Spinal opioid receptors and inhibition of urinary bladder motility in vivo

The effects of intrathecal injections of morphine and other opioid receptor selective drugs were tested on urinary bladder contractions in the anesthetized rat. Morphine produced dose-related inhibition of bladder motility which was abolished by naloxone. This action was also observed with mu- and delta-opioid receptor agonists but not with a kappa-opioid receptor agonist. These observations appear related to the urinary retention seen clinically with epidural administrations of morphine and support the hypothesis that urinary bladder activity is influenced by spinal opioid mechanisms involving mu- and delta-opioid receptors.     

Insurer Views on Reimbursement of Preventive Services in the Dental Setting: Results From a Qualitative Study

Objectives. We explored insurers’ perceptions regarding barriers to reimbursement for oral rapid HIV testing and other preventive screenings during dental care.Methods. We conducted semistructured interviews between April and October 2010 with a targeted sample of 13 dental insurance company executives and consultants, whose firms’ cumulative market share exceeded 50% of US employer-based dental insurance markets. Participants represented viewpoints from a significant share of the dental insurance industry.Results. Some preventive screenings, such as for oral cancer, received widespread insurer support and reimbursement. Others, such as population-based HIV screening, appeared to face many barriers to insurance reimbursement. The principal barriers were minimal employer demand, limited evidence of effectiveness and return on investment specific to dental settings, implementation and organizational constraints, lack of provider training, and perceived lack of patient acceptance.Conclusions. The dental setting is a promising venue for preventive screenings, and addressing barriers to insurance reimbursement for such services is a key challenge for public health policy.Health care providers, the public health community, payers, and health services researchers are increasingly recognizing oral health as a crucial component of the medical home, as well as the potential role of dentists as partners to perform public health screening and to engage patients who may not be receiving regular preventive health services.1–7 Previous research demonstrated high dental care utilization among key populations such as smokers, individuals at elevated risk for HIV, and individuals at risk for diabetes; many at-risk individuals use dental services even when they do not regularly receive primary medical care services.8–11 Furthermore, rapid advances have been made in salivary diagnostics for early disease detection and routine health monitoring. Emergence of the oral rapid HIV and hepatitis C tests has prompted calls for more aggressive screening in the dental setting.12,13 Increased attention is also focusing on the use of clinical periodontal markers and self-reported risk factors to detect undiagnosed diabetes.5,9,14The dental venue has been identified as an untapped resource for the provision of oral rapid HIV screening.8 The Centers for Disease Control and Prevention’s revised 2006 guidelines advocated routine opt-out HIV screening and near-universal screening in diverse settings.15 The oral health component of the Healthy People 2020 initiative includes the aim to “increase the proportion of adults who receive preventive interventions in dental offices [OH-14],” specifically, smoking cessation services [OH-14.1], oral cancer screenings [OH-14.2], and tests and referrals for glycemic control [OH-14.3].16 In a survey of dentists, the majority of respondents endorsed the importance of dental screening for specified systemic conditions, such as cardiovascular disease, hypertension, diabetes, and HIV; almost all respondents highly valued chairside medical screening in dental settings.4Despite this broadening view of dentists’ professional role, actual provision of preventive screenings, including cardiovascular and HIV screenings, is low.17 Low provision of routine tobacco cessation service delivery has also been documented, despite high perceived importance as part of the dentist’s professional responsibility.11 Furthermore, research has shown that dentists are not fully assuming the responsibility of conducting thorough oral cancer screenings, although this screening has been characterized as the single most essential service a dentist can offer and is one of the few dental services that can save a patient’s life when routinely performed.18Dentists’ reluctance to perform medical screenings in their clinical practice is multifactorial; cited barriers to performing HIV oral rapid screening, oral cancer examinations, and tobacco cessation services are lack of training and expertise, time constraints, scope of practice, confidentiality, low perceived disease prevalence, and low index of suspicion.4,19–23Limited insurance reimbursement is another major barrier to broad implementation of comprehensive public health screening in the dental setting.24 From a payer perspective, the feasibility and cost-effectiveness of broad dental chairside screenings remain unclear.8 Insurer perspectives regarding such questions are rarely explored. We investigated attitudes of dental insurers toward expanding routine screening, including oral rapid HIV testing, in the dental setting to promote early diagnosis and treatment of prevalent systemic diseases.     

Rapid HIV Testing in Dental Practices

Despite increasing discussion about the dental care setting as a logical, potentially fruitful venue for rapid HIV testing, dentists’ willingness to take on this task is unclear. Semistructured interviews with 40 private practice dentists revealed their principal concerns regarding offering patients HIV testing were false results, offending patients, viewing HIV testing as outside the scope of licensure, anticipating low patient acceptance of HIV testing in a dental setting, expecting inadequate reimbursement, and potential negative impact on the practice. Dentists were typically not concerned about transmission risks, staff opposition to testing, or making referrals for follow-up after a positive result. A larger cultural change may be required to engage dentists more actively in primary prevention and population-based HIV screening.An estimated one fifth of Americans infected with HIV, approximately 250 000 individuals, are unaware of their status.1 Consequently, individuals are often diagnosed only when their disease has progressed and they are symptomatic2 or they already have AIDS. The advent of the rapid HIV test has made it possible to offer HIV testing in a much wider array of settings, thus creating the opportunity for more infected individuals to be identified earlier. Paltiel et al.3 estimated that widespread routine HIV screening would extend survival by 1.5 years for the average detected HIV-infected individual who enters care. Furthermore, studies have also shown that most persons who learn that they are HIV positive reduce sexual risk behaviors, resulting in reduced transmission to others.4–6The rapid HIV test is a fast, reliable, simple, and cost-effective method to screen for HIV,7–11 yielding results typically in 20 minutes or less and relieving burdens on both patients and providers that arise from the need for tested persons to return later to obtain results. Although it is a screening test, and therefore a reactive-positive result must be confirmed with traditional testing, it has been shown to be comparable to the traditional Western blot in sensitivity and specificity.11 The Food and Drug Administration approved the rapid HIV test using whole blood from a finger stick in 200212 and using oral fluid in 2004.13 Rapid testing is now the preferred method for many providers and clients. Oral fluid collection for testing has demonstrated high acceptability in preliminary studies with various risk groups.14–18 Given the availability of a safe, reliable, and acceptable rapid test for HIV, and recognizing the value for both individuals and public health of identifying undiagnosed cases of HIV infection as early as possible, in 2006 the Centers for Disease Control and Prevention issued revised recommendations for HIV testing.19 In the recommendations, they advocated that all individuals aged 13 to 64 years be routinely tested in all private and public health care settings and that HIV testing be included among the routine prenatal tests pregnant women take.     

Demographic and psychosocial factors associated with appointment attendance among HIV-positive outpatients

Non-adherence to medical regimens is a critical threat to HIV-infected individuals. Persons living with HIV/AIDS must adhere to their outpatient medical appointments to benefit from continually improving HIV care regimens. The primary purpose of the present study was to identify individual and psychosocial characteristics associated with HIV-related medical appointment non-attendance. One hundred seventy eight adult participants attending the Outpatient Adult HIV/AIDS Immunology Clinic at Jackson Memorial Hospital (JMH) in Miami, Florida participated in the study. Scheduled and missed appointments obtained retrospectively over a 12-month period indicated that medical appointment non-attendance was a significant problem. Overall, 27.9% of scheduled appointments were missed during the study period. Young age and limited family support were predictors of non-attendance. These findings support those of others and highlight targeted intervention efforts to reduce appointment non-attendance among persons living with HIV/AIDS.     

HIV rapid testing in drug treatment: comparison across treatment modalities

Despite high rates of risky behavior among patients, many drug abuse treatment programs do not provide on-site HIV testing. This secondary analysis examined differences in outcome by program modality from a multi-site trial in which 1281 HIV-negative patients in three methadone programs, seven non-methadone outpatient programs, and three residential programs were randomly assigned to: (1) off-site referral for HIV risk reduction counseling and testing; or on-site rapid testing (2) with or (3) without risk reduction counseling. The parent study using generalized estimating equations with site as a cluster variable found significantly higher rates of HIV testing and feedback of results by 1 month post-enrollment for the combined on-site conditions compared to the offsite condition [RR = 4.52, 97.5% CI (3.57, 5.72)]. Utilizing the same statistical approach, we found neither significant treatment modality nor significant treatment modality by testing condition interaction effects either for receipt of HIV test results at 1 month or for sexual or drug use HIV-risk behaviors at 6-month follow-up. On-site HIV testing is effective across treatment modalities for achieving high rates of testing and results feedback. All programs should be encouraged to adopt or expand this service.     

Is Injection Serosorting Occurring among HIV-Positive Injection Drug Users? Comparison by Injection Partner’s HIV Status

Research needs to build evidence for the roles that HIV status of injection partners may or may not play in injection risk behaviors of injection drug users (IDUs). Using baseline data collected from a randomized controlled study (INSPIRE) conducted in four cities (Baltimore, Miami, New York, and San Francisco) from 2001 to 2005, we categorized 759 primarily heterosexual HIV-positive IDUs into four groups based on HIV serostatus of drug injection partners. Thirty-two percent of the sample injected exclusively with HIV-positive partners in the past 3 months and more than 60% had risky injection behavior with these partners. Eight percent injected exclusively with HIV-negative partners and 49% injected with any unknown status partners. The remaining 11% reported having both HIV-positive and -negative injection partners, but no partners of unknown HIV status. Riskier injection behavior was found among the group with mixed status partners. The risk among the group with any unknown status partners appeared to be driven by the greater number of injection partners. No major group differences were observed in socio-demographic and psychosocial factors. Our analysis suggests that serosorting appeared to be occurring among some, but not an overwhelming majority of HIV-positive IDUs, and knowledge of HIV status of all injection partners per se did not appear to be as important as knowledge of sexual partner’s HIV status in its association with risk behavior.     

Crack cocaine use in rural migrant populations: living arrangements and social support

Correlates of crack cocaine use were studied among a targeted sample of migrant workers and their sexual partners (n = 571) in rural Southern Florida. Employment among men and recent drug-user treatment among men and women are positively related to crack use, as is involvement in crime and prostitution. Among women but not men, living with children is negatively related to crack use. Drug use and HIV prevention programs should intervene with individuals and their families and social groups. Migrant workers and their sexual partners also need effective drug-user treatment with long-term relapse prevention services.     

Drug treatment experiences: rural and urban comparisons

This study sought to investigate treatment-seeking behaviors among drug users in rural populations and how they compare to their urban counterparts. Data for this analysis were drawn from the Miami and Immokalee sites of the National Institute on Drug Abuse's Cooperative Agreement Program for AIDS outreach/intervention research study targeting high-risk out-of-treatment injection drug users and crack smokers. Findings indicate that Miami subjects were 2.57 times more likely to have been in drug treatment compared to their rural counterparts. This differential may be explained in terms of the availability, accessibility, and acceptability of health care services.     

HIV seroprevalence across the rural/urban continuum

While the first decade of the AIDS epidemic was characterized by high prevalence rates of AIDS infection in urban areas, there is increasing recognition of the spread of HIV into rural communities in the United States. Data from the Miami CARES cohort collected on 3,555 chronic drug users from 1988 to 1994 provide a unique opportunity to assess sociodemographic characteristics, drug-using behaviors and HIV risk behaviors related to HIV seropositivity in three communities across the rural-urban continuum: Miami, Florida; Belle Glade, Florida and Immokalee, Florida. The three very different communities studied demonstrate that HIV is no respecter of ecological site. The spread of HIV between areas and within areas is specifically correlated with the risk factors including injection drug use, use of crack cocaine, exchange of sex for money, and the rates for sexually transmitted diseases. All of these factors are shown to increase the risk of HIV so that the constellation of these practices helps determine the differential rates and spread of HIV in the three different areas.     

Patterns of Substance Use and Arrest Histories Among Hospitalized HIV Drug Users: A Latent Class Analysis

Using baseline data from the NIDA Clinical Trials Network 0049 study (Project HOPE), we performed latent class analyses (LCA) to identify discrete classes, or clusters, of people living with HIV (PLWH) based on their past year substance use behaviors and lifetime arrest history. We also performed multinomial logistic regressions to identify key characteristics associated with class membership. We identified 5 classes of substance users (minimal drug users, cocaine users, substantial cocaine/hazardous alcohol users, problem polysubstance users, substantial cocaine/heroin users) and 3 classes of arrest history (minimal arrests, non-drug arrests, drug-related arrests). While several demographic variables such as age and being Black or Hispanic were associated with class membership for some of the latent classes, participation in substance use treatment was the only covariate that was significantly associated with membership in all classes in both substance use and arrest history LCA models. Our analyses reveal complex patterns of behaviors among substance using PLWH and suggest that HIV intervention strategies may need to take into consideration such nuanced differences to better inform future studies and program implementation.