The behavior of nonliving and living systems is generally viewed as being qualitatively different. The key difference is often summarized by saying that whereas living systems are complex, nonliving ones are simple. This distinction is often the basis for claiming essential differences in conceptual stances, methods, and theories between scientific fields. I argue first that nonliving systems can display the unpredictable, irreducible, irreversible, and emergent-in sum, complex-properties of living systems. Then I discuss an emerging field called complexity theory, the principles of which offer the promise of bringing quantitative unity to an enormous range of phenomena, living or dead.
Background
Medicaid expansion under the Affordable Care Act increased insurance coverage, access to healthcare, and substance use disorder treatment, for many Americans. We assessed differences in healthcare access and utilization among persons who inject drugs (PWID) by state Medicaid expansion status.
Methods
In 2018, PWID were interviewed in 22 US cities for National HIV Behavioral Surveillance. We analyzed data from PWID aged 18–64 years who reported illicit use of opioids (n = 9957) in the past 12 months. Poisson regression models with robust standard errors were used to estimate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) were used to examine differences by Medicaid expansion status in indicators of healthcare access and utilization.
Results
Persons who inject drugs in Medicaid expansion states were more likely to have insurance (87% vs 36%; aPR, 2.3; 95% CI, 2.0–2.6), a usual source of healthcare (53% vs 34%; aPR, 1.5; 95% CI, 1.3–1.9), and have used medication-assisted treatment (61% vs 36%; aPR, 1.4; 95% CI, 1.1–1.7), and they were less likely to have an unmet need for care (21% vs 39%; aPR, 0.6; 95% CI, 0.4–0.7) than those in nonexpansion states.
Conclusions
Low insurance coverage, healthcare access, and medication-assisted treatment utilization among PWID in some areas could hinder efforts to end the intertwined human immunodeficiency virus and opioid overdose epidemics.
ImportanceAt least 500 000 people in the US experience homelessness nightly. More than 30% of people experiencing homelessness also have a substance use disorder. Involuntary displacement is a common practice in responding to unsheltered people experiencing homelessness. Understanding the health implications of displacement (eg, “sweeps,” “clearings,” “cleanups”) is important, especially as they relate to key substance use disorder outcomes.ObjectiveTo estimate the long-term health effects of involuntary displacement of people experiencing homelessness who inject drugs in 23 US cities.Design, Setting, and ParticipantsA closed cohort microsimulation model that simulates the natural history of injection drug use and health outcomes among people experiencing homelessness who inject drugs in 23 US cities. The model was populated with city-level data from the Centers for Disease Control and Prevention’s National HIV Behavioral Surveillance system and published data to make representative cohorts of people experiencing homelessness who inject drugs in those cities.Main Outcomes and MeasuresProjected outcomes included overdose mortality, serious injection–related infections and mortality related to serious injection–related infections, hospitalizations, initiations of medications for opioid use disorder, and life-years lived over a 10-year period for 2 scenarios: “no displacement” and “continual involuntary displacement.” The population-attributable fraction of continual displacement to mortality was estimated among this population.ResultsModels estimated between 974 and 2175 additional overdose deaths per 10 000 people experiencing homelessness at 10 years in scenarios in which people experiencing homelessness who inject drugs were continually involuntarily displaced compared with no displacement. Between 611 and 1360 additional people experiencing homelessness who inject drugs per 10 000 people were estimated to be hospitalized with continual involuntary displacement, and there will be an estimated 3140 to 8812 fewer initiations of medications for opioid use disorder per 10 000 people. Continual involuntary displacement may contribute to between 15.6% and 24.4% of additional deaths among unsheltered people experiencing homelessness who inject drugs over a 10-year period.Conclusion and RelevanceInvoluntary displacement of people experiencing homelessness may substantially increase drug-related morbidity and mortality. These findings have implications for the practice of involuntary displacement, as well as policies such as access to housing and supportive services, that could mitigate these harms.
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