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Innovations in education: A prospective study of storytelling narratives to enhance hepatitis C virus knowledge among substance users. World J Hepatol 2022. [DOI: 10.4254/wjh.v14.i5.973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Talal AH, Ding YX, Markatou M. Innovations in education: A prospective study of storytelling narratives to enhance hepatitis C virus knowledge among substance users. World J Hepatol 2022; 14:972-983. [PMID: 35721284 PMCID: PMC9157714 DOI: 10.4254/wjh.v14.i5.972] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/21/2022] [Accepted: 04/21/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Even though substance users have the highest hepatitis C virus (HCV) burden, many lack knowledge about the infection. Lack of knowledge is an important obstacle to pursuing HCV care. Although printed materials are conventionally utilized to disseminate HCV-related knowledge, narrative story-telling videos may be an alternative. Data are extremely limited, however, in the ability of storytelling videos to increase HCV knowledge among substance users. In this study, we hypothesized that a story-telling narrative video would increase substance user’s immediate and 1-month HCV-related knowledge compared to a printed format.
AIM To assess immediate and 1-month HCV-related knowledge retention among substance users comparing education delivered via a storytelling narrative video compared to a printed format.
METHODS We conducted a prospective matched, case-control study among substance users actively prescribed buprenorphine enrolled from two sites. The intervention site received the video and the control site, the brochure. Participants (n = 176) were matched on age, gender, and race. We obtained extensive patient and stakeholder input on the video’s design, validated the video’s content, and developed a recruitment plan to guide participant enrollment. Knowledge was assessed by administration of a 25-item instrument immediately before, immediately after, or one month after the intervention. Data were analyzed using nonparametric and generalized linear mixed-effects models.
RESULTS We recruited a total of 176 substance users, 90 and 86 individuals, from each site, respectively. One-month follow up occurred in 92% and 94% of enrollees in the control and intervention groups, respectively. In comparison with the pre-intervention scores, immediate knowledge recall increased significantly for both the intervention (P < 0.0001) and control (P < 0.0001) groups. Multivariate modeling revealed a significant improvement in HCV-related knowledge and retention (P = 0.033) among participants who viewed the storytelling video.
CONCLUSION Storytelling narratives emphasizing HCV education appear to be an effective method to increase HCV-related knowledge among substance users. They should become an educational cornerstone to promote HCV management among this population.
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Affiliation(s)
- Andrew H Talal
- Department of Medicine, University at Buffalo, State University of New York, Buffalo, NY 14203, United States
| | - Yu-Xin Ding
- Department of Biostatistics, University at Buffalo, State University of New York, Buffalo, NY 14214, United States
| | - Marianthi Markatou
- Department of Biostatistics, University at Buffalo, State University of New York, Buffalo, NY 14214, United States
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Feng Y, Yao T, Gao Y, Li H, Dong S, Wu Y, Liu Y, Li J, Liu C, Liu J, Xue T, Yuan Y, Wu J, Wang F, Liang X, Wang S. Immunogenicity, safety, and compliance of high- and standard-strength four-dose hepatitis B vaccination regimens in patients receiving methadone maintenance therapy in China: a randomized, parallel-arm controlled trial. Expert Rev Vaccines 2021; 20:1629-1635. [PMID: 34503367 DOI: 10.1080/14760584.2021.1977629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND We evaluated the safety and immunogenicity of four doses of 20 or 60 µg, and the immunogenicity and compliance of the short-term vaccination regimen (0, 1, and 2 months) among patients receiving MMT. RESEARCH DESIGN AND METHODS We conducted a randomized controlled trial among 303 patients receiving MMT who were randomized to receive 3 or 4 doses of 20 or 60 µg of recombinant hepatitis B vaccine. RESULTS At month 7, the seroconversion rates in both IM20 × 4 and IM60 × 4 groups were numerically higher than the IM20 × 3 group (P > 0.05). The high-level responses and geometric mean concentration (GMC) of anti-HBs in both IM20 × 4 and IM60 × 4 groups were significantly higher than the IM20 × 3 group (P < 0.05). The completion rate of the short-term high-strength vaccination group was significantly higher than the standard vaccination group (P < 0.05), with similar immunogenicity (P > 0.05). CONCLUSIONS Both the high-strength and standard-strength four-dose hepatitis B vaccine regimens could improve the immune response for patients receiving MMT. The high-strength short-term vaccination regimen could improve compliance and attain comparable immunogenicity with the standard vaccination regimen. The high-strength short-term vaccination regimen is recommended and the fourth dose is encouraged for this population considering the compliance and immunogenicity. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov (NCT03962816).
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Affiliation(s)
- Yongliang Feng
- School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China.,Center of Clinical Epidemiology and Evidence Based Medicine, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Tian Yao
- School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China.,Center of Clinical Epidemiology and Evidence Based Medicine, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Yizhuo Gao
- School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China.,Center of Clinical Epidemiology and Evidence Based Medicine, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Hong Li
- Shanxi Provincial Center for Disease Control and Prevention, Taiyuan, Shanxi, China
| | - Shuang Dong
- School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China.,Center of Clinical Epidemiology and Evidence Based Medicine, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Yuanting Wu
- School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China.,Center of Clinical Epidemiology and Evidence Based Medicine, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Yuan Liu
- Methadone Maintenance Treatment Clinic, Compulsory Isolation Drug Rehabilitation Center, Taiyuan, Shanxi, China
| | - Jing Li
- Methadone Maintenance Treatment Clinic, Compulsory Isolation Drug Rehabilitation Center, Taiyuan, Shanxi, China
| | - Chunhua Liu
- Methadone Maintenance Treatment Clinic, Compulsory Isolation Drug Rehabilitation Center, Taiyuan, Shanxi, China
| | - Jinxia Liu
- Xinghualing District Methadone Maintenance Treatment Clinic, Taiyuan, Shanxi, China
| | - Tongchuan Xue
- Xinghualing District Methadone Maintenance Treatment Clinic, Taiyuan, Shanxi, China
| | - Yuan Yuan
- Methadone Maintenance Treatment Clinic, 109 Hospital, Taiyuan, Shanxi, China
| | - Junhua Wu
- Methadone Maintenance Treatment Clinic, 109 Hospital, Taiyuan, Shanxi, China
| | - Fuzhen Wang
- Chinese Center for Disease Control and Prevention, Beijing, PR China
| | | | - Suping Wang
- School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China.,Center of Clinical Epidemiology and Evidence Based Medicine, Shanxi Medical University, Taiyuan, Shanxi, China
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Setyowati D, Mubawadi T, Mirasa YA, Purwanto D, Amin M, Utsumi T, Soetjipto S, Juniastuti J, Lusida MI. Molecular epidemiology of hepatitis A outbreaks in two districts in Indonesia in 2018: Same subtype, but different strains. Biomed Rep 2019; 12:51-58. [PMID: 31929874 PMCID: PMC6951258 DOI: 10.3892/br.2019.1261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 10/18/2019] [Indexed: 12/26/2022] Open
Abstract
The present study aimed to analyse molecular epidemiological data from hepatitis A virus (HAV) outbreaks in two affected areas. The association between the knowledge of hepatitis A and incidence of infection was also determined. Serum samples were obtained from 88 individuals with clinical manifestations of acute hepatitis in Lamongan (n=54) in January 2018 and Bangkalan (n=34) in March 2018. The outbreak investigation was started one day after the outbreaks were reported by the Public Health Offices in Lamongan and Bangkalan. Anti-HAV immunoglobulin M (IgM) and PCR amplification products of the VP1 capsid protein-P2A protease and VP1-VP3 junctions were analysed. Positive PCR products were sequenced, and a phylogenetic tree was constructed using Molecular Evolutionary Genetics Analysis X software. The control group comprised healthy students and staff members from the two affected areas. Thus, 172 responses from the control and hepatitis A case groups were analysed to assess the association between the students' knowledge level and the incidence of HAV infection. A total of 32 (59.25%) of the 54 individuals from Lamongan and 19 (55.9%) of the 34 participants from Bangkalan were positive for anti-HAV IgM; 26 PCR tests were positive in the VP3-VP1 and/or VP1-P2A junction, which were identified as HAV subgenotype IA. The subtype of HAV in the two areas was IA, similar to those identified previously, but the viruses did not originate from the same strain, as identified by multiple alignment. The knowledge level of the students and staff members in Lamongan studying and working at a half-day school exhibited a significant association with the incidence; however, no association was observed among the students in Bangkalan studying at a full-day school with a dormitory.
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Affiliation(s)
- Dewi Setyowati
- Faculty of Medicine, Airlangga University, Surabaya, East Java 60131, Indonesia
| | - Teguh Mubawadi
- Regional Center for Environmental Health and Disease Control of Surabaya, Surabaya, East Java 60175, Indonesia
| | - Yudied Agung Mirasa
- Regional Center for Environmental Health and Disease Control of Surabaya, Surabaya, East Java 60175, Indonesia
| | - Didik Purwanto
- Regional Center for Environmental Health and Disease Control of Surabaya, Surabaya, East Java 60175, Indonesia
| | - Mochamad Amin
- Institute of Tropical Disease, Airlangga University, Surabaya, East Java 60115, Indonesia
| | - Takako Utsumi
- Institute of Tropical Disease, Airlangga University, Surabaya, East Java 60115, Indonesia.,Center for Infectious Diseases, Kobe University Graduate School of Medicine, Kobe, Hyogo 650-0017, Japan
| | - Soetjipto Soetjipto
- Faculty of Medicine, Airlangga University, Surabaya, East Java 60131, Indonesia.,Institute of Tropical Disease, Airlangga University, Surabaya, East Java 60115, Indonesia
| | - Juniastuti Juniastuti
- Faculty of Medicine, Airlangga University, Surabaya, East Java 60131, Indonesia.,Institute of Tropical Disease, Airlangga University, Surabaya, East Java 60115, Indonesia
| | - Maria Inge Lusida
- Faculty of Medicine, Airlangga University, Surabaya, East Java 60131, Indonesia.,Institute of Tropical Disease, Airlangga University, Surabaya, East Java 60115, Indonesia
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唐 琦, 林 榕, 姚 林, 张 争, 郝 瀚, 张 崔, 蔡 林, 李 学, 何 志, 周 利. [Clinicopathologic features and prognostic analyses of locally recurrent renal cell carcinoma patients after initial surgery]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2019; 51:628-631. [PMID: 31420612 PMCID: PMC7433486 DOI: 10.19723/j.issn.1671-167x.2019.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the clinicopathologic features and potential prognostic predictors of locally recurrent renal cell carcinoma patients after initial surgery. METHODS Authors retrospectively analyzed data extracted from 81 patients who were treated for postoperative locally recurrence of renal cell carcinoma from January 2006 to June 2016 in the Department of Urology, Peking University First Hospital. Postoperative locally recurrence of renal cell carcinoma was defined as disease recurring in the remnant kidney, renal fossa, adjacent abdomen, ipsilateral adrenal and retroperitoneal lymph nodes. RESULTS In the study, 81 patients were finally included, of whom 43 were initially treated in our hospital and 38 were initially treat in other centers. Partial nephrectomy (PN) was performed for 38 cases (26 in our hospital and 12 in other hospitals) as initial treatment and radical nephrectomy (RN) was conducted for the remnant 43 cases (17 in our hospital and 26 in other hospitals). Overall median recurrence time was 26 months (range: 3-164 months), in which 26 months (range: 3-55 months) for PN cases and 30 months (range: 4-164 months) for RN cases (P=0.009). Sixty-nine patients had single site recurrence, including remnant kidney (n=29), renal fossa (n=20), abdomen (n=4), ipsilateral lymph nodes (n=5), ipsilateral adrenal (n=11), while 12 patients had multiple sites recurrence. Seventy-eight patients were managed by complete surgical resection, while three patients were managed by radiofrequency ablation. Postoperative pathological diagnoses included clear cell carcinoma (n=72), papillary renal cell carcinoma (n=8, 7 cases with type 1, 1 case with type 2) and Xp11 translocation/TFE3 gene fusion renal cell carcinoma (n=1). Complete pathologic information of the initial surgery could be extracted from 43 patients who were initially treated in our hospital. Seventeen patients with initial radical nephrectomy were staged as T1a (n=4), T1b (n=2), T2a (n=1), T3a (n=8), and T3b (n=2). Twenty-six patients with initial partial nephrectomy were staged as T1a (n=18), T1b (n=7), and T3a (n=1). For PN cohort, the patients with T1a stage disease had longer median recurrence time than those with beyond T1a stage disease, and the difference was significant (29 months vs. 18 months, P=0.041). At the end of the follow-up, 58 patients were alive, 4 died and 19 lost the follow-up. Overall, 3-year and 5-year disease free survival rates were 81.9%, and 53.6%, respectively. CONCLUSION The present research reported a large-scale single central experience of locally recurrent renal cell carcinoma. The recurrence time of the PN group is shorter than that of the RN group. For patients after PN surgery, median recurrence time is longer for patients with T1a stage tumor when compared with those with stage beyond T1a. Patients can obtain relative long-term survival after complete secondary surgery resection.
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Affiliation(s)
- 琦 唐
- />北京大学第一医院泌尿外科,北京大学泌尿外科研究所, 北京 100034Department of Urology, Peking University First Hospital; Institute of Urology, Peking University, Beijing 100034, China
| | - 榕城 林
- />北京大学第一医院泌尿外科,北京大学泌尿外科研究所, 北京 100034Department of Urology, Peking University First Hospital; Institute of Urology, Peking University, Beijing 100034, China
| | - 林 姚
- />北京大学第一医院泌尿外科,北京大学泌尿外科研究所, 北京 100034Department of Urology, Peking University First Hospital; Institute of Urology, Peking University, Beijing 100034, China
| | - 争 张
- />北京大学第一医院泌尿外科,北京大学泌尿外科研究所, 北京 100034Department of Urology, Peking University First Hospital; Institute of Urology, Peking University, Beijing 100034, China
| | - 瀚 郝
- />北京大学第一医院泌尿外科,北京大学泌尿外科研究所, 北京 100034Department of Urology, Peking University First Hospital; Institute of Urology, Peking University, Beijing 100034, China
| | - 崔建 张
- />北京大学第一医院泌尿外科,北京大学泌尿外科研究所, 北京 100034Department of Urology, Peking University First Hospital; Institute of Urology, Peking University, Beijing 100034, China
| | - 林 蔡
- />北京大学第一医院泌尿外科,北京大学泌尿外科研究所, 北京 100034Department of Urology, Peking University First Hospital; Institute of Urology, Peking University, Beijing 100034, China
| | - 学松 李
- />北京大学第一医院泌尿外科,北京大学泌尿外科研究所, 北京 100034Department of Urology, Peking University First Hospital; Institute of Urology, Peking University, Beijing 100034, China
| | - 志嵩 何
- />北京大学第一医院泌尿外科,北京大学泌尿外科研究所, 北京 100034Department of Urology, Peking University First Hospital; Institute of Urology, Peking University, Beijing 100034, China
| | - 利群 周
- />北京大学第一医院泌尿外科,北京大学泌尿外科研究所, 北京 100034Department of Urology, Peking University First Hospital; Institute of Urology, Peking University, Beijing 100034, China
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Abstract
Hepatitis C virus infection is the most common chronic blood-borne infection in the United States (U.S.). Increasing rates of hepatitis C virus infection among drug users present a significant public health problem in the U.S. and globally. This article describes the effect an educational intervention on hepatitis C virus knowledge. A project was conducted using the Brief Hepatitis C Knowledge Scale to assess pre- and post-test intervention knowledge. An educational intervention consisting of a video (Hepatitis C: Get the Facts) and a written handout, as well as a question-and-answer session, was administered to participants at a local health department. Analysis of the data through use of descriptive statistics to compare percentage change of the mean from the pretest to post-test to 3-week post-test intervention was performed. Results demonstrated the use of an educational intervention to be effective in increasing hepatitis C virus knowledge. An increase in knowledge regarding hepatitis C virus transmission may lead to a decrease in overall hepatitis C virus infection rates as well as risky behaviors.
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Frimpong JA, D'Aunno T, Perlman DC, Strauss SM, Mallow A, Hernandez D, Schackman BR, Feaster DJ, Metsch LR. On-site bundled rapid HIV/HCV testing in substance use disorder treatment programs: study protocol for a hybrid design randomized controlled trial. Trials 2016; 17:117. [PMID: 26936623 PMCID: PMC4776446 DOI: 10.1186/s13063-016-1225-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 02/10/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND More than 1.2 million people in the United States are living with human immunodeficiency virus (HIV), and 3.2 million are living with hepatitis C virus (HCV). An estimated 25 % of persons living with HIV also have HCV. It is therefore of great public health importance to ensure the prompt diagnosis of both HIV and HCV in populations that have the highest prevalence of both infections, including individuals with substance use disorders (SUD). METHODS/DESIGN In this theory-driven, efficacy-effectiveness-implementation hybrid study, we will develop and test an on-site bundled rapid HIV/HCV testing intervention for SUD treatment programs. Its aim is to increase the receipt of HIV and HCV test results among SUD treatment patients. Using a rigorous process involving patients, providers, and program managers, we will incorporate rapid HCV testing into evidence-based HIV testing and linkage to care interventions. We will then test, in a randomized controlled trial, the extent to which this bundled rapid HIV/HCV testing approach increases receipt of HIV and HCV test results. Lastly, we will conduct formative research to understand the barriers to, and facilitators of, the adoption, implementation, and sustainability of the bundled rapid testing strategy in SUD treatment programs. DISCUSSION Novel approaches that effectively integrate on-site rapid HIV and rapid HCV testing are needed to address both the HIV and HCV epidemics. If feasible and efficacious, bundled rapid HIV/HCV testing may offer a scalable, potentially cost-effective approach to testing high-risk populations, such as patients of SUD treatment programs. It may ultimately lead to improved linkage to care and progress through the HIV and HCV care and treatment cascades. TRIAL REGISTRATION ClinicalTrials.gov: NCT02355080 . (30 January 2015).
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Affiliation(s)
- Jemima A Frimpong
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, USA.
| | - Thomas D'Aunno
- Robert F. Wagner Graduate School of Public Service, New York University, New York, USA.
| | - David C Perlman
- Mount Sinai Beth Israel; Ichan School of Medicine at Mount Sinai, New York, USA.
| | | | - Alissa Mallow
- Montefiore Health System, New York, USA, New York, USA.
| | - Diana Hernandez
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, USA.
| | - Bruce R Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York, USA.
| | - Daniel J Feaster
- Division of Biostatistics, Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, USA.
| | - Lisa R Metsch
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, USA.
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Perlman DC, Jordan AE, McKnight C, Young C, Delucchi KL, Sorensen JL, Des Jarlais DC, Masson CL. Viral hepatitis among drug users in methadone maintenance: associated factors, vaccination outcomes, and interventions. J Addict Dis 2015; 33:322-31. [PMID: 25299236 DOI: 10.1080/10550887.2014.969623] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Drug users are at high risk of viral Hepatitis A, B, and C. The prevalence of Hepatitis A, Hepatitis B, and Hepatitis C, associated factors, and vaccine seroconversion among drug treatment program participants in a randomized controlled trial of hepatitis care coordination were examined. Of 489 participants, 44 and 47% required Hepatitis A/Hepatitis B vaccinations, respectively; 59% were Hepatitis C positive requiring linkage to care. Factors associated with serologic statuses, and vaccine seroconversion are reported; implications for strategies in drug treatment settings are discussed. Results suggest generalizable strategies for drug treatment programs to expand viral hepatitis screening, prevention, vaccination, and linkage to care.
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Affiliation(s)
- David C Perlman
- a Chemical Dependency Institute, Mount Sinai Beth Israel , New York , New York , USA
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Longitudinal analysis of pain and illicit drug use behaviors in outpatients on methadone maintenance. Drug Alcohol Depend 2015; 149:285-9. [PMID: 25735466 PMCID: PMC4391061 DOI: 10.1016/j.drugalcdep.2015.02.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 01/28/2015] [Accepted: 02/06/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Little is known about the experience of chronic pain and the occurrence of illicit drug use behaviors in the population enrolled in methadone maintenance treatment (MMT) programs. METHODS This is a secondary analysis of longitudinal data from two MMT samples enrolled in a randomized controlled trial of hepatitis care coordination. Patients completed pain, illicit drug use, and other questionnaires at baseline and 3, 9, and 12 months later. Associations were sought over time between the presence or absence of clinically significant pain (average daily pain ≥ 4 or mean pain interference ≥ 4 during the past week) and current illicit drug use (i.e., non-therapeutic opioid, cocaine or amphetamine use identified from self-report or urine drug screening). RESULTS Of 404 patients providing complete data, within-patient variability in pain and illicit drug use was high across the four assessment periods. While 263 denied pain at baseline, 118 (44.9%) later experienced clinically significant pain during ≥ 1 follow-up assessments. Of 180 patients (44.6%) without evidence of illicit drug use at baseline, only 109 (27.0%) had similar negative drug use at all follow-up assessments. Across four assessment periods, there was no significant association between pain group status and current illicit drug use. CONCLUSIONS This one-year longitudinal analysis did not identify a significant association between pain and illicit drug use in MMT populations. This finding conflicts with some earlier investigations and underscores the need for additional studies to clarify the complex association between pain and substance use disorders in patients in MMT program settings.
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