In an effort to deepen our understanding of how circumstances of forced separation and the interd... more In an effort to deepen our understanding of how circumstances of forced separation and the interdiction of physical contact affect women’s sexual behavior, we investigated the development and maintenance of heterosexual couples ’ intimacy when the male partner is incarcerated. As HIV-prevention scientists who work with women visiting men at a California state prison, we recognize that correctional control extends to these women’s bodies, both when they are within the facility’s walls visiting their mates and when they are at home striving to remain connected to absent men. This paper analyzes the impact of a peculiar public “place”—a penitentiary — on couples ’ romantic and sexual interactions, drawing out the implications of imprisonment for relationship decision making, sexual health, and HIV risk. Using qualitative interviews with 20 women who visit their incarcerated partners and 13 correctional officers who interact with prison visitors, we examine how institutional constraints...
ABSTRACTBackgroundAccess to medications for opioid use disorder (MOUD) in the U.S. is highly rest... more ABSTRACTBackgroundAccess to medications for opioid use disorder (MOUD) in the U.S. is highly restricted. In March 2020, to reduce transmission of COVID-19, SAMHSA issued emergency regulations allowing up to two weeks of take-home doses for most patients.ObjectivesWe evaluated the benefits and unintended consequences of these new regulations expanding take-home eligibility to inform MOUD policy post-pandemicMethodsWe conducted a mixed-methods evaluation of an opioid treatment program in San Francisco caring for a diverse, low-income urban population. We assessed clinic-level intake, retention, and take-home prescribing; individual-level acute care utilization and mortality; and patient/provider perceptions of benefits, harms and challenges of the new regulations.ResultsClinic volume, intake and retention were largely unchanged after implementation of the new regulations, though the average monthly proportion of individuals receiving take-homes significantly increased from 31% to 47% ...
Objective The University of California (UC) leadership sought to develop a robust educational res... more Objective The University of California (UC) leadership sought to develop a robust educational response to the epidemic of opioid-related deaths. Because the contributors to this current crisis are multifactorial, a comprehensive response requires educating future physicians about safe and effective management of pain, safer opioid prescribing, and identification and treatment of substance use disorder (SUD). Methods The six UC medical schools appointed an opioid crisis workgroup to develop educational strategies and a coordinated response to the opioid epidemic. The workgroup had diverse specialty and disciplinary representation. This workgroup focused on developing a foundational set of educational competencies for adoption across all UC medical schools that address pain, SUD, and public health concerns related to the opioid crisis. Results The UC pain and SUD competencies were either newly created or adapted from existing competencies that addressed pain, SUD, and opioid and other...
Objectives: Many older homeless adults maintain contact with family. We conducted a qualitative s... more Objectives: Many older homeless adults maintain contact with family. We conducted a qualitative study examining the role of family caregiving for older homeless adults. Method: We conducted semi-structured qualitative interviews with a sample of 46 homeless participants who reported spending at least one night with a housed family member in the prior 6 months. Results: A total of 13 of 46 older adult participants provided caregiving. Themes included (a) the death of the care recipient led to the participant’s homelessness; (b) feeling a duty to act as caregivers; (c) providing care in exchange for housing; (d) caregivers’ ability to stay was tenuous; (e) providing care conflicted with the caregiver’s needs; and (f) resentment when family was ungrateful. Discussion: In a sample of older homeless adults in contact with family, many provided caregiving for housed family. For some, caregiving precipitated homelessness; for others, caregiving provided temporary respite from homelessness,...
The current “opioid epidemic” provides an opportunity to identify age-old social anxieties about ... more The current “opioid epidemic” provides an opportunity to identify age-old social anxieties about drug use while opening up new lines of inquiry about how and why drug use epidemics become gendered. This paper reflects on the intertwined phenomena of opioid and benzodiazepine prescribing to U.S. women to examine how gender, race, and class inform social anxieties about reproduction and parenting. Multiple discourses abound about the relationship between women and the “opioid epidemic.” Epidemiological reports attribute premature death among White women to the deadly combination of opioids and antianxiety medications. The National Institute on Drug Abuse reports that “every 25 minutes a baby is born suffering from opioid withdrawal,” leading to costly hospital stays for infants and the potential for mother–child separation and other forms of family adjudication postpartum. Primary care providers are reluctant to distinguish diagnoses of chronic noncancer pain from anxiety among their ...
Patients with a history of substance use are more likely than those without substance use to expe... more Patients with a history of substance use are more likely than those without substance use to experience chronic noncancer pain (CNCP), to be prescribed opioids, and to experience opioid misuse or overdose. Primary care practitioners (PCPs) in safety-net settings care for low-income patients with CNCP and substance use, usually without specialist consultation. To inform communication related to opioid risk, we explored PCPs' and patients' perceptions of the risks of chronic opioid therapy. We conducted semistructured interviews with 23 PCPs and 46 of their patients, who had a history of CNCP and substance use. We recruited from 6 safety-net health care settings in the San Francisco Bay Area. We transcribed interviews verbatim and analyzed transcripts using grounded theory methodology. (1) PCPs feared harming patients and the community by opioid prescribing. PCPs emphasized fear of opioid overdose. (2) Patients did not highlight concerns about the adverse health consequences o...
In the United States and internationally, providers have adopted guidelines on the management of ... more In the United States and internationally, providers have adopted guidelines on the management of prescription opioids for chronic noncancer pain (CNCP). For "high-risk" patients with co-occurring CNCP and a history of substance use, guidelines advise that providers monitor patients using urine toxicology screening tests, develop opioid management plans, and refer patients to substance use treatment. We report primary care provider experiences in the safety net interpreting and implementing prescription opioid guideline recommendations for patients with CNCP and substance use. We interviewed primary care providers who work in safety net settings (N = 23) on their experiences managing CNCP and substance use. We analyzed interviews using a content analysis method. Providers found management plans and urine toxicology screening tests useful for informing patients about clinic expectations of opioid therapy and substance use. However, they described that guideline-based clinic ...
Guideline recommendations to reduce prescription opioid misuse among patients with chronic non-ca... more Guideline recommendations to reduce prescription opioid misuse among patients with chronic non-cancer pain include the routine use of urine toxicology tests for high-risk patients. Yet little is known about how the implementation of urine toxicology tests among patients with co-occurring chronic non-cancer pain and substance use impacts primary care providers' management of misuse. In this paper, we present clinicians' perspectives on the benefits and challenges of implementing urine toxicology tests in the monitoring of opioid misuse and substance use in safety net healthcare settings. We interviewed 23 primary care providers from six safety net healthcare settings whose patients had a diagnosis of co-occurring chronic non-cancer pain and substance use. We transcribed, coded, and analyzed interviews using grounded theory methodology. The benefits of implementing urine toxicology tests for primary care providers included less reliance on intuition to assess for misuse and th...
Objectives. We determined associations between co-occurring psychiatric conditions and violence a... more Objectives. We determined associations between co-occurring psychiatric conditions and violence against homeless and unstably housed women. Methods. Between 2008 and 2010, we interviewed homeless and unstably housed women recruited from community venues about violence, socioeconomic factors, and psychiatric conditions. We used multivariable logistic regression to determine independent correlates of violence. Results. Among 291 women, 97% screened positive for 1 or more psychiatric conditions. Types of violence perpetrated by primary partners and persons who were not primary partners (non–primary partners) included emotional violence (24% vs 50%; P < .01), physical violence (11% vs 19%; P < .01), and sexual violence (7% vs 22%; P < .01). The odds of primary partner and non–primary partner violence increased with each additional psychiatric diagnosis and decreasing levels of social isolation. Conclusions. All types of violence were more commonly perpetrated by non–primary par...
Due to the significantly high levels of comorbid substance use and mental health diagnosis among ... more Due to the significantly high levels of comorbid substance use and mental health diagnosis among urban poor populations, examining the intersection of drug policy and place requires a consideration of the role of housing in drug user mental health. In San Francisco, geographic boundedness and progressive health and housing polices have coalesced to make single room occupancy hotels (SROs) a key urban built environment used to house poor populations with co-occurring drug use and mental health issues. Unstably housed women who use illicit drugs have high rates of lifetime and current trauma, which manifests in disproportionately high rates of post-traumatic stress disorder (PTSD), anxiety, and depression when compared to stably housed women. We report data from a qualitative interview study (n=30) and four years of ethnography conducted with housing policy makers and unstably housed women who use drugs and live in SROs. Women in the study lived in a range of SRO built environments, f...
In an effort to deepen our understanding of how circumstances of forced separation and the interd... more In an effort to deepen our understanding of how circumstances of forced separation and the interdiction of physical contact affect women’s sexual behavior, we investigated the development and maintenance of heterosexual couples ’ intimacy when the male partner is incarcerated. As HIV-prevention scientists who work with women visiting men at a California state prison, we recognize that correctional control extends to these women’s bodies, both when they are within the facility’s walls visiting their mates and when they are at home striving to remain connected to absent men. This paper analyzes the impact of a peculiar public “place”—a penitentiary — on couples ’ romantic and sexual interactions, drawing out the implications of imprisonment for relationship decision making, sexual health, and HIV risk. Using qualitative interviews with 20 women who visit their incarcerated partners and 13 correctional officers who interact with prison visitors, we examine how institutional constraints...
ABSTRACTBackgroundAccess to medications for opioid use disorder (MOUD) in the U.S. is highly rest... more ABSTRACTBackgroundAccess to medications for opioid use disorder (MOUD) in the U.S. is highly restricted. In March 2020, to reduce transmission of COVID-19, SAMHSA issued emergency regulations allowing up to two weeks of take-home doses for most patients.ObjectivesWe evaluated the benefits and unintended consequences of these new regulations expanding take-home eligibility to inform MOUD policy post-pandemicMethodsWe conducted a mixed-methods evaluation of an opioid treatment program in San Francisco caring for a diverse, low-income urban population. We assessed clinic-level intake, retention, and take-home prescribing; individual-level acute care utilization and mortality; and patient/provider perceptions of benefits, harms and challenges of the new regulations.ResultsClinic volume, intake and retention were largely unchanged after implementation of the new regulations, though the average monthly proportion of individuals receiving take-homes significantly increased from 31% to 47% ...
Objective The University of California (UC) leadership sought to develop a robust educational res... more Objective The University of California (UC) leadership sought to develop a robust educational response to the epidemic of opioid-related deaths. Because the contributors to this current crisis are multifactorial, a comprehensive response requires educating future physicians about safe and effective management of pain, safer opioid prescribing, and identification and treatment of substance use disorder (SUD). Methods The six UC medical schools appointed an opioid crisis workgroup to develop educational strategies and a coordinated response to the opioid epidemic. The workgroup had diverse specialty and disciplinary representation. This workgroup focused on developing a foundational set of educational competencies for adoption across all UC medical schools that address pain, SUD, and public health concerns related to the opioid crisis. Results The UC pain and SUD competencies were either newly created or adapted from existing competencies that addressed pain, SUD, and opioid and other...
Objectives: Many older homeless adults maintain contact with family. We conducted a qualitative s... more Objectives: Many older homeless adults maintain contact with family. We conducted a qualitative study examining the role of family caregiving for older homeless adults. Method: We conducted semi-structured qualitative interviews with a sample of 46 homeless participants who reported spending at least one night with a housed family member in the prior 6 months. Results: A total of 13 of 46 older adult participants provided caregiving. Themes included (a) the death of the care recipient led to the participant’s homelessness; (b) feeling a duty to act as caregivers; (c) providing care in exchange for housing; (d) caregivers’ ability to stay was tenuous; (e) providing care conflicted with the caregiver’s needs; and (f) resentment when family was ungrateful. Discussion: In a sample of older homeless adults in contact with family, many provided caregiving for housed family. For some, caregiving precipitated homelessness; for others, caregiving provided temporary respite from homelessness,...
The current “opioid epidemic” provides an opportunity to identify age-old social anxieties about ... more The current “opioid epidemic” provides an opportunity to identify age-old social anxieties about drug use while opening up new lines of inquiry about how and why drug use epidemics become gendered. This paper reflects on the intertwined phenomena of opioid and benzodiazepine prescribing to U.S. women to examine how gender, race, and class inform social anxieties about reproduction and parenting. Multiple discourses abound about the relationship between women and the “opioid epidemic.” Epidemiological reports attribute premature death among White women to the deadly combination of opioids and antianxiety medications. The National Institute on Drug Abuse reports that “every 25 minutes a baby is born suffering from opioid withdrawal,” leading to costly hospital stays for infants and the potential for mother–child separation and other forms of family adjudication postpartum. Primary care providers are reluctant to distinguish diagnoses of chronic noncancer pain from anxiety among their ...
Patients with a history of substance use are more likely than those without substance use to expe... more Patients with a history of substance use are more likely than those without substance use to experience chronic noncancer pain (CNCP), to be prescribed opioids, and to experience opioid misuse or overdose. Primary care practitioners (PCPs) in safety-net settings care for low-income patients with CNCP and substance use, usually without specialist consultation. To inform communication related to opioid risk, we explored PCPs' and patients' perceptions of the risks of chronic opioid therapy. We conducted semistructured interviews with 23 PCPs and 46 of their patients, who had a history of CNCP and substance use. We recruited from 6 safety-net health care settings in the San Francisco Bay Area. We transcribed interviews verbatim and analyzed transcripts using grounded theory methodology. (1) PCPs feared harming patients and the community by opioid prescribing. PCPs emphasized fear of opioid overdose. (2) Patients did not highlight concerns about the adverse health consequences o...
In the United States and internationally, providers have adopted guidelines on the management of ... more In the United States and internationally, providers have adopted guidelines on the management of prescription opioids for chronic noncancer pain (CNCP). For "high-risk" patients with co-occurring CNCP and a history of substance use, guidelines advise that providers monitor patients using urine toxicology screening tests, develop opioid management plans, and refer patients to substance use treatment. We report primary care provider experiences in the safety net interpreting and implementing prescription opioid guideline recommendations for patients with CNCP and substance use. We interviewed primary care providers who work in safety net settings (N = 23) on their experiences managing CNCP and substance use. We analyzed interviews using a content analysis method. Providers found management plans and urine toxicology screening tests useful for informing patients about clinic expectations of opioid therapy and substance use. However, they described that guideline-based clinic ...
Guideline recommendations to reduce prescription opioid misuse among patients with chronic non-ca... more Guideline recommendations to reduce prescription opioid misuse among patients with chronic non-cancer pain include the routine use of urine toxicology tests for high-risk patients. Yet little is known about how the implementation of urine toxicology tests among patients with co-occurring chronic non-cancer pain and substance use impacts primary care providers' management of misuse. In this paper, we present clinicians' perspectives on the benefits and challenges of implementing urine toxicology tests in the monitoring of opioid misuse and substance use in safety net healthcare settings. We interviewed 23 primary care providers from six safety net healthcare settings whose patients had a diagnosis of co-occurring chronic non-cancer pain and substance use. We transcribed, coded, and analyzed interviews using grounded theory methodology. The benefits of implementing urine toxicology tests for primary care providers included less reliance on intuition to assess for misuse and th...
Objectives. We determined associations between co-occurring psychiatric conditions and violence a... more Objectives. We determined associations between co-occurring psychiatric conditions and violence against homeless and unstably housed women. Methods. Between 2008 and 2010, we interviewed homeless and unstably housed women recruited from community venues about violence, socioeconomic factors, and psychiatric conditions. We used multivariable logistic regression to determine independent correlates of violence. Results. Among 291 women, 97% screened positive for 1 or more psychiatric conditions. Types of violence perpetrated by primary partners and persons who were not primary partners (non–primary partners) included emotional violence (24% vs 50%; P < .01), physical violence (11% vs 19%; P < .01), and sexual violence (7% vs 22%; P < .01). The odds of primary partner and non–primary partner violence increased with each additional psychiatric diagnosis and decreasing levels of social isolation. Conclusions. All types of violence were more commonly perpetrated by non–primary par...
Due to the significantly high levels of comorbid substance use and mental health diagnosis among ... more Due to the significantly high levels of comorbid substance use and mental health diagnosis among urban poor populations, examining the intersection of drug policy and place requires a consideration of the role of housing in drug user mental health. In San Francisco, geographic boundedness and progressive health and housing polices have coalesced to make single room occupancy hotels (SROs) a key urban built environment used to house poor populations with co-occurring drug use and mental health issues. Unstably housed women who use illicit drugs have high rates of lifetime and current trauma, which manifests in disproportionately high rates of post-traumatic stress disorder (PTSD), anxiety, and depression when compared to stably housed women. We report data from a qualitative interview study (n=30) and four years of ethnography conducted with housing policy makers and unstably housed women who use drugs and live in SROs. Women in the study lived in a range of SRO built environments, f...
(Note: Co-authors include: Jamie Chang, PhD, Kara Zamora, Emily Hurstak, MD MPH, Margot Kushel, M... more (Note: Co-authors include: Jamie Chang, PhD, Kara Zamora, Emily Hurstak, MD MPH, Margot Kushel, MD, Christine Miaskowski, RN PhD FAAN and Kelly Knight, PhD)
Background: Guideline recommendations to reduce prescription opioid misuse among patients with chronic non-cancer pain include the routine use of urine toxicology tests for high-risk patients. Yet little is known about how the implementation of urine toxicology tests among patients with co-occurring chronic non-cancer pain and substance use impacts primary care providers’ management of misuse. In this paper, we present clinicians’ perspectives on the benefits and challenges of implementing urine toxicology tests in the monitoring of opioid misuse and substance use in safety net healthcare settings.
Methods: We interviewed 23 primary care providers from six safety net healthcare settings whose patients had a diagnosis of co-occurring chronic non-cancer pain and substance use. We transcribed, coded, and analyzed interviews using grounded theory methodology.
Results: The benefits of implementing urine toxicology tests for primary care providers included less reliance on intuition to assess for misuse and the ability to identify unknown opioid misuse and/or substance use. The challenges of implementing urine toxicology tests included insufficient education and training about how to interpret and implement tests, and a lack of clarity on how and when to act on tests that indicated misuse and/or substance use.
Conclusions: These data suggest that primary care clinicians’ lack of education and training to interpret and implement urine toxicology tests may impact their management of patient opioid misuse and/or substance use. Clinicians may benefit from additional education and training about the clinical implementation and use of urine toxicology tests. Additional research is needed on how primary care providers implementation and use of urine toxicology tests impacts chronic non-cancer pain management in primary care and safety net healthcare settings among patients with co-occurring chronic non-cancer pain and substance use.
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Papers by Kelly Knight
Background: Guideline recommendations to reduce prescription opioid misuse among patients with chronic non-cancer pain include the routine use of urine toxicology tests for high-risk patients. Yet little is known about how the implementation of urine toxicology tests among patients with co-occurring chronic non-cancer pain and substance use impacts primary care providers’ management of misuse. In this paper, we present clinicians’ perspectives on the benefits and challenges of implementing urine toxicology tests in the monitoring of opioid misuse and substance use in safety net healthcare settings.
Methods: We interviewed 23 primary care providers from six safety net healthcare settings whose patients had a diagnosis of co-occurring chronic non-cancer pain and substance use. We transcribed, coded, and analyzed interviews using grounded theory methodology.
Results: The benefits of implementing urine toxicology tests for primary care providers included less reliance on intuition to assess for misuse and the ability to identify unknown opioid misuse and/or substance use. The challenges of implementing urine toxicology tests included insufficient education and training about how to interpret and implement tests, and a lack of clarity on how and when to act on tests that indicated misuse and/or substance use.
Conclusions: These data suggest that primary care clinicians’ lack of education and training to interpret and implement urine toxicology tests may impact their management of patient opioid misuse and/or substance use. Clinicians may benefit from additional education and training about the clinical implementation and use of urine toxicology tests. Additional research is needed on how primary care providers implementation and use of urine toxicology tests impacts chronic non-cancer pain management in primary care and safety net healthcare settings among patients with co-occurring chronic non-cancer pain and substance use.