How do people with homelessness and alcohol dependence cope when alcohol is unaffordable? A comparison of residents of Canadian managed alcohol programs and locally recruited controls

Introduction and Aims

We investigated coping strategies used by alcohol‐dependent and unstably housed people when they could not afford alcohol, and how managed alcohol program (MAP) participation influenced these. The aim of this study was to investigate potential negative unintended consequences of alcohol being unaffordable.

Design and Methods

A total of 175 MAP residents in five Canadian cities and 189 control participants from nearby shelters were interviewed about the frequency they used 10 coping strategies when unable to afford alcohol. Length of stay in a MAP was examined as a predictor of negative coping while controlling for age, sex, ethnicity, housing stability, spending money and drinks per day. Multivariate binary logistic and linear regression models were used.

Results

Most commonly reported strategies were re‐budgeting (53%), waiting for money (49%) or going without alcohol (48%). A significant proportion used illicit drugs (41%) and/or drank non‐beverage alcohol (41%). Stealing alcohol or property was less common. Long‐term MAP participants (>2 months) exhibited lower negative coping scores than controls (8.76 vs. 10.63, P < 0.001) and were less likely to use illicit drugs [odds ratio (OR) 0.50, P = 0.02], steal from liquor stores (OR 0.50, P = 0.04), re‐budget (OR 0.36, P < 0.001) or steal property (OR 0.40, P = 0.07). Long‐term MAP participants were also more likely to seek treatment (OR 1.91, P = 0.03) and less likely to go without alcohol (OR 0.47, P = 0.01).

Discussion and Conclusions

People experiencing alcohol dependence and housing instability more often reduced their alcohol consumption than used harmful coping when alcohol was unaffordable. MAP participation was associated with fewer potentially harmful coping strategies.

     

Reducing replacement donors in Sub-Saharan Africa: challenges and affordability

In 1975, the World Health Assembly recommended that blood for transfusion should come from voluntary, non-remunerated donors; yet, in Africa, 75-80% of blood for transfusion still comes from hospital-based replacement donors. Although comprehensive economic data are scarce, evidence indicates that blood from voluntary donors recruited and screened at centralized transfusion centres, costs four to eight times as much as blood from a hospital-based, replacement donor system. Donor recruitment, quality assurance systems and distribution mechanisms in the centralized system are major reasons for the cost difference. There are concerns about the sustainability of centralized voluntary donor systems and their compatibility with the levels of health care that exist in many poor countries yet burdening patients' families with the responsibility of finding replacement blood donors will exacerbate poverty and reduce the safety of the blood supply. There are measures that can be introduced into hospital-based systems to improve safe blood supply in Africa but their effectiveness in different contexts needs to be evaluated.     

Acceptability, feasibility and affordability of infant feeding options for HIV-infected women: a qualitative study in south-west Nigeria

The objective of this study was to explore the acceptability, feasibility, affordability, safety and sustainability of replacement feeding options for HIV-infected mothers in Ile-Ife, in south-west Nigeria. Six focus group discussions were conducted with a purposive sample of mothers, fathers and grandmothers. The HIV status of all participants was unknown to investigators. All text data were analysed using the Text-based Beta Software program. With regard to the acceptability of replacement feeds, respondents perceived the stigma associated with not breastfeeding to be an important consideration. In this community, breastfeeding is the norm--even though it is not necessarily exclusive. For infected mothers who choose to breastfeed exclusively and then to wean their infants before 6 months of age, respondents did not anticipate early cessation of breastfeeding to be problematic. Respondents noted that acceptable replacement foods included infant formula, soy milk and cow's milk. Barriers to replacement feeding that were mentioned included: the high costs of replacement foods and fuel for cooking; an unreliable supply of electrical power; poor access to safe water; and poor access to storage facilities. The research confirms the difficulty of replacement feeding for HIV-infected mothers in sub-Saharan Africa. The results also provide the basis for new issues and hypothesis for future research in other communities with similar socio-cultural and economic characteristics.     

Hemodialysis Use and Practice Patterns: An International Survey Study

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Food taxes: what type of evidence is available to inform policy development?

Summary Once dispatched to the bottom draw of policy options to address unhealthy eating, food taxes now seem back in the out tray of European policy makers. Even David Cameron made an offhand quip recently suggesting that this is something the British Government might explore. While the purpose of developing food taxes is likely their potential to raise money for national treasuries, governments have justified them on health grounds. But, what evidence is available that can inform policy development in this area from a health perspective? Most obvious are the studies that model different scenarios for taxes. Yet these studies form a relatively small part of the potential evidence‐base. The largest proportion of existing research on food prices has simply measured food prices in the marketplace and drawn hypotheses about the dietary implications. Other studies have estimated the costs of actually consumed diets. Another set of studies have quantified an association between price of specific foods and diet from real world data. Others have likewise taken a quantitative approach, but in experimental settings. A particularly large group of studies are qualitative – those asking consumers if and/or how their food choices are influenced by prices. The final type of study combines qualitative and quantitative methods. This paper examines the relevance of these different types of evidence as information for policy development in this area.     

Factors Affecting Buprenorphine Utilization and Spending in Medicaid, 2002-2018

ObjectiveBuprenorphine is an essential medication for the treatment of opioid use disorder (OUD), but studies show it has been underused over the last 2 decades. We sought to evaluate utilization of and spending on buprenorphine formulations in Medicaid and to evaluate the impact of key market and regulatory factors affecting availability of different formulations and generic versions.MethodsWe first identified all buprenorphine formulations approved by the Food and Drug Administration for OUD using Drugs@FDA. We then used National Drug Codes to identify each drug in the Medicaid State Drug Utilization Data and extracted annual utilization rates and spending between 2002 and 2018 by drug and according to whether a brand-name or generic version was dispensed. We compared these trends to market and regulatory factors that affected competition, which we identified through searching the Federal Register, Westlaw, PubMed, and Google News.ResultsBrand-name buprenorphine-naloxone sublingual tablet and film formulations (Suboxone) were dispensed 2.7 times more (n = 634 213 140) and reimbursed 4.4 times more (n = $4 440 556 473) than all other formulations combined (n = 237 769 689; $1 018 988 133). We identified numerous market and regulatory factors that contributed to an estimated 9-year delay in generic versions of the tablet formulation and 6-year delay for generic versions of the film formulation.ConclusionsBrand-name buprenorphine formulations have been widely used in Medicaid, leading to substantial costs, in part because generic versions were delayed by multiple years owing to market and regulatory factors. Timely availability of low-cost generics could have helped encourage OUD treatment with buprenorphine during the height of the opioid crisis.