1. After reading the article by Thomas et al., comment on where your research, or your research interests, fit into the generational framework for health disparities research. If your work is 1rst or 2nd generation, comment on how your work could lead in the future to 3rd or 4th generation work. If your work is 3rd or 4th generation, comment on what 1rst and 2nd generation work was necessary as a foundation for your current work (or current interests).
My research focuses on opioid use disorder and opioid overdose, an issue that disproportionately affects marginalized populations in the US. We have known about the 1st and 2nd generations of this research area for quite a long time: we know that rates of OUD and overdose are disproportionately high among men, blacks and those with lower SES. In recent years, however, risk of OUD has become increasingly more complex to capture. While these gender/race/economic groups still carry the highest burden of OUD, we have seen substantial spikes in OUD among women, younger individuals and those with higher SES. In many ways, in the last few years we have had to reassess generations 1 and 2. (I could talk about this “reassessment” extensively but I will refrain. But I will note that there has been substantial media attention and resources over the past 5-10 years as OUD reemerged as an issue of “white women and youth” as it had been in the early 20th century. The fact remains that the highest burden of OUD is still among Blacks but resources and attention are focused on the “new” emergent rural, white epidemic. While there is need for this, the interventions (and funding for them) are not being dispersed equitably).
Having 1st and 2nd generation information has been essential to the 3rd generation studies we design around OUD and overdose. Understanding the shift from heroin to illicit prescription opioids changed the way we presented certain interventions like naloxone dispensing. Naloxone used to only be available through syringe exchanges which targeted a particular subset of individuals with OUD. In a response to shifts in patient characteristics with OUD (including the increase of prescription opioids leading to OUD), we subsequently shifted our approach to begin co-prescribing naloxone in primary care settings. This is still a fairly new intervention, having only been widely implemented in a few cities. In 2014, San Francisco initiated an implementation project to encourage providers to co-prescribe naloxone to patients on long-term opioid therapy. We suggested that providers prescribe to anyone on long-term opioids or otherwise at risk of experiencing or witnessing an opioid overdose. The 1st and 2nd generation information was essential, not only because it motivated us to expand access beyond syringe exchanges, but also because we were able to inform providers about the general patient characteristics of opioid overdose decedents, to help motivate them to target these particular subpopulations e.g. fatal overdoses in SF are predominantly driven by prescription opioids, not heroin. Prior to the intervention, many providers told us they would have only considered prescribing naloxone for a street-opioid or heroin user but after our intervention they are more likely to prescribe it to anyone on long-term opioid therapy.
2. The barbershop hypertension intervention, while essentially a clinical services intervention operating at either the fence or safety-net level as described by Jones, has some engagement with the social determinants of health. What types of clinical interventions can you think of in your area of research that could similarly bridge levels of the socioecological model?
There has been a push to integrate OUD and overdose education into high school education, akin to the way sex ed is provided in many schools. The hope is that targeting youth while they’re still in school provides a “fence” to prevent OUD. Many advocates of integrating OUD and overdose education into schools also advocate for naloxone dispensing on those settings (naloxone could serve as either a fence or a safety net in this case). Research is starting to show that there may be a positive behavioral change related to receipt of naloxone, regardless of if it is ever used or not. If this is the case, it would take on the role of a fence, like education. On the other hand if it doesn’t modify behavior, but prevents an overdose from being fatal, then it is a net to catch you at the bottom of the cliff. Regardless, while OEND integration into schools is not my area of advocacy, I support the intervention and see how it fits into Jones’ cliff analogy.