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author:("kohler, Nancy")
1.  I Heard About It From a Friend: Assessing Interest in Buprenorphine Treatment 
In the United States, opioid abuse and dependence continue to be a growing problem, while treatment for opioid abuse and dependence remains fairly static. Buprenorphine treatment for opioid dependence is safe and effective but underutilized. Prior research has demonstrated low awareness and use of buprenorphine among marginalized groups. This study investigates syringe exchange participants’ awareness of, exposure to, and interest in buprenorphine treatment.
Syringe exchange participants were recruited from a mobile unit performing outreach to nine street-side sites in New York City. Computer-based interviews were conducted to determine: (1) opioid users’ awareness of, exposure to, and interest in buprenorphine treatment; and (2) the association between awareness or exposure and interest in buprenorphine treatment. Logistic regression models were used to examine the associations between awareness, direct exposure (i.e. having taken buprenorphine), or indirect exposure (i.e. knowing someone who had taken buprenorphine) and interest in buprenorphine treatment.
Of 158 opioid users, 70% were aware of, 32% had direct exposure to, and 31% had indirect exposure to buprenorphine; 12% had been prescribed buprenorphine. Of 138 opioid users who had never been prescribed buprenorphine, 57% were interested in buprenorphine treatment. In multivariate models, indirect exposure was associated with interest in buprenorphine treatment (AOR = 2.65, 95% CI: 1.22 – 5.77), but awareness and direct exposure were not.
Syringe exchange participants were mostly aware of buprenorphine and interested in treatment, but few had actually been prescribed buprenorphine. Because indirect exposure to buprenorphine was associated with interest in treatment, future interventions could capitalize on indirect exposure, such as through peer mentorship, to address underutilization of buprenorphine treatment.
PMCID: PMC3942801  PMID: 24588297
2.  Awareness of, experience with, and attitudes towards buprenorphine among opioid users visiting a New York City syringe exchange program 
Journal of opioid management  2013;9(6):407-413.
To examine awareness of, experience with, and attitudes towards buprenorphine, in order to begin to understand why opioid users may not access buprenorphine treatment. We also explored factors associated with attitudes towards buprenorphine.
Cross-sectional study.
A community-based organization’s syringe exchange program in mobile units at nine street-side outreach sites in New York City.
186 adult opioid users visiting a syringe exchange program.
Main Outcome Measures
Awareness of, experiences with, and attitudes toward buprenorphine.
Most (68.5%) participants were aware of buprenorphine, 27.8% had taken buprenorphine, and 58.6% knew someone who had taken buprenorphine. Of the 98 who had taken or knew someone who had taken buprenorphine, 85.7% endorsed positive attitudinal statements about its effectiveness, and up to 31.6% endorsed statements about its limited access. Participants’ attitudes about the need for formal buprenorphine treatment were mixed. Current heroin users were more likely than non-users to have heard of buprenorphine (76.0% vs. 61.5%, p<0.05), have taken buprenorphine (46.8% vs. 9.6%, p<0.01), endorse buprenorphine’s effectiveness (96.3% vs. 72.7%, p<0.01), and believe that illicit and prescribed buprenorphine have similar benefits (35.2% vs. 13.6%, p<0.02).
Most opioid users visiting a syringe exchange program had positive attitudes about buprenorphine’s effectiveness, and few believed that buprenorphine was difficult to access. Attitudes about the benefits of illicit versus prescribed buprenorphine use were inconsistent. Understanding awareness of, experience with, and attitudes towards buprenorphine is important, as these factors are likely to influence opioid users’ decisions about engaging in buprenorphine treatment.
PMCID: PMC4012750  PMID: 24481929
buprenorphine; opioid agonist treatment; community-based organization; attitudes; opioids; heroin
3.  Buprenorphine Treatment Outcomes among Opioid-Dependent Cocaine Users and Non-users 
Background and Objectives
National treatment guidelines state that polysubstance users, including cocaine users, may not be appropriate candidates for office-based buprenorphine treatment. However, data to support this recommendation are sparse and conflicting, and the implications of this recommendation may include limiting the usefulness of buprenorphine treatment, as cocaine use is common among opioid-dependent individuals seeking buprenorphine treatment. We compared buprenorphine treatment outcomes (6-month treatment retention and self-reported opioid use over 6 months) in opioid-dependent cocaine users versus non-users who initiated buprenorphine treatment at an urban community health center.
We followed 87 participants over 6 months, collecting interview and medical record data. We used logistic regression models to test whether baseline cocaine use was associated with treatment retention and mixed effects non-linear models to test whether baseline cocaine use was associated with self-reported opioid use.
At baseline, 39.1% reported cocaine use. In all participants, self-reported opioid use decreased from 89.7% to 27.4% over 6 months, and 6-month treatment retention was 54.5%. We found no significant difference in 6-month treatment retention (AOR=1.56, 95%CI=0.58–4.17, p=0.38) or self-reported opioid use (AOR=0.89, 95%CI=0.26–3.07, p=0.85) between cocaine users and non-users.
Conclusions and Scientific Significance
This study demonstrates that buprenorphine treatment retention is not worse in cocaine users than non-users, with clinically meaningful improvements in self-reported opioid use. These findings suggest that opioid-dependent cocaine users attain considerable benefits from office-based buprenorphine treatment and argue for the inclusion of these patients in office-based buprenorphine treatment programs.
PMCID: PMC3694744  PMID: 23795874
4.  Prior buprenorphine experience is associated with office-based buprenorphine treatment outcomes 
Journal of addiction medicine  2013;7(4):287-293.
As buprenorphine treatment and illicit buprenorphine use increase, many patients seeking buprenorphine treatment will have had prior experience with buprenorphine. Little evidence is available to guide optimal treatment strategies for patients with prior buprenorphine experience. We examined whether prior buprenorphine experience was associated with treatment retention and opioid use. We also explored whether type of prior buprenorphine use (prescribed or illicit use) was associated with these treatment outcomes.
We analyzed interview and medical record data from a longitudinal cohort study of 87 individuals who initiated office-based buprenorphine treatment. We examined associations between prior buprenorphine experience and 6-month treatment retention using logistic regression models, and prior buprenorphine experience and any self-reported opioid use at 1, 3, and 6 months using non-linear mixed models.
Most (57.4%) participants reported prior buprenorphine experience; of these, 40% used prescribed buprenorphine and 60% illicit buprenorphine only. Compared to buprenorphine-naïve participants, those with prior buprenorphine experience had better treatment retention (AOR=2.65, 95% CI=1.05–6.70). Similar associations that did not reach significance were found when exploring prescribed and illicit buprenorphine use. There was no difference in opioid use when comparing participants with prior buprenorphine experience to those who were buprenorphine-naive (AOR=1.33, 95% CI=0.38–4.65). Although not significant, qualitatively different results were found when exploring opioid use by type of prior buprenorphine use (prescribed buprenorphine vs. buprenorphine-naïve, AOR=2.20, 95% CI=0.58–8.26; illicit buprenorphine vs. buprenorphine-naïve, AOR=0.47, 95% CI=0.07–3.46).
Prior buprenorphine experience was common and associated with better retention. Understanding how prior buprenorphine experience affects treatment outcomes has important clinical and public health implications.
PMCID: PMC3737355  PMID: 23722632
buprenorphine; opioid; opioid dependence; office-based treatment
5.  Consumer Attitudes about Opioid Addiction Treatment: A focus group study in New York City 
Journal of opioid management  2013;9(2):111-119.
To develop effective programs for people who are opioid-dependent and to impact the opioid epidemic in New York City, it is crucial that we monitor attitudes about opioid addiction treatments among opioid users who have experienced barriers to engagement and retention in addiction treatment.
We conducted a qualitative study using focus groups.
We conducted six focus groups in three needle exchanges in New York City, which were audio recorded, transcribed, and systematically coded. We report on the main themes related to the study objectives.
Participants of each needle exchange who were opioid-dependent and had some knowledge of both methadone and buprenorphine were eligible.
There were four main findings. Participants felt: (1) buprenorphine is an appropriate option only for those heroin users who are motivated to stop using; (2) they have less control over their addiction treatment with methadone than they would have with buprenorphine; (3) buprenorphine treatment is not accessible to many New York City residents who would benefit from this treatment; and (4) lack of access to buprenorphine treatment is the cause of treatment-related diversion.
Both methadone maintenance and buprenorphine treatment opportunities are necessary to address the diverse treatment needs of opioid-dependent people in New York City. However, the current medical model of buprenorphine treatment may be too restrictive for some opioid-dependent people, and may be contributing to the use of illicit buprenorphine. New models to deliver buprenorphine treatment may address these problems.
PMCID: PMC4012752  PMID: 23709320
heroin dependence; buprenorphine; methadone; qualitative research
6.  Effects of Tailored Knowledge Enhancement on Colorectal Cancer Screening Preference across Ethnic and Language Groups 
Patient education and counseling  2012;90(1):103-110.
Tailoring to psychological constructs (e.g. self-efficacy, readiness) motivates behavior change, but whether knowledge tailoring alone changes healthcare preferences - a precursor of behavior change in some studies - is unknown. We examined this issue in secondary analyses from a randomized controlled trial of a tailored colorectal cancer (CRC) screening intervention, stratified by ethnicity/language subgroups (Hispanic/Spanish, Hispanic/English, non-Hispanic/English).
Logistic regressions compared effects of a CRC screening knowledge-tailored intervention versus a non-tailored control on preferences for specific test options (fecal occult blood or colonoscopy), in the entire sample (N = 1164) and the three ethnicity/language subgroups.
Pre-intervention, preferences for specific tests did not differ significantly between study groups (experimental, 64.5%; control 62.6%). Post-intervention, more experimental participants (78.6%) than control participants (67.7%) preferred specific tests (P <0.001). Adjusting for pre-intervention preferences, more experimental group participants than control group participants preferred specific tests post-intervention [average marginal effect (AME) = 9.5%, 95% CI 5.3-13.6; P <0.001]. AMEs were similar across ethnicity/language subgroups.
Knowledge tailoring increased preferences for specific CRC screening tests across ethnic and language groups.
Practice Implications
If the observed preference changes are found to translate into behavior changes, then knowledge tailoring alone may enhance healthy behaviors.
PMCID: PMC3522756  PMID: 22985627
7.  A buprenorphine education and training program for primary care residents: Implementation and evaluation 
Although substance use disorders are highly prevalent, resident preparation to care for patients with these disorders is frequently insufficient. With increasing rates of opioid abuse and dependence, and the availability of medication-assisted treatment, one strategy to improve resident skills is to incorporate buprenorphine treatment into training settings.
Residency faculty delivered our BupEd education and training program to 71 primary care residents. BupEd included: 1) a didactic session on buprenorphine, 2) an interactive motivational interviewing session, 3) monthly case conferences, and 4) supervised clinical experience providing buprenorphine treatment. To evaluate BupEd, we assessed: 1) residents' provision of buprenorphine treatment during residency, 2) residents' provision of buprenorphine treatment after residency, and 4) treatment retention among patients treated by resident versus attending physicians.
Of 71 residents, most served as a covering or primary provider to at least one buprenorphine-treated patient (84.5 and 66.2% respectively). Of 40 graduates, 27.5% obtained a buprenorphine waiver and 17.5% prescribed buprenorphine. Treatment retention was similar between patients cared for by resident PCPs versus attending PCPs ((90-day retention: 63.6% (n=35) vs. 67.9% (n=152), p=0.55)).
BupEd is feasible, provides residents with supervised clinical experience in treating opioid dependent patients, and can serve as a model to prepare primary care physicians to care for patients with opioid dependence.
PMCID: PMC3799907  PMID: 23844954
Opioid dependence; buprenorphine; substance abuse education
8.  Expansion of Electronic Health Record-Based Screening, Prevention, and Management of Diabetes in New York City 
To address the increasing burden of diabetes in New York City, we designed 2 electronic health records (EHRs)-facilitated diabetes management systems to be implemented in 6 primary care practices on the West Side of Manhattan, a standard system and an enhanced system. The standard system includes screening for diabetes. The enhanced system includes screening and ensures close patient follow-up; it applies principles of the chronic care model, including community–clinic linkages, to the management of patients newly diagnosed with diabetes and prediabetes through screening. We will stagger implementation of the enhanced system across the 6 clinics allowing comparison, through a quasi-experimental design (pre–post difference with a control group), of patients treated in the enhanced system with similar patients treated in the standard system. The findings could inform health system practices at multiple levels and influence the integration of community resources into routine diabetes care.
PMCID: PMC3562173  PMID: 23369766
9.  Tailored Interactive Multimedia Computer Programs to Reduce Health Disparities: Opportunities and Challenges 
Patient education and counseling  2010;85(2):323-330.
To review the theory and research evidence suggesting that tailored interactive multimedia computer programs (IMCPs) aimed at optimizing patient health behaviors could lessen socio-demographic health disparities.
Selective critical review of research regarding IMCPs tailored to psychological mediators of behavior and their effects on health behavior and outcomes among socio-demographically disadvantaged patients.
Tailored IMCPs can address patient factors (e.g. language barriers, low self-efficacy) and buffer provider (e.g. cognitive bias) and health system (e.g. office visit time constraints) factors that contribute to poor provider-patient communication and, thereby, suboptimal health behaviors. Research indicates disadvantaged individuals' interactions with providers are disproportionately affected by such factors, and that their behaviors respond favorably to tailored information, thus suggesting tailored IMCPs could mitigate disparities. However, no randomized controlled trials (RCTs) have examined this question. The optimal design and deployment of tailored IMCPs for disadvantaged patients also requires further study.
Preliminary research suggests tailored IMCPs have the potential to reduce health disparities. RCTs designed expressly to examine this issue are warranted.
Practice Implications
Many socio-demographic health disparities exist, and there is a dearth of proven disparity-reducing interventions. Thus, if tailored IMCPs were shown to lessen disparities, the public health implications would be considerable.
PMCID: PMC3070866  PMID: 21146950
health disparities; patient education as topic; tailored health information; therapy-computer assisted; vulnerable populations
11.  A comparison of buprenorphine induction strategies: patient-centered home-based inductions versus standard-of-care office-based inductions 
Although novel buprenorphine induction strategies are emerging, they have been inadequately studied. To examine our newly developed patient-centered home-based inductions, we conducted a subgroup analysis of 79 opioid-dependent individuals who had buprenorphine inductions at an urban community health center. Participants chose their induction strategy; standard-of-care office-based inductions were physician-driven, with multiple assessments, and observed, and patient-centered home-based inductions emphasized patient self-management and included a “kit” for induction at home. We conducted interviews and extracted medical records. Using mixed non-linear models, we examined associations between induction strategy and opioid use and any drug use. Compared to those with standard-of-care office-based inductions, participants with patient-centered home-based inductions had no significant differences in opioid use (AOR=0.63, 95%CI=0.13–2.97), but greater reductions in any drug use (AOR=0.05, 95%CI=0.01–0.37). Taking into account the limitations of our observational cohort study design, we conclude that participants with patient-centered home-based inductions had similar reductions in opioid use and greater reductions in any drug use than those with standard-of-care office-based inductions. It is essential that new induction strategies be based on existing models or theories and well-studied.
PMCID: PMC3081891  PMID: 21310583
12.  The Cost of Integrated HIV Care and Buprenorphine/ Naloxone Treatment: Results of a Cross-Site Evaluation 
Implementing integrated HIV and buprenorphine/ naloxone treatment requires cost estimates to plan and obtain funding.
We identified costs incurred at HIV clinical sites participating in a cross-site evaluation of integrated care that followed patients for 1 year. Costs include labor, overhead, and urine toxicology analyses (clinic perspective), buprenorphine/naloxone (payer perspective) and patient time and transportation (patient perspective). Sites provided resource utilization quarterly, and providers estimated time required for each activity. With site as the unit of analysis, results are reported as median (range) of average site costs in 2008 US dollars.
The median number of monthly provider encounters for integrated care patients was 3.2 (1.5–13.3) compared with 1.7 (1.1–4.2) for similar patients not in integrated care, but integrated care patients had fewer physician encounters. Median monthly clinic costs per integrated care patient were $136 ($67–$677) for labor and overhead and $8 ($2–$23) for toxicology analyses, $22 higher than clinic costs for patients not in integrated care. Median monthly costs for buprenorphine/naloxone were $209 ($165–$272), and monthly patient costs in integrated care were $11 ($1–$54) higher.
Integrated HIV and buprenorphine/naloxone treatment requires different resources, including costs that are not third-party reimbursed. Implementing integrated care will require funding for training and for new staff such as buprenorphine coordinators, in addition to reimbursement for buprenorphine/naloxone. Further research is needed to identify potential cost offsets outside of the clinic setting.
PMCID: PMC3270565  PMID: 21317599
buprenorphine/naloxone; cost; HIV; opioid dependency; integrated care; substance abuse
13.  Strategies to Improve Access to and Utilization of Health Care Services and Adherence to Antiretroviral Therapy Among HIV-Infected Drug Users 
Substance use & misuse  2011;46(2-3):218-232.
We review five innovative strategies to improve access, utilization, and adherence for HIV-infected drug users and suggest areas that need further attention. In addition, we highlight two innovative programs. The first increases access and utilization through integrated HIV and opioid addiction treatment with buprenorphine in a community health center, and the second incorporates adherence counseling for antiretroviral therapy in methadone programs. Preliminary evaluations demonstrated that these strategies may improve both HIV and opioid addiction outcomes and may be appropriate for wider dissemination. Further refinement and expansion of strategies to improve outcomes of HIV-infected drug users is warranted.
PMCID: PMC3150583  PMID: 21303242
drug treatment; HIV; access to care; health care utilization; adherence to antiretroviral therapy; integrated treatment; outreach; case management; directly observed therapy; peer support; patient navigation; adherence counselors
14.  Bringing health and social policy together: The case of the earned income tax credit 
Journal of public health policy  2009;30(2):198-207.
The principal objective of our research is to examine whether the earned income tax credit (EITC), a broad-based income support program that has been shown to increase employment and income among poor working families, also improves their health and access to care. A finding that the EITC has a positive impact on the health of the American public may help guide deliberations about its future at the federal, state, and local levels. The authors contend that a better understanding of the relationship between major socioeconomic policies such as the EITC and the public’s health will inform the fields of health and social policy in the pursuit of improving population health.
PMCID: PMC3148586  PMID: 19597453
social determinants; health policy; population health
15.  The relationship between non-injection drug use behaviors on progression to AIDS and death in a cohort of HIV seropositive women in the era of highly active antiretroviral therapy use 
Addiction (Abingdon, England)  2005;100(7):990-1002.
To evaluate the effects of longitudinal patterns and types of non-injection drug use (NIDU) on HIV progression in the highly active antiretroviral therapy (HAART) era.
Women’s Interagency HIV Study (WIHS), a prospective cohort study conducted at six US sites.
Data were collected semi-annually from 1994 to 2002 on 1046 HIV+ women. Multivariate Cox proportional hazards modeling was used to estimate relative hazards for developing AIDS and for death by pattern and type of NIDU.
During follow-up, 285 AIDS events and 287 deaths, of which 177 were AIDS-related, were reported. At baseline, consistent and former NIDU was associated with CD4+ counts of < 200 cells/μl (43% and 46%, respectively) and viral load > 40 000 copies/ml (53% and 55%, respectively). Consistent NIDU reported less HAART use (53%) compared with other NIDU patterns. Stimulant use was associated with CD4+ cell counts of < 200 cells/μl (53%) and lower HAART initiation (63%) compared with other NIDU types. In multivariate analyses, progression to AIDS was significantly higher among consistent (RH = 2.52), inconsistent (RH = 1.63) and former (RH = 1.56) users compared with never users; and for stimulant (RH = 2.04) and polydrug (RH = 1.65) users compared with non-users. Progression to all-cause death was higher only among former users (RH = 1.48) compared with never users in multivariate analysis. NIDU behaviors were not associated with progression to AIDS-related death.
In this study, pattern and type of NIDU were associated with HIV progression to AIDS and all-cause mortality. These differences were associated with lower HAART utilization among consistent NIDU and use of stimulants, and poor baseline immunological and virological status among former users.
PMCID: PMC3128378  PMID: 15955015
Acquired immunodeficiency syndrome; highly active anti-retroviral therapy; human immunodeficiency virus; mortality; non-injection drug use
16.  Improving Adherence to HIV Quality of Care Indicators in Persons With Opioid Dependence: The Role of Buprenorphine 
Opioid-dependent HIV-infected patients are less likely to receive HIV quality of care indicators (QIs) compared with nondependent patients. Buprenorphine/naloxone maintenance therapy (bup/nx) could affect the quality of HIV care for opioid-dependent patients.
We abstracted 16 QIs from medical records at nine HIV clinics 12 months before and after initiation of bup/nx versus other treatment for opioid dependence. Summary quality scores (number of QIs received/number eligible × 100) were calculated. We compared change in QIs and summary quality scores in patients receiving bup/nx versus other participants.
One hundred ninety-four of 268 participants (72%) received bup/nx and 74 (28%) received other treatment. Mean summary quality scores increased over 12 months for participants receiving bup/nx (45.6% to 51.6%, P < 0.001) but not other treatment (48.6% to 47.8%, P = 0.788). Bup/nx participants experienced improvements in six of 16 HIV QIs versus three of 16 QIs in other participants. Improvements were mostly in preventive and monitoring care domains. In multivariable analysis, bup/nx was associated with improved summary quality score (β 8.55; 95% confidence interval, 2.06–15.0).
In this observational cohort study, HIV-infected patients with opioid dependence received approximately half of HIV QIs at baseline. Buprenorphine treatment was associated with improvement in HIV QIs at 12 months. Integration of bup/nx into HIV clinics may increase receipt of high-quality HIV care. Further research is required to assess the effect of improved quality of HIV care on clinical outcomes.
PMCID: PMC3066190  PMID: 21317600
quality of health care; HIV; quality indicators; health care; buprenorphine; opioid-related disorders; heroin dependence
17.  Home- versus office-based buprenorphine inductions for opioid-dependent patients 
Recent legislation permits the treatment of opioid-dependent patients with buprenorphine in the primary care setting, opening doors for the development of new treatment models for opioid dependence. We modified national buprenorphine treatment guidelines to emphasize patient self-management by giving patients the opportunity to choose to have buprenorphine inductions at home or the physician’s office. We examined whether patients who had home-based inductions achieved greater 30-day retention than patients who had traditional office-based inductions in a study of 115 opioid-dependent patients treated in an inner-city health center. Retention was similar in both groups: 50 (78.1%) in office-based group versus 40 (78.4%) in home-based group, p = .97. Several patient characteristics were associated with choosing office- versus home-based inductions, which likely influenced these results. We conclude that opioid dependence can be successfully managed in the primary care setting. Approaches that encourage patient involvement in treatment for opioid dependence can be beneficial.
PMCID: PMC2849656  PMID: 19801178
Buprenorphine treatment; Buprenorphine induction; Opioid dependence; Primary care; Community health center
18.  Does Self-Report Data on HIV Primary Care Utilization Agree with Medical Record Data for Socially Marginalized Populations in the United States? 
AIDS Patient Care and STDs  2009;23(10):837-843.
To test whether self-report data agree with medical record data in marginalized, HIV-infected populations, we collected information about HIV primary care visits over a 6-month period from both sources. Patients were drawn from a large study of engagement and retention in care conducted between 2003 and 2005. Self-report data were collected in face-to-face interviews and medical records were extracted using a rigorous, standardized protocol with multiple quality checks. We found poor overall agreement (weighted κ = 0.36, 95% confidence interval = 0.28, 0.43). Factors associated with disagreement included younger age (adjusted odds ratio for 20 versus 40 years = 1.25, 95% confidence interval = 0.98, 1.60), non-Hispanic black race/ethnicity (adjusted odds ratio for non-Hispanic blacks versus non-Hispanic whites = 1.48, 95% confidence interval = 1.03, 2.13), lower education (adjusted odds ratio for high school education, GED, or less versus some college or college graduate = 1.43, 95% confidence interval = 0.96, 2.13), and substance use (adjusted odds ratio for any illicit drug/heavy alcohol use in the past 6 months versus no use = 1.39, 95% confidence interval = 1.02, 1.90). These findings do not support a conclusion that unconfirmed self-report data of HIV primary care visits are a sufficient substitute for rigorously collected medical record data in studies focusing on marginalized populations. Use of other data sources (e.g., administrative data), use of other self-reported outcome measures that have better concordance with medical records/administrative data (e.g., CD4 counts), or incorporation of rigorous measures to increase reliability of self-report data may be needed. Limitations of this study include the lack of a true gold standard with which to compare self-report data.
PMCID: PMC2859764  PMID: 19803677
19.  Gender Disparities in HIV Health Care Utilization among the Severely Disadvantaged: Can We Determine the Reasons? 
AIDS Patient Care and STDs  2009;23(9):775-783.
Data repeatedly demonstrate that HIV-infected people who regularly utilize primary health care services are more likely to have access to lifesaving treatments (including antiretroviral medications); have better indicators of health status; survive longer; and use acute care services far less. Women tend to have poorer HIV outcomes than men, which is likely due to gender disparities in optimal utilization of HIV primary care services. To understand the relationship between gender and the HIV health care system, we collected interview and medical record data between August 12, 2004 and June 7, 2005 from 414 severely marginalized, HIV-infected people in New York City and examined whether gender-related disparities in HIV health care utilization existed, and, if so, whether these patterns were explained by patient sociodemographic/behavioral characteristics and/or attitudes toward the health care system and providers. Women were significantly less likely to have optimal HIV health care services utilization, including lower use of HIV primary care services (odds ratio [OR] = 0.56, 95% confidence interval [CI] = 0.35, 0.90) and greater use of the emergency department (OR = 2.13, 95% CI = 1.31, 3.46). Although we identified several factors associated with suboptimal HIV health care services utilization patterns in addition to female gender (low education, insurance status, mistrust of the health care system, and poor trust in health care providers), we were unable to identify factors that explained the observed gender disparities. We conclude that gender disparities in HIV health care utilization are due to a complex array of factors, which require more qualitative and quantitative research attention. Development of intervention strategies that specifically target severely disadvantaged women's HIV health care utilization is in great need.
PMCID: PMC2859765  PMID: 19663745
21.  Factors affecting willingness to provide buprenorphine treatment 
Buprenorphine is an effective long-term opioid agonist treatment. As the only pharmacological treatment for opioid dependence readily available in office-based settings, buprenorphine may facilitate a historic shift in addiction treatment from treatment facilities to general medical practices. Although many patients have benefited from the availability of buprenorphine in the United States, almost half of current prescribers are addiction specialists suggesting that buprenorphine treatment has not yet fully penetrated general practice settings. We examined factors affecting willingness to offer buprenorphine treatment among physicians with different levels of prescribing experience. Based on their prescribing practices, physicians were classified as experienced, novice, or as a nonprescriber and asked to assess the extent to which a list of factors impacted their prescription of buprenorphine. Several factors affected willingness to prescribe buprenorphine for all physicians: staff training; access to counseling and alternate treatment; visit time; buprenorphine availability; and pain medications concerns. Compared with other physicians, experienced prescribers were less concerned about induction logistics and access to expert consultation, clinical guidelines, and mental health services. They were more concerned with reimbursement. These data provide important insight into physician concerns about buprenorphine and have implications for practice, education, and policy change that may effectively support widespread adoption of buprenorphine.
PMCID: PMC2866292  PMID: 18715741
Buprenorphine; Opioid-related disorders; HIV; Physician’s practice patterns; Willingness
22.  Buprenorphine Treatment in an Urban Community Health Center: What to Expect 
Family medicine  2008;40(7):500-506.
Despite new opportunities to expand buprenorphine treatment for opioid dependence, use of this treatment modality has been limited. Physicians may question their ability to successfully treat opioid-dependent patients with buprenorphine in a primary care setting. We describe a buprenorphine treatment program and treatment outcomes in an urban community health center.
We conducted retrospective chart reviews on the first 41 opioid-dependent patients treated with buprenorphine/naloxone. The primary outcome was 90-day retention in treatment.
Patients’ mean age was 46 years, 70.7% were male, 58.8% Hispanic, 31.7% black, 57.5% unemployed, and 70.0% used heroin prior to treatment. Twenty-nine (70.7%) patients were retained in treatment at day 90. Compared to those not retained, patients retained in treatment were more likely to have used street methadone (0% versus 37.9%) and less likely to have used opioid analgesics (54.6% versus 20.7%) and alcohol (50.0% versus 13.8%) prior to treatment. Of the 25 patients with urine toxicology tests, 24% tested positive for opioids.
Buprenorphine treatment for opioid dependence in an urban community health center resulted in a 90-day retention rate of 70.7%. Type of substance use prior to treatment appeared to be associated with retention. These findings can help guide program development.
PMCID: PMC2840630  PMID: 18928077
23.  HIV Provider Endorsement of Primary Care Buprenorphine Treatment: A Vignette Study 
Family medicine  2009;41(10):722-728.
Background and Objectives
Opioid dependence is common among HIV-infected persons in the United States. Factors associated with HIV care providers recommending buprenorphine for opioid dependence are poorly defined. Using vignettes, we sought to identify HIV provider characteristics associated with endorsing buprenorphine treatment in primary care.
We used a cross-sectional survey of HIV providers, including 497 physicians, nurse practitioners, and physician assistants attending HIV educational conferences in 2006. Anonymous questionnaires distributed to conference attendees contained one of two vignettes depicting opioid-dependent patients. Respondents recommended type of substance abuse treatment for the vignette patient. Using logistic regression, we tested patient and provider factors associated with HIV provider endorsement of buprenorphine in primary care.
Sixteen percent of providers endorsed buprenorphine treatment in primary care for vignette patients. Family physicians and general internists (AOR=2.8, CI=1.1–7.1), African American providers (AOR=3.0, CI=1.3–6.8), and those with previous buprenorphine prescribing experience (AOR=4.6, CI=1.2–17.9) were more likely to endorse buprenorphine treatment in primary care.
HIV providers infrequently endorsed buprenorphine treatment in primary care for vignette patients. Generalist and African American providers and those with previous buprenorphine prescribing experience are more likely to endorse buprenorphine treatment in primary care. Targeting generalist and minority providers may be one strategy to promote effective integration of HIV care and opioid addiction treatment.
PMCID: PMC2827924  PMID: 19882396
24.  Medical and Support Service Utilization in a Medical Program Targeting Marginalized HIV-infected Individuals 
One strategy to facilitate HIV health care services utilization is to incorporate support services with medical services. We developed a program that delivers HIV medical care and support services to marginalized people, and evaluated the association between support and medical services utilization.
We extracted data on 218 newly enrolled program participants 3 months prior to through 6 months after program enrollment, and analyzed associations between support and medical services.
Case management visits (AOR=1.95, 95% CI 1.04–3.67) and group visits (AOR=2.59, 95% CI 1.30–5.16) were associated with greater odds of quarterly medical visits. Outreach visits were associated with greater odds of having a medical visit in a traditional medical setting (AOR=2.31, 95% CI 1.15–4.67).
Case management, support groups, and outreach were associated with HIV medical visits. Further research exploring how integration of support services into HIV medical programs can improve health care delivery is crucial for health policy and program development.
PMCID: PMC2705623  PMID: 18677084
HIV; health services utilization; outreach; case management; support groups; support services; vulnerable population
25.  The complexities of measuring access to parks and physical activity sites in New York City: a quantitative and qualitative approach 
Proximity to parks and physical activity sites has been linked to an increase in active behaviors, and positive impacts on health outcomes such as lower rates of cardiovascular disease, diabetes, and obesity. Since populations with a low socio-economic status as well as racial and ethnic minorities tend to experience worse health outcomes in the USA, access to parks and physical activity sites may be an environmental justice issue. Geographic Information systems were used to conduct quantitative and qualitative analyses of park accessibility in New York City, which included kernel density estimation, ordinary least squares (global) regression, geographically weighted (local) regression, and longitudinal case studies, consisting of field work and archival research. Accessibility was measured by both density of park acreage and density of physical activity sites. Independent variables included percent non-Hispanic black, percent Hispanic, percent below poverty, percent of adults without high school diploma, percent with limited English-speaking ability, and population density.
The ordinary least squares linear regression found weak relationships in both the park acreage density and the physical activity site density models (Ra2 = .11 and .23, respectively; AIC = 7162 and 3529, respectively). Geographically weighted regression, however, suggested spatial non-stationarity in both models, indicating disparities in accessibility that vary over space with respect to magnitude and directionality of the relationships (AIC = 2014 and -1241, respectively). The qualitative analysis supported the findings of the local regression, confirming that although there is a geographically inequitable distribution of park space and physical activity sites, it is not globally predicted by race, ethnicity, or socio-economic status.
The combination of quantitative and qualitative analyses demonstrated the complexity of the issues around racial and ethnic disparities in park access. They revealed trends that may not have been otherwise detectable, such as the spatially inconsistent relationship between physical activity site density and socio-demographics. In order to establish a more stable global model, a number of additional factors, variables, and methods might be used to quantify park accessibility, such as network analysis of proximity, perception of accessibility and usability, and additional park quality characteristics. Accurate measurement of park accessibility can therefore be important in showing the links between opportunities for active behavior and beneficial health outcomes.
PMCID: PMC2708147  PMID: 19545430

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