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Dunham K, Rivas C, Medina Blanco P, Kolod B, Salvati C, Clark K, Sue KL, Hagaman A, Weiss JJ. "It's Like A Partnership": Exploring the Primary Care Experiences and Patient-Defined Goals of People Who Use Drugs. J Gen Intern Med 2024:10.1007/s11606-024-08743-5. [PMID: 38578536 DOI: 10.1007/s11606-024-08743-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 03/21/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Primary care is an important yet underutilized resource in addressing the overdose crisis. Previous studies have identified important aspects of primary care for people who use drugs (PWUD) and have found patient involvement in healthcare decisions and goal-setting to be especially critical. However, there has been limited research describing the primary care goals of PWUD. In harm reduction settings, where it is imperative that PWUD set their own goals, this research gap becomes especially relevant. OBJECTIVE To explore how PWUD navigate primary care with a focus on understanding their primary care goals. DESIGN A qualitative study using semi-structured interviews. PARTICIPANTS PWUD currently engaged in primary care at the Respectful and Equitable Access to Comprehensive Healthcare (REACH) Program, a harm reduction-based primary care program in New York City. APPROACH Between June 2022 and August 2022, we conducted 17 semi-structured interviews. Informed by phenomenology, transcripts were coded using both inductive and deductive codes and themes were developed using thematic analysis approaches. KEY RESULTS Phenomenological analysis identified four core components that, together, created an experience that participants described as "a partnership" between patient and provider: (1) patient-provider collaboration around patient-defined healthcare goals; (2) support provided by harm reduction-based approaches to primary care anchored in incrementalism and flexibility; (3) care teams' ability to address healthcare system fragmentation; and (4) the creation of social connections through primary care. This holistic partnership fostered positive primary care experiences and supported participants' self-defined care goals, thereby facilitating meaningful care outcomes. CONCLUSIONS To best meet the primary care goals of PWUD, these findings underscore the importance of primary care providers and programs facilitating such partnerships through organizational-level support anchored in harm reduction. Future research should explore how these experiences in primary care affect patient health outcomes, ultimately shaping best practices in the provision of high-quality primary care for PWUD.
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Affiliation(s)
- Katherine Dunham
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, USA.
| | - Catherine Rivas
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1087, New York, USA
| | - Paula Medina Blanco
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1087, New York, USA
| | - Betty Kolod
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1087, New York, USA
| | - Carli Salvati
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1087, New York, USA
| | - Katie Clark
- Clark Health Education and Research Solutions, Branford, USA
| | - Kimberly L Sue
- Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, USA
| | - Ashley Hagaman
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, USA
| | - Jeffrey J Weiss
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1087, New York, USA
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Affiliation(s)
- Kimberly L Sue
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, USA
- Sociobehavioral Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Kathryn Hawk
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
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Hill K, Dunham K, Brokos Z, Butner JL, Hull I, Sue KL, Li L, Thakarar K. In Support of Community Drug Checking Programs: Position Statement of AMERSA, Inc. (Association for Multidisciplinary Education and Research in Substance use and Addiction). Subst Use Addctn J 2024; 45:4-9. [PMID: 38258861 DOI: 10.1177/29767342231212787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
BACKGROUND Position statements clarify key issues that are in alignment with the vision, mission, and values of the AMERSA, Inc. (Association for Multidisciplinary Education and Research in Substance use and Addiction). This Position Statement, endorsed by the AMERSA Board of Directors on October 3, 2023, amplifies the position of the organization, guides their activities, and informs the public and policymakers on the organization's stance on this issue. ISSUE The unregulated drug supply in the United States evolves constantly, leaving those who use drugs potentially unaware of new adulterants in their drugs. Not knowing that information can leave people vulnerable to serious adverse events such as fatal overdoses, wounds, and other health consequences. Without real-time data on the composition of drugs available in a community, healthcare providers and public health practitioners are left with insufficient data, making it increasingly difficult to know how to best serve people who use drugs. In this context, community-based drug checking has become recognized as an important harm reduction strategy with the potential to provide those who use drugs with more information about their supply. RECOMMENDATIONS It is imperative to expand funding and increase access to drug checking programs in communities across the United States. Key policy changes, such as those related to decriminalizing drug and drug paraphernalia possession, are needed to increase the utilization of drug checking programs. Protection of persons who use drugs through harm reduction strategies, including drug checking programs needs to be widely available and accessible.
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Affiliation(s)
- Katherine Hill
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Katherine Dunham
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Zoe Brokos
- Church of Safe Injection, Lewiston, ME, USA
| | - Jenna L Butner
- Department of General Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA
| | - Ilana Hull
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kimberly L Sue
- Department of General Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA
| | - Li Li
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kinna Thakarar
- Center for Interdisciplinary Population and Health Research, MaineHealth Institute for Research, Portland, ME, USA
- Department of Medicine, Maine Medical Center, Portland, ME, USA
- Tufts University School of Medicine, Boston, MA, USA
- Maine Medical Partners Adult Infectious Diseases, South Portland, ME, USA
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Dowton A, Doernberg M, Heiman E, Barelli P, Golden M, Wang H, Leventhal J, Morford KL, Sue KL. Recognition and Treatment of Wounds in Persons Using Xylazine: A Case Report From New Haven, Connecticut. J Addict Med 2023; 17:739-741. [PMID: 37934550 DOI: 10.1097/adm.0000000000001198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
BACKGROUND Xylazine is an α 2 -adrenergic agonist that is commonly used as a veterinary tranquilizer and is increasingly present in the unregulated US drug supply since at least 2019. There are many suspected clinical complications of xylazine use, including unusual skin wounds, atypical overdose presentations, and possible dependence and withdrawal syndromes. However, there are few reports of cutaneous manifestations of xylazine in patients who inject drugs that can guide diagnosis and management in patients with confirmed xylazine toxicology. CASE SUMMARY We present the cases of 3 stably housed patients in Connecticut with opioid use disorder and intravenous use of fentanyl who presented with atypical, chronic wounds at the site of injection drug use. Xylazine toxicology sent on all 3 patients was positive. All patients were seen by wound care and dermatology, and 1 patient was followed by infectious diseases. Wound care management strategies are discussed as well as harm reduction strategies. For all patients, the dose of their medication for opioid use disorder was increased to decrease frequency of drug use given concern that patients were exposed to a drug supply containing xylazine. CLINICAL SIGNIFICANCE This case report presents wound characteristics that raise the index of suspicion for xylazine-involved injection wounds and might assist in their diagnosis and management. There is urgent need for more reporting of such cases as well as rigorous research to understand the potential impact of xylazine on people who use drugs. Multidisciplinary best practices should be established.
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Affiliation(s)
- Anne Dowton
- From the Department of Internal Medicine, Yale School of Medicine, New Haven, CT (AD, EH, PB, KLM, KLS); Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, CT (AD, EH, PB, KLM, KLS); Yale School of Medicine, New Haven, CT (MD); Department of Infectious Diseases, Yale School of Medicine, New Haven, CT (MG); Department of Pathology, Yale School of Medicine, New Haven, CT (HW); Department of Dermatology, Yale School of Medicine, New Haven, CT (JL); and Smilow Cancer Hospital, Yale New Haven Hospital, New Haven, CT (JL)
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Hill K, Thakarar K, Eslinger H, Prosperino L, Sue KL. Improving the Health of People Who Inject Drugs Through COVID-19-Related Policies. Public Health Rep 2023; 138:862-864. [PMID: 37610106 PMCID: PMC10576482 DOI: 10.1177/00333549231192468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023] Open
Affiliation(s)
- Katherine Hill
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Kinna Thakarar
- Center for Interdisciplinary Population & Health Research/Maine, Portland, ME, USA
- Department of Medicine, Maine Medical Center, Portland, ME, USA
- Tufts University School of Medicine, Boston, MA, USA
- Maine Medical Partners Adult Infectious Diseases, South Portland, ME, USA
| | | | | | - Kimberly L. Sue
- Department of General Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA
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Chayama KL, Ng C, Fleming T, Small W, Sue KL, McNeil R. Housing-based syringe services programs to improve access to safer injecting equipment for people who inject drugs in Vancouver, Canada: a spatially oriented qualitative study. Harm Reduct J 2023; 20:126. [PMID: 37679789 PMCID: PMC10483728 DOI: 10.1186/s12954-023-00862-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 08/27/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Housing environments shape injection drug-related risks and harms and thus represent a critical implementation setting for syringe services programs (SSPs). As critical harm reduction measures, SSPs provide safe injecting equipment to people who inject drugs (PWID). Vancouver, Canada, has well-established syringe distribution programs through which PWID have low-threshold access to unlimited syringes and related injecting equipment, including through non-profit operated supportive housing and single-room occupancy hotels. This study examines the role of housing-based SSPs in distributing injecting equipment to PWID in Vancouver. METHODS Between January and March 2020, semi-structured, in-depth interviews were conducted in Vancouver with 26 PWID. Interviews were audio-recorded, transcribed, and coded. Salient themes were identified using inductive and deductive approaches. RESULTS Many participants accessed SSPs in housing facilities and expressed preference for these programs over those offered at other locations and through other health and social services. Three major themes emerged to explain this preference. First, most participants injected in the buildings where they resided, and housing-based SSPs made injecting equipment available when and where it was most needed. Second, many participants preferred to avoid carrying syringes outside of the places where they inject due to fears that syringe possession may lead to criminal charges or confiscation of syringes and/or illicit drugs by police. Third, for some participants, anti-drug user stigma and concerns over unwillingly disclosing their drug use hindered access to SSPs outside of housing settings. Programs operated within housing facilities often offered greater client anonymity along with more supportive and less stigmatizing environments, particularly in the presence of peer staff. CONCLUSION The current study advances understanding of access to injecting equipment in a setting with city-wide syringe distribution programs. Our findings underscore the benefits of housing-based SSPs and encourage the expansion of such services to maximize access to harm reduction supports for PWID.
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Affiliation(s)
- Koharu Loulou Chayama
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, Canada
- Interdisciplinary Studies Graduate Program, University of British Columbia, 6371 Crescent Road, Vancouver, Canada
| | - Cara Ng
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, Canada
| | - Taylor Fleming
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, Canada
- Interdisciplinary Studies Graduate Program, University of British Columbia, 6371 Crescent Road, Vancouver, Canada
| | - Will Small
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, Canada
- Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, Canada
| | - Kimberly L Sue
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, 06520, USA
- Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, USA
| | - Ryan McNeil
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, Canada.
- Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, 06520, USA.
- Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, New Haven, USA.
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Cohen S, Tilley J, Yocheved A, Sue KL. Doing Our Best in a Broken System: The Urgent Need for Expansion of Medication for Opioid Use Disorder Treatments in the United States. J Addict Med 2023; 17:495-496. [PMID: 37579123 DOI: 10.1097/adm.0000000000001143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
In reply: In this commentary, we respond to Dr Vogel and Dr Dürstelar's letter to our original piece "A Plea From People Who Use Drugs to Clinicians: New Ways to Initiate Buprenorphine Are Urgently Needed in the Fentanyl Era" published in this journal in July to August 2022. We agree with much of their comment on buprenorphine initiation and point to the need for rapid expansion of medication for opioid use disorder (OUD) treatments here in the United States. It is critical to understand the context of current buprenorphine and methadone access. We point out how the treatment of OUD with agonist therapy remains limited to methadone or buprenorphine despite an increasingly toxic drug supply within our particular legal and regulatory environment and call for urgent research and pilot programs to trial additional agonist therapies for those with opioid OUD as well as regulatory changes to increase access to both methadone and buprenorphine.
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Hughes M, Edinoff A, Sue KL. Changing approaches to treating opioid withdrawal in the USA. Lancet Psychiatry 2023; 10:378-380. [PMID: 37167986 DOI: 10.1016/s2215-0366(23)00145-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 05/13/2023]
Affiliation(s)
- Marcus Hughes
- Department of Psychiatry and Behavioral Sciences, Howard University College of Medicine, Washington, DC 20060, USA.
| | - Amber Edinoff
- Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Kimberly L Sue
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA; Program in Addiction Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
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Sue KL, Chawarski M, Curry L, McNeil R, Coupet E, Schwartz RP, Wilder C, Tsui JI, Hawk KF, D’Onofrio G, O’Connor PG, Fiellin DA, Edelman EJ. Perspectives of Clinicians and Staff at Community-Based Opioid Use Disorder Treatment Settings on Linkages With Emergency Department-Initiated Buprenorphine Programs. JAMA Netw Open 2023; 6:e2312718. [PMID: 37163263 PMCID: PMC10173026 DOI: 10.1001/jamanetworkopen.2023.12718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 03/24/2023] [Indexed: 05/11/2023] Open
Abstract
Importance An increasing number of emergency departments (EDs) are initiating buprenorphine for opioid use disorder (OUD) and linking patients to ongoing community-based treatment, yet community-based clinician and staff perspectives regarding this practice have not been characterized. Objective To explore perspectives and experiences regarding ED-initiated buprenorphine among community-based clinicians and staff in geographically distinct regions. Design, Setting, and Participants This qualitative study reports findings from Project ED Health, a hybrid type 3 effectiveness-implementation study designed to evaluate the impact of implementation facilitation on ED-initiated buprenorphine with referral to ongoing medication treatment. Clinicians and staff from community-based treatment programs were identified by urban academic EDs as potential referral sites for ongoing OUD treatment in 4 cities across the US in a formative evaluation as having the capability to continue medication treatment. Focus groups were held from April 1, 2018, to January 11, 2019, to examine community OUD treatment clinician and staff perspectives on accepting patients who have received ED-initiated buprenorphine. Data were analyzed from August 2020 to August 2022. Main Outcomes and Measures Data collection and analysis were grounded in the Promoting Action on Research Implementation in Health Services (PARIHS) implementation science framework, focusing on domains including evidence, context, and facilitation. Results A total of 103 individuals (mean [SD] age, 45.3 [12.0] years; 76 female and 64 White) participated in 14 focus groups (groups ranged from 3-22 participants). Participants shared negative attitudes toward buprenorphine and variable attitudes toward ED-initiated buprenorphine. Prominent barriers included the community site treatment capacity and structure as well as payment and regulatory barriers. Perceived factors that could facilitate this model included additional substance use disorder training for ED staff, referrals and communication, greater inclusion of peer navigators, and addressing sociostructural marginalization that patients faced. Conclusions and Relevance In this study of community-based clinicians and staff positioned to deliver OUD treatment, participants reported many barriers to successful linkages for patients who received ED-initiated buprenorphine. Strategies to improve these linkages included educating communities and programs, modeling low-barrier philosophies, and using additional staff trained in addiction as resources to improve transitions from EDs to community partners.
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Affiliation(s)
- Kimberly L. Sue
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Marek Chawarski
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Leslie Curry
- Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Ryan McNeil
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Edouard Coupet
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Christine Wilder
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Judith I. Tsui
- Department of Medicine, University of Washington School of Medicine, Seattle
| | - Kathryn F. Hawk
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Gail D’Onofrio
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Patrick G. O’Connor
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
| | - David A. Fiellin
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut
| | - E. Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut
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Rosen JG, Glick JL, Zhang L, Cooper L, Olatunde PF, Pelaez D, Rouhani S, Sue KL, Park JN. Safety in solitude? Competing risks and drivers of solitary drug use among women who inject drugs and implications for overdose detection. Addiction 2022; 118:847-854. [PMID: 36468191 PMCID: PMC10073256 DOI: 10.1111/add.16103] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 11/11/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Solitary drug use (SDU) can amplify risks of fatal overdose. We examined competing risks and drivers of SDU, as well as harm reduction strategies implemented during SDU episodes, among women who inject drugs (WWID). DESIGN A cross-sectional qualitative study, including telephone and face-to-face in-depth interviews. SETTING Baltimore City, MD, USA. PARTICIPANTS Twenty-seven WWID (mean age = 39 years, 67% white, 74% injected drugs daily) recruited via outreach and street intercept (April-September 2021). MEASUREMENTS Interviews explored the physical (i.e. indoor/private, outdoor/public) and social (i.e. alone, accompanied) risk environments in which drug use occurred. Guided by the principles of emergent design, we used thematic analysis to interrogate textual data, illuminating women's preferences/motivations for SDU and strategies for minimizing overdose risks when using alone. FINDINGS Many participants reported experiences with SDU, despite expressed preferences for accompanied drug use. SDU motivations clustered around three primary drivers: (1) avoiding opioid withdrawal, (2) preferences for privacy when using drugs and (3) safety concerns, including threats of violence. Participants nevertheless acknowledged the dangers of SDU and, at times, took steps to mitigate overdose risk, including naloxone possession, communicating to peers when using alone ('spotting') and using drugs in public spaces. CONCLUSIONS WWID appear to engage frequently in SDU due to constraints of the physical and social environments in which they use drugs. They express a preference for accompanied drug use in most cases and report implementing strategies to mitigate their overdose risk, especially when using drugs alone.
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Affiliation(s)
- Joseph G Rosen
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Jennifer L Glick
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Leanne Zhang
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Lyra Cooper
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Praise F Olatunde
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Danielle Pelaez
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Saba Rouhani
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Kimberly L Sue
- National Harm Reduction Coalition, New York, New York, USA.,Department of General Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA
| | - Ju Nyeong Park
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.,Department of General Internal Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA.,Center of Biomedical Research Excellent on Opioids and Overdose, Rhode Island Hospital, Providence, RI, USA
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Sue KL. Violence at Rikers Island: Does the Doctor Make It Worse? A Clinician Ethnographer's Work Amidst Carceral Structural Violence. Cult Med Psychiatry 2022:10.1007/s11013-022-09812-2. [PMID: 36445550 PMCID: PMC9707201 DOI: 10.1007/s11013-022-09812-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2022] [Indexed: 12/02/2022]
Abstract
In this article, I describe the dilemmas of working as a physician-ethnographer within the Rikers Island jail healthcare system before and at the beginning of the COVID-19 epidemic in April 2020. The Rikers Island jail system in New York City has been in the national spotlight as a space of violence, trauma, and death amidst calls to decarcerate by community members and abolition advocates. This article is a personal reflection on the labor and subjectivity of healthcare providers and their positionality to multiple axes of structural and interpersonal violence while attempting to provide care in carceral institutions. I observe how COVID-19 functioned as an additional form of structural violence for incarcerated people. Clinical ethnography remains an essential tool for understanding complex social phenomena such as violence. However, physician-ethnographers working in these spaces of structural violence can have unique and conflicting constraints: tasked with providing evidence-based medicine but also simultaneously participating in an unusual form of labor that is an amalgamation of care, social suffering, and punishment. Despite and across at-times conflicting roles and obligations, I propose that these fragmented subjectivities can foment social criticism, propel advocacy toward decarceration, and produce a critically engaged dialogue between fields of anthropology and medicine toward a goal of health justice.
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Affiliation(s)
- Kimberly L Sue
- Department of Internal Medicine, Yale University School of Medicine, 367 Cedar Street, Room 304A, New Haven, CT, USA.
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Zhen‐Duan J, Gade N, Falgas‐Bagué I, Sue KL, DeJonckheere M, Alegría M. Using a structural vulnerability framework to understand the impact of COVID-19 on the lives of Medicaid beneficiaries receiving substance use treatment in New York City. Health Serv Res 2022; 57:1104-1111. [PMID: 35340033 PMCID: PMC9111318 DOI: 10.1111/1475-6773.13975] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 03/14/2022] [Accepted: 03/18/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To investigate how the COVID-19 pandemic impacted low-income individuals with substance use disorder (SUD) in New York City (NYC) during the beginning of the pandemic, using a structural competency and structural vulnerability theoretical framework and a qualitative research approach. DATA SOURCES Primary qualitative data were collected from racial/ethnic minority adults enrolled in Medicaid receiving outpatient substance use treatment (e.g., medication, counseling) in NYC. STUDY DESIGN Semi-structured in-depth qualitative interviews (N = 20) were conducted during "stay-at-home" orders in NYC, the first epicenter of the COVID-19 pandemic in the United States. Interviews were conducted over the phone during the earlier stages of the pandemic, between April 2020 and June 2020. DATA COLLECTION/EXTRACTION METHODS Semi-structured in-depth interviews were conducted and audio recorded, transcribed, and analyzed using a thematic analysis approach. PRINCIPAL FINDINGS Three themes were yielded from our thematic analysis: (1) COVID-19 heightened food insecurity and housing conditions increased risks of infection; (2) stay-at-home orders limited access to resources but had positive impacts in strengthening social relationships and reducing substance use triggers; and (3) although COVID-19 created challenges for treatment, most described that SUD care improved during the pandemic. CONCLUSIONS While COVID-19 exacerbated numerous structural vulnerabilities among low-income individuals with SUD, programmatic adaptations to COVID-19 SUD care, including telehealth and loosening restrictions around medications for opioid use disorders mitigated past difficulties that patients had faced. Reducing structural vulnerabilities for Medicaid patients will require continuation of telehealth treatment delivery, retaining flexible medication regulations, and mobilizing community resources to mitigate economic disparities.
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Affiliation(s)
- Jenny Zhen‐Duan
- Disparities Research Unit, Department of MedicineMassachusetts General HospitalBostonMassachusettsUSA,Department of MedicineHarvard Medical SchoolBostonMassachusettsUSA
| | - Neerav Gade
- Disparities Research Unit, Department of MedicineMassachusetts General HospitalBostonMassachusettsUSA,Department of Community HealthTufts UniversityMedfordMassachusettsUSA
| | - Irene Falgas‐Bagué
- Disparities Research Unit, Department of MedicineMassachusetts General HospitalBostonMassachusettsUSA,Department of MedicineHarvard Medical SchoolBostonMassachusettsUSA
| | - Kimberly L. Sue
- Department of Internal MedicineYale School of MedicineNew HavenConnecticutUSA
| | | | - Margarita Alegría
- Disparities Research Unit, Department of MedicineMassachusetts General HospitalBostonMassachusettsUSA,Department of MedicineHarvard Medical SchoolBostonMassachusettsUSA,Department of PsychiatryHarvard Medical SchoolBostonMassachusettsUSA
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13
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Abstract
Xylazine is a nonopioid veterinary anesthetic and sedative that is increasingly detected in the illicit drug supply in the United States. Data indicate a striking prevalence of xylazine among opioid-involved overdose deaths. The emergence of xylazine in the illicit drug supply poses many unknowns and potential risks for people who use drugs. The public health system needs to respond by increasing testing to determine the prevalence of xylazine, identifying its potential toxicity at various exposure levels, and taking mitigating action to prevent harms. Currently, there is little testing capable of identifying xylazine in drug supplies, which limits the possibility of public health intervention, implementation of harm reduction strategies, or development of novel treatment strategies. (Am J Public Health. 2022;112(8):1212-1216. https://doi.org/10.2105/AJPH.2022.306881).
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Affiliation(s)
- Ryan S Alexander
- Ryan S. Alexander, Bethany R. Canver, Kimberly L. Sue, and Kenneth L. Morford are with the School of Medicine, Yale University, New Haven, CT. Kimberly L. Sue is also with the National Harm Reduction Coalition, New York, NY
| | - Bethany R Canver
- Ryan S. Alexander, Bethany R. Canver, Kimberly L. Sue, and Kenneth L. Morford are with the School of Medicine, Yale University, New Haven, CT. Kimberly L. Sue is also with the National Harm Reduction Coalition, New York, NY
| | - Kimberly L Sue
- Ryan S. Alexander, Bethany R. Canver, Kimberly L. Sue, and Kenneth L. Morford are with the School of Medicine, Yale University, New Haven, CT. Kimberly L. Sue is also with the National Harm Reduction Coalition, New York, NY
| | - Kenneth L Morford
- Ryan S. Alexander, Bethany R. Canver, Kimberly L. Sue, and Kenneth L. Morford are with the School of Medicine, Yale University, New Haven, CT. Kimberly L. Sue is also with the National Harm Reduction Coalition, New York, NY
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14
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Sue KL, Cohen S, Tilley J, Yocheved A. A Plea From People Who Use Drugs to Clinicians: New Ways to Initiate Buprenorphine Are Urgently Needed in the Fentanyl Era. J Addict Med 2022; 16:389-391. [PMID: 35020693 DOI: 10.1097/adm.0000000000000952] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
With the worst opioid overdose death crisis in the United States history, urgent new approaches to assist people who use drugs onto medication for opioid use disorder are necessary. In this commentary, addiction medicine clinicians and drug user union representatives align to argue that conventional ways of buprenorphine initiation that require periods of withdrawal must be augmented with additional novel approaches to initiation. In the fentanyl era, members of the New England Users Union and Portland Users Union report encountering precipitated withdrawal, being unable to stop using full agonist opioids for a required period of time, and difficulty initiating this medication that could offer them some stability and life-saving treatment. People who use drugs should be involved at all levels with ongoing research, clinical and policy efforts to improve buprenorphine initiation as their lives and their suffering are at stake.
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Affiliation(s)
- Kimberly L Sue
- From the Program in Addiction Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT (KS, SC); National Harm Reduction Coalition New York, New York (KS); New England Users Union, Northampton,MA (JT); Portland Users Union, Portland, OR (AY)
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15
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Abstract
Harm reduction is an approach to reduce the risk of harms to an individual using substances without requiring abstinence. This review discusses substance-specific interventions for opioids, alcohol, and stimulants that can minimize harms for individuals who use these substances. Topics discussed include overdose prevention, infection prevention, and low-barrier substance use disorder treatment.
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Affiliation(s)
- Carolyn A Chan
- Program in Addiction Medicine, Section of General Internal Medicine, Department of Medicine, 367 Cedar Street, Harkness Hall A Suite - Suite 305, New Haven, CT 06510, USA
| | - Bethany Canver
- Section of General Internal Medicine, Department of Medicine, 367 Cedar Street, Harkness Hall A Suite - Suite 305, New Haven, CT 06510, USA
| | - Ryan McNeil
- Program in Addiction Medicine, Section of General Internal Medicine, Department of Medicine, 367 Cedar Street, Harkness Hall A, New Haven, CT 06510, USA
| | - Kimberly L Sue
- Program in Addiction Medicine, Section of General Internal Medicine, Department of Medicine, 367 Cedar Street, Harkness Hall A Suite - Suite 417A, New Haven, CT 06510, USA.
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16
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Essien UR, Ifidon A, Sue KL. Black Pain Matters: Prioritizing Antiracism and Equity in the Opioid Epidemic. J Hosp Med 2021; 16:638-639. [PMID: 34613902 PMCID: PMC8494278 DOI: 10.12788/jhm.3703] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 11/20/2022]
Affiliation(s)
- Utibe R Essien
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Ayomipo Ifidon
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kimberly L Sue
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
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17
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Affiliation(s)
- Kimberly L Sue
- From the Department of Internal Medicine (K.S., D.A.F.), the Program in Addiction Medicine (K.S., D.A.F.), and the Department of Emergency Medicine (D.A.F.), Yale School of Medicine, and the Department of Health Policy and Management, Yale School of Public Health (D.A.F.) - both in New Haven, CT; and the National Harm Reduction Coalition, New York (K.S.)
| | - David A Fiellin
- From the Department of Internal Medicine (K.S., D.A.F.), the Program in Addiction Medicine (K.S., D.A.F.), and the Department of Emergency Medicine (D.A.F.), Yale School of Medicine, and the Department of Health Policy and Management, Yale School of Public Health (D.A.F.) - both in New Haven, CT; and the National Harm Reduction Coalition, New York (K.S.)
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