Michael-John Milloy
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Recruitment
Graduate trainees and post-graduate-level fellows are invited to express their interest in working on two funded studies involving the health of marginalized people who use drugs in Vancouver, Canada:
1. The AIDS Care Cohort to evaluate Exposure to Survival Services (ACCESS): This United States National Institutes of Health-funded open observational prospective cohort follows more than 1,000 people who use illicit drugs and are living with HIV in Vancouver's Downtown Eastside. In this study, data from regular behavourial interview is confidentially linked to comprehensive HIV clinical data (e.g., antiretroviral therapy dispensations, HIV viral loads, etc.) allowing for longitudinal investigations into the links between prevalent behavioural and social/structural exposures, clinical exposures, and disease outcomes. With more than fifteen years of follow-up, 10,000 interviews and hundreds of thousands of clinical datapoints, the study is a poewrful platform for retrospective and prospective analyses. Studies using ACCESS data have been published in a wide variety of journals (including AIDS, Clinical infectious diseases, BMJ, and Addiction) and have made important contributions to the science of HIV disease progression, HIV treatment and care among people who use drugs and addiction medicine. ACCESS, alongside its sister cohorts (the Vancouver Injection Drug User Study and the At-Risk Youth Study) have provided valuable research and training opportunities to dozens of research and clinical trainees. Graduate trainees and post-doctoral fellows will have a strong background in analytic epidemiology with experience in longitudinal analyses and infectious disease an advantage. They will be expected to develop analyses and write first-author publications in collaboraton with the principal investigator, study statisticians, and co-investigators.
2. Generalizable Experiments in Medical Marijuana and Addiction (GEMMA): The GEMMA project aims to generate urgently-needed evidence on whether and how cannabis can beneficially address drug-related harms during the ongoing opioid overdose crisis. These controlled trials will evaluate the risks/benefits of cannabis use identified in observational research among people who use drugs living with chronic pain, trauma, or substance use disorders. Under the direction of the principal investigator and supported by an advisory panel of scientists, clinicians, and people with living experience, these trals will test the effect of intentional cannabis use on outcomes such as illicit opioid use, exposure to fentanyl, accidental overdose, retention in treatment for substance use disorders, and experiences of cravings, withdrawals, and pain. These investigator-initiated trials are fully funded through an arms' length gift to the university from Canopy Growth, a licensed producer of cannabis. Graduate trainees and post-doctoral trainees will have a strong background in analytic epidemiology, with expertise in clinical trial design an analysis an advantage.
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ADVICE AND INSIGHTS FROM UBC FACULTY ON REACHING OUT TO SUPERVISORS
These videos contain some general advice from faculty across UBC on finding and reaching out to a potential thesis supervisor.
Supervision Enquiry
Great Supervisor Week Mentions
Shout out to @mjsmilloy for #greatsupervisor week @UBC. Innovative, encouraging, chill, and easily photoshopped into my work glamour pics.
Graduate Student Supervision
Doctoral Student Supervision
Dissertations completed in 2010 or later are listed below. Please note that there is a 6-12 month delay to add the latest dissertations.
Background: While opioid-related morbidity and mortality have risen in jurisdictions across North America, recent reforms to cannabis policy have sparked scientific inquiry into cannabinoid-based interventions to prevent or mitigate opioid-related harm. After systematically reviewing the literature on cannabis use during medication-based treatment of opioid use disorder (Chapter 2), this dissertation sought to: explore the role of cannabis in the relationship between methadone maintenance treatment (MMT) dose and treatment outcomes (Ch.3); characterize motivations for cannabis use (Ch.4); examine the association between cannabis use and illicit opioid use in the context of chronic pain (Ch.5); and document the impact of cumulative cannabis use on mortality (Ch.6) among marginalized people who use illicit drugs (PWUD). Methods: Data for Chapters 3-6 were derived from two community-based prospective cohort studies of PWUD in Vancouver, Canada. Regression analyses of longitudinal data were conducted, including generalized estimating equations (GEEs) and Cox frailty models for recurrent events (Ch.3); latent class analysis and GEEs (Ch.4); generalized linear mixed effects models (Ch.5); and time-varying Cox regression with weighted cumulative exposure measures modelled as restricted cubic splines (Ch.6). Results: In Chapter 3, frequent cannabis use significantly reduced the magnitude of the association between lower MMT dose and frequent illicit opioid use (n=1389), but not treatment retention (n=611). In Chapter 4, four latent classes of cannabis-using PWUD were identified, and links with socio-structural and health-related factors were observed, including poorer physical and mental health among therapeutic cannabis-using classes. In Chapter 5, high-frequency cannabis use was significantly negatively associated with high-frequency illicit opioid use among 1152 PWUD living with chronic pain. In Chapter 6, time to all-cause mortality was not impacted by increasing cumulative exposure to cannabis among 2211 PWUD. Conclusions: Certain motivations for cannabis use among PWUD are rooted in unmet healthcare needs and self-directed harm reduction. The findings of this dissertation signal the importance of conducting experimental research into cannabis for the management of opioid withdrawal and craving and as an opioid-sparing agent in the treatment of pain. In a newly legal environment, cannabis-based harm reduction efforts should be integrated alongside the provision of broader social and structural supports.
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Background: Although optimal access and adherence to modern antiretroviral therapy (ART) reduces rates of HIV-related morbidity and mortality, HIV-positive people who use illicit drugs (PWUD) continue to experience suboptimal HIV treatment outcomes. This thesis sought to apply institutional perspectives to explore individual and organizational interactions in achieving person-centered care (PCC). This aim was met by first, systematically reviewing literature on medical and social service components linked to methadone maintenance therapy (MMT) in improving HIV care cascade outcomes, and second, in a series of empirical studies, assessing institutional-related structures associated with optimal adherence to ART among HIV-positive PWUD. These studies examined: 1) prescription of complex ART regimens, within a single domain of healthcare provision; 2) MMT-ART co-dispensation practices, within multiple domains of healthcare provision; and 3) the production of material insecurity through healthcare, social care and other institutional relationships. Methods: First, a specific search strategy was used to conduct the systematic review. Second, data from an ongoing prospective observational cohort study linked with comprehensive HIV clinical monitoring records in Vancouver, Canada was used to assess institutional-related structures. Multivariable models were built to estimate the relationships between institutional-related variables and adherence to ART, using longitudinal analytic techniques while controlling for relevant confounders. Results: The systematic review found a low number of studies that described MMT service delivery in detail and a lack of information on the effectiveness of social support within MMT programs on improving HIV care outcomes. Among HIV-positive PWUD in Vancouver, complex ART regimens, as demonstrated by greater number of pills, were significantly associated with suboptimal adherence; MMT-ART co-dispensation was positively associated with optimal adherence in a low-threshold setting; and although material insecurity was associated with institutional structures, it was not significantly associated with adherence. Conclusions: The alignment between institutional domains may potentially enhance HIV care outcomes among PWUD as they navigate institutional structures. Public health strategies that feature PCC approaches are needed to meet the complex needs of PWUD. Thus, future research should explore the application of implementation science as a potential avenue to align treatment and care services across institutions for HIV-positive PWUD.
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Master's Student Supervision
Theses completed in 2010 or later are listed below. Please note that there is a 6-12 month delay to add the latest theses.
Background: Although chronic pain is prevalent among people who use drugs (PWUD) and people living with HIV (PLWH), there have been few investigations of pain among PLWH who use drugs. To fill this gap, this thesis sought to evaluate the prevalence and correlates associated with chronic pain, analyze the associations of pain medication denial, and explore common pharmacologic and non-pharmacologic pain self-management strategies among PLWH who use drugs. Methods: Data were derived from the AIDS Care Cohort to Evaluate exposure to Survival Services (ACCESS) study, an open prospective cohort study of HIV-positive people who use drugs linked to comprehensive HIV clinical data. Generalized linear mixed-effects modelling (GLMM) was used to estimate the prevalence of and identify exposures linked to chronic pain (study 1) and to analyze associations of pain management strategies with substance use and socio-structural exposures (study 3). Generalized estimating equations (GEE) were used to explore the independent relationships between pain medication denial with various substance use, social-, and healthcare access measures (study 2). Results: In study 1, 374 (53%) participants reported recent moderate-to-extreme pain. Multivariable GLMM analysis revealed chronic pain was associated with pain self-management, non-fatal overdose, non-medical prescription opioid use, and mental illness. Being denied pain medication was reported by 84 (20%) participants in study 2. In a multivariable GEE model, recent pain medication denial was associated with recent incarceration, daily cocaine injection, pain self-management, attempted suicide, and not visiting a family physician. In study 3, pain self-management was reported by 342 (70%) participants; multivariable GLMM identified associations with homelessness, daily injection heroin and non-medical prescription opioid use, and being diagnosed with a chronic pain condition. Self-management strategies primarily involved illicit substances (66%), however, 34% indicated non-substance-based strategies. Conclusions: The findings of this research emphasize that chronic pain is often undertreated among PLWH who use drugs and frequently leads to use of higher-risk pain management alternatives and negative health outcomes. This research builds upon prior evidence calling for accessible, integrated care services that provide both pharmacologic and non-pharmacologic pain management strategies that may reduce the risks and consequences associated with being denied pain medication and self-managing pain.
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