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Background Opioid Use Disorder (OUD), a chronic condition with significant health and social consequences, has been intensified by synthetic opioids such as fentanyl. Although medications for OUD (MOUD) reduce mortality and improve treatment retention, many individuals continue to engage in non-prescribed opioid use while in treatment. Harm reduction services (HRSs), including syringe exchange sites, supervised injection facilities, or sites that distribute fentanyl test strips or naloxone, seek to mitigate the risks associated with substance use. This study explores engagement with harm reduction services and opioid use practices among adults receiving MOUD in Philadelphia and compares these patterns between methadone and buprenorphine recipients. Methods We conducted a cross-sectional survey of 116 adults receiving buprenorphine or methadone for moderate-to-severe OUD at three Philadelphia treatment sites between November 2023 and October 2024. Participants completed a RedCAP-based questionnaire assessing recent opioid use, HRS utilization and attitudes, and substance use practices. Group differences were examined using t-tests, chi-square, and Kruskal-Wallis tests. Results Overall, 37% of participants reported non-prescribed opioid use in the past 6 months, most commonly via injection. Sterile injection practices varied considerably. 61% of all participants had utilized harm reduction services at least once; however, regular use was uncommon, with only 29% reporting use in the past week. HRS utilization was significantly associated with fentanyl test strip use ( p  = 0.002) but not with consistent sterile injection practices ( p  = 0.20). Compared with methadone recipients, buprenorphine recipients were more likely to report HRS utilization, feel welcomed at these sites, recommend them to others, and perceive a positive community impact (all p  < 0.05). There was no observed difference in non-prescribed opioid use in the last six months between buprenorphine or methadone recipients. Conclusions Despite ongoing MOUD treatment, many patients reported continued, non-prescribed opioid use and infrequent engagement with HRS. More favorable attitudes and higher HRS utilization among buprenorphine recipients suggest that MOUD setting and structure may influence harm reduction engagement. These findings add quantitative evidence describing HRS use among MOUD populations and suggests that tailoring harm-reduction supports to these contextual factors may be an important consideration for MOUD programs.

Medetomidine, a veterinary α2-adrenergic agonist, has recently emerged as an adulterant in the non-medical opioid supply, yet human exposure has remained poorly characterized. We conducted a pragmatic retrospective cohort analysis utilizing chart review and liquid chromatography–tandem mass spectrometry (LC-MS/MS) toxicology testing on available urine samples from patients presenting to two hospitals in Philadelphia, PA, who fit two clinical phenotypes, intoxication or withdrawal. Samples also underwent glucuronidase pre-treatment to assess impact on the yield of medetomidine and xylazine metabolite detection. Testing identified universal exposure to medetomidine (58/58 samples) via the 3-hydroxy-medetomidine (3-OH-M) metabolite, post glucuronidase treatment and variable xylazine exposure (40/58 samples). Importantly, 32% of medetomidine exposures would have been missed without enzymatic pre-treatment. Patients exhibited two distinct clinical phenotypes: intoxication, characterized primarily by sedation; bradycardia; and often hypotension, and withdrawal, presenting with life-threatening tachycardia; hypertension and often encephalopathy. Notably, clinical phenotype correlated with urinary concentrations of 3-OH-M but not xylazine. These findings underscore the critical need for heightened clinical awareness and need for contemporaneous toxicologic screening mechanisms for medetomidine exposure, emphasizing its distinct clinical presentations and the potential public health implications posed by its widespread adulteration in illicit opioids.

Background People with SMI have often been excluded in advocacy efforts focused on physical health, health care and health and social policy. Objective Following a Photovoice project focused on barriers to healthy eating and physical activity in urban neighbourhoods, participant‐researchers were invited to present their insights in community advocacy settings. The purpose of this study was to explore the feasibility and participant–researchers’ experience of these community advocacy activities. Design We held four focus groups with the eight participant‐researchers after each community advocacy activity to explore their experience with public speaking, presenting their experiences and advocating. Setting and Participants People with serious mental illness who were overweight/obese living in supportive housing. Analysis approach Qualitative analysis of the focus group transcripts, using a modified grounded theory approach followed by structured coding focused on empowerment, participation and non‐discrimination. Results Participant‐researchers gave three oral presentations of their photographs at a variety of community‐based programmes and settings and participated in a rally to advocate for SNAP benefits. Two themes emerged from analysis: (a) Empowerment (the level of choice, influence and control that users of mental health services can exercise over events in their lives) and (b) Barriers to Empowerment (obstacles to participation and well‐being). Conclusions This evaluation strengthens the evidence that it is feasible for participant‐researchers in Photovoice projects to engage in robust advocacy activities, such as presentations and discussions with local policymakers. During focus groups, participant‐researchers demonstrated realistic optimism towards their roles as change agents and influencers in spite of acknowledged systemic barriers.

Housing First (HF) is an evidence-based practice that ends chronic homelessness for individuals with serious mental illness by providing immediate access to permanent independent housing and team-based community supports. Little is known about the health status of homeless individuals entering HF programs. Through a cross-sectional analysis, this paper reports on the chronic physical disease burden of people entering a newly established HF program and examines whether these individuals recognize and request support for ongoing health-related issues. The authors’ evaluation confirmed significantly higher rates of chronic disease (60%) and fair/poor self-reported health status (47%) than the general urban population of Philadelphia. The majority of clients reported they wanted to address both medical (67%) and mental health (68%) problems, but a much lower percentage reported wanting to reduce substance use (23%) or take psychiatric medications (25%). The authors conclude that formerly homeless entrants to HF programs have a high burden of chronic disease with complex health-related needs. Additionally, these individuals look to the program for health-related assistance. As the HF model is disseminated throughout the United States to end chronic homelessness, these findings support the development of flexible, integrated, person-centered health services within the HF service delivery system as a potentially effective method to address complex health needs.

People with mental illness in the United States are almost twice as likely to be obese compared with those without a mental illness. Lifestyle factors, such as poor dietary choices and physical inactivity, are often cited as causes of obesity in this population, which limits the response to the obesity epidemic primarily to behavioral change interventions. In response, this project is grounded in a human rights framework to assure that the people most affected by the problem are included in understanding and addressing the problem. We sought to investigate social and structural factors that affect weight loss in partnership with community co-researchers enrolled in a group lifestyle program for overweight/obese people with serious mental illness (SMI) living in supportive housing settings. Using Photovoice methodology, eight co-researchers identified barriers and facilitators to healthy living in their community over seven weekly sessions. Co-researchers selected 33 photos reflecting two overarching themes: 1) structural barriers, such as poor-quality food, high transportation costs, limited SNAP benefits, limits of food pantries, easy availability of tobacco and alcohol products, and limited places for exercise and 2) strategies for overcoming structural barriers. Co-researchers highlighted structural barriers that were a cause or consequence of food insecurity and situations that threaten the right to healthy food and opportunities for a healthy life. Co-researchers reported examples of knowledge and skills they learned through participation in the project that were used to overcome structural barriers to healthy eating and physical activity, and likely contributed to weight loss.

Endometrial cancer is the leading cause of gynecologic cancer in the United States. Etiologically, endometrial carcinoma usually results from unopposed estrogen stimulation of the endometrium, although non–estrogen-related forms occur as well. The most common presentation of endometrial cancer is postmenopausal bleeding. A variety of diagnostic modalities are available to aid in the detection of the disease, each with its own strengths and limitations. These modalities include endometrial biopsy, ultrasonography, saline infusion sonography, and hysteroscopy. A definitive diagnosis requires pathologic confirmation via endometrial biopsy or dilatation and curettage. Surgical staging of endometrial cancer will dictate how physicians manage the condition. For most women, staging and initial treatment are accomplished with total hysterectomy, bilateral salpingo-oophorectomy, and peritoneal washings. Surgery, radiation, and chemotherapy play a role in treatment, depending on tumor stage and grade. At present, there are no recommendations for screening the general population.

Objectives. To describe and report initial outcomes of a low-threshold, group-based primary care medication for opioid use disorder (OUD) program in a federally qualified health center. Methods. We performed a retrospective chart review of patients enrolled in the program from October 4, 2017, to October 3, 2018, in Philadelphia, Pennsylvania. The main outcome measure was time retained in treatment, defined as time from treatment initiation to unplanned treatment termination. Secondary outcomes were the relationships between treatment retention and cocaine use or housing status. We analyzed retention in treatment using Kaplan-Meier survival estimates. Results. The 3- and 6-month retention rates were 82% and 63%, respectively. The log-rank test showed no significant differences for comparisons between homeless versus not homeless (P = .25) and cocaine use versus no cocaine use (P = .12). Conclusions. The medication for OUD program engaged a large number of patients from marginalized groups. Three- and 6-month retention rates were comparable with those reported of other federally qualified health center populations. Public Health Implications. Integrating treatment of OUD into primary care shows promise for increasing access to and retention in medication for OUD services. The federally qualified health center payment structure supports the sustainability of the group visit model.

Women with serious mental illness (SMI) have disproportionately worse breast cancer profiles than those of other women. The purpose of this project was to examine barriers to and facilitators of breast cancer screening, specifically in formerly homeless women with SMI using the participatory methodology of concept mapping. A series of three concept mapping focus groups were held with 27 women over the age of 40 with a diagnosis of a SMI who live in supportive housing programs, and with 16 housing program staff. Data from the focus groups were combined through multidimensional scaling to create a visual cluster map . Barriers and facilitators to mammography screening generated by the participants clustered into eight categories. Participants rated addressing educational issues as most important and feasible. Interventions designed to improve mammogram screening in this population should address patients’ perception of personal risk and should target education and support systems as modifiable factors.

Background: People with serious mental illness (SMI) experience marked health disparities from preventable and treatable conditions and a prevalence of overweight/obesity almost twice the general US population. The problems and proposed solutions to obesity-related morbidity in people with SMI have mainly focused on the individual level. Difficulties with healthy eating and physical activity are attributed to behavior or lifestyle factors, such as poor diet, sedentary routines, and low motivation, as well as increasing use of second generation antipsychotic medications. Larger system level factors have received limited attention in the response to this epidemic and past research has not adequately involved people with SMI in a deeper exploration of these issues. Health disparities involving the problem of obesity in people with SMI have not been considered using a human rights framework. Methods: This dissertation used a participatory action orientation with a mixed-methods sequential explanatory model to explore the healthy equity factors that facilitate or limit clinically significant weight loss in people with SMI who are overweight or obese and participating in a 12-month, peer-led, group healthy lifestyle intervention. Study one utilized baseline data of 93 participants in the intervention arm of the parent Peer Group Lifestyle Balance study. Quantitative analysis was used to explore associations between the predictor variable of food security at baseline and the outcome variable of 6-month weight change. Studies two and three were developed through a participatory Photovoice project with 8 participant co-researchers. Study two explored the lived experience of healthy eating and physical activity through 7 weekly sessions with the co-researchers consisting of individual photo-elicitation and group discussion of photos and captions. Study three explored the co-researchers experience of presenting at four varied community events. Results: The results of the quantitative analysis revealed that 76.2% percent of the sample reported some level of food insecurity, 22.6% with marginal food security, 28.6% with low food security, and 25.0% with very low food security. The mean weight change at 6 months was –2.86 pounds ( SD = 13.67) with a range of –47.6 to 33.0. At six months, 65% of the total sample had a weight lower than their baseline weight. The association between metformin use and diagnosis of diabetes with weight change was significant with the metformin group losing a mean of 6.7lbs vs 0.3lbs in intervention participants not taking metformin. The analysis of the main effect for baseline food security on weight change between baseline and 6 months approached significance (F (2, 81) = 3.075, p =.052, partial η 2 = .071). In the Photovoice project, the eight co-researchers selected a total of 33 photos and captions to represent their experience and organized the photos into five themes: 1) Corner stores in our neighborhood, 2) Challenges to healthy eating and exercise, 3) Healthy eating ideas with limited supplies, 4) Exercise: Challenges and options, and 5) Recovery: Body, mind, and spirit. The themes from the photographs reflected two overarching themes: structural barriers and overcoming structural barriers. Four overlapping themes emerged from the analysis of the post-advocacy presentations: 1) Empowerment, 2) Influence, 3) Barriers to participation, and 4) The system. Conclusion: The strengths of this study are grounded in the mixed-methods exploration of the impact of the social determinants of health on healthy eating and physical activity in a highly marginalized population with significant health disparities resulting in part from obesity-related conditions. The human rights framework provides an organizing lens to understand the findings of this study. The qualitative findings provided concrete explanations of the quantitative findings. The Adult Food Security Survey revealed a 76% rate of any level of food insecurity in the sample. Fifty-four percent of the sample reported low or very low food security, higher than the national average of 12.3% (U.S. Department of Agriculture, 2015). The main effect of food security on 6-month weight change approached significance. Documenting this rate of food insecurity in the population is a critical finding and suggests many people with SMI are not achieving the right to food, despite living in supportive housing settings and receiving Supplemental Nutrition Assistance Program (SNAP) benefits. The reasons for this inequality are complex and the Photovoice project described in Chapter 3 provides some insights into this situation from the population itself. The high cost of poor quality food available in urban corner stores and fast food establishments as well as the cost of transportation out of the neighborhood contribute directly to food insecurity. The use of food pantries, with variable food quality is a consequence of food insecurity and limited SNAP benefits in the population. These situations are a threat not just to the right to healthy food, but the right to health itself. (Abstract shortened by ProQuest.)