Database Assessment Vulnerability Assessment Course

This course focuses on database security, covering topics such as database management systems, relational database management systems, technology breadth, and considerations for performing tests on live production systems. It discusses the importance of protecting systems and data from unauthorized access, updates, and more through various languages and engine functionalities. The agenda includes configuration guidance, operating system settings, database installation, and identification/authentication methods. Learn about the importance of non-destructive testing, penetration testing, and different product features unique to databases like Oracle, SQL Server, MySQL, and more.

• Database Security
• Vulnerability Assessment
• Relational Databases
• Production Systems
• Data Protection

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1. A Qualitative Analysis of Barriers to Opioid Agonist Treatment for Racial and Ethnic Minorities Jawad M. Husain, MD 1,2, Devin Cromartie MD, MPH 3,4, Emma Fitzelle-Jones, MPH 5, Annelise Brochier, MPH 6, Christina P.C. Borba, PhD, MPH 3,4, and Cristina Montalvo, MD, MBS 7,8 5 New England Geriatric Research Education and Clinical Center, VA Boston 1 Department of Psychiatry, Harvard Medical School 6 Department of Pediatrics, Boston Medical Center 2 Department of Psychiatry, Mass General Brigham 7 Department of Psychiatry, Tufts University School of Medicine 3 Department of Psychiatry, Boston University School of Medicine 8 Department of Psychiatry, Tufts Medical Center 4 Department of Psychiatry, Boston Medical Center

2. Disclosures The authors declare no potential conflicts of interest. 2

3. BACKGROUND OBJECTIVES METHODS RESULTS DISCUSSION & FUTURE DIRECTIONS

4. Background Increase in synthetic* opioid overdose deaths per 100,000 people, by ethnicity, 2013-20171 Opioid overdose mortality is rising fastest in the non-Hispanic Black population1,2 Racial/ethnic minorities are less likely to receive opioid agonist treatment (OAT) - especially buprenorphine3 9 4 *excluding methadone

5. BACKGROUND OBJECTIVES METHODS RESULTS DISCUSSION & FUTURE DIRECTIONS

6. Study objectives 1) Evaluate knowledge and perceptions regarding opioid agonist treatment (OAT) in a racially and ethnically diverse sample of patients with opioid use disorder (OUD) who are not on OAT. 2) Identify differences in barriers to OAT across racial/ethnic groups at the individual, interpersonal, community, and societal levels. 3) Hypothesize the relationships between racial, ethnic, and cultural identities, as well as structural factors, and attitudes towards OAT. 6

7. BACKGROUND OBJECTIVES METHODS RESULTS DISCUSSION & FUTURE DIRECTIONS

8. Participants 41 adults with opioid use disorder (OUD), not on OAT Recruited from Boston area via clinical data warehouse request, flyers, and online ads, between Sept 2020 and Feb 2021 8

9. Data collection Interview guide based on literature review of race disparities in OAT 1 author conducted semi-structured interviews by telephone Interviews audio-recorded and transcribed verbatim 9

10. Data analysis Interview transcriptsanalyzed using NVivo 12 Pro by 3 authors Developed codebook through author consensus based on review of themes in initial transcripts Coding and analysis performed according to principles of grounded theory and thematic analysis, stratified by race/ethnicity 10

11. BACKGROUND OBJECTIVES METHODS RESULTS DISCUSSION & FUTURE DIRECTIONS

12. Demographics Total (n=41) Asian (n=1) Non- Hispanic Black (n=24) 54.2 (9.6) Hispanic (n=3) Non- Hispanic White (n=9) 53.2 (10.1) More than one race (n=4) Age, mean (SD) Sex, n (%) 53.2 (10.9) 31 55.7 (7.5) 52.2 (10.8) Female Male 27 (65.9) 13 (31.7) 1 (2.4) 0 0 18 (75.0) 6 (14.6) 0 (0) 2 (66.7) 1 (33.3) 0 4 (44.4) 5 (55.6) 0 3 (75.0) 1 (25.0) 0 Nonbinary/Other Prior OAT*, n (%) Buprenorphine Methadone Currently using opioids, n (%) 1 (100) 14 (34.1) 15 (36.6) 1 (100) 0 4 (9.8) 8 (19.5) 0 7 (77.8) 6 (66.7) 2 (50.0) 0 1 (33.3) 7 (17.1) 0 7 (17.1) 0 0 0 12 *OAT = opioid agonist treatment

13. Interrater reliability Kappa=0.95 Agreement=98.5% 13

14. Themes, by race/ethnicity Racial/ethnic minority Strong negative opinions and distrust of OAT Non-Hispanic White Mixed opinions of OAT Perception of OAT Facilitators to addiction treatment Social support Self-motivation Barriers to addiction treatment Internalized stigma toward people on OAT Anticipated stigma for OAT from family or community Preferred treatment for OUD Cold turkey or residential treatment Naltrexone or cold turkey 14

15. Perception of OAT: Strong negative opinions and distrust of OAT [Suboxone] ain't doing nothing but making them more addicted to opiates... Only one that they really talk to is their primary care doctor and the first thing the doctors want to prescribe is some opiates. Racial/ethnic minority participant 15

16. Perception of OAT: Mixed opinions of OAT I'm very torn on this subject. I think that I have seen [OAT] be a wonderful resource to people getting sober and I've seen it save lives. I just think it's very important that it's a short-term plan that people get on and then they're weaned off. I've seen people stay addicted to those drugs and end up with a new ball and chain with their MAT. It keeps people sick, it keeps people around those kind of people. Non-Hispanic White participant 16

17. Facilitators to addiction treatment: Social support I developed friendships with people that were going through the same thing. And that kind of helped me there, developing a bond with people like me. Racial/ethnic minority participant 17

18. Facilitators to addiction treatment: Self-motivation No, I never did any inpatient or outpatient programs, I was just drawing upon my strength and will to quit. Non-Hispanic White participant 18

19. Barriers to addiction treatment: Internalized stigma towards people on OAT I have a lot of associates that are also addicts and they're also using Suboxone to help them with the using and to curb their craving. And it's supposed to help them. I've never taken a Suboxone. So I couldn't give you too much information, but it's from my observation, the people that were around me take Suboxones to curb the usage of [opioids]... but it's still the same effect to me. Looks like they're still high. Racial/ethnic minority participant 19

20. Barriers to addiction treatment: Anticipated stigma from family or community I was like a pariah. You know? They treated me worse on Suboxone, which is used to treat my addiction and to help me stay off of drugs... They treated me worse when I was on that than when they knew I was sniffing heroin. Non-Hispanic White participant 20

21. Preferred treatment for OUD: Cold turkey or residential treatment I always went cold turkey If I went to jail or just went in the program. Racial/ethnic minority participant 21

22. Preferred treatment for OUD: Naltrexone or cold turkey I'm a believer in Vivitrol, you don't get sick from the Vivitrol. Non-Hispanic White participant 22

23. BACKGROUND OBJECTIVES METHODS RESULTS DISCUSSION & FUTURE DIRECTIONS

24. Discussion From a structurally competent lens, we see racial/ethnic minority patients distrust of medication for OUD (MOUD) as a reaction to historical racial abuse, neglect, and stigmatization by healthcare institutions. Racial/ethnic minority patients preference for residential treatment suggests a desire for psychosocial and peer-recovery based care, addressing social determinants of health (e.g., lack of social support). 24

25. Limitations Single-region recruitment Unbalanced race/ethnicity and gender categories Many participants in remission from OUD 25

26. Future directions An approach rooted in structural humility should consider limitations of medication management-only OUD care in racial/ethnic minority populations. Addiction specialists may engage these populations better with culturally-tailored interventions for OUD that offer psychosocial treatment in combination with MOUD. 26

27. Acknowledgments This study was funded through grants from: APA/SAMHSA Minority Fellowship Program Gennaro Acampora Charitable Trust Fund 27

28. Questions? jhusain@mgh.harvard.edu @JawadHusainMD

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