There is growing concern among US-based clinicians, patients, policy makers, and in the media about the personal and community health risks associated with opioids. Perceptions about the efficacy and appropriateness of opioids for the management of chronic non-cancer pain (CNCP) have dramatically transformed in recent decades. Yet, there is very little social scientific research identifying the factors that have informed this transformation from the perspectives of prescribing clinicians. As part of an on-going ethnographic study of CNCP management among clinicians and their patients with co-occurring substance use, we interviewed 23 primary care clinicians who practice in safety-net clinical settings. In this paper, we describe the clinical and social influences informing three historic periods: (1) the escalation of opioid prescriptions for CNCP; (2) an interim period in which the efficacy of and risks associated with opioids were re-assessed; and (3) the current period of “opioid pharmacovigilance,” characterized by the increased surveillance of opioid prescriptions. Clinicians reported that interpretations of the evidence-base in favor of and opposing opioid prescribing for CNCP evolved within a larger clinical-social context. Historically, pharmaceutical marketing efforts and clinicians’ concerns about racialized healthcare disparities in pain treatment influenced opioid prescription decision-making. Clinicians emphasized how patients’ medical complexity (e.g. multiple chronic health conditions) and structural vulnerability (e.g. poverty, community violence) impacted access to opioids within resource-limited healthcare settings. This clinical-social history of opioid prescribing practices helps to elucidate the ongoing challenges of CNCP treatment in the US healthcare safety net and lends needed specificity to the broader, nationwide conversation about opioids.
Background The median age of the single adult homeless population is 50 and rising. While the prevalence of substance use decreases as individuals age, older adults now have a higher prevalence of substance use than older adults did ten years ago. Homeless individuals have a higher prevalence of substance use disorders than the general population. However, little is known about substance use in older homeless adults. Methods We examined prevalence of and factors associated with substance use in a population-based sample (n=350) of homeless individuals aged 50 and older in Oakland, CA. We examined the prevalence of and factors associated with moderate or greater severity illicit drug symptoms (ASSIST score ≥4) and moderate or greater alcohol symptoms (AUDIT score ≥8). Our independent variables included demographics, mental health problems, and negative life course events such as physical and sexual abuse, school expulsion and onset of homelessness. Results Almost two-thirds of participants, 64.6%, had moderate or greater severity symptoms for at least one illicit drug; 25.8% had moderate or greater severity alcohol symptoms. History of psychiatric hospitalization was associated with moderate or greater illicit drug symptoms (AOR 1.9, 1.0–3.6). The presence of major depressive symptoms was associated with moderate or greater severity alcohol symptoms (AOR 1.8, 1.1–3.0). Conclusions In this sample of older homeless adults, substance use is common. There is a need for substance use treatment programs, integrated with mental health services, which are targeted towards the needs of older homeless adults.
Background-Patients with a history of substance use are more likely than those without substance use to experience chronic noncancer pain (CNCP), to be prescribed opioids, and to experience opioid misuse or overdose. Primary care practitioners (PCPs) in safety-net settings care for low-income patients with CNCP and substance use, usually without specialist consultation. To inform communication related to opioid risk, we explored PCPs' and patients' perceptions of the risks of chronic opioid therapy.
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