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Housing instability, a growing public health problem, may be an independent environmental risk factor for hypertension, but limited prospective data exist. We sought to determine the independent association of housing instability in early adulthood (year 5, 1990-1991) and incident hypertension over the subsequent 15 years of follow-up (years 7, 10, 15, and 20) in the Coronary Artery Risk Development in Young Adults (CARDIA) study (N = 5,115). Because causes of inadequate housing and its effects on health are thought to vary by race and sex, we hypothesized that housing instability would exert a differential effect on incident hypertension by race and sex. At year 5, all CARDIA participants were asked about housing and those free of hypertension were analyzed (N = 4,342). We defined housing instability as living in overcrowded housing, moving frequently, or living doubled up. Of the 4,342 participants, 8.5 % were living in unstable housing. Across all participants, housing instability was not associated with incident hypertension (incidence rate ratio (IRR), 1.1; 95 % CI, 0.9-1.5) after adjusting for demographics, socioeconomic status, substance use, social factors, body mass index, and study site. However, the association varied by race and sex (p value for interaction,

Jocelyn Steward,1 Cheryl L Holt,2 David E Pollio,3 Erika L Austin,4,5 Nancy Johnson,4 Adam J Gordon,6,7 Stefan G Kertesz4,81Department of Health Care Management, Clayton State University, Morrow, GA, 2Department of Psychology, University of Maryland, College Park, MD, 3Department of Social Work, University of Alabama at Birmingham, 4Birmingham VA Medical Center, 5Department of Biostatistics, University of Alabama at Birmingham School of Public Health, Birmingham, AL, 6VA Pittsburgh Health Care System, 7University of Pittsburgh School of Medicine, Pittsburgh, PA, 8Department of Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USAPurpose: Homeless individuals face unique challenges in health care. Several US initiatives seeking to advance patient-centered primary care for homeless persons are more likely to succeed if they incorporate the priorities of the patients they are to serve. However, there has been no prior research to elicit their priorities in primary care. This study sought to identify aspects of primary care important to persons familiar with homelessness based on personal experience or professional commitment, and to highlight where the priorities of patients and professionals dedicated to their care converge or diverge.Methods: This qualitative exercise asked 26 homeless patients and ten provider/experts to rank 16 aspects of primary care using a card sort. Patient-level respondents (n=26) were recruited from homeless service organizations across all regions of the USA and from an established board of homeless service users. Provider/expert-level respondents (n=10) were recruited from veteran and non-veteran-focused homeless health care programs with similar geographic diversity.Results: Both groups gave high priority to accessibility, evidence-based care, coordination, and cooperation. Provider/experts endorsed patient control more strongly than patients. Patients ranked information about their care more highly than provider/experts.Conclusion: Accessibility and the perception of care based on medical evidence represent priority concerns for homeless patients and provider/experts. Patient control, a concept endorsed by experts, is not strongly endorsed by homeless patients. Understanding how to assure fluid communication, coordination, and team member cooperation could represent more worthy targets for research and quality improvement in this domain.Keywords: homeless persons, patient-centered care, primary care, provider perspectives

Abstract Background Comorbid psychiatric illness can undermine outcomes among homeless persons undergoing addiction treatment, and psychiatric specialty care is not always readily available. The prognosis for nonsubstance abuse psychiatric diagnoses among homeless persons receiving behaviorally-based addiction treatment, however, is little studied. Results Data from an addiction treatment trial for 95 cocaine-dependent homeless persons (1996–1998) were used to profile psychiatric diagnoses at baseline and 6 months, including mood-related disorders (e.g. depression) and anxiety-related disorders (e.g. post-traumatic stress disorder). Treatment interventions, including systematic reinforcement for goal attainment, were behavioral in orientation. There was a 32% reduction in the prevalence of comorbid non-addiction psychiatric disorder from baseline to 6 months, with similar reductions in the prevalence of mood (-32%) and anxiety-related disorders (-20%) (p = 0.12). Conclusion Among cocaine-dependent homeless persons with psychiatric comorbidity undergoing behavioral addiction treatment, a reduction in comorbid psychiatric disorder prevalence was observed over 6 months. Not all participants improved, suggesting that even evidence-based addiction treatment will prove insufficient for a meaningful proportion of the dually diagnosed homeless population.

Abstract Background Because individuals with HIV/AIDS often have complex medical and social needs, the impact of housing status on medical service utilization is difficult to isolate from the impact of conditions that may worsen during periods of homelessness such as depression and substance abuse. We examine whether episodes of homelessness are independently associated with suboptimal medical utilization even when accounting for concurrent addiction severity and depression. Methods We used data from a 30-month cohort of patients with HIV/AIDS and alcohol problems. Housing status, utilization (ambulatory visits, emergency department (ED) visits, and hospitalizations) and other features were assessed with standardized research interviews at 6-month intervals. Multivariable longitudinal regression models calculated incidence rate ratios (IRR) comparing utilization rates during 6-month intervals (homeless versus housed). Additional models assessed whether addiction severity and depressive symptoms could account for utilization differences. Results Of the 349 subjects, 139 (39%) reported homelessness at least once during the study period; among these subjects, the median number of nights homeless per 6-month interview period was 30. Homelessness was associated with higher ED utilization (IRR = 2.17; 95% CI = 1.72–2.74) and hospitalizations (IRR = 2.30; 1.70–3.12), despite no difference in ambulatory care utilization (IRR = 1.09; 0.89–1.33). These associations were attenuated but remained significant when adjusting for addiction severity and depressive symptoms. Conclusion In patients with HIV/AIDS and alcohol problems, efforts to improve housing stability may help to mitigate intensive medical utilization patterns.

In 2022, the CDC revised its and encourage clinicians to weight the risks versus harms of continued therapy and empathetically engage patients in patient-centered discussions around continued therapy while avoiding patient abandonment. This commentary discusses how the emphasis on "benefit" will almost always lead to discordance between the patient and provider since many clinicians find little benefit in opioid therapy for chronic pain with evidence questioning its efficacy for chronic pain. This disagreement between patients and providers has the potential to lead to unilateral tapers or patient abandonment and further increase patient harm. Considering this dilemma, we propose a revised framework that emphasizes weighing the harms of continuation of therapy against the harms of discontinuation of therapy when caring for patients on long-term opioid therapy. This revised harm-reductive decisional framework has the potential to retain patient-provider trust and increase opportunities for engagement in evidence-based multi-modal pain treatment, including non-opioid based treatment options., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Lagisetty has no conflicts of interest. Dr Kertesz reported holding stock in Zimmer Biomet and Thermo Fisher and receiving royalties from UpToDate (Wolters-Kluwer). He also held stock in CVS Caremark, in 2020 only. Dr Kertesz served voluntarily on the scientific advisors to the National Pain Advocacy Center, which receives no funds from industry. The opinions in this article are those of the authors alone and do not represent formal positions of the US Department of Veterans Affairs or any other government agency.

Background: Retention of patients in buprenorphine medication treatment for opioid use disorder (B-MOUD) reduces harms associated with opioid use disorder (OUD). We sought to characterize the patients receiving B-MOUD and courses of B-MOUD in a large healthcare system., Methods: We conducted a retrospective, open cohort study of patients with OUD who either did or did not receive B-MOUD courses within the Veterans Health Administration (VHA) from January 2006 through July 2019, using VHA clinical data. We compared patients receiving or not receiving B-MOUD, characterized B-MOUD courses (e.g., length and doses), and examined persistence, across patient characteristics, over time. We used analyses for normally or non-normally distributed continuous variables, categorical data, and persistence over time (Kaplan-Meier persistence curves)., Results: We identified 255,726 Veterans with OUD; 40,431 (15.8%) had received 63,929 B-MOUD courses. Compared to patients with OUD without B-MOUD, patients with B-MOUD were younger, more often of white race, and had more co-morbidities. The frequency of new B-MOUD starts and prevalent B-MOUD patients ranged from 1550 and 1989 in 2007 to 8146 and 16,505 in 2018, respectively. The median duration of B-MOUD was 157 (IQR: 37-537) days for all courses and 33.8% patients had more than one course. The average proportion days covered was 90% (SD: 0.15), and the average prescribed daily dose was 13.44 (SD: 6.5)., Conclusions: Within a VHA B-MOUD cohort, courses increased more than 10-fold from 2006 to 2016 with nearly half of patients experiencing multiple courses. Patient demographics seem to dictate the length of courses., Competing Interests: Declaration of Competing Interest AJG receives an honorarium for an online chapter on alcohol management in the perioperative period from Wolters-Kluwer; is on the board of directors (not-for profit; not remunerated) for the American Society of Addiction Medicine (ASAM), the Association for Multidisciplinary Education and Research in Substance use and Addiction (AMERSA), and the International Society of Addiction Journal Editors (ISAJE), all non-for profit organizations; and receives current grant support from the Veterans Health Administration (VHA) and NIH. SGK receives an honorarium for an online chapter on homeless health care from Wolters-Kluwer, and research grant funding from the Veterans Health Administration (VHA). He serves on the board of scientific advisors (not-for-profit; not remunerated) of both the National Pain Advocacy Center and the Albert Schweitzer Fellowship, Inc. He reports current ownership of stock in medical product companies unrelated to this topic, Zimmer Biomet, Dow and Thermo Fisher. He reports stock ownership in CVS/Caremark in 2020, only., (Published by Elsevier B.V.)

Objective: Among veterans with posttraumatic stress disorder (PTSD), supported employment that utilizes the individual placement and support (IPS) model has resulted in consistently better employment and functional outcomes than usual vocational rehabilitation services. This study aimed to compare these two approaches in terms of health services use and associated costs., Methods: A secondary analysis of a multisite randomized controlled trial of 541 unemployed veterans with PTSD used archival data from electronic medical records to assess the use and costs of health services of IPS and usual care (i.e., a transitional work [TW] program) over 18 months. Comparisons were also made to an 18-month postintervention period., Results: The two study groups did not differ in number of inpatient days or in utilization or cost of high-intensity services. Annual per-person costs of health services were approximately 20% higher for IPS than for TW participants (mean difference=$4,910 per person per year, p<0.05) during the intervention period, largely driven by higher utilization and costs for vocational services in the IPS group (p<0.001). These costs declined postintervention to nonsignificant differences. The mean annual per-person vocational service cost was $6,388 for IPS and $2,549 for TW (mean difference=$3,839, p<0.001) during the intervention period., Conclusions: In keeping with IPS’s intensive case management approach, veterans receiving IPS used more vocational services and had correspondingly higher costs than veterans receiving TW. The two groups did not differ in use or cost of other types of health services. Future research should examine whether higher short-term costs associated with IPS relative to usual care result in long-term cost savings or higher quality of life for persons with PTSD.

We sought to estimate the impact of temporary financial assistance (TFA) for housing-related expenses from the U.S. Department of Veterans Affairs on costs for a variety of health care services. We conducted a retrospective cohort study of Veterans who entered the Supportive Services for Veteran Families (SSVF) program between 10/2015 and 9/2018. We assessed the effect of TFA on health care costs using a multivariable difference-in-difference approach. Outcomes were direct medical costs of health care encounters (i.e., emergency department, outpatient mental health, inpatient mental health, outpatient substance use disorder treatment, and residential behavioral health) in the VA system. Temporary financial assistance was associated with a decrease in ED (-$11, p<.003), outpatient mental health (-$28, p<.001), outpatient substance use disorder treatment (-$25, p<.001), inpatient mental health (-$258, p<.001), and residential behavioral health (-$181, p<.001) costs per quarter for Veterans in the rapid re-housing component of SSVF. These results can inform policy debates regarding proper solutions to housing instability.

Background: Prescription opioids (PO) have been widely used for chronic non-cancer pain, with commensurate concerns for overdose. The long-term effect of these medications on non-overdose mortality in the general population remains poorly understood. This study's objective was to examine the association of prescription opioid use and mortality in a large cohort, accounting for gender differences and concurrent benzodiazepine use, and using propensity score matching. Methods : 29,025 US community-dwellers were enrolled in the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort between 2003 and 2007, and followed through December 31, 2012. At baseline there were 1907 participants with PO; 1864 of them were matched to participants without PO, based on the model-derived propensity to receive opioid prescriptions. Causes of death were expert-adjudicated. Results : Over median follow-up of 6 years there were 4428 deaths (413 among persons with PO). The risk for all-cause mortality was 12% higher, in absolute terms, for persons with PO compared to those without PO in the overall sample, with gender differences (interaction p  = .0008). The risk of death was increased for women with PO (hazard ratio [HR] 1.21 [95% Confidence Interval (CI) 1.04-1.40]), but not men (HR 0.92 [95% CI 0.77-1.10]). Women with PO were at higher risk of cardiovascular disease (CVD) death (HR 1.43 [95% CI 1.12-1.84]), sudden death (HR 2.02 [95% CI 1.29-3.15]) (a subset of CVD death), and accidents (HR 2.18 [95% CI 1.03-4.60]). These risks were not observed for men with PO. Conclusion : Over 6 years of follow-up, women but not men who had opioid prescriptions were at higher risk of all-cause mortality, CVD death, sudden death, and accidents. Special caution in prescribing opioids for women may be warranted until these findings are confirmed.

Background: The purpose of this study was to estimate opioid use disorder prevalence rates at the county level among veterans in Alabama and to determine hotspots of said rates. Methods: By combining data from the National Survey on Drug Use and Health and the American Community Survey, we developed a mixed-effects generalized linear model of opioid use disorder and modeled probabilities onto veteran-specific population counts at the county level in Alabama. Results : The average model-based estimate for opioid use disorder prevalence among veterans in Alabama from 2015 to 2017 was 0.79% ( SD  = 0.16), with a minimum of 0.52% (i.e., Lowndes county, Alabama) and a maximum of 1.10% (Dale county, Alabama). Hotspot analysis revealed a significant cluster of "high-high" veteran opioid use disorder prevalence in neighboring Marion, Winston, and Cullman counties. Conclusions : The application of the statistical technique presented in this study can provide feasible, cost-effective, and practical county-level prevalence estimates of veteran-specific opioid use disorder and should be widely applied by states and counties so that they can more accurately and efficiently allocate resources to caring for veterans with an opioid use disorder.

High-quality research demonstrating a lack of effectiveness may facilitate the 'de-adoption' of ineffective health services. However, there has been little debate on the optimal design for ineffectiveness research-studies exploring the research hypothesis that an intervention is ineffective. The aim of this study was to explore investigators' preferences for trial design for ineffectiveness research. We conducted a mixed-methods online survey with principle investigators identified from clinicaltrials.gov. A vignette described researchers planning a trial to test a widely used intervention they hypothesised was ineffective. One multiple-choice question asked whether a superiority trial or equivalence trial design was favoured, and one free-response question asked about the reasons for that choice. Free-response answers were analysed using content analysis to identify related reasons. 139 participants completed the survey (completion rate 37.5%). Overall, 56.8% favoured superiority trials, 27.3% favoured equivalence trials and 15.8% were unsure. Reasons identified for favouring superiority trials were: (1) evidence of superiority should be required to justify active treatment, (2) superiority trials are more familiar, (3) placebo should not be the comparator in equivalence trials and (4) superiority trials require smaller sample sizes. Reasons identified for favouring equivalence trials were: (1) negative superiority trials represent a lack of evidence of effectiveness, not evidence of ineffectiveness and (2) the research hypothesis should not be the same as the null hypothesis. A minority of experienced researchers favour equivalence trials for ineffectiveness research, and misconceptions and lack of familiarity with equivalence trials may be contributing factors., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Chronic pain is an important and understudied comorbidity in people living with HIV (PLWH). We conducted a pilot trial of Skills TO Manage Pain (STOMP), an innovative social cognitive theory-based pain self-management intervention tailored to PLWH, to assess feasibility, acceptability, and preliminary efficacy. Eligibility criteria included being HIV+, ≥ moderate pain for ≥ 3 months and a score of ≥ 4 on the three-item PEG pain severity and interference scale. Participants were randomized in a 1:1 fashion to STOMP or a usual care comparison. Among 22 participants randomized to STOMP, median session attendance was 9/12 (75%). Of 19 STOMP participants surveyed, 13 reported being "much better" overall since beginning treatment. Brief pain inventory-total scores decreased by 2 points in the intervention group and 0.9 in the control group (p = 0.11). STOMP is feasible, acceptable, and shows preliminary evidence of efficacy and promise for a full-scale trial.

Background: Homeless patients describe poor experiences with primary care. In 2012, the Veterans Health Administration (VHA) implemented homeless-tailored primary care teams (Homeless Patient Aligned Care Team, HPACTs) that could improve the primary care experience for homeless patients., Objective: To assess differences in primary care experiences between homeless and nonhomeless Veterans receiving care in VHA facilities that had HPACTs available (HPACT facilities) and in VHA facilities lacking HPACTs (non-HPACT facilities)., Research Design: We used multivariable multinomial regressions to estimate homeless versus nonhomeless patient differences in primary care experiences (categorized as negative/moderate/positive) reported on a national VHA survey. We compared the homeless versus nonhomeless risk differences (RDs) in reporting negative or positive experiences in 25 HPACT facilities versus 485 non-HPACT facilities., Subjects: Survey respondents from non-HPACT facilities (homeless: n=10,148; nonhomeless: n=309,779) and HPACT facilities (homeless: n=2022; nonhomeless: n=20,941)., Measures: Negative and positive experiences with access, communication, office staff, provider rating, comprehensiveness, coordination, shared decision-making, and self-management support., Results: In non-HPACT facilities, homeless patients reported more negative and fewer positive experiences than nonhomeless patients. However, these patterns of homeless versus nonhomeless differences were reversed in HPACT facilities for the domains of communication (positive experience RDs in non-HPACT versus HPACT facilities=-2.0 and 2.0, respectively); comprehensiveness (negative RDs=2.1 and -2.3), shared decision-making (negative RDs=1.2 and -1.8), and self-management support (negative RDs=0.1 and -4.5; positive RDs=0.5 and 8.0)., Conclusions: VHA facilities with HPACT programs appear to offer a better primary care experience for homeless versus nonhomeless Veterans, reversing the pattern of relatively poor primary care experiences often associated with homelessness.

Introduction: Homeless Veterans are vulnerable to poor care transitions, yet little research has examined their risk of readmission following inpatient surgery. This study investigates the predictors of surgical readmission among homeless relative to housed Veteran patients., Methods: Inpatient general, vascular, and orthopedic surgeries occurring in the Veterans Health Administration from 2008 to 2014 were identified. Administrative International Classification of Diseases, Ninth Revision, Clinical Modification codes and Veterans Health Administration clinic stops were used to identify homeless patients. Bivariate analyses examined characteristics and predictors of readmission among homeless patients. Multivariate logistic models were used to estimate the association between homeless experience and housed patients with readmission following surgery., Results: Our study included 232,373 surgeries: 43% orthopedic, 39% general, and 18% vascular with 5068 performed on homeless patients. Homeless individuals were younger (56 vs. 64 y, P<0.01), more likely to have a psychiatric comorbidities (51.3% vs. 19.4%, P<0.01) and less likely to have other medical comorbidities such as hypertension (57.1% vs. 70.8%, P<0.01). Homeless individuals were more likely to be readmitted [odds ratio (OR), 1.43; confidence interval (CI), 1.30-1.56; P<0.001]. Discharge destination other than community (OR, 0.57; CI, 0.44-0.74; P<0.001), recent alcohol abuse (OR, 1.45; CI, 1.15-1.84; P<0.01), and elevated American Society Anesthesiologists classification (OR, 1.86; CI, 1.30-2.68; P<0.01) were significant risk factors associated with readmissions within the homeless cohort., Conclusions: Readmissions are higher in homeless individuals discharged to the community after surgery. Judicious use of postoperative nursing or residential rehabilitation programs may be effective in reducing readmission and improving care transitions among these vulnerable Veterans. Relative costs and benefits of alternatives to community discharge merit investigation.

Chronic pain is an important comorbidity among individuals with HIV. Behavioral interventions are widely regarded as evidence-based, efficacious non-pharmacologic interventions for chronic pain in the general population. An accepted principle in behavioral science is that theory-based, systematically-developed behavioral interventions tailored to the unique needs of a target population are most likely to be efficacious. Our aim was to use Intervention Mapping to systematically develop a Social Cognitive Theory (SCT)-based intervention for chronic pain tailored to individuals with HIV that will improve pain intensity and pain-related functional impairment. Our Intervention Mapping process was informed by qualitative inquiry of 24 patients and seven providers in an HIV primary care clinic. The resulting intervention includes group and one-on-one sessions and peer and staff interventionists. We also developed a conceptual framework that integrates our qualitative findings with SCT-based theoretical constructs. Using this conceptual framework as a guide, our future work will investigate the intervention's impact on chronic pain outcomes, as well as our hypothesized proximal mediators of the intervention's effect.

Background: Chronic pain is a common, disabling, and costly comorbidity, particularly in people living with HIV (PLWH). This study developed and pilot tested a pain self-management intervention for chronic pain tailored to PLWH called Skills TO Manage Pain (STOMP)., Objectives: Given the additional resources needed to deliver STOMP in HIV clinical settings, an important objective of the pilot study was to assess not only STOMP's preliminary efficacy, but also its cost-effectiveness., Research Design and Subjects: The present study draws from a 44-participant, 2-arm randomized pilot trial of the STOMP intervention vs usual care among PLWH and at least moderate chronic pain (Clinicaltrials.gov: NCT02824562). Cost-effectiveness is presented as the incremental cost-effectiveness ratio (ICER). Costs were considered from the clinic perspective over a 1-year time horizon using real costs from the pilot trial. It was conservatively assumed there would be no costs savings. The Standard Gamble (SG) method was used to directly measure utilities., Results: Thirty-six participants met inclusion criteria for the present analyses. Mean age was 52 years; 61% were female and 86% were black. The total cost of STOMP was $483.83 per person. Using the SG method, the change in QALYs was 0.15, corresponding to an ICER of $3,225., Conclusions: STOMP's cost/QALY is substantially lower than the $50,000 to $100,000/QALY benchmark often used to indicate cost-effectiveness. Although based on a pilot trial and, therefore, preliminary, these findings are promising, and suggest the importance of cost analyses in future STOMP trials.

Objective: Opioid prescribing recently has come under intense scrutiny. However, longitudinal patterns of prescription opioid receipt in a population-based cohort of patients with chronic pain, such as those with rheumatoid arthritis (RA), have not been well characterized. The aim of this study was to examine both trends over time and variability in individual physician prescribing of short-term and long-term use of opioids., Methods: We identified a cohort of RA patients based on 2006-2014 Medicare data and evaluated longitudinal time trends in "regular" use of opioids. A separate analysis conducted in 2014 assessed rheumatologist-specific variability in regular use of opioid prescriptions in patients with RA., Results: We identified 97,859 RA patients meeting the eligibility criteria. The mean age of the patients was 67 years, 80% were female, 82% were white, and 12% were African American. The most commonly used opioids were those that combined acetaminophen with hydrocodone or propoxyphene. Regular opioid prescribing increased slowly but peaked in 2010 before propoxyphene was withdrawn from the market. Following the withdrawal of propoxyphene, receipt of hydrocodone and tramadol increased commensurately, and overall opioid use declined only slightly. Factors associated with regular use of opioids included younger age, female sex, African American race, back pain, fibromyalgia, anxiety, and depression. Variability between US rheumatologists (n = 4,024) in prescribing the regular use of opioids for their RA patients was high; in the average rheumatologist's practice, 40% of RA patients used prescription opioids regularly. In almost half of the patients, at least some opioid prescriptions were written by a rheumatologist, and 14% received opioids that were co-prescribed concurrently by more than 1 physician., Conclusion: In the US, opioid use in older patients with RA peaked in 2010 and is now declining slightly. Withdrawal of propoxyphene from the US market in 2010 had minimal effect on overall opioid use, because use of propoxyphene was replaced by increased use of other opioids., (© 2017, American College of Rheumatology.)

Background: Chronic pain is a common and disabling comorbidity in individuals living with HIV. Behavioral interventions are among the most effective and safe nonpharmacologic treatments for chronic pain. However, the success of a behavioral intervention is influenced by how well it is tailored to the target population's biological, psychological, and social context. Given well-documented psychosocial vulnerabilities among persons with HIV, it is critical to develop a behavioral intervention for chronic pain tailored to this population., Objective: To use qualitative methods to investigate patient preferences for the structure and delivery of a behavioral intervention for chronic pain in individuals with HIV., Methods: Interviews and focus groups were used to elicit participant preferences. A thematic analysis approach, with an initial round of open coding, was used to develop the codebook and analyze the data., Results: Qualitative data from 12 interviews and 3 focus groups with patients living with HIV and chronic pain (total N = 24) were analyzed. Emergent themes fell into four major categories: perceived value of group sessions, incorporating peer leadership, and two key elements of how the intervention should be delivered: the HIV status of group participants and views on phone-delivered intervention content., Discussion: This study provides a framework for the structure and delivery of a behavioral intervention for chronic pain in individuals with HIV based on patient preferences. We will use these results to design our intervention, and hope that our approach informs the work of investigators in other disciplines who seek to incorporate patient preferences during intervention development., (© 2016 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Opioids are often prescribed for chronic pain, and opioid risks such as overdose and death are heightened when opioids are co-prescribed with other sedating medications. We investigated factors associated with chronic opioid prescription, alone and in combination with benzodiazepines and muscle relaxants, in a clinical cohort of individuals with HIV. We used multivariable logistic regression models to determine participant clinical and demographic characteristics that are associated with chronic prescription of opioids or chronic co-prescription of opioids with sedating medications. Among 1474 participants, chronic prescription of opioids occurred in 253 individuals (17.2 %), and chronic co-prescription occurred in 90 individuals (6.1 %). Age >50, public insurance as compared to private insurance, and symptoms of depression and anxiety were significantly associated with chronic opioid prescription and chronic co-prescription. Our findings raise concern that opioid prescription and co-prescription of sedating medications occurs disproportionately in patients for whom use is riskier.

Objective: Despite unknown risks, prescription opioid use (POU) for nonmalignant chronic pain has grown in the US over the last decade. The objective of this study was to examine associations between POU and coronary heart disease (CHD), stroke, and cardiovascular disease (CVD) death in a large cohort., Design, Setting, Subjects: POU was assessed in the prospective cohort study of 29,025 participants of the REasons for Geographic and Racial Differences in Stroke study, enrolled between 2003 and 2007 from the continental United States and followed through December 31, 2010. CHD, stroke, and CVD death were expert adjudicated outcome measures., Methods: Cox proportional hazards models adjusted for CVD risk factors were used., Results: Over a median (SD) of 5.2 (1.8) years of follow-up, 1,362 CHD events, 749 strokes, and 1,120 CVD death occurred (105, 55, and 104, respectively, in the 1,851 opioid users). POU was not associated with CHD (adjusted hazard ratio [aHR]) 1.03 [95% CI 0.83-1.26] or stroke (aHR 1.04 [95% CI 0.78-1.38]), but was associated with CVD death (aHR 1.24 [95% CI 1.00-1.53]) in the overall sample. In the sex-stratified analyses, POU was associated with increased risk of CHD (aHR 1.38 [95% CI 1.05-1.82]) and CVD death (aHR 1.66 [95% CI 1.27-2.17]) among females but not males (aHR 0.70 [95% CI 0.50-0.97] for CHD and 0.78 [95% CI 0.54-1.11] for CVD death)., Conclusion: Female but not male POU were at higher risk of CHD and CVD death. POU was not associated with stroke in overall or sex-stratified analyses., (© 2015 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

A method to rapidly identify the presence of chronic pain would enhance the care of HIV-infected individuals, but such an instrument has not been assessed in this population to date. We assessed the construct validity of the two-question Brief Chronic Pain Questionnaire (BCPQ) in HIV-infected patients by assessing the association between BCPQ responses and known correlates of chronic pain. Participants in the University of Alabama Center for AIDS Research Network of Integrated Clinical Systems cohort completed the BCPQ, along with the EuroQOL to assess physical function, the PHQ-9 to assess depression, and the PHQ-anxiety module to assess anxiety. Among 100 participants, 25% were female, the mean age was 45 (SD 12), 63% were African American, 27% were publicly insured, the median CD4(+) T cell count was 572 cells/mm(3) (IQR 307-788), and 82% had an undetectable viral load. Participants with chronic pain were more likely to have impaired mobility (43% vs. 12%, p=0.001), difficulty with usual activities (47% vs. 12%, p<0.001), lower overall health state (70 vs. 84, p=0.002), pain today (80% vs. 27%, p<0.001), depression (30% vs. 15%, p=0.10), and anxiety (43% vs. 10%, p<0.001) than those without chronic pain. This study provides preliminary evidence for the BCPQ as a brief questionnaire to identify the presence of chronic pain in HIV care settings.

Objectives: The U.S. Department of Veterans Affairs (VA) is transitioning to a Housing First approach to placement of veterans in permanent supportive housing through the use of rental vouchers, an ambitious organizational transformation. This qualitative study examined the experiences of eight VA facilities undertaking this endeavor in 2012., Methods: A multidisciplinary team interviewed facility leadership, midlevel managers, and frontline staff (N=95 individuals) at eight VA facilities representing four U.S. regions. The team used a semistructured interview protocol and the constant comparative method to explore how individuals throughout the organizations experienced and responded to the challenges of transitioning to a Housing First approach., Results: Frontline staff faced challenges in rapidly housing homeless veterans because of difficult rental markets, the need to coordinate with local public housing authorities, and a lack of available funds for move-in costs. Staff sought to balance their time spent on housing activities with intensive case management of highly vulnerable veterans. Finding low-demand sheltering options (that is, no expectations regarding sobriety or treatment participation, as in the Housing First model) for veterans waiting for housing presented a significant challenge to implementation of Housing First. Facility leadership supported Housing First implementation through resource allocation, performance monitoring, and reliance on midlevel managers to understand and meet the challenges of implementation., Conclusions: The findings highlight the considerable practical challenges and innovative solutions arising from a large-scale effort to implement Housing First, with particular attention to the experiences of individuals at all levels within an organization.

Unlabelled: Chronic pain in HIV-infected patients is prevalent but understudied. A limitation of HIV/chronic pain research to date is the lack of a widely used chronic pain screening tool. A Brief Chronic Pain Screening tool (BCPS) has been described, but has not yet been tested in a clinical population. This study sought to evaluate how the BCPS is experienced by HIV-infected individuals, and adapt its questions if necessary. We conducted cognitive interviews using cognitive inquiry in participants from the UAB 1917 HIV Clinic Cohort. Data were analyzed using a process of inductive, iterative coding by three investigators., Results: Of 30 participants, most were male, African American, and less than 50 years old. Participants reported that the questions were understandable; however, feedback suggested concerns regarding lack of specificity in regard to the intensity and consistency of pain. An introductory statement aimed at improving clarity resulted in more divergent responses. This research team concluded that the version of the BCPS used in the first 30 interviews was optimum. Its inclusive language allows the respondent to decide what pain merits reporting. This study is the first investigation of the BCPS in a clinical population, and should lead to further quantitative validation studies of this tool.

We used isolated chicken retina to induce spreading depression by the glutamate receptor agonist N-methyl-d-aspartate. The N-methyl-d-aspartate-induced latency time of spreading depression was extended by the glycine(B) binding site competitive antagonist 7-chlorokynurenic acid. Addition of the glycine transporter type-1 inhibitors NFPS and Org-24461 reversed the inhibitory effect of 7-chlorokynurenic acid on N-methyl-d-aspartate-evoked spreading depression. The glycine uptake inhibitory activity of Org-24461, NFPS, and some newly synthesized analogs of NFPS was determined in CHO cells stably expressing human glycine transporter type-1b isoform. Compounds, which failed to inhibit glycine transporter type-1, also did not have effect on retinal spreading depression. These experiments indicate that the spreading depression model in chicken retina is a useful in vitro test to determine activity of glycine transporter type-1 inhibitors. In addition, our data serve further evidence for the role of glycine transporter type-1 in retinal neurotransmission and light processing., (Copyright © 2012 Elsevier B.V. All rights reserved.)

To date, most genetic association studies of tobacco use have been conducted in European American subjects using the phenotype of smoking quantity (cigarettes per day). However, smoking quantity is a very imprecise measure of exposure to tobacco smoke constituents. Analyses of alternate phenotypes and populations may improve our understanding of tobacco addiction genetics. Cotinine is the major metabolite of nicotine, and measuring serum cotinine levels in smokers provides a more objective measure of nicotine dose than smoking quantity. Previous genetic association studies of serum cotinine have focused on individual genes. We conducted a genetic association study of the biomarker in African American (N=365) and European American (N=315) subjects from the Coronary Artery Risk Development in Young Adults study using a chip containing densely-spaced tag SNPs in ∼2100 genes. We found that rs11187065, located in the non-coding region (intron 1) of insulin-degrading enzyme (IDE), was the most strongly associated SNP (p=8.91 × 10(-6)) in the African American cohort, whereas rs11763963, located on chromosome 7 outside of a gene transcript, was the most strongly associated SNP in European Americans (p=1.53 × 10(-6)). We then evaluated how the top variant association in each population performed in the other group. We found that the association of rs11187065 in IDE was also associated with the phenotype in European Americans (p=0.044). Our top SNP association in European Americans, rs11763963 was non-polymorphic in our African American sample. It has been previously shown that psychostimulant self-administration is reduced in animals with lower insulin because of interference with dopamine transmission in the brain reward centers. Our finding provides a platform for further investigation of this, or additional mechanisms, involving the relationship between insulin and self-administered nicotine dose.

Context: Marijuana smoke contains many of the same constituents as tobacco smoke, but whether it has similar adverse effects on pulmonary function is unclear., Objective: To analyze associations between marijuana (both current and lifetime exposure) and pulmonary function., Design, Setting, and Participants: The Coronary Artery Risk Development in Young Adults (CARDIA) study, a longitudinal study collecting repeated measurements of pulmonary function and smoking over 20 years (March 26, 1985-August 19, 2006) in a cohort of 5115 men and women in 4 US cities. Mixed linear modeling was used to account for individual age-based trajectories of pulmonary function and other covariates including tobacco use, which was analyzed in parallel as a positive control. Lifetime exposure to marijuana joints was expressed in joint-years, with 1 joint-year of exposure equivalent to smoking 365 joints or filled pipe bowls., Main Outcome Measures: Forced expiratory volume in the first second of expiration (FEV(1)) and forced vital capacity (FVC)., Results: Marijuana exposure was nearly as common as tobacco exposure but was mostly light (median, 2-3 episodes per month). Tobacco exposure, both current and lifetime, was linearly associated with lower FEV(1) and FVC. In contrast, the association between marijuana exposure and pulmonary function was nonlinear (P < .001): at low levels of exposure, FEV(1) increased by 13 mL/joint-year (95% CI, 6.4 to 20; P < .001) and FVC by 20 mL/joint-year (95% CI, 12 to 27; P < .001), but at higher levels of exposure, these associations leveled or even reversed. The slope for FEV(1) was -2.2 mL/joint-year (95% CI, -4.6 to 0.3; P = .08) at more than 10 joint-years and -3.2 mL per marijuana smoking episode/mo (95% CI, -5.8 to -0.6; P = .02) at more than 20 episodes/mo. With very heavy marijuana use, the net association with FEV(1) was not significantly different from baseline, and the net association with FVC remained significantly greater than baseline (eg, at 20 joint-years, 76 mL [95% CI, 34 to 117]; P < .001)., Conclusion: Occasional and low cumulative marijuana use was not associated with adverse effects on pulmonary function.

A person's decision to drink alcohol is potentially influenced by both price and availability of alcohol in the local area. This study uses longitudinal data from 1985 to 2001 to empirically assess the impact of distance from place of residence to bars on alcohol consumption in four large U.S. cities from 1985 to 2001. Density of bars within 0.5 km of a person's residence is associated with small increases in alcohol consumption as measured by: daily alcohol consumption (ml) drinks per week, and weekly consumption of beer, wine, and liquor. When person-specific fixed effects are included, the relationship between alcohol consumption and the number of bars within a 0.5 km radius of the person's place of residence disappears. Tests for endogeneity of the number of bars within the immediate vicinity of respondents' homes fail to reject the null hypothesis that the number of bars is exogenous. We conclude that bar density in the area surrounding the individuals' homes has at most a very small positive effect on alcohol consumption.

Clinical trials with cocaine-dependent outpatients have found a strong relation between in-treatment and follow-up abstinence, and the strength of this relation is constant across treatment conditions with variable efficacy in generating abstinence. The authors conducted secondary analyses of data from 3 clinical trials to determine whether this relation generalizes to cocaine-dependent homeless persons. The 3 trials (total N = 543) were conducted in a community health care facility for homeless people. The 7 treatment arms across the 3 trials were combinations of day treatment, abstinence-contingent housing, and vocational training. Drug use was measured with urine toxicology testing. Consecutive weeks of abstinence during treatment were strongly related to abstinence at the 12-month follow-up, whether or not missing 12-month data were included in the analysis. The treatment arms differed in their efficacy in generating abstinence, but the relation between in-treatment and follow-up abstinence did not differ across treatment arms. These results replicate earlier reports of these relations and extend them to a population of homeless people. The lack of differences between treatment arms in the in-treatment-follow-up abstinence relation implies that that relation is independent of the treatment-specific intervention components that generate group differences in abstinence.