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Nowels MA, Duberstein PR, Crystal S, Treitler P, Miles J, Olfson M, Samples H. Suicide within 1 year of non-fatal overdose: Risk factors and risk reduction with medications for opioid use disorder. Gen Hosp Psychiatry 2024; 86:24-32. [PMID: 38061284 PMCID: PMC10880030 DOI: 10.1016/j.genhosppsych.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/15/2023] [Accepted: 11/03/2023] [Indexed: 01/27/2024]
Abstract
OBJECTIVE Individuals with substance use disorders and overdoses have high risk of suicide death, but evidence is limited on the relationship between interventions following the initial overdose and subsequent suicide death. METHODS National Medicare data were used to identify Medicare disability beneficiaries (MDBs) with inpatient or emergency care for non-fatal opioid overdoses from 2008 to 2016. Data were linked with National Death Index (NDI) to obtain dates and causes of death for the sample. Cox proportional hazards models estimated the associations between exposure to interventions (mechanical ventilation, MOUD) and suicide death. RESULTS The sample (n = 81,654) had a suicide rate in the year following a non-fatal overdose of 566 per 100,000 person-years. Post-overdose MOUD was associated with an adjusted hazard ratio of 0.20 (95%CI: 0.05,0.85). Risk of suicide was elevated for those whose initial overdoses required mechanical ventilation as part of the treatment (aHR: 1.86, 95%CI:[1.48,2.34]). CONCLUSIONS The year following a non-fatal opioid overdose is a very high-risk period for suicide among MDBs. Those receiving MOUD had an 80% reduction in the hazards of suicide, while those whose overdose treatment involved mechanical ventilation had 86% higher hazards of death by suicide. Our findings highlight the importance of psychiatric intervention in this high-risk population. Efforts are needed to initiate and retain more patients in MOUD.
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Affiliation(s)
- Molly A Nowels
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, 683 Hoes Lane West, Piscataway, NJ 08854, USA; Institute for Health, Health Care Policy, and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ 08901, USA.
| | - Paul R Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, 683 Hoes Lane West, Piscataway, NJ 08854, USA
| | - Stephen Crystal
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ 08901, USA
| | - Peter Treitler
- School of Social Work, Boston University, 264 Bay State Road, Boston, MA 02215, USA
| | - Jennifer Miles
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ 08901, USA
| | - Mark Olfson
- New York Psychiatric Institute, Columbia University, 1051 Riverside Drive, New York, NY 10032, USA
| | - Hillary Samples
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, 683 Hoes Lane West, Piscataway, NJ 08854, USA; Institute for Health, Health Care Policy, and Aging Research, Rutgers University, 112 Paterson St, New Brunswick, NJ 08901, USA
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Miles J, Treitler P, Hermida R, Nyaku AN, Simon K, Gupta S, Crystal S, Samples H. Racial/ethnic disparities in timely receipt of buprenorphine among Medicare disability beneficiaries. Drug Alcohol Depend 2023; 252:110963. [PMID: 37748421 PMCID: PMC10615876 DOI: 10.1016/j.drugalcdep.2023.110963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Medicare disability beneficiaries (MDBs) have disproportionately high risk of opioid use disorder (OUD) and related harms given high rates of comorbidities and high-dose opioid prescribing. Despite this increased risk, little is known about timely receipt of medication for opioid use disorder (MOUD), including potential disparities by patient race/ethnicity or moderation by county-level characteristics. METHODS National Medicare claims for a sample of MDBs with incident OUD diagnosis between March 2016 and June 2019 were linked with county-level data. Multivariable mixed effects Cox proportional hazards models estimated time (in days) to buprenorphine receipt within 180 days of incident OUD diagnosis. Primary exposures included individual-level race/ethnicity and county-level buprenorphine prescriber availability, percent non-Hispanic white (NHW) residents, and Social Deprivation Index (SDI) score. RESULTS The sample (n=233,079) was predominantly White (72.3%), ≥45 years old (76.3%), and male (54.8%). Black (adjusted hazard ratio [aHR]=0.50; 95% CI, 0.47-0.54), Asian/Pacific Islander (aHR=0.54; 95% CI, 0.41-0.72), Hispanic/Latinx (aHR=0.81; 95% CI, 0.76-0.87), and Other racial/ethnic groups (aHR=0.75; 95% CI, 0.58-0.97) had a lower likelihood of timely buprenorphine than non-Hispanic white beneficiaries after adjusting for individual and county-level confounders. Timely buprenorphine receipt was positively associated with county-level buprenorphine prescriber availability (aHR=1.05; 95% CI, 1.04-1.07), percent non-Hispanic white residents (aHR=1.01; 95% CI, 1.00-1.01), and SDI (aHR=1.06; 95% CI, 1.01-1.10). CONCLUSIONS Racial/ethnic disparities highlight the need to improve access to care for underserved groups. Implementing equity-focused quality and performance measures and developing interventions to increase office-based buprenorphine prescribing in predominantly minority race/ethnicity counties may reduce disparities in timely access to medication for OUD.
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Affiliation(s)
- Jennifer Miles
- Rutgers Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ, USA.
| | - Peter Treitler
- Rutgers Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ, USA; School of Social Work, Rutgers University, New Brunswick, NJ, USA
| | - Richard Hermida
- Rutgers Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ, USA
| | - Amesika N Nyaku
- Department of Medicine, Division of Infectious Diseases, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Kosali Simon
- O'Neill School of Public and Environmental Affairs, Indiana University, Bloomington, IN, USA; National Bureau of Economic Research, Cambridge, MA, USA
| | - Sumedha Gupta
- Department of Economics, Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA
| | - Stephen Crystal
- Rutgers Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ, USA; School of Social Work, Rutgers University, New Brunswick, NJ, USA; School of Public Health, Rutgers University, Piscataway, NJ, USA
| | - Hillary Samples
- Rutgers Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ, USA; Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, NJ, USA
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Niznik JD, Hughes T, Armistead LT, Kashyap J, Roller J, Busby-Whitehead J, Ferreri SP. Patterns and disparities in prescribing of opioids and benzodiazepines for older adults in North Carolina. J Am Geriatr Soc 2023; 71:1944-1951. [PMID: 36779609 PMCID: PMC10258120 DOI: 10.1111/jgs.18288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/18/2023] [Accepted: 01/25/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND We characterized real-world prescribing patterns of opioids and benzodiazepines (BZDs) for older adults to explore potential disparities by race and sex and to characterize patterns of co-prescribing. METHODS A retrospective evaluation was conducted using electronic health data for adults ≥65 years old who presented to one of 15 primary care practices between 2019 and 2020 (n = 25,141). Chronic opioid and BZD users had ≥4 prescriptions in the year prior, with at least one in the last 90 or 180 days, respectively. We compared demographic characteristics between all older adults versus chronic opioid and BZD users. We used logistic regression to identify characteristics (age, sex, race, Medicaid use, fall history) associated with opioid and BZD co-prescribing. RESULTS We identified 833 (3.3%) chronic opioid and 959 chronic BZD users (3.8%) among all older adults seen in these practices. Chronic opioid users were less likely to be Black (12.7% vs. 14.3%) or other non-White race (1.4% vs. 4.3%), but more likely to be women (66.8% vs. 61.3%). A similar trend was observed for BZD users, with less prescribing among Black (5.4% vs. 14.3%) and other races (2.2% vs. 4.3%) older adults and greater prescribing among women (73.6% vs. 61.3%). Co-prescribing was observed among 15% of opioid users and 13% of BZD users. Co-prescribing was largely driven by the presence of relevant co-morbid conditions including chronic pain, anxiety, and insomnia rather than demographic characteristics. CONCLUSIONS We observed notable disparities in opioid and BZD prescribing by sex and race among older adults in primary care. Future research should explore if such patterns reflect appropriate prescribing or are due to disparities in prescribing driven by biases related to perceived risks for misuse.
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Affiliation(s)
- Joshua D Niznik
- Division of Geriatric Medicine, Department of Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
- UNC Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Tamera Hughes
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Lori T Armistead
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Jayanth Kashyap
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jessica Roller
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Jan Busby-Whitehead
- Division of Geriatric Medicine, Department of Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
- UNC Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Stefanie P Ferreri
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
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Predictors of older adults' chronic pain in the context of opioid adverse drug events. J Am Assoc Nurse Pract 2022; 34:968-977. [PMID: 35652802 DOI: 10.1097/jxx.0000000000000734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 04/15/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Factors predictive of chronic pain in older adults could help focus prevention and treatment efforts for those most at risk of chronic pain. PURPOSE The objective of the study was to describe demographic and pain self-management factors predictive of chronic pain in the context of opioid adverse drug events (ADEs) reported for a cohort of older adults within the same year. METHOD The design was a post hoc analysis of 9,095 cases aged 65 years and older from the 2019 National Health Interview Survey that reported chronic pain and 380 cases aged 65 years and older with opioid adverse events reported to the Food and Drug Administration Adverse Event Reporting System (FAERS) during the second quarter of 2019. Logistic regression predicted chronic pain. RESULTS Less than a baccalaureate education increased the odds of chronic pain by 28.0% while lower income minimally increased the odds. Male gender increased the odds of chronic pain by 12.0%. Increased age minimally increased the odds for chronic pain. Use of opioids, other pain treatments, complementary treatments, and antidepressants were all associated with increased odds of chronic pain. FAERS opioid ADEs ranged from pruritus to death, with death identified in 16 (4.2%) cases. Misuse, abuse, or dependence was documented in 1.8% of cases. CONCLUSIONS AND IMPLICATIONS Less-educated older adults may be particularly at risk of chronic pain and should be routinely assessed and prescribed safe and efficacious pain self-management as needed. Some men may need additional support to use pain treatments.
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Niznik JD, Ferreri SP, Armistead LT, Kelley CJ, Schlusser C, Hughes T, Henage CB, Busby-Whitehead J, Roberts E. Primary-Care Prescribers' Perspectives on Deprescribing Opioids and Benzodiazepines in Older Adults. Drugs Aging 2022; 39:739-748. [PMID: 35896779 PMCID: PMC9330848 DOI: 10.1007/s40266-022-00967-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2022] [Indexed: 11/23/2022]
Abstract
Purpose Opioids and benzodiazepines (BZDs) are frequently implicated as contributing to falls in older adults. Deprescribing of these medications continues to be challenging. This study evaluated primary-care prescribers’ confidence in and perceptions of deprescribing opioids and BZDs for older adults. Methods For this study, we conducted a quantitative analysis of survey data combined with an analysis of qualitative data from a focus group. A survey evaluating prescriber confidence in deprescribing opioids and BZDs was distributed to providers at 15 primary-care clinics in North Carolina between March-December 2020. Average confidence (scale 0–100) for deprescribing opioids, deprescribing BZDs, and deprescribing under impeding circumstances were reported. A virtual focus group was conducted in March 2020 to identify specific barriers and facilitators to deprescribing opioids and BZDs. Audio recordings and transcripts were analyzed using inductive coding. Results We evaluated 61 survey responses (69.3% response rate). Respondents were predominantly physicians (54.8%), but also included nurse practitioners (24.6%) and physician assistants (19.4%). Average overall confidence in deprescribing was comparable for opioids (64.5) and BZDs (65.9), but was lower for deprescribing under impeding circumstances (53.7). In the focus group, prescribers noted they met more resistance when deprescribing BZDs and that issues such as lack of time, availability of mental health resources, and patients seeing multiple prescribers were barriers to deprescribing. Conclusion Findings from quantitative and qualitative analyses identified that prescribers were moderately confident in their ability to deprescribe both opioids and BZDs in older adults, but less confident under potentially impeding circumstances. Future studies are needed to evaluate policies and interventions to overcome barriers to deprescribing opioids and BZDs in primary care. Supplementary Information The online version contains supplementary material available at 10.1007/s40266-022-00967-6.
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Affiliation(s)
- Joshua D Niznik
- Division of Geriatric Medicine, Department of Medicine, University of North Carolina at Chapel Hill, School of Medicine, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA. .,UNC Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. .,Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA. .,Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | - Stefanie P Ferreri
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Lori T Armistead
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Casey J Kelley
- UNC Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Courtney Schlusser
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Tamera Hughes
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Cristine B Henage
- UNC Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jan Busby-Whitehead
- Division of Geriatric Medicine, Department of Medicine, University of North Carolina at Chapel Hill, School of Medicine, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA.,UNC Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ellen Roberts
- Division of Geriatric Medicine, Department of Medicine, University of North Carolina at Chapel Hill, School of Medicine, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA.,UNC Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Niznik J, Ferreri SP, Armistead L, Urick B, Vest MH, Zhao L, Hughes T, McBride JM, Busby-Whitehead J. A deprescribing medication program to evaluate falls in older adults: methods for a randomized pragmatic clinical trial. Trials 2022; 23:256. [PMID: 35379307 PMCID: PMC8981935 DOI: 10.1186/s13063-022-06164-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/09/2022] [Indexed: 11/18/2022] Open
Abstract
Background Opioids and benzodiazepines (BZDs) are some of the most commonly prescribed medications that contribute to falls in older adults. These medications are challenging to appropriately prescribe and monitor, with little guidance on safe prescribing of these medications for older patients. Only a handful of small studies have evaluated whether reducing opioid and BZD use through deprescribing has a positive impact on outcomes. Leveraging the strengths of a large health system, we evaluated the impact of a targeted consultant pharmacist intervention to deprescribe opioids and BZDs for older adults seen in primary care practices in North Carolina. Methods We developed a toolkit and process for deprescribing opioids and BZDs in older adults based on a literature review and guidance from an interprofessional team of pharmacists, geriatricians, and investigators. A total of fifteen primary care practices have been randomized to receive the targeted consultant pharmacist service (n = 8) or usual care (n = 7). The intervention consists of several components: (1) weekly automated reports to identify chronic users of opioids and BZDs, (2) clinical pharmacist medication review, and (3) recommendations for deprescribing and/or alternate therapies routed to prescribers through the electronic health record. We will collect data for all patients presenting one of the primary care clinics who meet the criteria for chronic use of opioids and/or BZDs, based on their prescription order history. We will use the year prior to evaluate baseline medication exposures using morphine milligram equivalents (MMEs) and diazepam milligram equivalents (DMEs). In the year following the intervention, we will evaluate changes in medication exposures and medication discontinuations between control and intervention clinics. Incident falls will be evaluated as a secondary outcome. To date, the study has enrolled 914 chronic opioid users and 1048 chronic BZD users. We anticipate that we will have 80% power to detect a 30% reduction in MMEs or DMEs. Discussion This clinic randomized pragmatic trial will contribute valuable evidence regarding the impact of pharmacist interventions to reduce falls in older adults through deprescribing of opioids and BZDs in primary care settings. Trial registration Clinicaltrials.govNCT04272671. Registered on February 17, 2020 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06164-5.
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Crystal S, Nowels M, Olfson M, Samples H, Williams AR, Treitler P. Medically treated opioid overdoses among New Jersey Medicaid beneficiaries: Rapid growth and complex comorbidity amid growing fentanyl penetration. J Subst Abuse Treat 2021; 131:108546. [PMID: 34391586 DOI: 10.1016/j.jsat.2021.108546] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/11/2021] [Accepted: 06/14/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Medically treated opioid overdoses identify a population at high risk of subsequent mortality and need for treatment. This study reports on medically treated opioid overdose trends in a state with rapid fentanyl spread. METHODS We conducted stratified trend analysis of medically treated overdose due to heroin, synthetic opioids, methadone, or other natural opioids among New Jersey Medicaid beneficiaries aged 12-64 years (2014-2019); evaluated associations with demographics and co-occurring conditions; and examined trends in fentanyl penetration in suspected heroin seizures from New Jersey State Police data. RESULTS Overdose risk more than tripled from 2014 to 2019, from 120.5 to 426.8 per 100,000 person-years, respectively. Increases primarily involved heroin and synthetic opioids and were associated with co-occurring alcohol and other non-opioid drug disorders, major depressive disorder, and hepatitis C. Concurrent changes in the drug exposure environment (2015-2019) included an increase in fentanyl penetration (proportion of suspected heroin seizures that included fentanyls) from 2% to 80%, and a decrease in the proportion of Medicaid beneficiaries who received opioid analgesic prescriptions from 23% to 13%. CONCLUSION Results document a rapid increase in overdose risk among individuals with opioid use disorder in an environment in which fentanyl is highly prevalent, and highlight the need for intensified services and engagement of non-treatment seekers, and integrated models to address multiple co-occurring conditions and risk factors.
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Affiliation(s)
- Stephen Crystal
- Center for Health Services Research, Institute for Health, Rutgers University, 112 Paterson Street, New Brunswick, NJ 08901, USA; School of Social Work, Rutgers University, 536 George Street, New Brunswick, NJ 08901, USA; School of Public Health, Department of Health Behavior, Society and Policy, Rutgers University, 683 Hoes Ln W, Piscataway, NJ 08854, USA.
| | - Molly Nowels
- Center for Health Services Research, Institute for Health, Rutgers University, 112 Paterson Street, New Brunswick, NJ 08901, USA; School of Public Health, Department of Health Behavior, Society and Policy, Rutgers University, 683 Hoes Ln W, Piscataway, NJ 08854, USA.
| | - Mark Olfson
- Vagelos College of Physicians and Surgeons, 630 W 168th Street, Columbia University, New York, NY 10032, USA; Mailman School of Public Health, Columbia University, 722 W 168th Street, New York, NY 10032, USA.
| | - Hillary Samples
- Center for Health Services Research, Institute for Health, Rutgers University, 112 Paterson Street, New Brunswick, NJ 08901, USA; School of Public Health, Department of Health Behavior, Society and Policy, Rutgers University, 683 Hoes Ln W, Piscataway, NJ 08854, USA.
| | - Arthur Robinson Williams
- Department of Psychiatry, New York State Psychiatric Institute, Columbia University Medical Center, 1051 Riverside Drive, New York, NY 10032, USA
| | - Peter Treitler
- Center for Health Services Research, Institute for Health, Rutgers University, 112 Paterson Street, New Brunswick, NJ 08901, USA; School of Social Work, Rutgers University, 536 George Street, New Brunswick, NJ 08901, USA.
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