We did not find an association with length of time spent homeless as an adult. These findings suggest participants may have had an increased risk for poor oral health status prior to becoming homeless. Consistent with prior research we found strong associations between having lost half or more of teeth and evidence of problem drinking, cocaine use, or having ever smoked . Alcohol may impair oral health through diminished salivary flow and altered salivary composition, which can exacerbate upper respiratory irritation, including gastric acid regurgitation, further worsening oral health . Cigarette smoking is an independent risk factor for chronic periodontal disease leading to tooth loss . Cigarette smoke contains toxins that locally alter salivary flow and systemically lead to destruction of tooth-supporting tissue . Cocaine use can increase the risk of tooth loss due to bruxism and a decrease in salivary pH . We found a non-statistically significant elevated odds of tooth loss with moderate to severe cannabis use, consistent with prior research . Cannabis use is thought to be related to tooth loss via an association with infrequent dental visits and high cariogenic diets after cannabis use. . We found an inverse association between moderate-to-high risk methamphetamine use and tooth loss. Other studies have found a positive association between methamphetamine use and better self-reported oral health among homeless populations or have not identified a significant association between methamphetamine use and oral health need . Our study has several limitations. As our analysis relies on cross-sectional data, we cannot establish causality. We used self-reports of tooth loss,hydroponic racks system rather than clinical dental exams. This left the potential for over or under-estimation of missing teeth and made it more difficult to make direct comparisons to other studies. In order to minimize misclassification, we used a broad measure of tooth loss that participants were more likely to understand. The study recruitment period occurred during a period of expansion of services, which could have increased access to dental care in those who were recruited later in the recruitment year.

Access to dental care may have improved with the expansion of Medi-Cal during the study period, or with recent increases in covered services . In one of the first studies of oral health in a population-sampled cohort of older homeless adults, we found evidence for poor oral health and limited access to dental care. There is an urgent need to increase the access to and provision of both preventive and restorative dental care to older homeless adults in order to decrease morbidity and improve quality of life. When it comes to science, we are living in strange times. Although much of the health, wealth, and power of our society derives from extraordinary achievements in physics, biochemistry, engineering, and medicine over the last 100 years, it seems curious indeed that political figures who trumpet America’s material success are launching assaults on the nature of scientific endeavor—challenging the value of expertise, positing ‘‘alternative facts,’’ rejecting evidence-based findings in favor of bombastic claims and personal beliefs. It is in this context of seeming open hostility toward scientific evidence that our society considers important deliberations about how to schedule, regulate, criminalize, and otherwise govern whether its citizens will have legal access to a host of molecules—some plant-derived, some synthesized—for therapeutic uses. For we palliative care clinicians, the paramount uses in question relate to reducing intractable suffering—in particular, suffering for which our available treatments are often inadequate. As an instructive example of the current disconnect between science and policy discourse in the public square, compare the scholarly 2017 monograph on the health effects of cannabis and cannabinoids produced by the National Academy of Sciences1 —which cites good clinical-trial evidence supporting the efficacy of cannabis and cannabinoids for pain management, —to an assertion by the future Attorney General of the United States during his Senate confirmation hearings: that ‘‘..good people don’t smoke marijuana..’’.

Witness also the Attorney General’s recent rollback3 of Obama-era directives that prohibited federal law enforcers from expending their resources to enforce the antiquated and unscientific 1970s-era Drug Enforcement Agency Controlled Substances Schedule in states with cannabis legalization statutes. In case readers need reminding, DEA still rates cannabis as a Schedule I compound . Elements of that four-decade-old assertion are simply false. In this issue of JPM, our colleague Ira Byock, a wise and thoughtful palliative care physician who helped introduce Western readers 20 years ago to the concept of ‘‘Dying Well,’’ —now brings to our Journal a provocative commentary on high-quality clinical data suggesting that ‘‘psychedelic’’ drugs may play an important new role in managing intractable suffering. specifically, Dr. Byock reviews recent trials of psilocybin, lysergic acid diethylamide , 3,4- methylenedioxy-methamphetamine , and ketamine, and describes strong evidence for improvement in refractory symptoms related to end-of-life anxiety/depression in patients with cancer and other terminal illnesses , treatment-resistant depression in healthy individuals and endof-life depression in cancer patients , and severe post-traumatic stress disorder . Byock weaves a compelling narrative, summarizing the unmet needs that are all-too common in patients who face catastrophic medical illness. He integrates into his review a discussion of the reasons given by patients who have sought to utilize the Oregon ‘‘Death With Dignity’’ act, pointing out that most of these patients are looking to death for relief from what Byock terms ‘‘nonphysical suffering’’—loss of autonomy, dignity, and the ability to enjoy life—symptoms that might, it turns out, be amenable to the therapeutic effects of psychedelics. In the face of Washington’s stubborn resistance to reclassifying anything in the Controlled Substance Act Schedule, perhaps a sense of common cause may emerge among those of us who would advocate for our palliative care patients a ‘‘right to try’’ psychedelics regardless of our personal positions on physician aid in dying. If larger scale trials confirm that safe therapeutic doses of any of these agents help reduce suffering, death fears, or treatment-resistant end-of-life depression, I believe our field and our patients would welcome them as important new options. It is hard to imagine that palliative care clinicians would object to the idea that in carefully supervised trials, these old/new drugs might be offered to patients with existential concerns, intense death anxiety/fear, or treatment resistant depression as primary drivers for their pursuit of physician aid in dying.

We would welcome the potential safe relief in suffering these substances might provide, and would consider it a therapeutic success if patients experiencing benefit might choose to rescind or defer their legal pursuit of Physician Aid in Dying or Physician Assisted Death . Why do I juxtapose a brief narrative about cannabis with the emerging data regarding psychedelics? Is there a unifying thread? Sadly, I think there is: it is the unfortunate legacy of the ‘‘drug culture’’ of the 1960s mixed with the legacy of the ‘‘club culture’’ of the 1980s. The excesses of those eras, mixed with the social upheaval and challenges to authority that accompanied them and terrified ‘‘the establishment’’,provide a rich topsoil of images and impressions to support reactionary resistance to the emerging evidence. Dr. Byock is no stranger to the politics and regulatory barriers that might lie ahead; he describes them plainly in the article. And even beyond those expectable barriers, we find ourselves in a ‘‘1984’’ world of political suppression of scientific and public policy discourse. A painful recent example: in an early 2018 editorial in the Annals of Internal Medicine, a group of Emory University public health experts called attention to an effort by the White House to ban specific words from the U.S. Center for Disease Control’s 2019 annual budget request.6 What those words mean—‘‘vulnerable, ‘‘diversity,’’ ‘‘transgender,’’ ‘‘fetus,’’ ‘‘evidence-based,’’ and ‘‘science based’’—is essential in all of medicine, and particularly in the field of palliative care. Is the idea that, if we do not use those words, vulnerability, diversity,rolling benches canada transgender people, unborn fetuses, evidence, and science will just go away? Palliative medicine physicians are accustomed to being outside the spotlight of high-tech modern medicine, and we routinely advocate for patients who do not get first-priority attention from our medical colleagues. If clinical trials continue to demonstrate new hope from psychedelics for some of our patients’ most intractable symptoms, we may find ourselves a bit blinded by an unfamiliar spotlight, and we may feel compelled to join an advocacy effort for the ‘‘right to try’’ these treatments. Common sense and good science are not likely to prevail on their own.Clinical settings offer an opportunity to address substance use in persons living with HIV . Substance use in PLWH is associated with HIV transmission risk behavior, low anti-retroviral therapy adherence, HIV progression, detectable viral load, and poorer perceived quality of life . Not all substance use that PLWH engage in constitutes an alcohol or substance use disorder; nonetheless, PLWH have reported experiencing physical, social, and psychological harmful effects of substance use. In addition, studies have reported the harms of alcohol, tobacco, and illicit substance use in this population . In the general population as well as in PLWH, the consequences of unrecognized and untreated substance use are clinically, socially, and economically significant. The U.S. Public Health Service has endorsed routine and universal alcohol and tobacco screening in primary care ; however, few HIV primary care clinics routinely assess patients for alcohol or other substance use .

The effects of alcohol, tobacco, and illicit substance use take a greater combined toll on the health and well being of Americans than any other preventable factor. Alcohol and tobacco use are significant risk factors for cardiovascular disease and cancer, which are the leading causes of death . In a national survey on substance use and health, more than 71% of U.S. adults reported alcohol use in the previous year . In 2007, substance use contributed to more than half of suicides and violent crimes in the United States . The economic cost of the global burden of disease and health care utilization that are attributable to alcohol use are immense . Alcohol, tobacco, and illicit drug use can complicate HIV health care and health outcomes by interfering with medication access and adherence, contributing to HIV pathogenesis, increasing transmission risk behaviors, and destabilizing sources of social and financial support. PLWH who use substances are less likely to be prescribed ART and those on ART have shown reduced ART adherence . Studies that have enrolled active substance users show mixed results on HIV medication adherence. Historically, studies with PLWH who reported illicit drug use while on ART had poorer health outcomes than those who did not use drugs, while more current studies among PLWH who inject drugs and are on HIV treatment show survival rates that are similar when comparing people who inject drugs with those who do not . In addition to complicating treatment and HIV outcomes, research has also shown an association between active substance use and high-risk HIV transmission behaviors, including unprotected anal and vaginal intercourse with uninfected partners .Cocaine use has been shown to enhance viral replication and quiescent T-cell permissiveness to HIV infection, increasing the viral reservoir; cocaine is also an independent factor for unsuppressed viral load and increased neurocognitive disorders . Methamphetamine use has been associated with primary drug resistance to non-nucleoside reverse transcriptase inhibitors, increased cognitive decline, inflammation in the brain, and ischemic events . Methamphetamine use also doubles or triples the probability of engaging in high-risk sexual behavior and acquisition of sexually transmitted infections including HIV . HIV infection is more likely among women who use crack cocaine than women who don’t, and suicide attempts for PLWH are more prevalent in persons who use drugs and are related to poorer emotional and cognitive quality of life measures. Several studies have now demonstrated the relationship between substance use and HIV acquisition and increased morbidity and mortality for PLWH . Screening for substance use and identifying those with risky alcohol and drug use behaviors in primary care settings allows for an integrated approach to respond to harmful substance use. As with many chronic diseases, screening and early detection can serve as a form of preventive care as well as to identify patients where further clinical intervention may be warranted. A study of alcohol and drug use screening is especially relevant in HIV clinical settings, where substance use is widespread . HIV care providers have the opportunity to identify and intervene with patients who otherwise would be unlikely to access specialty treatment for substance use.