitudes and clinical practice. Participants' experiences of medical dismissal often resulted in disengagement from care or delay in care. The findings suggest healthcare providers must understand the structural and historical forces that influence racial disparities in healthcare and personal attitudes in clinical practice. Adequate clinical protocols for pain management within the context of illicit substance use are urgently needed. The valuation of Aboriginal peoples and cultures within healthcare is paramount to addressing the health gap between Aboriginal and non-Aboriginal Canadians.

Identifying and Addressing the Unmet Health Care Needs of Drug Court Clients

Drug courts address issues such as employment and housing but largely miss the opportunity to address important health care issues. The current study examined the prevalence and correlates of chronic medical conditions among a sample of drug court clients who were participating in a clinical trial of an intervention to reduce HIV risk. A total of 256 clients completed a health survey at entry into the drug court program and 9 months post-entry. The baseline health survey included a comprehensive list of chronic medical conditions, and participants were asked to indicate which, if any, they had ever been diagnosed as having. They were also asked to indicate whether or not they were currently receiving treatment for each chronic condition that they endorsed. The follow-up survey was identical to the baseline survey, with the exception that it contained items reflecting (1) whether or not any member of the drug court team engaged in discussion with the client about each of the chronic conditions reported and (2) whether the client received a referral to medical care for endorsed conditions while in the drug court program. Results indicated that over 50% of clients reported at least one chronic condition and 21% reported more than one condition. Among those with chronic conditions, 71% reported having chronic conditions for which they were not currently receiving treatment. Unfortunately, drug court clients reported that the drug court team did little to address these unmet health needs. Findings from this study suggest that clients could benefit if drug court programs began to widen their focus to include addressing health-related issues.

Spillover effects of HIV testing policies: changes in HIV testing guidelines and HCV testing practices in drug treatment programs in the United States

BACKGROUND

To examine the extent to which state adoption of the Centers for Disease Control and Prevention (CDC) 2006 revisions to adult and adolescent HIV testing guidelines is associated with availability of other important prevention and medical services. We hypothesized that in states where the pretest counseling requirement for HIV testing was dropped from state legislation, substance use disorder treatment programs would have higher availability of HCV testing services than in states that had maintained this requirement.

METHODS

We analyzed a nationally representative sample of 383 opioid treatment programs from the 2005 and 2011 National Drug Abuse Treatment System Survey (NDATSS). Data were collected from program directors and clinical supervisors through telephone surveys. Multivariate logistic regression models were used to measure associations between state adoption of CDC recommended guidelines for HIV pretest counseling and availability of HCV testing services.

RESULTS

The effects of HIV testing legislative changes on HCV testing practices varied by type of opioid treatment program. In states that had removed the requirement for HIV pretest counseling, buprenorphine-only programs were more likely to offer HCV testing to their patients. The positive spillover effect of HIV pretest counseling policies, however, did not extend to methadone programs and did not translate into increased availability of on-site HCV testing in either program type.

CONCLUSIONS

Our findings highlight potential positive spillover effects of HIV testing policies on HCV testing practices. They also suggest that maximizing the benefits of HIV policies may require other initiatives, including resources and programmatic efforts that support systematic integration with other services and effective implementation.

Sociodemographic and access-related correlates of health-care utilization among African American injection drug users: The BESURE study

Persons who inject drugs (PWID) may have less access to, and utilization of, health-care services, and African American PWID may be less likely than other racial groups to utilize health care in the United States. The present study evaluated the prevalence of health-care utilization (HCU) among a cohort of African American PWID in Baltimore. Data were from the 2012 Baltimore National HIV Behavioral Surveillance study. Participants were adult PWID and recruited using respondent-driven sampling (RDS). They completed a comprehensive sociobehavioral survey and voluntary HIV test with trained study interviewers. Analyses included descriptive and bivariate statistics to examine the prevalence of HCU, defined as seeing a health-care provider in the past year. Poisson regression assessed correlates of HCU. Participants were 61% male; 23% self-reported HIV seropositivity. Nearly 90% reported unemployment and/or disability; HCU prevalence was 85%. Significant negative correlates of HCU included age and higher injection frequency; positive correlates included previous incarceration and moderate financial stability. Interaction analyses showed unemployed publicly insured individuals had 30% higher HCU than unemployed and uninsured individuals (χ² = 2.52; p < .05). There is a need to improve health-care utilization among PWID. High prevalence of disability was still found, despite insurance coverage and access to care in this population. While the recent Affordable Care Act has increased health-care coverage and access, our results suggest that is only a first step to improving health outcomes among PWID; targeted intervention to integrate these individuals is still needed.

Access to primary care in adults in a provincial correctional facility in Ontario

Background

Little is known about access to primary care either prior to or following incarceration in Canada. International data demonstrate that the health of people in prisons and jails is poor, and access to primary care in the community may be inadequate for incarcerated persons. We aimed to describe the primary care experience of adults in custody in a provincial correctional facility in Ontario in the 12 months prior to admission.

Methods

We conducted a written survey, and invited all persons in the institution to participate, excluding those in segregation.

Results

One hundred and twenty-five persons participated, 16.8 % of whom were women. The median age was 33. In the 12 months prior to admission to custody, 32.2 % (95 % CI 23.5–40.8 %) of respondents did not have a family doctor or other primary care provider and 48.2 % (95 % CI 38.8–57.6 %) had unmet health needs. Participants reported a mean of 2.1 (SD = 2.8) emergency department visits in the 12 months prior to admission.

Conclusions

Study participants report a lack of access to primary care, a high mean number of emergency department visits, and high unmet health care needs in the 12 months prior to incarceration. Time in custody may present an opportunity for connecting this population with primary care and improving health.

Visits to primary care physicians among persons who inject drugs at high risk of hepatitis C virus infection: room for improvement

The role of primary care physicians (PCP) in hepatitis C virus (HCV) prevention is increasingly emphasized. Yet, little is known about the patterns of contacts with PCP among persons who inject drugs (PWID). We sought to assess the 6-month prevalence of PCP visiting among PWID at risk of HCV infection and to explore the associated factors. Baseline data were collected from HCV-seronegative PWID recruited in HEPCO, an observational Hepatitis Cohort study (2004-2011) in Montreal, Canada. An interviewer-administered questionnaire elicited information on socio-demographic factors, drug use patterns and healthcare services utilization. Blood samples were tested for HCV antibodies. Using the Gelberg-Andersen Behavioral Model, hierarchical logistic regression analyses were conducted to identify predisposing, need and enabling factors associated with PCP visiting. Of the 349 participants (mean age = 34; 80.8% male), 32.1% reported visiting a PCP. In the multivariate model, among predisposing factors, male gender [adjusted odds ratio (AOR) = 0.45 (0.25-0.83)], chronic homelessness [AOR = 0.08 (0.01-0.67)], cocaine injection [AOR = 0.46 (0.28-0.76)] and reporting greater illegal or semi-legal income [AOR = 0.48 (0.27-0.85)] were negatively associated with PCP visits. Markers of need were not associated with the outcome. Among enabling factors, contact with street nurses [AOR = 3.86 (1.49-9.90)] and food banks [AOR = 2.01 (1.20-3.37)] was positively associated with PCP visiting. Only one third of participating PWID reported a recent visit to a PCP. While a host of predisposing factors seems to hamper timely contacts with PCP among high-risk PWID, community-based support services may play an important role in initiating dialogue with primary healthcare services in this population.

Alcohol and Drug Use Among Postoperative Bariatric Patients: A Systematic Review of the Emerging Research and Its Implications

BACKGROUND

Emerging research suggests that some bariatric surgery patients are at a heightened risk for developing substance use problems, especially alcohol use problems.

METHODS

An exhaustive literature review was conducted in January 2015 to investigate all articles published that included data on postoperative alcohol use, alcohol use disorders, and illicit drug use among bariatric surgery patients.

RESULTS

Twenty-three studies reported on alcohol and/or substance use among bariatric patients. Six studies longitudinally assessed alcohol use behaviors; 3 of these studies found an increase in alcohol use following surgery. Six studies were cross-sectional, and 2 studies assessed medical records. Five studies investigated the prevalence of admissions to substance abuse treatment, and 3 studies combined alcohol and drug use data in a single index. Six studies reported on illicit drug use and reported low-postoperative use. The studies' samples were primarily non-Hispanic white females in their upper 40s, and only 11 of the 23 studies utilized validated assessment instruments.

CONCLUSIONS

Studies employing longitudinal designs and large sample sizes indicate that bariatric patients who had the gastric bypass procedure are at an elevated risk for alcohol use problems postoperatively. Research also indicates that bariatric surgery patients might be overrepresented in substance abuse treatment facilities. Risk factors for problematic postoperative alcohol use include regular or problematic alcohol use presurgery, male gender, younger age, tobacco use, and symptoms of attention deficient and hyperactivity disorder. As a whole, however, studies indicate bariatric surgery patients demonstrate a low prevalence of problematic alcohol use, and studies about gastric bypass patients are not entirely conclusive. Prospective, longitudinal studies are needed, utilizing standardized and validated alcohol assessment instruments that follow postoperative bariatric patients well beyond 2 years, and account for types of bariatric procedure. Finally, study samples with greater racial/ethnic diversity and wider age ranges are needed.

Clinical profile of injection drug users presenting to the ED

BACKGROUND

Injection drug users (IDUs) commonly use the emergency department (ED) as their primary health care access point.

OBJECTIVE

We sought to characterize infectious disease clinical presentations and laboratory results of IDUs admitted to the hospital from the ED and contrast them with those of non-IDUs.

METHODS

We enrolled all admitted adult patients with infectious disease-related diagnoses at a county level 1 trauma center from June 2010 to January 2011 and used a structured chart abstraction tool to record patient characteristics and clinical outcomes. We compared clinical presenting features, laboratory data, and microbiological culture results of IDUs with concomitantly enrolled non-IDUs.

RESULTS

Of 603 total participants, 189 were IDUs, and 414 were non-IDUs. Injection drug users had higher rates of skin and soft tissue infection admission but had similar hospital length of stay (7.5 vs 6.1 days) and mortality (2.1% vs 2.9%). Compared with non-IDUs, IDUs more commonly had hyponatremia, 38.1% vs 27.1% (mean difference, 11.4%; 95% confidence intervals [CIs], 3.4%-19.6%) and thrombocytopenia, 18.5% vs 11.0% (mean difference, 7.5%; 95% CI, 1.5%-14.2%) but less frequently had leukocytosis, 36.0% vs 52.7% (mean difference, 16.7%; 95% CI, 8.2%-24.8%). Injection drug users and non-IDUs had similar rates of positive ED-derived blood cultures, 16.5% vs 22.6% (mean difference, 6.1%; 95% CI, -13.3 to 1.7%).

CONCLUSIONS

When admitted from the ED for infectious disease-related diagnoses, IDUs had similar rates of fever, higher rates of hyponatremia and thrombocytopenia, and lower rates of leukocytosis than non-IDUs. Although they had similar rates of bacteremia, only IDUs were positive for methicillin-resistant Staphylococcus aureus.

Patterns, determinants and barriers of health and social service utilization among young urban crack users in Brazil

Background

Crack use is prevalent across the Americas, and specifically among marginalized urban street drug users in Brazil. Crack users commonly feature multiple physical and mental health problems, while low rates of and distinct barriers to help service use have been observed in these populations. This study examined profiles and determinants of social and health service utilization, and unmet service needs, in a two-city sample of young (18–24 years), marginalized crack users in Brazil.

Methods

N = 160 study participants were recruited by community-based methods from impoverished neighborhoods in the cities of Rio de Janeiro (n = 81) and Salvador (n = 79). A mixed methods protocol was used. Participants’ drug use, health, and social and health service utilization characteristics were assessed by an anonymous interviewer-administered questionnaire completed in a community setting; descriptive statistics on variables of interest were computed. Service needs and barriers were further assessed by way of several focus groups with the study population; narrative data were qualitatively analyzed. The study protocol was approved by institutional ethics review boards; data were collected between November 2010 and June 2011.

Results

The majority of the sample was male, without stable housing, and used other drugs (e.g., alcohol, marijuana). About half the sample reported physical and mental health problems, yet most had not received medical attention for these problems. Only small minorities had utilized locally available social or health services; utilization appeared to be influenced by sex, race and housing characteristics in both sites. Participants cited limited service resources, lack of needs-specific professional skills, bureaucratic barriers and stigma as obstacles to better service access. However, most respondents stated strong interest and need for general social, health and treatment services designed for the study population, for which various key features were emphasized as important.

Conclusions

The study contributes substantive evidence to current discussions about the development and utilization of health and treatment interventions for crack use in Brazil. Based on our data, crack users’ social, service needs are largely unmet; these gaps appear to partly root in systemic barriers of access to existing services, while improved targeted service offers for the target population seem to be needed also.

Differences in HIV risk behavior of injection drug users in New York City by health care setting

The purpose of this study is to examine the HIV risk behaviors and demographic characteristics of injection drug users (IDUs) by type of health care setting, which can inform development of tailored structural interventions to increase access to HIV prevention and medical treatment services. IDU syringe customers were recruited from pharmacies as part of the "Pharmacist As Resources Making Links to Community Services" (PHARM-Link) study, a randomized community-based intervention in New York City (NYC) aimed at connecting IDUs to HIV prevention, medical, and social services. An ACASI survey ascertained demographics, risk behavior, health-care utilization, and location where health care services were received in the past year. Data were analyzed using logistic regression. Of 602 participants, 34% reported receiving health care at a community clinic, 46% a private medical office, 15% a mobile medical unit, and 59% an emergency room (ER). After adjustment, participants who attended a community clinic were significantly more likely to have health insurance, report syringe sharing, and be HIV positive. Whites, nondaily injectors, insured, and higher income IDUs were more likely to attend a private medical office. Participants who recently used a case manager and had multiple sexual partners were more likely to use a mobile medical unit. ER attendees were more likely to be homeless and report recent drug treatment use. These findings show that IDU demographics and risk behaviors differ by health care setting, suggesting that risk reduction interventions should be tailored to health care settings. Specifically, these data suggest that community clinics and mobile medical units serve high-risk IDUs, highlighting the need for more research to develop and test innovative prevention and care programs within these settings.

Injection drug users' perspectives on placing HIV prevention and other clinical services in pharmacy settings

In their role as a source of sterile syringes, pharmacies are ideally situated to provide additional services to injection drug users (IDUs). Expanding pharmacy services to IDUs may address the low utilization rates of healthcare services among this population. This qualitative study of active IDUs in San Francisco explored perspectives on proposed health services and interventions offered in pharmacy settings, as well as facilitators and barriers to service delivery. Eleven active IDUs participated in one-on-one semistructured interviews at a community field site and at a local syringe exchange site between February and May 2010. Results revealed that most had reservations about expanding services to pharmacy settings, with reasons ranging from concerns about anonymity to feeling that San Francisco already offers the proposed services in other venues. Of the proposed health services, this group of IDUs prioritized syringe access and disposal, clinical testing and vaccinations, and provision of methadone. Pharmacists' and pharmacy staff's attitudes were identified as a major barrier to IDUs' comfort with accessing services. The findings suggest that although IDUs would like to see some additional services offered within pharmacy settings, this is contingent upon pharmacists and their staff receiving professional development trainings that cultivate sensitivity towards the needs and experiences of IDUs.

Smoking, HIV status, and HIV risk behaviors in a respondent-driven sample of injection drug users in Baltimore, Maryland: The BeSure Study

Tobacco use is the largest preventable cause of death in the United States. Associations between cigarette smoking and HIV risk behaviors were examined among 669 injection drug users (IDU) in the 2006 wave of the National HIV Behavioral Surveillance System in Baltimore, Maryland, using respondent-driven sampling. The adjusted prevalence of smoking among IDU was 92.1%, with 32.7% smoking < 1 pack of cigarettes per day (light smoking) and 59.3% smoking ≥ 1 packs per day (heavy smoking). Self-reported HIV prevalence decreased as smoking frequency increased (p = 0.001). In multivariate analysis, heavy smokers were more likely to report painkiller use and binge drinking and less likely to report anal sex or health care use in the past year than light smokers. Results suggest that health care use mediates the relationship between heavy smoking and self-reported HIV. Integrating smoking cessation with HIV prevention services could address unmet health needs in IDU.

Is unhealthy substance use associated with failure to receive cancer screening and flu vaccination? A retrospective cross-sectional study

Objective To compare cancer screening and flu vaccination among persons with and without unhealthy substance use. Design The authors analysed data from 4804 women eligible for mammograms, 4414 eligible for Papanicolou (Pap) smears, 7008 persons eligible for colorectal cancer (CRC) screening and 7017 persons eligible for flu vaccination. All patients were screened for unhealthy substance use. The main outcome was completion of cancer screening and flu vaccination. Results Among the 9995 patients eligible for one or more of the preventive services of interest, 10% screened positive for unhealthy substance use. Compared with women without unhealthy substance use, women with unhealthy substance use received mammograms less frequently (75.4% vs 83.8%; p<0.0001), but Pap smears no less frequently (77.9% vs 78.1%). Persons with unhealthy substance use received CRC screening no less frequently (61.7% vs 63.4%), yet received flu vaccination less frequently (44.7% vs 50.4%; p=0.01). In multivariable analyses, women with unhealthy substance use were less likely to receive mammograms (adjusted odds ratio 0.68; 95% CI 0.52 to 0.89), and persons with unhealthy substance use were less likely to receive flu vaccination (adjusted odds ratio 0.81; 95% CI 0.67 to 0.97). Conclusions Unhealthy substance use is a risk factor for not receiving all appropriate preventive health services.

Addressing the HIV-related needs of substance misusers in New York State: the benefits and barriers to implementing a "one-stop shopping" model

Substance misusers are at risk for contracting HIV/AIDS, and substance user treatment programs (SUTPs) are uniquely situated to address their HIV-related needs. In New York State, some SUTPs have implemented a centralized model of substance user treatment and HIV care. We synthesize past literature and use data from semistructured interviews with SUTP staff, analyzed with qualitative software, to describe implementation barriers. These interviews were conducted in 2003-2004 at three SUTPs in Texas and New York as part of a study funded by the National Institutes of Health. With study limitations noted, main implications include a need for a combined medical-addiction treatment philosophy to facilitate multidisciplinary care.

Health and oral health care needs and health care-seeking behavior among homeless injection drug users in San Francisco

Few existing studies have examined health and oral health needs and treatment-seeking behavior among the homeless and injection drug users (IDUs). This paper describes the prevalence and correlates of health and oral health care needs and treatment-seeking behaviors in homeless IDUs recruited in San Francisco, California, from 2003 to 2005 (N = 340). We examined sociodemographic characteristics, drug use patterns, HIV status via oral fluid testing, physical health using the Short Form 12 Physical Component Score, self-reported needs for physical and oral health care, and the self-reported frequency of seeking medical and oral health care. The sample had a lower health status as compared to the general population and reported a frequent need for physical and oral health care. In bivariate analysis, being in methadone treatment was associated with care-seeking behavior. In addition, being enrolled in Medi-Cal, California's state Medicaid program, was associated with greater odds of seeking physical and oral health care. Methamphetamine use was not associated with higher odds of needing oral health care as compared to people who reported using other illicit drugs. Homeless IDUs in San Francisco have a large burden of unmet health and oral health needs. Recent cuts in Medi-Cal's adult dental coverage may result in a greater burden of oral health care which will need to be provided by emergency departments and neighborhood dental clinics.

Barriers and Facilitators to Undergoing Hepatitis C Virus (HCV) Testing through Drug Treatment Programs

Given the high prevalence of hepatitis C virus (HCV) infection among drug users, HCV testing is critical in this population. While many drug treatment programs offer HCV testing, patients often do not utilize this essential program-facilitated service. Summarizing data collected in semi-structured interviews and surveys with patients in 25 programs, this paper identifies barriers and facilitators to being tested for HCV through the program. Barriers include the patient's belief that she/he is not HCV infected, fear of needles, fear of obtaining a positive HCV test result, fear of disclosure of such a result, and fear of inappropriate or disrespectful treatment during the testing process. In addition, 38% of HCV sero-unaware or sero-negative patients completing the survey did not know that HCV testing was offered through their programs. Salient facilitators for those tested through their programs include support from staff in explaining the importance of testing and help in understanding and coping with test results.

Exploring drug users' attitudes and decisions regarding hepatitis C (HCV) treatment in the U.S

Individuals with a history of injecting drugs are at the highest risk of becoming infected with the hepatitis C virus (HCV), with studies of patients in methadone maintenance treatment programmes (MMTPs) reporting that 60-90 percent of intravenous drug users (IDUs) have the virus. Fortunately, HCV therapy has been shown to be effective in 42-82 percent of all patients with chronic HCV infection, including IDUs. While the decision to start HCV therapy requires significant consideration, little research exists that explores the attitudes of drug users toward HCV therapy. Therefore, this paper examines how drug users perceive the treatment, as well as the processes by which HCV-positive individuals examined the advantages and disadvantages of starting the HCV medications. Interviews were conducted with 164 patients from 14 drug treatment programmes throughout the United States, and both uninfected and HCV-positive drug users described a pipeline of communication among their peers that conveys largely negative messages about the medications that are available to treat HCV. Although many of the HCV-positive individuals said that these messages heightened their anxiety about the side effects and difficulties of treatment, some patients said that their peers helped them to consider, initiate HCV treatment or both. Gaining a better understanding of drug users' perceptions of HCV treatment is important, because so many of them, particularly IDUs, are already infected with HCV and may benefit from support in addressing their HCV treatment needs. In addition, currently uninfected drug users will likely remain at high risk for contracting HCV and may need to make decisions about whether or not to start the HCV medical regimen in the future.

Longitudinal correlates of health care-seeking behaviors among HIV-seropositive injection drug users: how can we intervene to improve health care utilization?

OBJECTIVE

To identify modifiable factors associated with health care utilization by HIV-negative seropositive injection drug users (IDUs).

METHODS

We analyzed longitudinal data from 966 participants in a randomized controlled trial of a behavioral intervention designed to address medical care, adherence, and risk reduction. The outcomes of this study were usual place for care (clinic vs. emergency room) and frequency of primary care visits.

RESULTS

Results of multiple logistic regression analysis showed that increase in "importance of HIV care scale" score (odds ratio [OR]=2.99; P<0.001), empowerment (OR=3.53; P<0.001), utilization of case management (OR=3.07; P=0.007), and having a stable residence (OR=2.63; P=0.008) were significantly associated with participants being "clinic users." Increase in importance of HIV care scale score (OR=5.65; P=0.01) increased empowerment (OR=2.42; P=0.005), taking greater control of one's health (OR=2.17; P=0.001), having health insurance (OR=2.58; P=0.003), utilization of case management (OR=3.14; P=0.027), and CD4 count>or=200 cells/mm (OR=2.09; P=0.007) were significantly associated with reporting 2 or more primary HIV care visits in the past 6 months.

CONCLUSIONS

Future interventions for this population may be strengthened by addressing the importance of HIV primary care; empowering participants with respect to the health care system; and promoting linkages to case management, health insurance, and local housing programs.

Vaccine immunogenicity in injecting drug users: a systematic review

Injection drug use is a prevalent global phenomenon; one not bound by a country's level of development or geographical location. Injection drug users (IDUs) are at high risk for a variety of parenterally acquired and transmitted infections. Licensed vaccines are available for some of these infectious diseases, such as tetanus, influenza, and hepatitis A and B viruses; however, there have been conflicting reports as to their immunogenicity in IDUs. We summarise the lessons learned from studies evaluating the immunogenicity of vaccination strategies in IDUs. A common theme across these diseases is that although there is a tendency towards decreased antibody responses after immunisation, there is no conclusive evidence linking these observations to a decrease in clinical protection from infection. There is a clear need for definitive studies of vaccination strategies in IDUs; however, a synthesis of the available published evidence suggests that immunisation does result in effective clinical protection from disease in this population. The inclusion of IDUs as a high-risk study population in future trials evaluating HIV and hepatitis C virus vaccines will help to assess the immunogenicity of candidate vaccines against parenteral exposure, and also to evaluate the efficacy of candidates as promising antigens become available.

Primary care affiliations of adults in a methadone program with onsite care

Methadone maintenance treatment programs (MMTP) often provide onsite primary care. It is unclear whether patients in these settings consider the MMTP their usual source of care. We conducted cross-sectional interviews of 62 adults in an inner-city MMTP with onsite primary care to determine their usual source of care. Program enrollment ranged from 1 to 27 years (median, 4) and 63% attended > or = 5 days per week. Seventy-six percent had > or = 1 chronic disease. Only 53% reported having a usual source of care, which included hospital-based clinics (45%), the MMTP (23%), private physicians (19%), other sites (13%). Patients were more likely to identify the MMTP as their usual source of care if they had cardiovascular disease (RR 6.9, 95% CI 2.2 to 21.9) or HIV (RR 5.6, 95% CI 1.7 to 18.5). Successfully promoting appropriate utilization of onsite primary care may require a better understanding of MMTP patients' perceptions of primary care.

Utilization of health care services in hard-to-reach marginalized HIV-infected individuals

To benefit from HIV treatment advances individuals must utilize ambulatory primary care services. Few studies focus on marginalized populations, which tend to have poor health care utilization patterns. This study examined factors associated with health care utilization in hard-to-reach marginalized HIV-infected individuals. As part of a multisite initiative evaluating outreach programs that target underserved HIV-infected individuals, 610 participants were interviewed about their HIV disease, health services utilization, substance use, mental health, and case management. Primary outcomes included ambulatory, emergency department, and inpatient visits. Generalized estimating equations were used in logistic regression analyses. On regression analyses ambulatory visits were associated with having insurance (adjusted odds ratio [AOR] = 2.46), mental health medications (AOR = 7.46), and case management (AOR = 4.81). Emergency department visits were associated with having insurance (AOR = 1.74), homelessness (AOR = 2.23), poor health status (AOR = 2.02), length of HIV infection (AOR = 2.02), mental health care (AOR = 1.47), mental health medications (AOR = 1.59), and heavy alcohol intake (AOR = 1.46). Hospitalizations were associated with high school education (AOR = 1.57), having insurance (AOR = 10.45), homelessness (AOR = 2.18), poor health status (AOR = 2.64), length of HIV infection (AOR = 2.03), and mental health medications (AOR = 1.87). In hard-to-reach marginalized HIV-infected individuals, having insurance, case management and mental health care were associated with increased ambulatory visits. These findings support HIV multidisciplinary care with marginalized populations. Understanding factors associated with health care utilization is essential for outreach programs to facilitate engagement in HIV care.

Type of substance use and access to HIV-related health care

HIV-infected substance users have poorer health outcomes than other HIV risk groups. Few studies have examined the impact of specific types of substance use on health care. This study investigated the associations between specific types of substances of abuse and access to health care. HIV-infected individuals living in eight different single room occupancy hotels in the Bronx, New York, were interviewed between August 1999 and February 2001 regarding demographics, health care access and utilization, and drug and alcohol use. Of the 238 participants, the majority were male (59%), black or Hispanic (93%), and active drug users (61%). Individuals reporting any drug or crack/cocaine use were less likely to have a regular provider than those reporting no drug or no crack/cocaine use (adjusted odds ratio [AOR] = 0.50, p = 0.05; AOR =0.35, p = 0.004, respectively), while those with binge alcohol use were more likely to have a regular doctor than those without binge alcohol use (AOR = 2.61, p = 0.05). Individuals reporting any drug or crack/cocaine use were also less likely to perceive quality of health care positively (AOR = 0.50, p = 0.02; AOR = 0.37, p = 0.002, respectively). Heroin use, and injection drug use were not associated with these outcomes. When the sample was limited to recent drug users, similar patterns were found. Although drug use in general is associated with negative health outcomes, in this study, poorer measures of access to health care among substance users was associated predominantly with crack/cocaine use. It is important that clinicians and researchers working with substance-using populations understand how specific types of substance use differentially impact on health care.

Unmet need for recommended preventive health services among clients of California syringe exchange programs: implications for quality improvement

BACKGROUND

Comprehensive preventive services are recommended for injection drug users (IDU), including screening tests, vaccinations, risk reduction counseling, and sterile syringes. Syringe exchange programs (SEP) may facilitate receipt of preventive services by IDUs, but whether SEP clients receive recommended preventive care is not known. We examined use of recommended preventive services by clients of 23 SEPs throughout California.

METHODS

Five hundred and sixty SEP clients were recruited from 23 SEPs throughout California between March and September 2003. Receipt of 10 recommended preventive services and source of care (SEP versus non-SEP providers) was ascertained from client interviews.

RESULTS

On average, SEP clients received only 13% of recommended preventive services and 49% of clients received none of the recommended services. Of services that were received, 76% were received from SEPs. In multivariate analysis, use of drug treatment and more frequent SEP visits were associated with receipt of recommended preventive services by clients.

CONCLUSIONS

SEPs are often the only source of preventive care for their IDU clients. Still, SEP clients fail to receive most recommended preventive services. Interventions to increase use of preventive services and improve the quality of preventive care received by IDUs, such as increased access to drug treatment and SEPs, are needed.

Factors predicting unmet health services needs among incarcerated substance users

Negative health consequences of illicit drug use, such as cardiovascular complications and infectious diseases, increase the likelihood of the need for health care. However, evidence suggests that, with the exception of emergency services, drug users generally are medically underserved. Furthermore, the effect of illicit drug use on health care utilization is becoming an especially important issue for the criminal justice system, because an increasing proportion of inmates in correctional institutions have a history of drug use. This 1998-1999 study of 661 incarcerated men in the Kentucky prison system focused on predictors of unmet physical, behavioral, and overall health care needs among chronic substance users. Analyses revealed that White incarcerated drug users were more likely to report unmet physical and overall health care needs than non-Whites and those with high school education or above were more likely to report unmet physical, behavioral, and overall health care needs. In addition, more episodes of serious illness, more mental health problems, and poorer self-rated health were predictive of all three types of unmet health care needs. A longer career of drug use emerged as a significant predictor of unmet behavioral health care needs, whereas more frequent drug use in the year before incarceration predicted unmet physical health care needs. Further research directions and implications for in-prison health care planning are discussed.

Health care access and utilization patterns in unstably housed HIV-infected individuals in New York City

As part of a multisite initiative to evaluate outreach targeting underserved HIV-infected individuals, we describe baseline characteristics of unstably housed HIV-infected individuals from New York City, and their health care access and utilization patterns. Interviews with 150 HIV-infected single room occupancy (SRO) hotel residents on health care access and utilization, barriers to accessing health care, demographic characteristics, history of incarceration, severity of HIV disease, depressive symptoms, substance use, and exposure to violence were conducted. Most participants were 40 years of age or older, male, black or Latino, had public insurance, a history of substance use, depressive symptoms, and a CD4(+) count above 200 cells/mm(3). Access to and utilization of care was high with 91% reporting having a regular provider, 95% identifying a non-emergency department (ED) clinic or office as their usual location of care, 89% reporting at least one ambulatory visit, and 82% reporting optimal (>/=2) ambulatory visits during the previous 6 months. Additionally, 45% reported at least one ED visit, and 30% at least one hospitalization within the previous 6 months. Among black and Latino marginalized SRO hotel residents in New York City, this study found surprisingly high measures of access to and utilization of ambulatory care services, along with high use of acute care services. Understanding HIV-related health services access and utilization patterns among marginalized populations is essential to improve their HIV care. These patterns of high levels of access to and utilization of health care services contradict clinical experiences and other studies, and require further exploration.

The experience of chronic severe pain in patients undergoing methadone maintenance treatment

Recent studies indicate that severe chronic pain is common among patients in methadone maintenance treatment (MMT), but no qualitative studies have examined such patients' experiences of pain and pain treatment. This study used qualitative methods to explore the experiences of MMT patients with chronic pain. Twelve patients screening positive for chronic severe pain on the Brief Pain Inventory were interviewed for the study. Results suggest that chronic severe pain has major consequences in the lives of methadone maintenance patients and may be linked to illegal drug use, social isolation, and role failure. A variety of barriers limited access to effective treatment. A common complaint with care was providers' lack of concern or inability to "listen." Patients who were satisfied with treatment focuses on the psychosocial dimensions of care. These preliminary results suggest that treatment approaches should emphasize emotional support, negotiation of explanatory models, and an emphasis on the psychosocial sequelae of pain. However, more research is needed to guide the development of effective treatment strategies.

Use of emergency room services by out-of-treatment drug users in Long Beach, California

The purpose of this study was to investigate the use of emergency room services among out-of-treatment drug users in Long Beach, CA. Primary data collection occurred between 1991-1996. The study setting was a community-based location through which out-of-treatment drug users were recruited using a standard research protocol. The original study randomized 1,728 participants into a standard or enhanced HIV prevention protocol. Data were collected longitudinally at two points in time, with 1,201 returning for follow-up interview. Standardized instruments were used at baseline and follow-up. Logistic regression and test-retest reliability were performed using the SAS System. Factors associated with emergency room use included income from public assistance sources, ever using other opiates, income less than 500 dollars in the last month, reporting White race/ethnicity, and HIV positive serostatus. Having income from public assistance programs is highly predictive of emergency room use in out-of-treatment drug users.

Satisfaction with access to health care among injection drug users, other drug users, and nonusers

This article examines the satisfaction of users of cocaine and/or opiates and non-drug users with access to the health care system. Data were obtained from a sample of 1,477 injection drug users, non-injection drug users, and non-drug users recruited from neighborhoods with high drug use. Multiple regression examined the relationship between satisfaction with access to health care and demographic, health status and health care utilization, ability to pay, and alcohol and drug use variables. Age, ethnicity, health status, having received health care in the last 12 months, not having received health care when needed, having received preventive health care, health insurance, and drug use were independently associated with satisfaction. Injection drug users and non-injection drug users were less satisfied with access to health care. The article discusses strategies to improve health care delivery to drug users.

Met and unmet need for dental services among active drug users in Miami, Florida

This study considers both met and unmet need for dental services among chronic drug users in Miami, Florida, and compares them with non-drug users recruited from the same neighborhoods (N = 1,479). Three primary findings emerged: (1) dental problems are among the most frequently reported health problems, (2) drug use is independently associated with need for dental services, and (3) injection drug use is independently associated with increased odds of unmet need for dental services. These findings suggest that policies that increase access to dental services for drug users and other disadvantaged groups are needed. These services could be integrated into existing behavioral health programs already targeting active drug users.