Publications

BACKGROUND

Patients with chronic noncancer pain treated with higher doses of opioids or concurrent substance use are at increased risk of adverse events. Although several national guidelines recommend maximum dosing thresholds and urine drug testing, adherence to these guidelines is inconsistent.

METHODS

To identify predictors of higher-risk opioid prescriptions in 2 academic primary care clinics, the authors developed a retrospective cohort of 842 patients who were prescribed ≥5 opioid prescriptions for noncancer pain between March 2012 and March 2013. The authors evaluated odds of higher-dose opioid prescriptions and urine drug testing using multivariate logistic models.

RESULTS

Among study subjects, 47% received prescriptions for the equivalent of ≥50 mg morphine per day. After adjustment for confounders, patients with a resident primary care provider were less likely to receive higher-dose prescriptions compared with faculty providers (odds ratio = 0.66, 95% confidence interval [CI]: 0.46-0.94), whereas patients with a nonlocal home address were more likely to be prescribed higher doses (odds ratio = 2.1, 95% CI: 1.5-2.9). Hispanic, Asian, and older patients were also less likely to be prescribed higher doses. Urine drug testing was not regularly completed (35% over 2 years), but odds of testing were higher for patients who self-identified as black, had resident primary care providers, lived locally, or were prescribed higher opioid doses.

CONCLUSIONS

In this academic clinical setting, patients with a resident primary care provider are less likely to receive higher-risk opioid prescriptions, as are Hispanic, Asian, and older patients. Black patients complete urine drug tests more frequently independent of other patient and provider characteristics. Additional studies are needed to assess why patients who travel larger distances to their primary care clinic are prescribed higher doses of opioids for chronic noncancer pain.

Mobile health (mHealth) applications (apps) have the potential to support self-management and improve health outcomes in persons living with HIV (PLWH). In this paper, we report on the final step in a three-stage user-centered design process for the development of a mHealth app for PLWH. We conducted a usability evaluation with 10 targeted end-users and a heuristic evaluation with 5 persons with informatics expertise to assess the usability of a prototype mHealth app for PLWH to manage their health. At the end of our usability evaluation, we finalized a Design Document that included the user interface design and functional specifications of the mHealth app. The functional areas which were identified at the end of our iterative process included: Communication, Reminders, Medication Logs, Lab Reports, Pharmacy Info, Nutrition and Fitness, Resources and Settings.

BACKGROUND

Guideline recommendations to reduce prescription opioid misuse among patients with chronic noncancer pain include the routine use of urine toxicology tests for high-risk patients. Yet little is known about how the implementation of urine toxicology tests among patients with co-occurring chronic noncancer pain and substance use impacts primary care providers' management of misuse. Clinicians' perspectives on the benefits and challenges of implementing urine toxicology tests in the monitoring of opioid misuse and substance use in safety net health care settings are presented in this paper.

METHODS

Twenty-three primary care providers from 6 safety net health care settings whose patients had a diagnosis of co-occurring chronic noncancer pain and substance use were interviewed. Interviews were transcribed, coded, and analyzed using grounded theory methodology.

RESULTS

The benefits of implementing urine toxicology tests for primary care providers included less reliance on intuition to assess for misuse and the ability to identify unknown opioid misuse and/or substance use. The challenges of implementing urine toxicology tests included insufficient education and training about how to interpret and implement tests, and a lack of clarity on how and when to act on tests that indicated misuse and/or substance use.

CONCLUSIONS

These data suggest that primary care clinicians' lack of education and training to interpret and implement urine toxicology tests may impact their management of patient opioid misuse and/or substance use. Clinicians may benefit from additional education and training about the clinical implementation and use of urine toxicology tests. Additional research is needed on how primary care providers implementation and use of urine toxicology tests impacts chronic noncancer pain management in primary care and safety net health care settings among patients with co-occurring chronic non cancer pain and substance use.

Semi-structured interviews were conducted with 16 Latino cancer patients diagnosed in California; 10 health professionals from the San Francisco Bay Area and Fresno, California; and 10 Cancer Information Services (CIS) information specialists from the regional offices handling calls from Spanish-speakers. Interview guides were designed by the investigators to answer three main research questions: 1) How do Latinos obtain information about cancer and what types of information do they access?; 2) What sources of cancer information do they seek out and find credible?; and 3) What are the barriers and facilitators to Latinos obtaining cancer information? Stakeholders generally viewed health professionals as the most credible source of cancer information. All groups regarded family and friends as important sources of information. Patients and health professionals tended to differ on the value of print materials. Although patients found them generally useful, health professionals tended to view them as inadequate for meeting the informational needs of their Latino patients due to the challenge of low health literacy. Health professionals also tended to undervalue Internet resources compared to patients and CIS specialists. All stakeholders viewed language, ethnic discordance and the impact on patients of the initial diagnosis as barriers to effective communication of cancer information. Health professionals and CIS specialists, but not patients, mentioned low literacy as a barrier. Our findings underscore the importance of the physician-patient relationship as a point of intervention to address the unmet informational and psychosocial needs of Latino cancer patients.

OBJECTIVES

Little cigars and cigarillos are gaining in popularity as cigarette use wanes, mainly due to relaxed regulatory standards that make them cheaper, easier to buy individually, and available in a variety of flavors not allowed in cigarettes. To address whether they should be regulated as strictly as cigarettes, we investigated whether little cigar secondhand smoke (SHS) decreases vascular endothelial function like that of cigarettes.

METHODS

We exposed rats to SHS from little cigars, cigarettes, or chamber air, for 10 minutes and measured the resulting acute impairment of arterial flow-mediated dilation (FMD).

RESULTS

SHS from both little cigars and cigarettes impaired FMD. Impairment was greater after exposure to little cigar SHS than by cigarette SHS relative to pre-exposure values, although the post-exposure FMD values were not significantly different from each other.

CONCLUSIONS

Exposure to little cigar SHS leads to impairment of FMD that is at least equal to that resulting from similar levels of cigarette SHS. Our findings support the need to prevent even brief exposure to little cigar SHS, and support tobacco control policies that regulate little cigars as strictly as cigarettes.