Interest in Electronic Cigarettes for Smoking Cessation Among Adults With Opioid Use Disorder in Buprenorphine Treatment: A Mixed-Methods Investigation

INTRODUCTION

Individuals in treatment for opioid use disorder (OUD) have high smoking rates and limited success with Food and Drug Administration (FDA)-approved cessation aids, suggesting need for novel approaches. Electronic cigarettes (e-cigarettes) might benefit this population, but e-cigarettes' acceptability for tobacco reduction or cessation among smokers in OUD treatment is not known.

METHODS

A cross-sectional mixed-methods study of 222 adults in OUD treatment with buprenorphine in the Boston, Massachusetts metropolitan area was conducted in 2020. We used quantitative and qualitative data to investigate individuals' experience with and interest in e-cigarettes and other methods for smoking cessation and assessed factors associated with interest in e-cigarette use.

RESULTS

One hundred sixty (72%) of the 222 participants were past 30-day cigarette smokers. They most frequently reported having ever used nicotine replacement therapy (NRT; 83%) and e-cigarettes (71%) for smoking cessation and most often indicated interest in using NRT (71%) and e-cigarettes (44%) for future smoking cessation. In multiple logistic regression analysis, interest in using e-cigarettes for future smoking cessation was independently associated with having ever used e-cigarettes for smoking cessation, current e-cigarette use, and perceiving e-cigarettes to be less harmful than cigarettes (ps < .05). In qualitative data, many current vapers/former smokers reported that e-cigarettes had been helpful for quitting cigarettes. For current smokers who currently or formerly vaped, frequently reported challenges in switching to e-cigarettes were concerns about replacing one addiction with another and e-cigarettes not adequately substituting for cigarettes.

CONCLUSIONS

E-cigarettes had a moderate level of acceptability for smoking cessation among cigarette smokers in OUD treatment. More research is warranted to test the efficacy of this approach.

IMPLICATIONS

Individuals in treatment for opioid use disorder (OUD) have high smoking rates and limited success with existing smoking cessation tools, suggesting a need for novel cessation treatment approaches. In this mixed-methods study of individuals receiving medication treatment for OUD with buprenorphine in Massachusetts in 2020, we found a moderate level of acceptability of e-cigarettes for smoking cessation.

Perceptions of E-cigarettes among adults in treatment for opioid use disorder

Background

Individuals with opioid use disorder (OUD) have a high prevalence of smoking and limited success quitting smoking with existing tools. There is ongoing debate about whether electronic cigarettes (e-cigarettes) may be a viable harm reduction strategy. We sought to determine the potential acceptability of e-cigarettes for cigarette harm reduction among individuals receiving medication treatment for opioid use disorder (MOUD) with buprenorphine. Among individuals receiving MOUD we investigated health harm perceptions of cigarettes, nicotine e-cigarettes, and nicotine replacement therapy (NRT), and perceptions of the helpfulness of e-cigarettes and NRT for quitting cigarettes.

Methods

Cross-sectional telephone survey conducted among adults in buprenorphine treatment at five community health centers in the Boston, MA metropolitan area from February to July 2020.

Results

93% and 63% of participants rated cigarettes and e-cigarettes, respectively, as very or extremely harmful to health, and 62% rated NRT as not to slightly harmful to health. Over half (58%) rated cigarettes as more harmful than e-cigarettes; 65% and 83% perceived e-cigarettes and NRT, respectively, to be helpful for reducing/quitting cigarette use. In bivariate analyses, nicotine e-cigarette users, compared to nonusers, perceived e-cigarettes to be less harmful to health and more often rated e-cigarettes as helpful for reducing/quitting cigarette use (both p<0.05).

Conclusions

This study suggests that Massachusetts patients receiving MOUD with buprenorphine have concerns about the health harms of e-cigarettes yet rate them as helpful tools for reducing or quitting cigarette smoking. Future research is needed to test the efficacy of e-cigarettes for cigarette harm reduction.

Prevalence of Cannabis Use and Cannabis Route of Administration among Massachusetts Adults in Buprenorphine Treatment for Opioid Use Disorder

BACKGROUND

Recent prevalence estimates of cannabis use among individuals receiving medication treatment for OUD (MOUD) are lacking, and no study has characterized cannabis route of administration (cROA) in this population. These knowledge gaps are relevant because cannabis' effects and health outcomes vary by cROA and the availability and perceptions of cROA (e.g., vaping devices) are changing.

METHODS

The Vaping In Buprenorphine-treated patients Evaluation (VIBE) cross-sectional survey assessed the prevalence and correlates of cannabis use and cROA among adults receiving buprenorphine MOUD from 02/20 to 07/20 at five community health centers in Massachusetts, a state with legal recreational and medical cannabis use.

RESULTS

Among the 92/222 (41%) respondents reporting past 30-day cannabis use, smoking was the most common cROA (75%), followed by vaping (38%), and eating (26%). Smoking was more often used as a single cROA vs. in combination others (p = 0.01), whereas vaping, eating, and dabbing were more often used in combination with another cROA (all p < 0.05). Of the 39% of participants reporting multiple cROA, smoking and vaping (61%), and smoking and eating (50%), were the most prevalent combinations. Nonwhite race (vs. white) and current cigarette smoking (vs. no nicotine use) were associated with past 30-day cannabis use in multiple logistic regression.

CONCLUSIONS

Prevalence of past 30-day cannabis use among individuals receiving buprenorphine MOUD in Massachusetts in 2020 was nearly double the prevalence of cannabis use in Massachusetts' adult general population in 2019 (21%). Our data are consistent with state and national data showing smoking as the most common cROA.

Higher Marijuana use among Young Adults Persists Even during Pregnancy

BACKGROUND

Marijuana is linked to adverse pregnancy health effects, yet limited data exist regarding demographic and regional differences in marijuana use during pregnancy.

OBJECTIVE

To determine the prevalence of prenatal marijuana use among reproductive-age women and assess regional and age-related differences.

METHODS

This study secondarily analyzed cross-sectional, population-based Pregnancy Risk Assessment Monitoring System data from states querying about marijuana use. It included 10,350 women with live births in 2009-2011. Primary outcome was "any use of marijuana" during pregnancy. Logistic regression analysis examined associations between marijuana use, age, and other socio demographic characteristics.

RESULTS

In all states, marijuana use during pregnancy was more likely in adolescent and young adults (AYA; <25 years) than older mothers: Alaska, prevalence rate ratio (PRR), 2.07 (95% confidence interval [CI], 1.5-2.6); Hawaii, PRR, 1.55 (95% CI, 1.2-1.9); Vermont, PRR, 2.44 (95% CI, 1.9-2.9). Regression analyses, controlling for other demographic characteristics, showed that age <25 was associated with higher odds of marijuana use in Alaska (adjusted odds ratio [aOR], 2.24 [95% CI, 1.9-2.5]) and Vermont (aOR, 1.74 [95% CI, 1.5-1.9]). Smoking cigarettes during pregnancy was associated with higher odds of concomitant marijuana use in Alaska (aOR, (P<0.05)) and Vermont (aOR, 1.2 (P<0.05)).

CONCLUSIONS

AYA reported higher marijuana use rates during pregnancy than older women. Cigarette use during pregnancy was associated with marijuana use. Additional research, examining national marijuana use patterns and maternal and child health outcomes in the context of evolving marijuana policies, is warranted.

Perceived risk, attitudes, and behavior of cigarette smokers and nicotine vapers receiving buprenorphine treatment for opioid use disorder during the COVID-19 pandemic

BACKGROUND

Cigarette smoking may increase the risk of COVID-19 complications, reinforcing the urgency of smoking cessation in populations with high smoking prevalence such as individuals with opioid use disorder (OUD). Whether the COVID-19 pandemic has altered perceptions, motivation to quit, or tobacco use among cigarette smokers and nicotine e-cigarette vapers with OUD is unknown.

METHODS

A telephone survey was conducted in March-July 2020 of current cigarette smokers or nicotine vapers with OUD who were stable on buprenorphine treatment at five Boston (MA) area community health centers. The survey assessed respondents' perceived risk of COVID-19 due to smoking or vaping, interest in quitting, quit attempts and change in tobacco consumption during the pandemic.

RESULTS

222/520 patients (43 %) completed the survey, and 145 were asked questions related to COVID-19. Of these, 61 % smoked cigarettes only, 13 % vaped nicotine only, and 26 % were dual users. Nearly 80 % of participants believed that smoking and vaping increased their risk of COVID-19 infection or complications. Smokers with this belief reported an increased interest in quitting (AOR 4.6, 95 % CI:1.7-12.4). Overall, 49 % of smokers and 42 % of vapers reported increased interest in quitting due to the pandemic; 24 % and 20 %, respectively, reported attempting to quit since the pandemic. However, 35 % of smokers and 27 % of vapers reported increasing smoking and vaping, respectively, during the pandemic.

CONCLUSIONS

Most patients with OUD believed that smoking and vaping increased their vulnerability to COVID-19, half reported increased interest in quitting, but others reported increasing smoking and vaping during the COVID-19 pandemic.

Improving LARC Access for Urban Adolescents and Young Adults in the Pediatric Primary Care Setting

The objective of this quality improvement study was to assess the feasibility, acceptability, and impact of integrating long-acting reversible contraceptive (LARC) delivery services into an academic pediatric primary care practice. Adolescent medicine providers in Baltimore, Maryland, were trained in LARC placement with gynecology providers integrated to offer onsite LARC placement and procedural support. Referrals, appointments, and contraceptive method choice/receipt were tabulated. Of 212 individuals referred for LARC consultations, 104 attended appointments. LARC placement at the initial referral increased from year 1 (N = 1) to year 2 (N = 42; P < .01). Adolescent medicine providers placed more LARCs in year 2 (N = 34) than year 1 (N = 0; P < .01). Patients aged 18 to 24 years were less likely to have a LARC placed than those aged 13 to 17 years (unadjusted odds ratio = 0.47 [0.26-0.86]). In conclusion, provider training and service integration of LARC services within a pediatric practice is feasible, acceptable, and increases LARC access and placement.

The role of spirituality in diabetes self-management in an urban, underserved population: a qualitative exploratory study

BACKGROUND

Although many studies examine motivators for diabetes self-management, few explore the role spirituality plays in this disease, especially in low-income urban populations.

METHODS

This qualitative, focus group study elicits thoughts of diabetic patients regarding spirituality in diabetes self-care, at an urban primary care practice in Rhode Island. Focus group discussions were audiotaped, transcribed verbatim, and analyzed using the immersion/crystallization technique.

RESULTS

Themes included: significant impact of diabetes on daily life; fear and family as prominent self-care motivators; relationships with self, others, nature and the divine as major sources of hope and strength. Patients varied considerably regarding the role spirituality played in their illness, ranging from minimal to profound impact. All appeared comfortable discussing spirituality within the context of strength and hope.

CONCLUSION

Patients in this urban, underserved population are willing to discuss spirituality related to their diabetes care. They vary in the role spirituality plays in their illness experience.

Ability of an information mastery curriculum to improve residents' skills and attitudes

BACKGROUND AND OBJECTIVES

Teaching evidence-based medicine is becoming more frequent in family medicine residency education, as is the teaching of information mastery, which is using techniques to answer clinical questions at the point of care and to keep up with changes in medical knowledge. The goal of this study was to determine the effect of an integrated curriculum of information mastery on residents' evidence-based medicine knowledge and skills as well as their confidence at critically appraising medical literature and using evidence to inform clinical decisions.

METHODS

We used a before-after study in a single residency over 5 years. Residents completed the Fresno Test of Evidence-based Medicine and an attitude questionnaire at the start of the curriculum and then again before graduation. The integrated curriculum consisted of intensive instruction over the course of 1 month (30 hours), followed by a longitudinal series of ongoing conferences, integrated into the teaching of clinical content. Teaching was also integrated into day-to-day clinical activities via precepting interactions.

RESULTS

Twenty-three residents completed the study. Modified Fresno Test scores significantly improved from 104.0 to 121.5. Using a pass/fail approach, nine residents (40.1%) passed the test at the start of training, increasing to 17 (73.4%) at the end of the intervention. Confidence in critical appraisal scores increased from an average 17.90 (95% CI=16.55--19.25) to 21.10 (95% CI=19.49--22.71), out of a possible score of 25. Confidence scores were significantly lower in residents who did not pass the posttest (18.5 versus 21.9). Attitudes regarding confidence in the use of evidence and a decreased reliance on experts were also improved following the curriculum.

CONCLUSIONS

A curriculum of information mastery, integrated across the greater curriculum, improved trainees' evidence-based medicine knowledge and skills and attitude toward using evidence to inform clinical decision making.

Implications of new hypertension guidelines in the United States

The American Heart Association Task Force released a scientific statement in 2007 for the treatment of hypertension in the prevention of coronary artery disease (CAD). These guidelines recommend more aggressive control of blood pressure (BP) among those at high risk for CAD: individuals with diabetes mellitus, chronic kidney disease, cardiovascular disease, congestive heart failure, or a 10-year Framingham risk score ≥10%. These individuals are advised to maintain a BP <130/80 mm Hg. We estimated the burden of uncontrolled BP among those at an increased risk of CAD using the updated task force guidelines. We used a cross-sectional analysis of National Health and Nutrition Examination Survey 2005-2008 participants. Participants were 24 989 adults aged 18 to 85 years. Using the old definition of hypertension (>140/90 mm Hg), 98 million (21%) Americans have hypertension. Using the updated guidelines, an additional 52 million (11%) American adults now have elevated BP requiring treatment, for a total of 150 million adults (32%). Adults with diabetes mellitus have the greatest population burden of uncontrolled BP (50.6 million), followed by adults with chronic kidney disease (43.7 million) and cardiovascular disease (43.3 million). Although individuals at a higher risk for CAD are more likely to be aware of their hypertension and to be taking antihypertension medication, they are less likely to have their BP under control. Additional efforts are needed in the treatment of elevated BP, especially among individuals with an increased risk of CAD.

Post-thaw development of in vitro produced buffalo embryos cryopreserved by cytoskeletal stabilization and vitrification

The present study was conducted to examine post-thaw in vitro developmental competence of buffalo embryos cryopreserved by cytoskeletal stabilization and vitrification. In vitro produced embryos were incubated with a medium containing cytochalasin-b (cyto-b) in a CO₂ incubator for 40 min for microfilament stabilization and were cryopreserved by a two-step vitrification method at 24℃ in the presence of cyto-b. Initially, the embryos were exposed to 10% ethylene glycol (EG) and 10% dimethylsulfoxide (DMSO) in a base medium for 4 min. After the initial exposure, the embryos were transferred to a 7 µl drop of 25% EG and 25% DMSO in base medium and 0.3 M sucrose for 45 sec. After warming, the embryos were cultured in vitro for 72 h. The post-thaw in vitro developmental competence of the cyto-b-treated embryos did not differ significantly from those vitrified without cyto-b treatment. The hatching rates of morulae vitrified without cyto-b treatment was significantly lower than the non-vitrified control. However, the hatching rate of cyto-b-treated vitrified morulae did not differ significantly from the non-vitrified control. This study demonstrates that freezing of buffalo embryos by cytoskeletal stabilization and vitrification is a reliable method for long-term preservation.

Effect of commercially available PMSG on maturation, fertilization and embryo development of buffalo oocytes in vitro

In vitro fertilization (IVF) technology provides an opportunity to produce embryos for genetic manipulation, embryo transfer and basic research in developmental physiology, and can be exploited for emerging biotechnologies such as transgenesis and cloning. In the present study, the effects of different concentrations of commercially available pregnant mare serum gonadotrophin (PMSG) (Folligon; Intervet, International B.V, Boxmeer, Holland) in oocyte culture media, on maturation, fertilization and embryonic development of buffalo oocytes in vitro were investigated. Oocytes aspirated from abattoir-derived ovaries were cultured in media containing TCM-199 + PMSG at 0, 2.5, 20, 30, 40 and 50 IU mL(-1) in presence or absence of steer serum (10%) for 24 h in a CO2 incubator. The maturation rate was assessed on the basis of degree of expansion of cumulus cells. The matured oocytes were inseminated with 9-10 x 10(6) spermatozoa mL(-1) in Brackett and Oliphant medium and the cleavage rate was recorded 40-42 h after insemination. Uncleaved oocytes were stained with aceto-orcein for evaluation of fertilization rates. The cleaved embryos were further cultured in TCM-199 + 10% steer serum on buffalo oviducal cell monolayer for 7 days. Maturation, fertilization, cleavage and embryonic development were significantly higher (P < 0.05) in oocytes cultured in TCM-199 + 10% steer serum supplemented with 40 and 50 IU PMSG mL(-1). It is concluded that commercially available PMSG can effectively be used in place of pure follicle-stimulating hormone for in vitro maturation of buffalo oocytes, making it cost effective for IVF studies.

Biochemical studies on stimulation of mouse peritoneal macrophages by interaction with preformed immune complexes

Mouse peritoneal macrophages (MPM) were observed to be stimulated by both in vivo and in vitro interactions with preformed HSA-anti HSA immune complexes (IC) having different antigen-antibody ratios. This was indicated by cellular alterations in morphology, increase in cellular protein and lysosomal enzyme contents and a marked fall in 5' nucleotidase level. Analysis of cellular proteins of IC-elicited cells by SDS-polyacrylamide gel electrophoresis showed accumulation of 80, 47, 33, 28, 18 and 14 kDa proteins. Insoluble immune complexes at equivalence (IC-Eq) was found to be more effective in the stimulation process as compared to the soluble antigen excess complexes (IC-Ag). These IC-elicited cells secreted lesser amounts of lysosomal hydrolases when explanted in culture medium as compared to resting cells, whereas in vitro stimulation of resident MPM with IC resulted in enhanced lysosomal hydrolase release. IC-induced lysosomal secretion was time and dose dependent and varied with the nature of the complexes. Complement coated immune complexes (IC-CC) induced maximum enzyme secretion followed by IC-Eq and IC-Ag.

CT appearances in macronodular hepatosplenic tuberculosis: a review with five additional new cases

Pseudotumoral or macronodular hepatosplenic tuberculosis (HSTB) is rare. Only 31 cases have been documented in imaging literature so far. Presented is the clinico-imaging review with five additional new cases of this uncommon variety. Due to nonspecific wide spectrum of imaging appearances, biopsy is mandatory in almost all cases. Clinical recovery and resolution of lesions on imaging may not be directly proportional.

Colonic immunity in patients and amoebic liver abscess

Secretory immunoglobulin A (S-IgA), coproantibody titre (antiamoebic) and IgA, IgG, IgM immunocytes in rectal mucosa were studied in 13 patients with amoebic liver abscess (ALA) prior to and 4-6 weeks after completion of antiamoebic therapy. Ten asymptomatic Entamoeba histolytica cyst passers and 17 healthy age and sex matched volunteers served as controls. Fecal S-IgA levels and counts of IgA bearing immunocytes in mucosa were significantly higher in patients with ALA and cyst passers as compared to healthy controls and showed a significant fall after treatment. Fecal antiamoebic antibodies were high in cyst passers and in cases of ALA after treatment. Raised levels of S-IgA and IgA class immunocyte counts probably indicate a local mucosal immune response directed at containing the infection.

Demographic features of sporadic acute hepatitis as determined by viral hepatitis markers

The demographic features of acute x sporadic viral hepatitis as diagnosed by specific markers of viral infection in four different cities in north and north-east India, were examined. Of 405 patients examined, 26 per cent had HB,Ag, 5.9 per cent IgM-anti-HAV antibody, and 8.4 per cent IgM-anti-HBc antibody. Hepatitis B occurred more frequently in male patients (76 per cent) compared to hepatitis A (54 per cent), and in the young adult age group (21-30 years), compared to the latter, which occurred predominantly in children (0-10 years). By using tests to detect HbsAg and IgM-anti-HBc antibody, this study found that hepatitis B accounted for 3 per cent and 8.8 per cent of clinically detected acute sporadic hepatitis in patients less than and older than 10 years of age respectively, which is in contrast with previously-reported rates from India. This study also suggests that many of the infections thought to have been due to HBV, may be due to NANB hepatitis virus. This study emphasizes the importance of specific laboratory tests to draw epidemiologic conclusions regarding hepatitis.

Cellulose acetate precipitation test in sero-diagnosis of amoebiasis

Cellulose acetate precipitation (CAP) test for the detection of antibody against Entamoeba histolytica using the axenic antigen, was performed on the 127 serum samples obtained from patients with amoebic liver abscess (14), amoebic hepatitis (21), amoebic dysentry (11), amoebic colitis (31), other parasitic infestations (25) and normal individuals (25). The percent positivity was 100, 95.23, 90.9, 67.74 and 16 and 12 respectively whereas the corresponding figures for the indirect immunoflourescence (IFAT) test were 100, 100, 100, 74.19, 12 and 8 respectively. Although CAP is not as good a test as IFAT, yet it can be recommended for routine testing due to its sensitivity, speed of performance and applicability to a single serum sample.

Immunodiagnosis of amoebiasis

Serological studies were done on 127 cases using three different techniques namely indirect haemagglutination (IHA), indirect fluorescent antibody test (IFT) and counter immunoelectrophoresis (CIEP) to detect antiamoebic antibodies. All amoebic liver abscess cases showed significant titre of antibodies by all the three tests used. In the group of patients suffering from amoebic pathology of liver, 90.47 per cent were positive by IHA, 100 per cent by IFT and 85.71 per cent by CIEP respectively. Among amoebic dysentry and amoebic colitis cases 81.81 per cent and 80.64 per cent respectively were positive by IHA. The corresponding figures for IFT were 100 per cent and 74.19 per cent and for CIEP 90.90 per cent and 64.51 per cent respectively. Follow up study showed no significant fall in antibody titre in nine cases studied upto 10 weeks after treatment. Amoebic antigen could be detected in pus from all the nine cases with amoebic liver abscess by CIEP test.

Mucormycosis in a diabetic

A case of juvenile diabetes mellitus with rhino-orbital mucormycosis treated successfully with amphotericin B is described.

Gastric tuberculosis

A 63-year-old female presented with upper epigastric pain. On endoscopy a giant gastric ulcer was observed on the lesser curvature of the stomach. Biopsies taken from the ulcer showed epitheloid cell granulomas with caseation, suggesting a diagnosis of granulomatous gastritis probably tubercular in origin. No AFB was seen in the biopsied material, the culture also failed to grow AFB. Radiograph of the chest was normal. On anti-tubercular treatment the patient showed remarkable recovery and the ulcer healed completely following 3 1/2 months of treatment.

Intrathecal human tetanus immunoglobulin in early tetanus

97 patients with symptoms of early tetanus at the time of admission to hospital were treated with sedation, antibiotics, and human tetanus immune globulin (TIG). After intrathecal TIG 250 IU 3 patients out of 49 got worse but only 1 died while in a closely similar group of 48 patients in whom TIG was administered intramuscularly in dose of 1000 IU, the clinical features of the disease became severer in 15 (31%) and 10 (21%) died. The intrathecal use of TIG was devoid of side effects.

A comparative study of urban and rural tetanus in adults

An analysis of 240 patients, aged 15+, admitted to the tetanus ward of Irwin Hospital, New Delhi, with clinically diagnosed tetanus is reported. 134 patients (55.8%) came from rural areas and 106 (44.2%) from urban areas. The male--female ratio for both groups was approximately 2:1. Rural patients were younger, showed a longer incubation period and experienced a lower crude case fatality rate. Traditional practices like the application of cow dung to wounds, ear piercing and tatooing, and chronic ear infections were important factors in developing tetanus, demonstrating a need for health education in rural communities.