So, welcome. Good afternoon, I think, for everyone, no matter which coast you're dialing in from. I'm Dr. Karen Drexler. I serve as the Medical Director for the American Academy of Addiction Psychiatry, and I am delighted and honored to moderate this poster session this afternoon. We have three, sorry, paper session this afternoon. We have three terrific papers from three wonderful investigators from all across the country. And so, we will give each presenter about 10 minutes to present their paper, and then we will pause at the end for another 10 minutes for questions and answers. Please use the Q&A function. You'll see a button with an icon at the bottom of your screen in the Zoom platform. Please type in your questions, and I will moderate a discussion at the end. So, without any further ado, I'd like to introduce Dr. Joseph Aikekweri from the University of Chicago. Welcome. I'm Joseph Aikekweri, and I completed my addiction psychiatry training at the University of Illinois at Chicago, actually, so it's UIC, and also currently working as an inpatient psychiatrist here at Southwest Psychiatric Hospital. And so, the title of my presentation is Alcohol Use Among People Living with HIV Treated with Antiretroviral Therapy, and here are my other contact information. My team and I have no relevant disclosures. By way of objectives, we plan to describe the epidemiology of HIV, alcohol risk, behavioral factors, and treatment with heart. Heart here means highly active antiretroviral therapy. And then number two is to interpret the association between the use of heart and alcohol use, as well as the confounders that might impact the relationship. And number three is to formulate preventative interventions that target alcohol use, as well as improve the use of heart, as well as reduce HIV transmission. So, by way of introduction, we all know that alcohol use is highly prevalent globally, with numerous negative consequences to the human health, including HIV progression, especially among people living with HIV. And then those who have people living with HIV that are not on treatment, particularly highly active antiretroviral therapy, heart. The HIV, as we know, can be transmitted by different methods. The most common method is through sexual transmission. Interestingly, all over the world, heterosexual contact is by far, particularly in sub-Saharan Africa. But here in the U.S., it looks like it's kind of turning to be mostly among, particularly among LGBTQ, even more so people identifying as gay and lesbian. People living with HIV with co-occurring alcohol use often report risky sexual behaviors and poor medication adherence. This study aims to evaluate the association between alcohol use and treatment with heart among people living with HIV, and also examine the impact of common covariates in this relationship. So, this study was actually, originally, was an NIH grant led by Dr. Fred Salfo in sub-Saharan Africa in Ghana. So, actually, it was called Everlast. So, Everlast means the evaluation of vascular event risk while on long-term antiretroviral suppressive therapy, which is the same thing as heart. It was originally a prospective cohort study and was actually conducted among individuals, people living with HIV, in an adult HIV clinic at Kofa Noche Teaching Hospital in Ghana. And so, for the purpose of this study, it was actually a retrospective data analysis of secondary outcomes that are extracted from the Everlast study. This had a total population of about 502 patients that were included in this study. So, the method was a multivariable logistic regression to determine if the likelihood of alcohol use was different in patients who are currently on heart versus those who are not on heart. In this situation, I'll call those not currently on heart, no heart. We addressed it for age, sex, place of residence, generalized anxiety, and major depression, which are typical co-founders. The variables that we kind of factored in was age. In this study, it was mostly adult population. So, the age was from 30 and greater. We looked at male versus female. We looked at those living in urban versus rural. We also looked at generalized anxiety, major depression, and then also people that were currently on heart. So, these are some of the codes that we used. Some characteristics at baseline here, we could see from 502 total population, about 63% of the males were not on heart treatment, yet why 56% of females were on heart. Also, the percentage in the overall sample that had generalized anxiety was 75%, and those that have major depression disorder was about 73%. So, right here. Okay. Then, patients not on heart treatment had a higher percentage of major depression than those that are currently on heart. So, that's another thing to kind of keep in mind. So, for those that are currently on heart right here, they had major depressive disorder. So, we're kind of looking at it here, 44%, which is almost like the inverse here. So, 63% and then 85% also. So, no significant differences were found between people who have alcohol use and also being currently on heart treatment. However, there was a difference in alcohol use between males and females. So, like just being on heart here, whenever we kind of separated them out, after we run the analysis, so the p-value here was 0.15, which is significant, but whenever we stratified by age, we did see it was significant here. No, actually not by age. Age was significant at 0.05 exactly. Gender was even more significant right here, whenever we kind of separated out between male and female. No significance in place of residence, generalized anxiety, no significant major depression disorder also did not kind of separate out. So, then we came out here and then we ran different models to include. So, model one was currently on heart treatment and model two was kind of like including heart treatment and also controlling for just demographic characteristics, including age, gender, and then a place of residence. And then the model three was actually we did factor in putting in anxiety and major depression disorder, which also is a major confounder for alcohol use. So, in the unadjusted right here, on the unadjusted regression here, patients currently on heart were 1.3 times more likely to have a history of alcohol use compared to those who were not yet started on heart treatment. However, after adjusting for other covariates, the patient was 1.8, whenever we control for all these three different factors, 1.82, more likely to have a history of alcohol use than not on heart. And there was no difference in age, place of residence, generalized anxiety, or major depressive disorder. So, just because whenever we stratified different, so there was no significant difference because the course is one year, a place of residence also, but in terms of gender, there was actually a statistically significant 4.85 right here. Looking forward to increase effect of art from the unadjusted adjusted odds ratio, we stratified the model by sex that I pointed out earlier, while still adjusting for other covariates. In the female only population, so this is a female only population here, patients that were on heart treatment were two times, were two times more likely to have a history of alcohol use compared to those not on heart treatment. So, we thought that was particularly interesting. Then also the male model here, there was no statistically significant, even though it was 1.44 here, but there's really no statistically significant because the course is the one between patients that were on heart treatment versus not being on heart treatment. In conclusion, the association between heart treatment in people living with HIV and alcohol use was significantly, was significant after controlling for possible confounding variables, including just the characteristics including age, sex, but we did find that sex was particularly significant. Therefore, it is imperative for clinicians to assess alcohol use among people living with HIV on heart treatment as this will also be a pointer to potential treatment non-adherence and consequently poor management outcome. Alcohol consumption could also be targeted using evidence-based behavioral kind of methods, and then also pharmacological interventions, including the use of anti-alcohol, like anti-craving medications, naltrexone, and then also cambra and other pharmacological methods to improve adherence on heart for people living with HIV. Here are the scientific findings. Relationship between alcohol use and use of heart may be confounded by other variables like we established in this research. Sex is also an important factor in the relationship between alcohol use and heart, although males are more likely to have a history of alcohol use just based on baseline characteristics, but the association between alcohol use and also being currently on heart was only found in males from our study. Alcohol use in relation to HIV treatment outcomes like heart initiation compliance are potential targets for intervention among alcohol drinking HIV positive adults at greater risk of poor management outcomes. Here are some of the references, and I just also wanted to give a shout out to Dr. Fred Saffo, who actually originally got the NIH grant to run the Everlast study, and Dr. Igard, program director at UIC. Dr. Edward was actually my national mentor from this rich grant, and then my other collaborators, Dr. Anwar Bouezid, Dr. Ayissiri, Dr. Agbedia, Dr. Modri, also a fellow at Ghana, and Dr. Long Khoi for running the analysis, as well as Dr. Jekade, who is currently an assistant professor of psychiatry at Yale. Thank you so much for listening. Thank you, Dr. Ikekueri, and thank you for the question in the chat. I'd like to remind everyone to please put your questions into the Q&A at the bottom. There's an icon at the bottom. Next, I would like to introduce and welcome Dr. Mohamed Keshkar, who is from Washington State University. Welcome. Hi, all. I am Mohamed Keshkar, and during this talk, we are going to discuss the impact of COVID-19 on individuals with co-occurring alcohol use disorder and serious mental illness. I want to let you know that our team has no relevant disclosures, and after this talk, you'll be able to describe the impact of COVID-19 on individuals with co-occurring alcohol use disorder and serious mental illness. You'll be able to compare the experience of this population in a major city, such as Seattle, compared to a smaller city, such as Spokane, and you'll realize the need for more education and outreach regarding COVID-19 prevention and vaccination among this group. In this pilot study, our study population includes individuals with co-occurring alcohol use disorder and serious mental illness. In the study, we investigate the impact of COVID-19 pandemic on a sample of 61 adults with co-occurring disorder participating in a contingency management intervention study conducted in Seattle and Spokane of Washington State. Our data was gathered between February and July of 2021, and we asked our participants about their beliefs of COVID-19, their likelihood of receiving any COVID-19 vaccine, and how the pandemic affected their finances, employment, and mental health. Now, let's start by looking at the impact of COVID-19 on mental health of this population. Looking at the column chart on the left side, we see that roughly 66 percent of our participants reported moderate to extreme impact on their mental health by the pandemic, and looking at the pie chart on the right, we see that roughly 60 percent of individuals reported drinking to cope with social distancing and isolation. Now, let's look at the financial impact of COVID-19 on this population. I want to let you know that here individuals could endorse more than one of these answers. On the right end of this column chart, we see that roughly 30 percent reported having had their income or pay reduced, having had work reduced hours, or experienced serious financial problems as a result of COVID-19, and even though some were able to work remotely or from home or were able to work more, a similar percentage were either not able to work at all or were not paid at all during this period. And when it comes to beliefs and attributions to the pandemic, looking at the column chart on the left, most, about 90 percent of our participants believe that COVID-19 is a serious disease. However, a smaller percentage of them, about 67 percent, believe that they're at risk of being infected with the virus, and looking at the bar chart on the right side, it shows us an overwhelming majority of our participants, more than 90 percent of them, know about the effective methods of protecting themselves against COVID-19. So the take-home message here is that our participants know COVID-19 is serious and they have the knowledge on how to protect themselves from COVID-19. Now let's look at the vaccination. Let's start with the column chart on the left. Roughly 80 percent of our Seattle participants are fully vaccinated for COVID-19, whereas in Spokane, only about 50 percent, just below 50 percent, are fully vaccinated. We've also included the data from King County and Spokane County in the general public between ages of 18 to 64, just to show you, give you a sense of where the general public is and in regard to full vaccination rates in these locations. The trend is that a higher percentage of general public is fully vaccinated for COVID-19 in Seattle area compared to Spokane area. And in general, the vaccination rate of our participants in Seattle and Spokane follow the same rate, the same trend, as their respective communities. Now let's look at the reasons why participants got vaccinated, looking at the bar chart on the right side. The top reason our participants reported they got vaccinated include to protect their family and friends, to protect their health, and to contribute to public health and health of their community. What I want you to take from this is that individuals in this population are getting vaccinated and they're getting vaccinated for the same reason that everybody else is getting vaccinated. Here, let's look at the vaccination vaccine hesitancy. Let's start with the column chart on the left. Roughly 20% of our Seattle participants reported experiencing vaccine hesitancy, whereas in Spokane, about 60% reported vaccine hesitancy. And here also, again, we included the data for Seattle public and Spokane public to give you a sense of vaccine hesitancy of general public in these locations. And the trend is that a higher percentage of general public experiences vaccine hesitancy regarding COVID-19 vaccines in Spokane area compared to Seattle area. And in general, again, the vaccine hesitancy rates of our participants in Seattle and Spokane follow the same trend as their respective communities. And looking at the reasons why participants are hesitant to get vaccinated, looking at the bar chart on the right side, the top reasons include possibility of dangerous side effects from the vaccine, other reasons, and possibility of allergic reactions to the vaccine. And lastly, let's look at the source of news that our participants reported using regarding COVID-19 information, including vaccination. Majority of our participants get their information from internet, from local news and newspapers, and from word of mouth. And knowing how influential these sources are, it's worth making sure that the information that's going through these channels are accurate and digestible in an effort to just prevent the spread of misinformation. Now, in summary, people with co-occurring disorders know COVID-19 is dangerous, and they have knowledge of risk reduction when it comes to COVID-19. And the pandemic has had a negative mental health and economic impact on this population. And our descriptive data suggests that COVID-19 vaccination and vaccine hesitancy may interact with location, with Seattle participants having rates of both consistent with their communities, and participants in Spokane having lower levels of vaccination and higher levels of vaccine hesitancy relative to the general population. And the next step with regard to this includes having more education and outreach regarding COVID-19 vaccination to help this community recover. And with that, I want to thank NIAAA for their leadership and support. I want to thank AAAP. I want to thank our partner sites, SoundHealth and Frontier Behavioral Health. I want to thank our participants and all my wonderful colleagues. And I want to thank you so much for all your attention and time. Thank you, Dr. Kashkar, for a wonderful presentation. There was one clarifying question that I might take a privilege and ask. Can you tell us whether these are ACT patients or community outpatients both? What was the setting that the patients were in in this clinical trial of contingency management? Absolutely. So this is a part of a bigger study that individuals are involved in. The study is contingency management for people who experience alcohol use disorder and serious mental illness. And the COVID-19 study was added as a part of that study in a community setting. Okay. Thank you very much. Without any further ado, I would like to now introduce Dr. Carrie Mintz, who is from Washington University in St. Louis. Welcome, Dr. Mintz. Thank you so much. So very excited to be here. I'm an assistant professor of psychiatry at WashU, as Dr. Drexler said. And I'm also boarded in addiction medicine through the practice pathway offered by the American Board of Preventive Medicine. I have no relevant disclosures. My research is funded by a NIDA K-12 award, but nothing relevant. And then two big major objectives for my presentation. So the first is to illustrate that persons with co-occurring opioid use disorder and ADHD have both positive and negative outcomes associated with prescription stimulant use. And then second, which is probably many people in these audience have experienced this clinically, it is a really complicated risk-benefit ratio that clinicians are making when treating patients with both of these disorders. And just to recognize that it's complicated. So as a background, we'll go real fast for this audience. Everybody knows buprenorphine is a life-saving treatment for persons with opioid use disorder. ADHD, a neurodevelopmental disorder, often persists into adulthood. And we know that the centrally acting stimulants are considered most effective treatment for ADHD, even in the adult population, but they do carry this potential for misuse. Most data that we have, this is a dramatically understudied area, but most data that we do have examining folks with ADHD who use stimulants with a co-occurring substance use disorder, we think that stimulants are not associated with an increased risk of returning to illicit drug use. But there are few studies in these areas I alluded to, and particularly when the co-occurring substance use disorder is an opioid use disorder. And I don't know of any studies where we've looked at an opioid use disorder cohort who's getting buprenorphine treatment, now the most common form of medication treatment, as well as co-occurring ADHD. So in our study, we had two major questions. First, is prescription stimulant use associated with drug-related poisoning or overdose risk, I'll use them interchangeably, among persons with opioid use disorder who are getting treatment with buprenorphine? And secondly, is prescription stimulant use associated with buprenorphine treatment retention among persons with opioid use disorder? So if stimulant prescriptions did improve your adherence to buprenorphine, or was associated with improvement in adherence to buprenorphine, might that offer an indirect benefit through the protective benefit against overdose that buprenorphine has? So for a study design and analytic plan, we used a retrospective recurrent event case crossover cohort study design. So this is obviously an observational study design, so we can't perfectly get at causality. But what's really nice about a case crossover study design is that each person serves as their own control. So a lot of those confounding variables that you worry about with observational study designs, a lot of those are taken care of because the person is compared to his or her or their self. Our primary outcomes were drug-related poisoning, and then also buprenorphine treatment retention. Our unit of analysis was the person day, and each person day was characterized by the presence or absence of buprenorphine treatment, stimulant treatment, or both. And then we use a conditional logistic regression to estimate the risk of an event, the poisoning remaining in treatment, on days when you got those prescriptions compared to the risk of event on days when you didn't. Our data source and sample, IBM MarketScan commercial and multi-state Medicaid databases through this 11-year period. These big data sources offer a really nice way for us to look at relatively rare outcomes and be adequately powered to do so. So this is a commonly used, at least in our group, insurance claims database to look at these kinds of questions. And our sample was persons age 12 to 64 with an OUD diagnosis, either ICD-9 or 10, who had received buprenorphine and who had incurred a non-fatal drug overdose. So this is admittedly a sick population. These are people who have had an overdose, right? Because we have to compare the risk of event to days they don't. So to be in the cohort, you had to have had an event. So what did we find? So the take-home is right there on the top. So stimulant use, so stimulant use was associated with an increased risk of drug-related poisoning on days you got stimulants about 18% higher relative to not getting them, but also associated with about a 34% decreased risk of leaving buprenorphine treatment. So I'll just briefly walk through the table. So you see that first model, that's modeling the risk of drug-related poisoning. And again, beauty of big data sources, you get a nice sample size. So we had 23,000 people and over 14 million person days that we were able to study. And you see, it surprises no one that buprenorphine is protective against overdose. And then here's that increased risk of overdose, about 18% associated with stimulants. There were no interaction effects. So stimulants had that risk regardless of whether or not they got buprenorphine in addition. And then our second model, what does it do to your likelihood to stay in buprenorphine treatment? So again, stimulants decrease your risk of leaving buprenorphine treatment by about a third, 34%. So how the heck do we make sense of these results, right? So we got on the one hand, there's a little bit increased risk, but on the other hand, you're staying in treatment with buprenorphine, which is, you know, decreases your risk of overdose by 40%. So you're staying in treatment longer. So how do we make sense of these two things? So we came up with an equation that calculates kind of both of these findings. So I'll kind of walk you through this figure. I apologize. I'm seeing people, so I'm going to move people so I can see it. So the tan gray bar is a length of time that someone is in treatment, okay? And first we're modeling, or first we're demonstrating the incidence as if they were not getting any prescription stimulants. And you see the red and white vertical bars here, that's how long they're getting buprenorphine. So if we kind of come up with a net overall risk, what's the likelihood you're going to have a drug-related poisoning during this treatment time, your whole course of treatment? So you have the known protective benefit, that hazard ratio less than one, right, associated with buprenorphine, 0.63. Multiply that times the length you're getting buprenorphine, but now that's shorter than if you were also getting a stimulant. So it's about 66% shorter, right? So you get 0.42. And then your overdose risk without buprenorphine treatment, right, which would be one, that's our reference, multiply it down your treatment length without buprenorphine, 0.34. And so what do we get there? So we sum those things, there's a roughly 24% decrease odds of overdose relative to not getting any medication treatment for opioid use disorder. So then what happens if you get treated with stimulants? So now that length of time that you're exposed to buprenorphine and its protective effect against overdose is much longer, right, about a third longer. So now the kind of net overall risk of overdose, we still have the protective effect of bup. We have to account for the higher per day risk associated with stimulants of about 18%. And now our treatment length with buprenorphine is longer than it is without buprenorphine. So when we come up with those things, about a 26% decrease odds of overdose relative to not getting buprenorphine treatment. So a relative wash. And these, we actually put this in our discussion because this assumes causality and we can't do that with our data. But so it's more of an interpretation, but we think it does really sort of show both the risks and benefits kind of associated with stimulants. So in conclusion, among people with opioid use disorder and ADHD who have had a drug-related poisoning, stimulants are associated with an increased per day risk of overdose, but that risk may be offset by the association between stimulant use and the longer duration of buprenorphine treatment, which we all know protects against overdose. Certainly people who are prescribed both stimulants and buprenorphine should not be discontinued from buprenorphine. And both the risks and benefits of stimulant medication should be considered when treating folks with co-occurring OUD and ADHD. These are my co-authors and collaborators. Kevin Chiu is actually my co-first author and presenting on behalf of both of us. And thank you very much. Thank you, Dr. Mintz. And thank you to all three of our presenters for wonderful, very dense, but brief presentations. And thanks to the participants for asking questions. We have several questions. One clarifying question quickly for you, Dr. Mintz. Can you tell us again, how is drug-related poisoning defined? Yeah. So any ICD-9 or 10 code that qualified as a drug-related poisoning. Okay. Thank you. So there was a lot of interest, Dr. Keshkar, in the COVID-19 study. So I will just start and ask some general questions. Do you know, do urban rates of vaccination generally exceed those for rural areas? You gave us data about two particular cities in Washington state, but do you know more in general? Well, thank you so much for all the questions and interest. Overall, it depends where the location is to a point, but some trend is that, yes, in more dense populated areas or in urban settings, metropolitan areas, vaccination seems to be higher compared to rural areas. Especially in Washington, we've seen that. There are programs that there are individuals sent from different healthcare facilities to come to more rural areas or even less dense areas to encourage vaccination and to increase the vaccination rate in these areas. Yeah. Okay. Thank you for that insight. Do you know what was the rate of relapse among the participants in the COVID-19 paper for AUD patients? So that's a great question. Since the other study is still ongoing, we haven't done any analysis when it comes to the treatment phase. What I can talk about is that the main goal of the contingency management study is to encourage abstinence from alcohol and to get individuals to reach that goal. But what we saw is when it comes to the pandemic, there are other stressors that sometimes interfere with that. So just looking at it from the COVID-19 paper perspective, we saw that individuals reported their alcohol consumption directly as a result of COVID-19. Okay. Thank you. Let's see. We're doing fine. Let me ask one more question about your study, Dr. Keshtar, before I move on. How much of an impact, if any, did the government relief package have in economic hardship that you have in your sample? That's a really good question. I can say we didn't directly ask with regard to that, but in interacting with all our participants, I can say that much that the relief package is all helped, and especially with individuals who had, for example, hardship with child care expenses. When it comes to one part, though, there were individuals who couldn't get the relief packages because they didn't have an address, or there were individuals who had a really hard time managing, for example, to get any relief from unemployment, and it took them a very long time to get there. But overall speaking, they were helpful just because of the nature of the jobs that these individuals do, that they all have most involved in person work, and knowing historically, and when the pandemic happened, a lot of jobs moved to remote work. So what happened was this population faced a unique difficulty in not being able to move forward with a lot of the remote job options that were available. So the relief packages all, to a certain extent, were helpful for all individuals, I believe. Okay, thank you. That's very helpful. Thank you for all the questions. Yes. Dr. Aikikweri, there was a question in the chat for you. Do you have any thoughts about why there may be increased rates of alcohol use in patients on heart? Yeah, that's actually a very interesting question. I think it was asked by Dr. Laura Moss. Yeah, so yes, I would say that, you know, as a very kind of contrary to studies that have shown that people live with HIV and are not adhering to heart because of the alcohol status, a few studies have shown that. So, which is exactly why we actually, we found something negative is the reason why we got it submitted. So I guess our hypothesis is the Sub-Saharan Africa, particularly Ghana, is a little kind of different. So we found that the association between alcohol use and non-adherence is due to like really complex kind of different situations. So a few of those reasons, by number one, like complex dosing regimens of heart, the highly active antiretroviral in Ghana itself, but they have like the different first lines, second lines, a little more complex than what is obtained here in the U.S. The other thing too is intentional missed doses due to that cultural or social beliefs in Ghana regarding, also regarding potential toxic interactions between heart and also alcohol is another thing. Over there, people, you know, even though this sample was gotten from the HIV community, HIV clinic, so that would be an assumption that, oh, because you're on heart, you should take it. But it's interestingly, sometimes they come back and we see, we mark how often they come back. Sometimes they intentionally miss doses also due to those factors. And then also there's a very high instance of discrimination among people with HIV also. So it doesn't really encourage people, but I would still give kudos to those that typically comply, but those are the few reasons that we found that might have given us a negative finding in our study. Okay. Thank you very much. We are almost at the end of our time. So I'd just like to take this moment to thank all three of our presenters again for your work and for your terrific presentations. Thank you very much. Thank you.

alcohol use

HAART

COVID-19

co-occurring disorders

prescription stimulants

buprenorphine treatment

interventions