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Emenyonu N, Kekibiina A, Woolf-King S, Kyampire C, Fatch R, Dawson-Rose C, Muyindike W, Hahn J. Digital Health Screening in People With HIV in Uganda to Increase Alcohol Use Reporting: Qualitative Study on the Development and Testing of the Self-administered Digital Screener for Health. JMIR Form Res 2022; 6:e35015. [PMID: 36048519 PMCID: PMC9478818 DOI: 10.2196/35015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 06/10/2022] [Accepted: 07/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background Alcohol consumption is a critical driver of the HIV epidemic worldwide, particularly in sub-Saharan Africa, where unhealthy alcohol use and HIV are prevalent. Brief alcohol interventions are effective in reducing alcohol use; however, they depend on effective screening for unhealthy alcohol use, which is often underreported. Thus, there is a need to develop methods to improve reporting of unhealthy alcohol use as an essential step toward referral to brief alcohol interventions. Self-administered digital health screeners may improve reporting. Objective This study aimed to develop and test a digital, easy-to-use self-administered health screener. The health screener was designed to be implemented in a busy, underresourced HIV treatment setting and used by patients with varying levels of literacy. Methods We conducted a qualitative study at the Immune Suppression Syndrome (ISS) Clinic of Mbarara Regional Referral Hospital in Uganda to develop and test a digital self-administered health screener. The health screener included a training module and assessed behaviors regarding general health, HIV care, and mental health as well as sensitive topics such as alcohol use and sexual health. We conducted focus group discussions with clinicians and patients with HIV of the Mbarara ISS Clinic who consumed alcohol to obtain input on the need for and content, format, and feasibility of the proposed screener. We iteratively revised a tablet-based screener with a subset of these participants, piloted the revised screener, and conducted individual semistructured in-depth interviews with 20 participants who had taken part in our previous studies on alcohol and HIV, including those who had previously underreported alcohol use and with low literacy. Results A total of 45 people (n=5, 11% clinicians and n=40, 89% Mbarara ISS Clinic patients) participated in the study. Of the patient participants, 65% (26/40) were male, 43% (17/40) had low literacy, and all (40/40, 100%) had self-reported alcohol use in previous studies. Clinicians and patients cited benefits such as time savings, easing of staff burden, mitigation of patient-provider tension around sensitive issues, and information communication, but also identified areas of training required, issues of security of the device, and confidentiality concerns. Patients also stated fear of forgetting how to use the tablet, making mistakes, and losing information as barriers to uptake. In pilot tests of the prototype, patients liked the feature of a recorded voice in the local language and found the screener easy to use, although many required additional help and training from the study staff to complete the screener. Conclusions We found a self-administered digital health screener to be appealing to patients and clinicians and usable in a busy HIV clinic setting, albeit with concerns about confidentiality and training. Such a screener may be useful in improving reporting of unhealthy alcohol use for referral to interventions.
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Affiliation(s)
- Nneka Emenyonu
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Allen Kekibiina
- MUST Grants Office, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Sarah Woolf-King
- Department of Psychology, Syracuse University, Syracuse, NY, United States
| | - Catherine Kyampire
- MUST Grants Office, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Robin Fatch
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Carol Dawson-Rose
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Winnie Muyindike
- MUST Grants Office, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Judith Hahn
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
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Prevalence and Correlates of Positive Follow-up Screens in Primary Care for Unhealthy Alcohol and Other Drug Use After a Negative Screen. J Addict Med 2021; 16:e219-e224. [PMID: 34799491 DOI: 10.1097/adm.0000000000000917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the proportion and characteristics of adults in primary care (PC) who screen positive for unhealthy substance use (SU) (alcohol and/or other drug) 1 year or more after screening negative. METHODS Screening consisted of single-item questions for unhealthy use of alcohol and other drugs (illicit drugs and prescription medications). Health educators conducted in-person screening of patients presenting for a PC appointment. SU severity (low, moderate, high) was assessed with the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). Multivariate logistic regression models estimated predictors of a positive follow-up screen. RESULTS Among 9215 patients who previously screened negative, 237 (2.6%) screened positive for unhealthy SU (42% alcohol only, 43% other drug only, 15% alcohol and other drug). The mean interval between screens was 19 months. Most alcohol use was low risk (ASSIST score ≤ 10) (81%), whereas most drug use was moderate risk (ASSIST score 4-26) (77%). Patients between ages of 18 to 25 had a higher proportion of positive follow-up screens (7.4% [33/443]) as well as those with a self-identified history of SU problems (9.4% [40/421]). Patients with a higher odds of a positive follow-up screen were male (adjusted odds ratio [AOR] 2.64; 95% CI: 2.02-3.45), used tobacco (AOR 2.38; 95% CI: 1.75-3.23), had a longer interval between screenings (AOR 3.26; 95% CI: 1.84-5.75). CONCLUSIONS Screening for unhealthy SU 1 year or more after screening negative identified additional patients at-risk. These findings highlight the need to empirically determine the incremental benefits of screening all PC patients annually.
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Singer A, Kosowan L, Loewen S, Spitoff S, Greiver M, Lynch J. Who is asked about alcohol consumption? A retrospective cohort study using a national repository of Electronic Medical Records. Prev Med Rep 2021; 22:101346. [PMID: 33767948 PMCID: PMC7980052 DOI: 10.1016/j.pmedr.2021.101346] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 01/05/2021] [Accepted: 02/20/2021] [Indexed: 11/17/2022] Open
Abstract
Documentation of alcohol use in electronic medical record (EMR) informs interventions to reduce alcohol-related morbidity and mortality. This retrospective cohort study explored EMR data from 960 primary care providers participating in the Canadian Primary Care Sentinel Surveillance Network to describe documentation of alcohol use (e.g. none, current or past use) in the EMR. Included providers represented 700,620 adult patients from across Canada with an encounter between 2015 and 2018. Bivariate comparisons characterized the patients with, and without, documentation of alcohol use. Multivariate generalized estimating equation models with logit function assessed patient and provider characteristics associated with (1) documentation of alcohol and (2) patients with heightened risk for alcohol-related problems. Forty percent of patients had alcohol use documentation in the EMR. Light alcohol consumption was recorded for 43.6% of these patients. Male patients (OR1.09, CI 1.07-1.12), who were older (OR1.26, CI 1.23-1.30), had more frequent visits to their provider (OR1.11, CI 1.09-1.13) and had hypertension (OR1.07, CI 1.06-1.09) or depression (OR1.07, CI 1.09-1.14) had higher odds of alcohol documentation. There were 4.7% of patients with a record indicating heightened risk for alcohol-related problems. Male patients (OR3.27 CI 3.14-3.4), patients with depression (OR2.01 CI1.93-2.1) and rural residency (OR1.35 CI1.29-1.42) was associated with risk for alcohol-related problems. Heavy alcohol consumption is associated with an increased risk of negative health outcomes, particularly for patients with certain chronic conditions. However, these patients do not have alcohol use consistently documented in the EMR. Strategies should be designed and implemented to support more consistent alcohol-screening among high-risk patients.
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Affiliation(s)
- Alexander Singer
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Corresponding author at: Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, D009-780 Bannatyne Ave., Winnipeg, Manitoba R3T2N2, Canada.
| | - Leanne Kosowan
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shilpa Loewen
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sheryl Spitoff
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Greiver
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Joanna Lynch
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Intention to Drive After Drinking Among Medical Students: Contributions of the Protection Motivation Theory. J Addict Med 2016; 11:70-76. [PMID: 27898498 DOI: 10.1097/adm.0000000000000276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The aim of this study was to investigate whether cognitive variables proposed by the protection motivation theory (PMT) were predictive of occasional and frequent intention to drive after drinking in medical students. METHODS One hundred fifty-five students attending preclinical years at a Medical School in São Paulo, Brazil, participated in the study. They were asked about their last month substance use, history of drinking and driving, including driving after binge drinking, and risk perceptions based on a self-report questionnaire with statements about protection motivation, threat, and coping appraisals from the PMT model. RESULTS Fifty-two students (33%) had previous experience of driving after drinking during the last year, and 54 students (35%) reported intention to drive after drinking within the next year. Regression analysis showed that higher scores in perception of personal vulnerability to risks were associated with occasional and frequent intention to continue pursuing this particular behavior. Poorer evaluations about short-term consequences of alcohol consumption and cognitions regarding external rewards were significantly associated with reported intention to continue driving after drinking. CONCLUSIONS Considering the social and health impact of alcohol-impaired behaviors, our findings suggest the need of interventional efforts focused in increasing students' awareness about the negative consequences of drinking and driving aiming to enhance their motivation towards more adaptive behaviors.
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Mundt MP, Zakletskaia LI, Shoham DA, Tuan WJ, Carayon P. Together Achieving More: Primary Care Team Communication and Alcohol-Related Healthcare Utilization and Costs. Alcohol Clin Exp Res 2015; 39:2003-15. [PMID: 26350957 DOI: 10.1111/acer.12831] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 06/29/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Identifying and engaging excessive alcohol users in primary care may be an effective way to improve patient health outcomes, reduce alcohol-related acute care events, and lower costs. Little is known about what structures of primary care team communication are associated with alcohol-related patient outcomes. METHODS Using a sociometric survey of primary care clinic communication, this study evaluated the relation between team communication networks and alcohol-related utilization of care and costs. Between May 2013 and December 2013, a total of 155 healthcare employees at 6 primary care clinics participated in a survey on team communication. Three-level hierarchical modeling evaluated the link between connectedness within the care team and the number of alcohol-related emergency department visits, hospital days, and associated medical care costs in the past 12 months for each team's primary care patient panel. RESULTS Teams (n = 31) whose registered nurses displayed more strong (at least daily) face-to-face ties and strong (at least daily) electronic communication ties had 10% fewer alcohol-related hospital days (rate ratio [RR] = 0.90; 95% confidence interval [CI]: 0.84, 0.97). Furthermore, in an average team size of 19, each additional team member with strong interaction ties across the whole team was associated with $1,030 (95% CI: -$1,819, -$241) lower alcohol-related patient healthcare costs per 1,000 team patients in the past 12 months. Conversely, teams whose primary care practitioner (PCP) had more strong face-to-face communication ties and more weak (weekly or several times a week) electronic communication ties had 12% more alcohol-related hospital days (RR = 1.12; 95% CI: 1.03, 1.23) and $1,428 (95% CI: $378, $2,478) higher alcohol-related healthcare costs per 1,000 patients in the past 12 months. The analyses controlled for patient age, gender, insurance, and comorbidity diagnoses. CONCLUSIONS Excessive alcohol-using patients may fair better if cared for by teams whose face-to-face and electronic communication networks include more team members and whose communication to the PCP has been streamlined to fewer team members.
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Affiliation(s)
- Marlon P Mundt
- Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Larissa I Zakletskaia
- Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - David A Shoham
- Stritch School of Medicine, Loyola University Chicago Stritch School of Medicine, Chicago, Illinois
| | - Wen-Jan Tuan
- Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Pascale Carayon
- College of Engineering, University of Wisconsin-Madison, Madison, Wisconsin
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Klimas J, Marie Henihan A, McCombe G, Swan D, Anderson R, Bury G, Dunne C, Keenan E, Saunders J, Shorter GW, Smyth BP, Cullen W. Psychosocial Interventions for Problem Alcohol Use in Primary Care Settings (PINTA): Baseline Feasibility Data. J Dual Diagn 2015; 11:97-106. [PMID: 25985200 DOI: 10.1080/15504263.2015.1027630] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Many individuals receiving methadone maintenance receive their treatment through their primary care provider. As many also drink alcohol excessively, there is a need to address alcohol use to improve health outcomes for these individuals. We examined problem alcohol use and its treatment among people attending primary care for methadone maintenance treatment, using baseline data from a feasibility study of an evidence-based complex intervention to improve care. METHODS Data on addiction care processes were collected by (1) reviewing clinical records (n = 129) of people who attended 16 general practices for methadone maintenance treatment and (2) administering structured questionnaires to both patients (n = 106) and general practitioners (GPs) (n = 15). RESULTS Clinical records indicated that 24 patients (19%) were screened for problem alcohol use in the 12 months prior to data collection, with problem alcohol use identified in 14 (58% of those screened, 11% of the full sample). Of those who had positive screening results for problem alcohol use, five received a brief intervention by a GP and none were referred to specialist treatment. Scores on the Alcohol Use Disorders Identification Test (AUDIT) revealed the prevalence of hazardous, harmful, and dependent drinking to be 25% (n = 26), 6% (n = 6), and 16% (n = 17), respectively. The intraclass correlation coefficient (ICC) for the proportion of patients with negative AUDITs was 0.038 (SE = 0.01). The ICCs for screening, brief intervention, and/or referral to treatment (SBIRT) were 0.16 (SE = 0.014), -0.06 (SE = 0.017), and 0.22 (SE = 0.026), respectively. Only 12 (11.3%) AUDIT questionnaires concurred with corresponding clinical records that a patient had any/no problem alcohol use. Regular use of primary care was evident, as 25% had visited their GP more than 12 times during the past 3 months. CONCLUSIONS Comparing clinical records with patients' experience of SBIRT can shed light on the process of care. Alcohol screening in people who attend primary care for substance use treatment is not routinely conducted. Interventions that enhance the care of problem alcohol use among this high-risk group are a priority.
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Frank DA, Kuranz S, Appugliese D, Cabral H, Chen C, Crooks D, Heeren T, Liebschutz J, Richardson M, Rose-Jacobs R. Problematic substance use in urban adolescents: role of intrauterine exposures to cocaine and marijuana and post-natal environment. Drug Alcohol Depend 2014; 142:181-90. [PMID: 24999059 PMCID: PMC4180288 DOI: 10.1016/j.drugalcdep.2014.06.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Revised: 05/16/2014] [Accepted: 06/11/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Linkages between intrauterine exposures to cocaine and marijuana and adolescents' problematic substance use have not been fully delineated. METHODS Prospective longitudinal study with assessors unaware of intrauterine exposure history followed 157 urban participants from birth until late adolescence. Level of intrauterine exposures was identified by mother's report and infant's meconium. Problematic substance use, identified by the Voice Diagnostic Interview Schedule for Children (V-DISC) or the Audio Computer Assisted Self-Interview (ACASI) and urine assay, was a composite encompassing DSM-IV indication of tolerance, abuse, and dependence on alcohol, marijuana, and tobacco and any use of cocaine, glue, or opiates. RESULTS Twenty percent (32/157) of the sample experienced problematic substance use by age 18 years, of whom the majority (22/157) acknowledged abuse, tolerance or dependence on marijuana with or without other substances. Structural equation models examining direct and indirect pathways linking a Cox survival model for early substance initiation to a logistic regression models found effects of post-natal factors including childhood exposure to violence and household substance use, early youth substance initiation, and ongoing youth violence exposure contributing to adolescent problematic substance use. CONCLUSION We did not identify direct relationships between intrauterine cocaine or marijuana exposure and problematic substance use, but did find potentially modifiable post-natal risk factors also noted to be associated with problematic substance use in the general population including earlier substance initiation, exposure to violence and to household substance use.
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Affiliation(s)
- Deborah A. Frank
- Department of Pediatrics, Boston University School of Medicine and Boston Medical Center, 771 Albany Street, Dowling Ground, Boston, MA 02118, United States
| | - Seth Kuranz
- Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118, United States
| | - Danielle Appugliese
- Data Coordinating Center, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118, United States
| | - Howard Cabral
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Avenue, 3rd floor, Boston, MA 02118, United States
| | - Clara Chen
- Data Coordinating Center, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118, United States
| | - Denise Crooks
- Department of Pediatrics, Boston Medical Center, 771 Albany Street, Dowling Ground, Boston, MA 02118, United States
| | - Timothy Heeren
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Avenue, 3rd floor, Boston, MA 02118, United States
| | - Jane Liebschutz
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, 801 Massachusetts Avenue, 3rd floor, Boston, MA 02118, United States
| | - Mark Richardson
- Department of Psychiatry, Boston University School of Medicine, 771 Albany Street, Dowling 7 Boston, Massachusetts 02118, United States
| | - Ruth Rose-Jacobs
- Department of Pediatrics, Boston University School of Medicine and Boston Medical Center, 771 Albany Street, Dowling Ground, Boston, MA 02118, United States
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Saitz R, Palfai TPA, Cheng DM, Alford DP, Bernstein JA, Lloyd-Travaglini CA, Meli SM, Chaisson CE, Samet JH. Screening and brief intervention for drug use in primary care: the ASPIRE randomized clinical trial. JAMA 2014; 312:502-13. [PMID: 25096690 PMCID: PMC4667772 DOI: 10.1001/jama.2014.7862] [Citation(s) in RCA: 226] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The United States has invested substantially in screening and brief intervention for illicit drug use and prescription drug misuse, based in part on evidence of efficacy for unhealthy alcohol use. However, it is not a recommended universal preventive service in primary care because of lack of evidence of efficacy. OBJECTIVE To test the efficacy of 2 brief counseling interventions for unhealthy drug use (any illicit drug use or prescription drug misuse)-a brief negotiated interview (BNI) and an adaptation of motivational interviewing (MOTIV)-compared with no brief intervention. DESIGN, SETTING, AND PARTICIPANTS This 3-group randomized trial took place at an urban hospital-based primary care internal medicine practice; 528 adult primary care patients with drug use (Alcohol, Smoking, and Substance Involvement Screening Test [ASSIST] substance-specific scores of ≥4) were identified by screening between June 2009 and January 2012 in Boston, Massachusetts. INTERVENTIONS Two interventions were tested: the BNI is a 10- to 15-minute structured interview conducted by health educators; the MOTIV is a 30- to 45-minute intervention based on motivational interviewing with a 20- to 30-minute booster conducted by master's-level counselors. All study participants received a written list of substance use disorder treatment and mutual help resources. MAIN OUTCOMES AND MEASURES Primary outcome was number of days of use in the past 30 days of the self-identified main drug as determined by a validated calendar method at 6 months. Secondary outcomes included other self-reported measures of drug use, drug use according to hair testing, ASSIST scores (severity), drug use consequences, unsafe sex, mutual help meeting attendance, and health care utilization. RESULTS At baseline, 63% of participants reported their main drug was marijuana, 19% cocaine, and 17% opioids. At 6 months, 98% completed follow-up. Mean adjusted number of days using the main drug at 6 months was 12 for no brief intervention vs 11 for the BNI group (incidence rate ratio [IRR], 0.97; 95% CI, 0.77-1.22) and 12 for the MOTIV group (IRR, 1.05; 95% CI, 0.84-1.32; P = .81 for both comparisons vs no brief intervention). There were also no significant effects of BNI or MOTIV on any other outcome or in analyses stratified by main drug or drug use severity. CONCLUSIONS AND RELEVANCE Brief intervention did not have efficacy for decreasing unhealthy drug use in primary care patients identified by screening. These results do not support widespread implementation of illicit drug use and prescription drug misuse screening and brief intervention. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00876941.
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Affiliation(s)
- Richard Saitz
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts2Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston
| | - Tibor P A Palfai
- Department of Psychology, Boston University, Boston, Massachusetts
| | - Debbie M Cheng
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts4Department of Biostatistics, Boston University Schoo
| | - Daniel P Alford
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - Judith A Bernstein
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
| | | | - Seville M Meli
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
| | - Christine E Chaisson
- Data Coordinating Center, Boston University School of Public Health, Boston, Massachusetts
| | - Jeffrey H Samet
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts2Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston
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