Boston Health Care for the Homeless Program

This Viewpoint discusses the implications of the current administration’s policy on homelessness, which treats people experiencing homelessness as criminals instead of focusing on providing housing and care, and suggests that state and local governments should work together to provide community-based care.

Lung cancer is a major cause of death among people who experience homelessness. Patient navigation is an effective strategy for promoting lung cancer screening (LCS) in Health Care for the Homeless (HCH) settings, but little is known about whether the impact of this intervention differs for patients currently vs formerly experiencing homelessness. To examine the effect of LCS patient navigation on individuals currently vs formerly experiencing homelessness, and to explore how navigation process measures differ for these subgroups. This is a subgroup analysis of the Investigating Navigation to Help Advance Lung Equity (INHALE) pragmatic randomized clinical trial of LCS patient navigation. The INHALE trial was conducted at Boston Health Care for the Homeless Program (BHCHP), a federally qualified health center serving nearly 10 000 patients who have experienced homelessness annually. The study included BHCHP primary care patients with a lifetime history of homelessness who were proficient in English and eligible for LCS under pre-2022 Medicare coverage criteria. The study was conducted between November 20, 2020, and March 29, 2023. Current vs former homelessness, defined by self-reported responses to a detailed residential inventory. Sensitivity analyses further categorized individuals who formerly experienced homelessness as having stable or unstable housing. The primary outcome was verified receipt of a 1-time LCS low-dose computed tomography (LDCT) scan within 6 months after randomization. The risk difference (RD) in primary outcome attainment between navigation and usual care within each homelessness subgroup was calculated, and these RDs were compared by testing the interaction between study group and homelessness status in a linear binomial regression model with the identity link. This study included 260 participants (mean [SD] age, 60.5 [4.7] years; 184 male individuals [70.8%]). At baseline, 84 patients (32.3%) were currently experiencing homelessness and 176 (67.7%) had formerly experienced homelessness. Patient navigation significantly increased LCS LDCT completion among both those currently (15 of 56 [26.8%] vs 2 of 28 [7.1%]; P = .04) and formerly (60 of 117 [51.3%] vs 6 of 59 [10.2%]; P < .001) experiencing homelessness. However, the treatment effect was significantly smaller among participants currently experiencing homelessness (RD, 19.7% vs 41.1%; P = .03), such that a disparity in LCS completion between these subgroups emerged under the navigation condition. Navigation process measures highlighted communication challenges with participants currently experiencing homelessness. In sensitivity analyses, LCS LDCT completion rates and navigation process measures were generally similar for stably vs unstably housed participants who formerly experienced homelessness. In this subgroup analysis of a randomized clinical trial, patient navigation increased LCS participation among both patients currently and formerly experiencing homelessness; however, the effect size was smaller for those currently experiencing homelessness. Further improving cancer outcomes among HCH patients may require refinement of the patient navigation intervention, coupled with policy efforts to promote housing attainment among people experiencing homelessness. ClinicalTrials.gov Identifier: NCT04308226.

Weeping is a profound and universal human expression that transcends cultures, borders, and time. This article delves into the historical, cultural, physiological, and psychological dimensions of weeping, exploring its significance, causes, and implications. Beginning with an exploration of the historical and cultural tapestry of weeping, the article highlights its revered place in human expression, from ancient rituals to modern interpretations. It examines how literature and art have portrayed weeping as a poignant motif, reflecting the depths of human emotion and resilience. Moving beyond its cultural and artistic significance, the article delves into the physiology and psychology of tears, elucidating their complex composition and therapeutic functions. It then examines the essence of weeping, its causes, and the role of the limbic system in orchestrating emotional responses. The article addresses the importance of context and support in understanding healthy versus unhealthy weeping, emphasizing the role of supportive social networks and professional interventions. It also explores cultural norms and stigma surrounding weeping, acknowledging the diverse attitudes toward emotional expression worldwide. Furthermore, the article discusses common and rare diseases associated with weeping, ranging from mood disorders to neurological conditions, underscoring the need for comprehensive medical evaluation and treatment. It also touches upon the role of homeopathy in addressing emotional distress and restoring balance.

As xylazine increasingly adulterates the unregulated opioid supply, people who use drugs (PWUD) are more likely to experience sequalae from xylazine. Given xylazine exposure is consistently associated with development of wounds which can heal with medically directed wound care, we sought to understand the level of preparedness and ability of front-line addiction professionals who interact with PWUD to provide wound care treatment. We administered a 26-item online survey assessing participant and organizational characteristics, level of wound care training, ability to test for xylazine and treat xylazine-associated wounds, and funding and billing characteristics to a national sample of addiction professionals using a listserv of over 11,000 individuals. We had a response rate of 12.8% in which 1,280 met eligibility criteria and completed the survey, with the majority (23.7%) being nurses. While nearly all participants had cared for patients who had experienced any xylazine-associated harms, less than half (43.6%) had cared for patients with xylazine wounds and 43.4% had any training or certification in wound care, including 26.9% of physicians. Although 75.9% of participants had access to wound care supplies, just 19.5% provided wound care services onsite. Most addiction professionals, especially physicians, lack wound care training and do not provide onsite treatment for drug-associated wounds at the organizational level. There is a critical need to bridge this gap in knowledge and build capacity to provide evidence-based wound care services to PWUD in areas impacted by xylazine adulteration.

BackgroundWomen who use drugs face sexism and intersectional stigma that influence their drug use experiences and treatment needs. There is a need to build the capacity of addiction medicine specialists who can deliver gender-responsive services and advance research and policy in women-focused addiction care. We describe the development of a Women’s Health track within an addiction medicine fellowship program and reflect on successes, challenges, and future directions.Main bodyThe Women’s Health track was developed in collaboration between program leaders in Addiction Medicine and Obstetrics/Gynecology. Implementing the track led to the development of women-focused rotations and continuity clinics, as well as enrichment of women’s health didactic education for all fellows. The fellowship track spurred interdepartmental mentorship and collaboration on research and advocacy projects.ConclusionAddiction medicine fellowships can replicate this curriculum model to advance women-focused education, research, and policy. Future curricula should focus on structural sexism in drug use and addiction treatment throughout a woman’s life course.

BackgroundInspiratory muscle training (IMT) using a threshold device improves inspiratory muscle strength. What factors influence the IMT outcome has not been examined.ObjectiveTo identify predictors of the positive outcome following IMT in persons with advanced multiple sclerosis (PwAMS).MethodsInclusion criteria were non-ambulatory PwAMS, Expanded Disability Status Scale (EDSS) ≥6.5, age >18 years, no acute medical conditions, current non-smokers, and ability to consent. Participants (n = 38) performed daily inspiratory exercises using a resistive threshold device for 10 weeks. Baseline measurements included age, sex, body mass index, year post multiple sclerosis diagnosis, comorbidities, EDSS, Modified Fatigue Impact Scale-5, and oral Symbol Digit Modality Test. The percentage of completed prescribed exercise trials (Trials%) during the 10-week intervention was calculated. Age- and sex-adjusted predicted values of maximum inspiratory pressure (MIP%pred) and maximum expiratory pressure (MEP%pred) were obtained before and after the 10-week intervention. Backward multivariable regression analyses for the primary outcome (MIP%pred) were conducted.ResultsAfter controlling for the initial MIP%pred, perceived fatigue at the baseline and Trial% were significant and independent predictors of MIP%pred after IMT.ConclusionLess fatigue at the baseline and higher adherence to the prescribed exercise repetitions were positive predictors of the positive outcome following IMT in PwAMS.

Abstract The COVID-19 pandemic left an unprecedented impact on the general public health, resulting in hundreds of thousands of deaths in the U.S. alone. Nationwide testing plans were initiated with drive-through being the currently dominant testing approach, which, however, exhausts personal protective equipment supplies, and is unfriendly to individuals not owning a vehicle. Walkup positive pressure testing booths are a safe alternative, whereby a health care provider situated on the inside of an enclosed and positively pressurized booth swabs a patient on the outside through chemical resistant gloves. The booths, however, are too prohibitively priced on the market to allow for nationwide deployment. To mitigate this, we present in this paper a safe, accessible, mobile, and affordable design of positive-pressure COVID-19 testing booths. The booths have successfully passed the Centers for Disease Control and Prevention and Health care Infection Control Practices Advisory Committee pressure, air exchange, and air quality requirements for positive-pressure rooms, following the guidelines for environmental infection control in health care facilities. The booths are manufactured using primarily off-the-shelf components from U.S. vendors with minimized customization, and the final bill of materials does not surpass USD 3,900. Since August 2019, five booths were deployed and used at the Johns Hopkins University School of Nursing, Baltimore City Health Department, and two community health centers in Baltimore. No health care provider was infected when using our booths, which have shown to facilitate walkup testing with decreased personal protective equipment consumption, reduced risk of infection, and enhanced accessibility to lower-income communities and nondrivers.

Despite high rates of drug overdose death among people experiencing homelessness, patterns in drug overdose mortality, including the types of drugs implicated in overdose deaths, remain understudied in this population. To describe the patterns in drug overdose mortality among a large cohort of people experiencing homelessness in Boston vs the general adult population of Massachusetts and to evaluate the types of drugs implicated in overdose deaths over a continuous 16-year period of observation. This cohort study analyzed adults aged 18 years or older who received care at Boston Health Care for the Homeless Program (BHCHP) between January 1, 2003, and December 31, 2017. Individuals were followed up from the date of their initial BHCHP encounter during the study period until the date of death or December 31, 2018. Data were analyzed from December 1, 2020, to June 6, 2021. Drug overdose deaths and the types of drugs involved in each overdose death were ascertained by linking the BHCHP cohort to the Massachusetts Department of Public Health death records. In this cohort of 60 092 adults experiencing homelessness (mean [SD] age at entry, 40.4 [13.1] years; 38 084 men [63.4%]), 7130 individuals died by the end of the study period. A total of 1727 individuals (24.2%) died of a drug overdose. Of the drug overdose decedents, 456 were female (26.4%), 194 were Black (11.2%), 202 were Latinx (11.7%), and 1185 were White (68.6%) individuals, and the mean (SD) age at death was 43.7 (10.8) years. The age- and sex-standardized drug overdose mortality rate in the BHCHP cohort was 278.9 (95% CI, 266.1-292.3) deaths per 100 000 person-years, which was 12 times higher than the Massachusetts adult population. Opioids were involved in 91.0% of all drug overdose deaths. Between 2013 and 2018, the synthetic opioid mortality rate increased from 21.6 to 327.0 deaths per 100 000 person-years. Between 2004 and 2018, the opioid-only overdose mortality rate decreased from 117.2 to 102.4 deaths per 100 000 person-years, whereas the opioid-involved polysubstance mortality rate increased from 44.0 to 237.8 deaths per 100 000 person-years. Among opioid-involved polysubstance overdose deaths, cocaine-plus-opioid was the most common substance combination implicated throughout the study period, with Black individuals having the highest proportion of cocaine-plus-opioid involvement in death (0.72 vs 0.62 in Latinx and 0.53 in White individuals; P < .001). In this cohort study of people experiencing homelessness, drug overdose accounted for 1 in 4 deaths, with synthetic opioid and polysubstance involvement becoming predominant contributors to mortality in recent years. These findings emphasize the importance of increasing access to evidence-based opioid overdose prevention strategies and opioid use disorder treatment among people experiencing homelessness, while highlighting the need to address both intentional and unintentional polysubstance use in this population.