Insufficient Impact: Limited Implementation of Federal Regulatory Changes to Methadone and Buprenorphine Access in Arizona During COVID-19

Introduction

This study examined the impact of federal regulatory changes on methadone and buprenorphine treatment during COVID-19 in Arizona.

Methods

A cohort study of methadone and buprenorphine providers from September 14, 2021 to April 15, 2022 measured the proportion of 6 treatment accommodations implemented at 3 time periods: before COVID-19, during Arizona's COVID-19 shutdown, and at the time of the survey completion. Accommodations included (1) telehealth, (2) telehealth buprenorphine induction, (3) increased multiday dosing, (4) license reciprocity, (5) home medications delivery, and (6) off-site dispensing. A multilevel model assessed the association of treatment setting, rurality, and treatment with accommodation implementation time.

Results

Over half (62.2%) of the 74-provider sample practiced in healthcare settings not primarily focused on addiction treatment, 19% practiced in methadone clinics, and 19% practiced in treatment clinics not offering methadone. Almost half (43%) were unaware of the regulatory changes allowing treatment accommodation. Telehealth was most frequently reported, increasing from 30% before COVID-19 to 80% at the time of the survey. Multiday dosing was the only accommodation substantially retracted after COVID-19 shutdown: from 41% to 23% at the time of the survey. Providers with higher patient limits were 2.5-3.2 times as likely to implement telehealth services, 4.4 times as likely to implement buprenorphine induction through telehealth, and 15.2-20.9 times as likely to implement license reciprocity as providers with lower patient limits. Providers of methadone implemented 12% more accommodations and maintained a higher average proportion of implemented accommodations during the COVID-19 shutdown period but were more likely to reduce the proportion of implemented accommodations (a 17-percentage point gap by the time of the survey).

Conclusions

Federal regulatory changes are not sufficient to produce a substantive or sustained impact on provider accommodations, especially in methadone medical treatment settings. Practice change interventions specific to treatment settings should be implemented and studied for their impact.

Come back when you're infected: pharmacy access to sterile syringes in an Arizona Secret Shopper Study, 2023

BACKGROUND

Pharmacies are critical healthcare partners in community efforts to eliminate bloodborne illnesses. Pharmacy sale of sterile syringes is central to this effort.

METHODS

A mixed methods "secret shopper" syringe purchase study was conducted in the fall of 2022 with 38 community pharmacies in Maricopa and Pima Counties, Arizona. Pharmacies were geomapped to within 2 miles of areas identified as having a potentially high volume of illicit drug commerce. Daytime venue sampling was used whereby separate investigators with lived/living drug use experience attempted to purchase syringes without a prescription. Investigator response when prompted for purchase rationale was "to protect myself from HIV and hepatitis C." A 24-item instrument measured sales outcome, pharmacy staff interaction (hostile/neutral/friendly), and the buyer's subjective experience.

RESULTS

Only 24.6% (n = 28) of 114 purchase attempts across the 38 pharmacies resulted in syringe sale. Less than one quarter (21.1%) of pharmacies always sold, while 44.7% never sold. Independent and food store pharmacies tended not to sell syringes. There emerged distinct pharmacy staff interactions characterized by body language, customer query, normalization or othering response, response to purchase request and closure. Pharmacy discretion and pharmacy policy not to sell syringes without a prescription limited sterile syringe access. Investigators reported frequent and adverse emotional impact due to pharmacy staff negative and stigmatizing interactions.

CONCLUSIONS

Pharmacies miss opportunities to advance efforts to eliminate bloodborne infections by stringent no-sale policy and discretion about syringe sale. State regulatory policy facilitating pharmacy syringe sales, limiting pharmacist discretion for syringe sales, and targeting pharmacy-staff level education may help advance the achievement of public health goals to eliminate bloodborne infections in Arizona.

SI-CBPAR: Towards structural indicators of community-based participatory action research

INTRODUCTION

Structural aspects of community-engaged research are not well measured yet have critical implications for community research empowerment. This is particularly so with people who use drugs. We introduce the Structural Indicators of Community-Based Participatory Action Research (SI-CBPAR) to measure structural indicators of community-research entity relationships.

METHODS

A three-phased process of iterative development, feasibility and applicability assessment was used to examine the instrument with community-engaged studies as a first stage of instrument development. The development team included people with university, non-government organisation and lived/ing drug use experience. Four studies on the health of people who use drugs were reviewed for indicator evidence followed by iterative discussion about construct and item discrepancies. Indicators were measured for the degree to which they were observed using a three-point scale.

RESULTS

All but two constructs were confirmed for meaning. Constructs of 'community' and 'coalition' required revision and explanation. The need for further exploration of power differentials between community and community-based organisations was identified. Indicator evidence was found for all six categories across studies. The instrument was deemed applicable and easy to use. It was observed that categories could apply to studies with various degrees of community engagement and to other research focal areas.

DISCUSSION AND CONCLUSIONS

SI-CBPAR applicability testing and initial category confirmation indicate its potential utility for community research collaboratives. The next phase of development involves cognitive interviewing with researchers from across community engaged research orientations, and with communities engaged in research beyond drug user health.

Opportunities and Challenges: Hepatitis C Testing and Treatment Access Experiences Among People in Methadone and Buprenorphine Treatment During COVID-19, Arizona, 2021

Introduction

The purpose of this study was to characterize hepatitis C virus screening and treatment access experiences among people in treatment for opioid use disorder in Arizona during COVID-19.

Methods

Arizonans receiving treatment for opioid use disorder from methadone clinics and buprenorphine providers during COVID-19 were interviewed about hepatitis C virus testing, curative treatment, and knowledge about screening recommendations. Interviews were conducted with 121 people from August 4, 2021 to October 10, 2021. Qualitative data were coded using the categories of hepatitis C virus testing, knowledge of screening recommendations, diagnosis, and experiences seeking curative treatment. Data were also quantitated for bivariate testing with outcome variables of last hepatitis C virus test, diagnosis, and curative treatment process. Findings were arrayed along an adapted hepatitis C virus cascade framework to inform program and policy improvements.

Results

Just over half of the sample reported ever having tested for hepatitis C virus (51.2%, n=62) and of this group, 58.1% were tested in the past 12 months. Among those who were ever tested, 54.8% reported a hepatitis C virus diagnosis and 16.1% reported either being in treatment or having been declared cured of the hepatitis C virus. Among those who were diagnosed with hepatitis C, 14.7% indicated that they unsuccessfully tried to access curative treatment and would not attempt to again. Reasons cited for not accessing or receiving curative treatment included beliefs about treatment safety, barriers created by access requirements, natural resolution of the infection, and issues with healthcare coverage and authorization.

Conclusions

Structural barriers continue to prevent curative hepatitis C virus treatment access. Given that methadone and buprenorphine treatment providers serve patients who are largely undiagnosed or treated for hepatitis C virus, opportunities exist for them to screen their patients regularly and provide support for and/or navigation to hepatitis C virus curative treatment.

Valuation of milk composition and genotype in cheddar cheese production using an optimization model of cheese and whey production

A mass balance optimization model was developed to determine the value of the kappa-casein genotype and milk composition in Cheddar cheese and whey production. Inputs were milk, nonfat dry milk, cream, condensed skim milk, and starter and salt. The products produced were Cheddar cheese, fat-reduced whey, cream, whey cream, casein fines, demineralized whey, 34% dried whey protein, 80% dried whey protein, lactose powder, and cow feed. The costs and prices used were based on market data from March 2004 and affected the results. Inputs were separated into components consisting of whey protein, ash, casein, fat, water, and lactose and were then distributed to products through specific constraints and retention equations. A unique 2-step optimization procedure was developed to ensure that the final composition of fat-reduced whey was correct. The model was evaluated for milk compositions ranging from 1.62 to 3.59% casein, 0.41 to 1.14% whey protein, 1.89 to 5.97% fat, and 4.06 to 5.64% lactose. The kappa casein genotype was represented by different retentions of milk components in Cheddar cheese and ranged from 0.715 to 0.7411 kg of casein in cheese/kg of casein in milk and from 0.7795 to 0.9210 kg of fat in cheese/kg of fat in milk. Milk composition had a greater effect on Cheddar cheese production and profit than did genotype. Cheese production was significantly different and ranged from 9,846 kg with a high-casein milk composition to 6,834 kg with a high-fat milk composition per 100,000 kg of milk. Profit (per 100,000 kg of milk) was significantly different, ranging from $70,586 for a high-fat milk composition to $16,490 for a low-fat milk composition. However, cheese production was not significantly different, and profit was significant only for the lowest profit ($40,602) with the kappa-casein genotype. Results from this model analysis showed that the optimization model is useful for determining costs and prices for cheese plant inputs and products, and that it can be used to evaluate the economic value of milk components to optimize cheese plant profits.

Growth of Holstein calves from birth to 90 days: the influence of dietary zinc and BLAD status

The main objective of this study was to describe Holstein neonatal growth and development as influenced by dietary zinc supplementation and the CD18 genotype, both of which may affect immune competence. Holstein calves (n = 421), after being fed colostrum, were brought to a calf facility, randomly assigned to one of four zinc supplementation groups (control at 40 mg Zn/kg DM or the control diet supplemented with an additional 60 mg Zn/kg DM provided as either zinc sulfate, zinc lysine, or zinc methionine), weighed, and measured for morphometric growth parameters. Measurements were repeated at 30, 60, and 90 d. Calves were also genotyped for the presence of the mutant D128G CD18 allele, which, if present in two copies, causes bovine leukocyte adhesion deficiency. Zinc supplementation above 40 mg Zn/kg DM, regardless of the chemical form, did not accelerate growth (P > 0.25). Further, overall calf growth performance was not suppressed or improved (P > 0.4) in calves heterozygous at the CD18 locus relative to calves homozygous for the normal CD18 allele, although genotype negatively affected some morphometric measurements (P < 0.05). Using these data, quadratic models of early growth were generated as a preliminary step to develop growth criteria that will allow producers, veterinarians, and animal scientists to identify poor growth performance early in neonatal life. Such criteria provide the basis for tools to improve economic performance.

Quantity and economic importance of nine selected by-products used in California dairy rations

Food processing representatives, brokers, nutritionists, livestock producers, and trade associations were surveyed to quantify 9 by-products used for feeding livestock during 1992 in California. The commodities were almond hulls, dried beet pulp, wet brewers grains, wet citrus pulp, pressed citrus pulp, wet corn gluten feed, corn gluten meal, whole cottonseed, and rice bran. The 9 by-products contributed over 2.5 million tonnes and about 27% of the total feed concentrate moved within California during 1992. Market value of these 9 by-products was almost .25 billion dollars. Whole cottonseed accounted for about 31% of the total tonnage of these 9 by-products and provided about 66% of the total CP and 53% of the total NEL of these 9 by-products. The by-products were more valuable as energy sources than CP sources compared with NEL from corn and CP from soybean meal, respectively. Calculations of milk production, based on the CP content or NEL content of the by-products, showed that these 9 by-products could have contributed sufficient CP or NEL for over 31% of the milk produced in California during 1992. Ration formulations demonstrated that the economic value of by-products changed with feedstuffs available and, in general, would be used in rations over a range of market prices.

Prenatal and postnatal influences on growth and fat measurements in swine

Data from 153 foster groups, each consisting of a dam and a nurse, were analyzed separately for breed (Lacombe, Yorkshire) parity (first, second), and sex of piglet (boar, gilt) to estimate prenatal, postnatal and prenatal X postnatal influences on growth and fat measurements. Significant differences were not observed between breeds, parity and sex of piglets; the estimates were pooled over these traits. Prenatal effects were the major contributing factor in the determination of preweaning growth rate, weaning weight, postweaning average daily gain and allometric growth coefficient, rib and loin fat deposition coefficients. Postnatal influence was of minor importance and the prenatal X postnatal interaction was of negligible consequence. These observations indicated that crossfostering of piglets between parities and breeds without regard for the sex of the piglet would not seriously bias subsequent performance testing results. Heritability estimates for weaning weight, postweaning growth rate and backfat thickness differed from published values.

The genetic relationship between the Hbb locus and body size in a population of mice divergently selected for six-week body weight

Both pleiotropy and linkage were examined as possible explanations for the fixation of the Hbb3 allele in the six Large lines of a population of mice divergently selected for six-week body weight (six replicates in each direction and six controls). A survey of over 1200 individuals in the lines still segregating at the Hbb locus excluded pleiotropy as a possible explanation. The results showed a nonsignificant effect of haemoglobin genotype on body weight. The linkage relationship of the Hbb locus was examined using a backcross mating system. The Hbb3 c+ region (chromosome 7) of a Large line was backcrossed into its corresponding Small line (Hbb4 c). The resultant difference in body weight between the two segregants (Hbb8 c+ [Hbb4 c; Hbb4 c/Hbb4 c) was measured. The results suggested linkage as the most plausible explanation for the fixation of the Hbb4 allele in the six Large lines.

Protein variation in strains of mice differing in body size

Nine (41%) of the 22 enzymic and non-enzymic loci examined in a strain of mice divergently selected for six-week body weight (six lines selected in each direction and six controls) were found to be polymorphic. The degree of polymorphism varied between the replicates from a maximum of 38% to a minimum of 14% with an average individual heterozygous at 7·7% of its loci. There was no obvious association between any of the isozyme variants and body size. The frequency distribution among the 18 lines was adequately accounted for by random genetic drift. However, an association was observed between body size and theHbblocus; theHbbsallele was found to be fixed in all of the six Large lines. An examination of the variance of gene frequencies at this locus excluded random genetic drift as an explanation for the fixation.