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BYLINE: Yadira Galindo

Newswise — A defining development of the 20th century that changed the course of public health was when governments around the world improved access to safe water, sanitation and hygiene. However, a binational study led by University of California San Diego researchers found that, during the peak of the COVID-19 pandemic, people experiencing homelessness and individuals who inject drugs in San Diego and the bordering city of Tijuana, Mexico often did not have access to these basic resources.

There are estimated to be 10,000 people who inject drugs in Tijuana and another 21,800 in San Diego, many of whom are experiencing homelessness.

Reporting in the International Journal for Equity in Health, study first author Alhelí Calderón Villarreal, M.D., M.P.H., who conducted the research as part of her doctoral dissertation as a student in the UC San Diego-San Diego State University Joint Doctoral Program in Public Health, wrote that access to water, sanitation and hygiene was very low by international standards, and lower than the national averages in the United States and Mexico, for people who inject drugs and live in San Diego and Tijuana.

“We found that even in Southern California — one of the wealthiest parts of the world — people who use drugs often go without access to water, showers and toilets. The lack of these basic services also places people who use drugs at risk of serious, but preventable, illnesses, and poses risks to society at large,” said Calderón Villarreal, who will graduate in June with a Doctor of Philosophy in Public Health from the Herbert Wertheim School of Public Health and Human Longevity Science at UC San Diego.

Researchers interviewed 586 people in Tijuana (202) and San Diego (384) between 2020 and 2021, when COVID-19 infection was highest and when having access to water, showers and toilets should have been a public health priority.

Researchers found that 78 percent of individuals interviewed did not have access to an acceptable toilet, 54 percent did not have regular access to showers, and 11 percent reported having insufficient access to drinking water. Only 38 percent of study participants had access to water and soap for handwashing and the same number of participants reported defecating outdoors, placing themselves and the general public at health risk.

Abscesses and vascular damage are common injuries among people who inject drugs. Unsafe water used for preparing drugs or cleaning wounds can lead to life-threatening health problems including the risk of viral, parasitic and bacterial infections which include multi-drug resistant organisms, said the study authors.

Twenty percent of study participants said they felt thirsty daily, without access to drinking water. In fact, nearly all participants – 96.9 percent – drank less water daily than is medically recommended for proper hydration.

“Access to water, sanitation and hygiene are needed in both cities to reduce disparities and improve health and well-being among people who inject drugs, especially for those who are unhoused. It also benefits public health for the region as a whole,” said senior author Georgia Kayser, Ph.D., assistant professor at the Herbert Wertheim School of Public Health.

Experiencing homelessness increased the difficulty of finding toilets, bathing facilities and clean water sources. This was made even more difficult if the individual was unsheltered or on the street. Compared to participants who had housing, those who were unsheltered were 3.1 times more likely to be unable to access clean water sources for cleansing wounds and abscesses and 2.6 for preparing drugs for injection. They were twice as likely to be unable to access basic drinking water, 1.8 times more unlikely to have bathing opportunities, and 1.7 times less likely to have access to sanitation.

Participants residing in Tijuana reported a lack of access to basic drinking water and body and hand hygiene significantly more often than those living in San Diego. In Tijuana, 30 percent of people had access to basic hygiene (handwashing with water and soap) and 37 percent to bathing compared to 47 percent and 50 percent respectively in San Diego.

While San Diego provides more public access to water, sanitation and hygiene services, both cities have similar challenges and therefore can implement similar solutions.

The study authors suggest two solutions. Ideally, provide safe and secure places to live with access to safe water and sanitation to improve overall health and wellbeing. In the interim, expand access to mobile hygiene services and public restrooms, for those who do not have a traditional housing setting. This could involve extending hours of operation for existing public facilities, creating more public restrooms, increasing the number of mobile water, sanitation and hygiene service providers, and the integration of showers and toilet facilities in harm reduction programs.

“Providing everyone with access to drinking water, sanitation and hygiene services is necessary to prevent disease transmission and improve public health in the region,” said Gudelia Rangel, Ph.D., professor and investigator at the Colegio de la Frontera Norte and Border Health Coalition, Baja California, Mexico.

Co-authors include: Lourdes Johanna Avelar Portillo, UC San Francisco; Daniela Abramovitz, UC San Diego; Shira Goldenberg, Shawn Flanigan, Penelope J. E. Quintana, all of San Diego State University; Alicia Harvey‑Vera, UC San Diego and Universidad de Xochicalco; Carlos F. Vera, UC San Diego; and Steffanie Strathdee, principal investigator, UC San Diego School of Medicine.  

This research was funded, in part, by the National Institute of Drug Abuse (R01DA049644, 3R01DA04964403S2), National Council of Science and Technology (CONACYT) 2020 in Mexico, Fogarty International Center of the National Institutes of Health (D43TW009343), and the National Institute of Environmental Health Sciences (K01ES031697).

Disclosures: The authors report no conflicts of interest.

DOI: 10.1186/s12939-024-02163-x

Newswise — A growing number of states and territories in the United States have legalized medical and recreational cannabis use. As such, recreational cannabis has been associated with a lower perception of risk of harm in the general U.S. population.

However, in women of childbearing age, evidence has shown that cannabis use may increase the risk of adverse reproductive and perinatal health outcomes. Furthermore, research on the perception of risk from using cannabis among vulnerable populations such as those with disabilities is lacking.

Using data from the 2021 National Survey on Drug Use and Health, researchers from Florida Atlantic University’s Schmidt College of Medicine conducted a study to assess the perceived risk of harm associated with weekly cannabis use in a sample of 20,234 women ages 18 to 49 by disability status.

Disabilities included sensory (hearing and vision), cognitive (difficulty remembering and concentrating) and daily activities (e.g., walking and self-care). Researchers included race/ethnicity, age, marital status, federal poverty level, past-year health insurance gap, and whether the state of residence legalized medical cannabis. They also assessed perceived overall health status, past-year major depressive episode, past-month tobacco/alcohol use, and illicit drug use.

Results of the study, published in the journal Cannabis and Cannabinoid Research, showed that approximately 60% of women with disabilities who used cannabis in the past 12 months perceived no risk of harm from weekly cannabis use. A significantly higher percentage of women with any disability perceived no risk associated with weekly cannabis use (37.9%) compared to those with no disabilities (26.1%).

More than one-quarter (27.4%) of women perceived no risk of harm associated with weekly cannabis use. Overall, perceiving no risk associated with weekly cannabis use was evident among women ages 21 to 29 (34.4%), those who were never married (32%), were non-Hispanic Black (32.2%), living in poverty (31%), perceiving their health as fair/poor (35.1%), and experienced a past 12-month major depressive episode (36.4%). The likelihood of perceiving no risk also was higher among women using tobacco and those using both alcohol and tobacco.

“Given women’s attitudes toward cannabis as a harmless drug, the increasing rates of its use among those with disabilities, and the potential adverse health outcomes, it is imperative to monitor and understand perceptions of risk of harm from cannabis use among women with disabilities,” said Panagiota “Yiota” Kitsantas, Ph.D., senior author, professor and chair, Department of Population Health and Social Medicine, FAU Schmidt College of Medicine. 

Overall, women with disabilities and cannabis use in the past 12 months had 2.9 times higher odds of perceiving no risk associated with weekly use of cannabis compared to women without any disability and no cannabis use. The odds also were higher for those who did not have a disability but used cannabis in the past year, which indicates that cannabis exposure, in general, may increase a woman’s likelihood of not perceiving any harm to her health from weekly use.

Exposure to cannabis use during pregnancy has been associated with adverse birth outcomes including low birth weight, preterm delivery, small for gestational age, admission to the neonatal intensive care unit and infant death. Cannabis use also may affect sex hormones essential to fertility and the timing of ovulation in reproductive age. 

“As legalization of cannabis use becomes more prevalent across states, attitudes regarding the risk of cannabis use are changing,” said Lea Sacca, Ph.D., co-author and an assistant professor in the Department of Population Health and Social Medicine, FAU Schmidt College of Medicine. “A multi-pronged approach to address cannabis use among vulnerable populations such as women of childbearing age with disabilities will require clinical guidance, provider and patient education and evidence-based public health programs.”

Although research evidence shows that residents in states where cannabis is legal are more likely to believe that cannabis has benefits than those living in states with just medically legal cannabis or nonlegal states, this study suggests that living in a state that has legalized medical cannabis was associated with a decreased likelihood of perceiving no risk from using weekly cannabis relative to states with no legalized use of medical cannabis.

“There is an urgent need for effective cannabis screening and subsequent dissuasion of cannabis use for reproductive-aged women at risk of substance use. Obstetrician-gynecologists can play an important role by informing patients about healthy behaviors and encouraging long-term adoption as well as identifying patients abusing drugs for proper referral to addiction treatment professionals,” said Kitsantas. “Importantly, health policies should include holistic programs to proactively educate the population, pharmacists, medical and public health professionals of the associated benefits and risks of cannabis use among reproductive-aged women with disabilities.”

Study co-author is Salman M. Aljoudi, a health data analyst, a Ph.D. researcher and an instructor at George Mason University. 

– FAU –

About the Charles E. Schmidt College of Medicine:

FAU’s Charles E. Schmidt College of Medicine is one of approximately 157 accredited medical schools in the U.S. The college was launched in 2010, when the Florida Board of Governors made a landmark decision authorizing FAU to award the M.D. degree. After receiving approval from the Florida legislature and the governor, it became the 134th allopathic medical school in North America. With more than 70 full and part-time faculty and more than 1,300 affiliate faculty, the college matriculates 64 medical students each year and has been nationally recognized for its innovative curriculum. To further FAU’s commitment to increase much needed medical residency positions in Palm Beach County and to ensure that the region will continue to have an adequate and well-trained physician workforce, the FAU Charles E. Schmidt College of Medicine Consortium for Graduate Medical Education (GME) was formed in fall 2011 with five leading hospitals in Palm Beach County. The Consortium currently has five Accreditation Council for Graduate Medical Education (ACGME) accredited residencies including internal medicine, surgery, emergency medicine, psychiatry, and neurology.

About Florida Atlantic University: Florida Atlantic University, established in 1961, officially opened its doors in 1964 as the fifth public university in Florida. Today, the University serves more than 30,000 undergraduate and graduate students across six campuses located along the southeast Florida coast. In recent years, the University has doubled its research expenditures and outpaced its peers in student achievement rates. Through the coexistence of access and excellence, FAU embodies an innovative model where traditional achievement gaps vanish. FAU is designated a Hispanic-serving institution, ranked as a top public university by U.S. News & World Report and a High Research Activity institution by the Carnegie Foundation for the Advancement of Teaching. For more information, visit www.fau.edu.

Newswise — Supplementing standard opioid addiction treatment with Mindfulness Oriented Recovery Enhancement (MORE) — an intervention that incorporates mindfulness training, savoring skills, and cognitive reappraisal — cuts program dropout rates by 59 percent and relapses by 42 percent, according to Rutgers-led research.

These trial results come from Rutgers Health amid unprecedented opioid abuse. An estimated 10 million Americans misuse opioids or have opioid use disorder, while annual overdose deaths have exceeded 80,000.

Treatment with methadone or buprenorphine – alone or in combination with cognitive behavioral therapy – is imperfect. Half of all people drop out of treatment within a year, and half of all people who continue treatment keep using opioids.

“Better treatment protocols could save thousands of lives per year, and the data we have from our pilot study and this phase II trial suggest mindfulness training may create a genuinely better treatment protocol,” said Nina Cooperman, an associate professor of psychiatry at Rutgers Robert Wood Johnson Medical School and first author of the study published in JAMA Psychiatry.

Mindfulness training teaches people to focus on the present moment, without judgment, and on sensory inputs such as the feeling of breathing in and out. Previous studies demonstrating that such training can prevent addiction to opioid pain medication led Cooperman’s team to ask whether similar techniques could help people who already have an opioid use disorder.

A small pilot study found that mindfulness training combined with methadone treatment produced good outcomes. The pilot’s success paved the way for this larger study, which, in turn, has justified two large-scale studies that could change standards of care.

The current trial provided eight two-hour sessions to 77 of 154 patients in methadone treatment for opioid use disorder.

“Opioid use disorder changes your brain so that opioid use becomes the only thing that feels rewarding. MORE helps people retrain themselves to find healthy experiences rewarding again by focusing mindfully on the taste of a meal, the beauty of a landscape or the smell of a flower,” said Cooperman, who added the program literally includes observing and smelling roses during sessions.

Mindfulness training also gives people another tool for handling cravings.

“Cognitive behavioral therapy, which is common in treatment programs, teaches people to reframe their thoughts and distract themselves from cravings,” Cooperman said. “Mindfulness training teaches them to stay present with the craving and notice that they pass. Both strategies can work, so both are valuable.”

The success of mindfulness training in Cooperman’s study may stem from its ability to help patients manage pain. Most patients began the study with significant chronic pain — and, thus, a strong incentive to use pain-killing opioids — but patients who received MORE reported a 10 percent reduction in pain over the 16 weeks of the study.

Looking forward, Cooperman and her team are working on larger studies, which are designed to provide further evidence for the efficacy of MORE and to optimize protocols for use in the real world.

“We still have lots of open questions. How can we train clinicians to implement MORE in treatment programs? What is the best structure for implementing MORE—in-person or virtual? Our current research is working to answer some of these questions,” Cooperman said. “The findings from this study suggest MORE really can improve outcomes for a lot of people in substance abuse treatment.”

Newswise — HOUSTON ― For most smokers, quitting on the first attempt is likely to be unsuccessful, but a new study from The University of Texas MD Anderson Cancer Center found patients were more likely to quit if their cessation regimen was altered and doses were increased. Researchers also found that varenicline, a cessation medication, was more effective than combined nicotine replacement therapy (CNRT), such as patches or lozenges.

The study, published today in JAMA, revealed smokers who failed to quit with varenicline in the trial’s first phase were seven times more likely to quit by the end of the second phase if varenicline doses were increased. There also was a nearly two-fold increase in those who successfully quit if they were switched from a CNRT regimen to varenicline. These results are favorable compared to the near zero chance of abstinence seen in patients who were switched from varenicline to CRNT or left on the same treatment plans.

“These data indicate that sticking to the same medication isn’t effective for smokers who are unable to quit in the first six weeks of treatment,” said lead researcher Paul Cinciripini, Ph.D., chair of Behavioral Science. “Our study should encourage doctors to check in on patients early in their cessation journey and, if patients are struggling, to try a new approach, such as increasing medication dosage.”

The double-blind, placebo-controlled trial followed 490 smokers who were randomized to receive six weeks of varenicline or CNRT. After the first phase, those unable to quit were re-randomized to continue, switch or increase medication dose for an additional six weeks. Initial treatment included 2 mg of varenicline or CNRT (21 mg patch plus 2 mg lozenge). Participants who were re-randomized either continued the same varenicline or CNRT dose, switched between varenicline and CNRT, or were given an increased dose of 3 mg of varenicline or CNRT (42 mg patch plus 2 mg lozenge). The study was conducted in Texas from June 2015 to October 2019.

Of the patients who received varenicline and had their doses increased, 20% were still abstaining six weeks later. Meanwhile, the abstinence rate was 14% among patients who switched from CRNT to varenicline or who had their CRNT doses increased. However, varenicline patients who switched to CNRT saw a 0% quit rate. After six months, only those who had their doses increased remained continuously abstinent.

Tobacco use remains the leading preventable cause of death and disease in the U.S. Each year, about 480,000 Americans die from tobacco-related illnesses. Currently, more than 16 million Americans suffer from at least one disease caused by smoking, including cancer. Quitting tobacco can improve the chances of survival by 30-40% for cancer patients who smoke. Since the average smoker makes several attempts to quit before successfully beating the addiction, MD Anderson tackles the barriers to cessation at an individual and population level, factoring in cost, access to cessation services, and knowledge gaps among health care providers on treating tobacco addiction.

In a larger ongoing trial, researchers are testing several different medication combinations as an alternative for those unable to quit on their initial doses of varenicline or CNRT.

The research was supported by the Cancer Prevention and Research Institute of Texas (CPRIT) (RP150228), MD Anderson’s Lung Cancer Moon Shot^®, the National Cancer Institute (P30CA016672), and the State of Texas Permanent Health Funds awarded to MD Anderson. Varenicline and matching placebo were provided by Pfizer Pharmaceuticals (WI192533). CRNT products and matching placebo were purchased from NAL Pharma. A full list of collaborating authors and their disclosures can be found here.

Newswise — New York, NY (April 29, 2024) – Opioid (including heroin) overdose-related deaths continue to increase at staggering rates among adults in the United States. Inhibitory control – the ability to suppress unwanted behaviors, such as drug use, despite substantial negative consequences and a desire to quit – is impaired in individuals with drug addiction and is accompanied by functional deactivations in the prefrontal cortex (PFC), a brain region that subserves self-control processes.

In line with their previous work, researchers from the Icahn School of Medicine at Mount Sinai showed that individuals with heroin use disorder have lower activity in the anterior and dorsolateral PFC when performing an inhibitory control task compared with healthy controls. Importantly, they revealed that 15 weeks of medication-assisted therapy, which included supplemental group therapy, improves impaired function of the anterior and dorsolateral PFC during an inhibitory control task among the group of participants with heroin use disorder, suggesting a time-dependent recovery of inhibitory control and PFC function in individuals with heroin use disorder after such a treatment intervention. 

Specifically, 26 inpatient individuals with heroin use disorder undergoing medication-assisted treatment and 24 demographically-matched healthy controls were recruited for a longitudinal task-based functional MRI (fMRI) study. Participants attended two fMRI sessions, separated by 15 weeks of medication-assisted inpatient treatment for individuals with heroin use disorder and a comparable time interval for healthy controls. During fMRI, the study participants performed a stop-signal task – a well-validated tool for estimating brain function during inhibitory control behavior. During the task, study participants responded to directional arrow stimuli and withheld their responses when the arrow occasionally turned red (the stop signal). In addition to showing increased activity in the PFC regions after 15 weeks of inpatient treatment, the increased activity correlated with better behavioral performance in the stop-signal task by individuals with heroin use disorder.

“Overall, our findings identify the anterior and dorsolateral PFC regions as potentially amenable to targeted interventions to potentially expedite their recovery during inhibitory control, which may have translational value to help inform future treatment methods,” says Ahmet O. Ceceli, PhD, senior postdoctoral fellow and lead author of the paper.

“More research is needed to determine if there is a specific aspect of inpatient treatment that substantially contributes to the improvement and to examine other specific factors. For example, our research team plans to test whether the recovery effects we observed in this study are attributable to the mindfulness-based intervention that was part of the supplemental group therapy intervention” says Rita Z. Goldstein, PhD, Professor of Psychiatry and Neuroscience at Icahn Mount Sinai and senior author of the paper.

To learn more about this study, please visit: https://www.nature.com/articles/s44220-024-00230-4

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Newswise — For years, even as opioid overdose deaths dramatically increased, doctors and other prescribers in the United States needed special permission from the federal government if they wanted to prescribe buprenorphine, a medication that helps patients overcome opioid addiction and prevents fatal overdoses.

That requirement, called an “X waiver”, was eliminated on January 12, 2023 due to an item in a major federal budget bill. This meant that suddenly, any clinician who had a license to prescribe controlled substances could prescribe buprenorphine.

Now, a new study by University of Michigan researchers looks at what happened in the year after that federal policy change.

Published in the New England Journal of Medicine, the study finds that the number of buprenorphine prescribers increased rapidly after the policy change. By December 2023, more than 53,600 clinicians prescribed buprenorphine, an increase of 11,500 over December 2022. 

But the rise in available treatment providers didn’t spark meaningful increases in patients getting care in 2023, the new findings show. In any given month of 2022, about 810,000 to 830,000 Americans were prescribed buprenorphine, but these numbers changed little after January 2023. 

“Our findings suggest that elimination of the federal waiver requirement reduced barriers to buprenorphine prescribing but unfortunately was insufficient to increase overall use,” said Kao-Ping Chua, M.D., Ph.D., the study’s first author.

“The fact that this policy failed to increase the number of patients with buprenorphine prescriptions through the first year of implementation highlights the many other barriers to buprenorphine prescribing that must be overcome,” added Thuy Nguyen, Ph.D., the senior author of the manuscript.

The study found a small jump in January 2023 in the number of patients starting buprenorphine for the first time. And in December 2023, more than 48,200 patients started taking the medication – up from the 46,500 patients who started in December 2022. These numbers include any patient who hadn’t received buprenorphine in at least six months.

People with opioid addiction often need to take buprenorphine daily for months to years to overcome addiction to the opioid they are trying to quit – whether it’s heroin, prescription painkillers such as hydrocodone and oxycodone, or synthetic opioids like fentanyl.

The government’s decision to eliminate the waiver was designed to decrease barriers to buprenorphine prescribing and promote access to this lifesaving drug.

The January 2023 change came after the federal government tried other tactics during the COVID-19 era, including allowing telehealth-based prescribing of buprenorphine and allowing prescribers to obtain an X waiver to prescribe buprenorphine to 30 or fewer patients without undergoing 8 hours of training.

Chua and colleagues previously showed that even with these earlier changes, the number of new patients using buprenorphine for the first time was flat between 2019 and 2022. 

The stigma against treating people with opioid addiction, and the challenge of adding new types of care and support in primary care clinics and pain clinics that are already overburdened by other patient demands may be affecting the number of patients seeking or getting care.

Chua is co-director of the Research and Data Domain at the U-M Opioid Research Institute (ORI), as well as being an assistant professor of pediatrics in the Medical School with a joint appointment in the School of Public Health, and a member of the Susan B. Meister Child Health Evaluation and Research Center and the Institute for Healthcare Policy and Innovation (IHPI).

Nguyen is a health economist at the U-M School of Public Health and member of ORI and IHPI. Co-authors include ORI co-director Amy Bohnert, Ph.D., and ORI/IHPI members Mark Bicket, M.D., Ph.D., and Pooja Lagisetty, Ph.D., as well as Rena Conti, Ph.D. of Boston University.

Several of the authors have been involved in the Michigan Opioid Collaborative, which since 2017 has helped primary care providers, hospitals and others increase the availability of buprenorphine to patients in Michigan through free consultations, training events and more.

Recently, the MOC team, including Bohnert, published findings from the effort’s first years in JAMA Network Open.

Because the MOC effort rolled out gradually across Michigan’s 83 counties, they were able to track how the number of prescribers offering buprenorphine, and the number of patients receiving it, changed in counties where MOC had a presence, compared with those where it wasn’t yet available.

The study showed a clear, sharp rise in both prescribers offering the treatment, and people receiving it, starting soon after MOC became available to support prescribers in a county. Meanwhile, no such rises happened in counties that had not yet become part of the MOC coverage area. MOC now covers all areas of the state, though the study covers a time period through 2020 when there were still more than 20 counties not yet participating.

MOC recently merged with another U-M opioid effort to become the Overdose Prevention Engagement Network, and continues to offer consultation, on-demand online training to comply with the current federal requirement, and more as well as screening tools for opioid use disorders and opioid-sparing surgical prescribing tools.  Visit https://michigan-open.org/ for more information or to seek a consultation about prescribing buprenorphine.

The study was funded by the National Institute on Drug Abuse, part of the National Institutes of Health (R01DA056438). This content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Buprenorphine Dispensing after Elimination of the Waiver Requirement, New England Journal of Medicine, DOI:10.1056/NEJMc2312906, https://www.nejm.org/doi/full/10.1056/NEJMc2312906

Newswise — Dara Ghahremani and Edythe London, faculty in the UCLA Health Department of Psychiatry and Biobehavioral Sciences, have been selected to join a coalition of experts from international universities to research new methods to diagnose, treat and prevent addiction disorders.  

Ghahremani and London, who are also a part of The Jane and Terry Semel Institute for Neuroscience and Human Behavior at UCLA, will be co-principal investigators in the Untangling Addiction program launched this year by the nonprofit health research organization Wellcome Leap. The three-year, $50 million project includes 13 other partnering universities and organizations and is aimed at developing new ways to quantify addiction risk and progression through biomarkers. 

The UCLA team will conduct the first large-scale probe of a nucleus in the brain known as the habenula — a region associated with the negative states experienced during withdrawal. The habenula has had strong links to addiction in animal studies but has not been adequately studied in humans. The team will assess MRI data from thousands of individuals with problematic alcohol use to determine if similar relationships are observed in humans. 

“If we do find those links, the habenula could be an important therapeutic neural target,” Ghahremani said. “For example, a relatively novel noninvasive brain stimulation technique, called low-intensity focused ultrasound, may be used to temporarily alter habenula function during periods of alcohol withdrawal to reduce symptoms and thereby reduce vulnerability to continued drug use.”