Understanding the rural-urban differences in nonmedical prescription opioid use and abuse in the United States

Nonmedical prescription opioid misuse remains a growing public problem in need of action and is concentrated in areas of US states with large rural populations such as Kentucky, West Virginia, Alaska, and Oklahoma. We developed hypotheses regarding the influence of 4 factors: (1) greater opioid prescription in rural areas, creating availability from which illegal markets can arise; (2) an out-migration of young adults; (3) greater rural social and kinship network connections, which may facilitate drug diversion and distribution; and (4) economic stressors that may create vulnerability to drug use more generally. A systematic consideration of the contexts that create differences in availability, access, and preferences is critical to understanding how drug use context varies across geography.

Reducing risky relationships: a multisite randomized trial of a prison-based intervention for reducing HIV sexual risk behaviors among women with a history of drug use

Women involved in the criminal justice system, particularly those with a history of drug use, are at elevated risk of HIV infection, yet few HIV prevention interventions have been tailored for delivery to incarcerated women. Drawing on the Relational Model, the Reducing Risky Relationships for HIV (RRR-HIV) intervention was developed and evaluated in a multisite randomized clinical trial. Women with weekly drug use prior to incarceration (n = 444) who were incarcerated within correctional institutions in four states were randomized to (1) the RRR-HIV intervention consisting of an HIV educational video, five group sessions, and one postrelease booster session or (2) a control condition consisting of the HIV educational video. The RRR-HIV intervention combined didactic and interactive content regarding seven "thinking myths" about intimate relationships that may result in decisions to engage in risky sexual behaviors. Data were collected while women were still incarcerated and approximately 90 days following release from prison by trained interviewers. A negative binomial regression (NBR) model of unprotected sexual behaviors at the 90-day follow-up indicated that RRR-HIV participants reported fewer unprotected sexual behaviors than women in the control condition once the analysis was adjusted for study site. Future studies should examine the sustainability of the RRR-HIV intervention's effect on risk reduction. Implementation research is needed to determine whether delivery of this intervention by correctional staff or peers, rather than research staff, yields similar reductions in unprotected sexual behaviors.

Factors associated with high-frequency illicit methadone use among rural Appalachian drug users

BACKGROUND

In recent years there has been a sharp increase in the use of illicit methadone as well as methadone-related overdose deaths.

OBJECTIVE

The purpose of this study was to describe factors associated with low- and high-frequency methadone use in a cohort of rural Appalachian drug users.

METHODS

Interviews assessing sociodemographics, illicit drug use and drug treatment, psychiatric disorders, health and sociometric drug network characteristics were conducted with 503 rural drug users between 2008 and 2010. A two-level mixed effects regression model was utilized to differentiate low- (one use per month or less in the past six months) versus high-frequency (daily or weekly use in the past six months) illicit methadone users.

RESULTS

The lifetime prevalence of illicit methadone use in this population was 94.7% (n = 476) and slightly less than half (46.3%) were high-frequency users. In the mixed effects regression model, initiating illicit methadone use at a younger age was associated with high-frequency illicit methadone use. Taking a prescribed medication for a physical problem, undergoing additional weeks of outpatient drug free treatment, daily OxyContin® use in the past month, and having fewer ties and second-order connections in the drug network reduced the odds of high-frequency illicit methadone use.

CONCLUSIONS

Rates of illicit methadone use and high-frequency illicit methadone use among this sample of rural drug users were considerably higher than those previously reported in the literature. Health practitioners in rural areas should routinely screen for illicit opioid use, including methadone.

Predictors of alcohol use among rural drug users after disclosure of hepatitis C virus status

OBJECTIVE

Alcohol consumption dramatically increases the risk of liver damage among those with hepatitis C virus (HCV) infection, yet the impact of HCV status disclosure and standard informational counseling on alcohol use among rural drug users remains poorly understood.

METHOD

In this prospective study, 503 rural Appalachian drug users were recruited using respondent-driven sampling. Participants were tested for HCV antibodies, and data on sociodemographic characteristics, lifetime and past-30-day drug and alcohol use, and psychiatric disorders were collected by interviewer-administered questionnaires. A total of 470 participants returned after 6 months for follow-up; however,4 of those had no history of alcohol use, thus leaving a final sample size of 466. Multivariate negative binomial regression was used to determine the effect of disclosure of HCV status and posttest counseling on alcohol consumption at follow-up.

RESULTS

Despite an overall decrease in drinking frequency in the cohort, those who were HCV-positive were drinking at a frequency similar to their HCV-negative counterparts at follow-up, despite posttest counseling informing them of the risks of alcohol use with an HCV diagnosis (adjusted incidence rate ratio = 1.07, 95% CI [0.72, 1.61]). Significant predictors of increased days of alcohol use after 6 months included baseline alcohol use, baseline marijuana use, and meeting the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for antisocial personality disorder. Those using OxyContin at baseline had significantly fewer days of alcohol use at follow-up.

CONCLUSIONS

HCV status disclosure and standard informational counseling alone do not curtail drinking among HCV-positive drug users in the rural setting. Targeted interventions with regard to alcohol use are warranted in order to mitigate the damage of the HCV epidemic.

Feeling good in your own skin: the influence of complimentary sexual stereotypes on risky sexual attitudes and behaviors in a community sample of African American women

Although negative racial stereotypes may affect the mental and physical health of African Americans, little research has examined the influence of positive or complimentary racial stereotypes on such outcomes. More specifically, this study explored the relationship between African American women's endorsement of complimentary stereotypes about their sexuality and attitudes/behaviors that have been associated with sexual risk. Data were gathered from 206 African American women as part of the Black Women in the Study of Epidemics project. Multivariate regression models were used to examine associations between women's endorsement of complimentary stereotypes about their sexuality and selected sex-related attitudes and behaviors. Participants' endorsement of complimentary sexual stereotypes was significantly positively associated with beliefs that having sex without protection would strengthen their relationship (B = .28, SE = .10, p < .01) and that they could use drugs and always make healthy choices about using protection (B = .31, SE = .09, p < .01). Significant positive associations were also found between complimentary sexual stereotypes and the number of casual sexual partners women reported in the past year (B = .29, SE = .15, p = .05) as well as their willingness to have sex in exchange for money or drugs during that time (B = .78, OR = 2.18, p < .05). These findings suggest that endorsement of complimentary sexual stereotypes by African American women can lead to increased risk behavior, particularly relating to possible infection with HIV or other sexually transmitted infections.

Inability to access buprenorphine treatment as a risk factor for using diverted buprenorphine

BACKGROUND

As buprenorphine prescribing has increased in the United States so have reports of its diversion. The study purpose was to examine frequency and source of and risk factors for diverted buprenorphine use over a 6-month period in an Appalachian community sample of prescription opioid abusers.

METHODS

There were 503 participants at baseline; 471 completed the 6-month follow-up assessment. Psychiatric disorders and demographic, drug use, and social network characteristics were ascertained at baseline and follow-up. Multivariable logistic regression was used to determine the predictors of diverted buprenorphine use over the 6-month period.

RESULTS

Lifetime buprenorphine use "to get high" was 70.1%. Nearly half (46.5%) used diverted buprenorphine over the 6-month follow-up period; among these persons, 9.6% and 50.6% were daily and sporadic (1-2 uses over the 6-months) users, respectively. The most common sources were dealers (58.7%) and friends (31.6%). Predictors of increased risk of use of diverted buprenorphine during the 6-month follow-up included inability to access buprenorphine treatment (AOR: 7.31, 95% CI: 2.07, 25.8), meeting criteria for generalized anxiety disorder, and past 30 day use of OxyContin, methamphetamine and/or alcohol.

CONCLUSIONS

These results suggest that improving, rather than limiting, access to good quality affordable buprenorphine treatment may be an effective public health strategy to mitigate buprenorphine abuse. Future work should evaluate why more persons did not attempt to access treatment, determine how motivations change over time, and how different motivations affect diversion of the different buprenorphine formulations.

Individual and network factors associated with prevalent hepatitis C infection among rural Appalachian injection drug users

OBJECTIVES

We determined the factors associated with hepatitis C (HCV) infection among rural Appalachian drug users.

METHODS

This study included 394 injection drug users (IDUs) participating in a study of social networks and infectious disease risk in Appalachian Kentucky. Trained staff conducted HCV, HIV, and herpes simplex-2 virus (HSV-2) testing, and an interviewer-administered questionnaire measured self-reported risk behaviors and sociometric network characteristics.

RESULTS

The prevalence of HCV infection was 54.6% among rural IDUs. Lifetime factors independently associated with HCV infection included HSV-2, injecting for 5 or more years, posttraumatic stress disorder, injection of cocaine, and injection of prescription opioids. Recent (past-6-month) correlates of HCV infection included sharing of syringes (adjusted odds ratio = 2.24; 95% confidence interval = 1.32, 3.82) and greater levels of eigenvector centrality in the drug network.

CONCLUSIONS

One factor emerged that was potentially unique to rural IDUs: the association between injection of prescription opioids and HCV infection. Therefore, preventing transition to injection, especially among prescription opioid users, may curb transmission, as will increased access to opioid maintenance treatment, novel treatments for cocaine dependence, and syringe exchange.

Hepatitis C viremia and genotype distribution among a sample of nonmedical prescription drug users exposed to HCV in rural Appalachia

Research has demonstrated that hepatitis C (HCV) genotype distribution varies geographically and demographically. This exploratory study examines HCV viremia, viral concentration, and genotype distribution among anti-HCV positive, rural Appalachian nonmedical prescription drug users. The study population was randomly selected from a pool of 200 anti-HCV positive participants in a longitudinal study. Those randomly chosen were representative of the overall pool in terms of demographics, drug use, and other risk behaviors. Participants were tested serologically for HCV RNA, viral concentration, and genotype, and interview-administered questionnaires examined behavioral and demographic characteristics. Of the 81 participants, 69% tested RNA positive, 59% of which had viral loads exceeding 800,000 IU/ml. Approximately 66% of the RNA positive sample had genotype 1a; types 2b (16%) and 3a (13%) were less common. RNA positive participants were not significantly different than RNA negative participants demographically or behaviorally. Likewise, with the exception of education, genotype 1 participants were not significantly different than those with genotype 2 or 3. The prevalence of active HCV infection highlights a need for prevention and treatment in this population. However, the predominance of genotype 1 may present challenges due to its association with decreased responsiveness to drug treatment, although the novel class of direct-acting antivirals such as telaprevir and boceprevir offer new hope in this regard. The prevalence of genotype 1 may also foreshadow heightened burden of hepatocellular carcinoma and elevated healthcare expenditures. More research is needed to characterize HCV infection and genotype in this population.

Prevalence of HIV and risky sexual behaviors among rural drug users: does age matter?

OBJECTIVES

To determine the seroprevalence of HIV among a representative sample of drug-using adults in a rural area. Also, to determine whether young drug-using adults in a rural area engage in greater levels of sexual risk behavior than their older counterparts.

METHODS

Cross-sectional study of 503 adult drug users. Rapid tests for antibodies to HIV were used, and self-reported data were collected via computer.

RESULTS

None of the participants tested positive for antibodies to HIV. In bivariate tests, only 2 differences were observed between young and older participants. Young males were more likely to engage in unprotected vaginal sex (P = .018) and young females were more likely to engage in unprotected sex with persons injecting drugs (P = .016). In controlled multivariate analyses, age had a modest but significant association with an 8-item index of sexual risk behavior (β = -0.15) and a reduced 6-item index of risk (β = -0.18).

CONCLUSION

Despite a fairly dense and interactive sexual network and relatively high-levels of sexual risk behaviors, this rural population has not yet been affected by the HIV epidemic. In the event an outbreak of HIV in this population the observed levels of sexual behavior suggest that rapid sexual transmission could occur among drug-using populations and may include persons of all ages.

Nonmedical use of prescription medications among adolescents in the United States: a systematic review

PURPOSE

The purpose of this review was to systematically summarize research on nonmedical use of prescription medications (NMUPM) among U.S. adolescents, with specific focus on scheduled medications falling into one of the following drug classes: pain relievers, stimulants, sedatives, or tranquilizers.

METHODS

Databases were searched for peer-reviewed primary quantitative research published between January 2000 and June 2011 on NMUPM among out-of-treatment U.S. adolescents aged 12-17 years (or age 18 if enrolled in high school).

RESULTS

Thirty publications met inclusion criteria. A total of 25 studies were represented; 15 involved nationally representative samples. The prevalence and correlates of NMUPM varied across studies and by drug class. Nonmedical use of pain relievers was more prevalent than for stimulants, sedatives, and tranquilizers. Female gender was generally associated with pain reliever use and, to a lesser degree, with tranquilizer use. White adolescents also appeared to have a higher prevalence of NMUPM, although there was some evidence to the contrary. Older age, illicit drug use, and delinquency were consistently associated with NMUPM across studies.

CONCLUSIONS

This review identified several areas for further research, including that of racially/ethnically diverse samples of adolescents, more focus on sedative and tranquilizer use, and longitudinal research to examine temporal patterns in NMUPM and other illicit drug use, delinquency, and substance abuse and dependence.

OxyContin® as currency: OxyContin® use and increased social capital among rural Appalachian drug users

Studies have shown that position within networks of social relations can have direct implications on the health behaviors of individuals. The present study examines connections between drug use and individual social capital within social networks of drug users (n = 503) from rural Appalachian Kentucky, U.S.A. Respondent driven sampling was used to recruit individuals age 18 and older who had used one of the following drugs to get high: cocaine, crack, heroin, methamphetamine, or prescription opioids. Substance use was measured via self-report and social network analysis of participants' drug use network was used to compute effective size, a measure of social capital. Drug network ties were based on sociometric data on recent (past 6 month) drug co-usage. Multivariate multi-level ordinal regression was used to model the independent effect of socio-demographic and drug use characteristics on social capital. Adjusting for gender, income, and education, daily OxyContin(®) use was found to be significantly associated with greater social capital, and daily marijuana use was associated with less social capital. These results suggest that in regions with marked economic disparities such as rural Appalachia, OxyContin(®) may serve as a form of currency that is associated with increased social capital among drug users. Interventions focusing on increasing alternate pathways to acquiring social capital may be one way in which to alleviate the burden of drug use in this high-risk population.

Transition from first illicit drug use to first injection drug use among rural Appalachian drug users: a cross-sectional comparison and retrospective survival analysis

AIM

The study's objectives were to characterize initiation of injection drug use, examine the independent association of specific substance use with injection drug use and determine factors associated with rates of transition from first illicit drug use to first injection among a sample of rural Appalachian drug users.

DESIGN

Interview-administered questionnaires were administered to a sample of drug users recruited via respondent-driven sampling.

SETTING

Appalachian Kentucky.

PARTICIPANTS

Injection drug users (IDUs) (n = 394) and non-IDUs (n = 109).

MEASUREMENTS

Data were collected on substance use and years from age at initiation of illicit substance use to 'event' (initiation of injection or date of baseline interview for non-IDUs). Logistic regression and Cox regression were used to identify factors associated with life-time injection drug use and transition time to injection, respectively.

FINDINGS

OxyContin(®) was involved in nearly as many initiations to injection (48%), as were stimulants, other prescription opioids and heroin combined; for participants who initiated with OxyContin(®), the median time from which they began OxyContin(®) use to their first injection of OxyContin(®) was 3 years. Adjusting for demographics, five prescription drugs (benzodiazepines, illicit methadone, oxycodone, OxyContin(®) and other opiates) were associated with an increased hazard for transitioning from first illicit drug use to first injection drug use (each at P < 0.01).

CONCLUSIONS

In Appalachia, in the United States, the prescription opioid OxyContin(®) is widely used non-medically and appears to show a particularly high risk of rapid transition to injection compared with the use of other illicit drugs.

A comparison of rural and urban nonmedical prescription opioid users' lifetime and recent drug use

BACKGROUND

Nonmedical prescription opioid use has emerged as a major public health concern. The growing burden of nonmedical prescription opioid use in America may have unique manifestations and consequences in rural areas, which to a large extent have yet to be explored.

OBJECTIVES

To describe rural-urban differences among drug users in recent and lifetime use and age of onset of use for alcohol, heroin, OxyContin(®), oxycodone, hydrocodone, barbiturates, benzodiazepines, cocaine, crack, methamphetamine, amphetamine, marijuana, hallucinogens, and inhalants.

METHODS

A purposive sample of 212 prescription drug users was recruited from a rural Appalachian county (n = 101) and a major metropolitan area (n = 111) in Kentucky. Consenting participants were given an interviewer-administered questionnaire examining sociodemographics, psychiatric characteristics, and self-reported drug use.

RESULTS

Rural drug users had significantly earlier ages of onset for use of oxycodone, hydrocodone, benzodiazepines, cocaine, and crack. In age-, gender-, and race-adjusted logistic regression analyses, rural drug users had significantly higher odds of lifetime and recent use of methadone, OxyContin(®), and oxycodone. Rural drug users also had significantly higher odds of lifetime cocaine and crack use. However, urban participants as expected had significantly higher odds of recent crack use.

CONCLUSIONS

The findings demonstrate that, in this sample, nonmedical prescription opioid use is dissimilar among rural and urban drug users. Additional research is needed to better understand the individual, social, and structural level factors contributing to the burden of nonmedical opioid use, particularly in rural populations, with the aim of developing tailored substance abuse treatment and prevention.

Injection risk behaviors among rural drug users: implications for HIV prevention

OBJECTIVE

The purpose of this study was to examine injection drug use (IDU) among a cohort of felony probationers from rural Appalachian Kentucky.

METHODS

An interviewer-administered questionnaire given to 800 rural felony probationers ascertained data regarding demographics, drug use, criminal behavior, psychological distress, and HIV-risk behaviors.

RESULTS

The sample was primarily white (95.1%) and male (66.5%) and the median age was 32.3 years (interquartile range: 25.2, 40.5). There were no cases of HIV in the sample. Of the 800 rural probationers, 179 (22.4%) reported lifetime IDU. Receptive syringe sharing (RSS) and distributive syringe sharing (DSS) were reported by 34.5% and 97.1% of the IDUs, respectively. Independent correlates of risky injection behaviors included cocaine injection (adjusted odds ratio (AOR): 14.9, 95% confidence interval (CI): 8.0, 27.7) and prescription opioid injection (AOR: 14.7, 95% CI: 7.7, 28.1).

DISCUSSION

Although HIV was not prevalent, data suggest that the rural felony probationers in this sample were engaging in risky injection practices that could facilitate transmission of HIV. This is especially problematic since those involved in the criminal justice system may be more likely to be exposed to HIV. Therefore, prevention aimed at reducing HIV-risk behaviors among rural, criminally involved individuals is warranted.

Individual and network factors associated with non-fatal overdose among rural Appalachian drug users

BACKGROUND

Fatal overdoses involving prescription opioids have increased significantly in recent years in the United States--especially in rural areas. However, there are scant data about non-fatal overdose among rural drug users. The purpose of this study is to examine the prevalence and correlates of non-fatal overdose and witnessed overdose among rural Appalachian drug users.

METHODS

Rural drug users were participants in a longitudinal study of social networks and HIV transmission. An interviewer-administered questionnaire elicited information in the following domains: sociodemographic characteristics, drug use (including lifetime overdose and witnessed overdose), psychiatric disorders, HIV risk behaviors and social networks (support, drug and sex networks). Negative binomial regression was used to model the number of lifetime overdoses and witnessed overdoses.

RESULTS

Of the 400 participants, 28% had ever experienced a non-fatal overdose, while 58.2% had ever witnessed an overdose (fatal or non-fatal). Factors independently associated with a greater number of overdoses included having ever been in drug treatment, past 30-day injection of prescription opioids, meeting the criteria for post-traumatic stress disorder and/or antisocial personality disorder and having more members in one's support network.

CONCLUSIONS

Rural drug users with history of overdose were more likely to have injected with prescription opioids--which is different from urban heroin users. However, the remaining correlates of non-fatal overdose among this cohort of rural drug users were similar to those of urban heroin users, which suggests current overdose prevention strategies employed in urban settings may be effective in preventing fatal overdose in this population.

Examining gender differences in substance use and age of first use among rural Appalachian drug users in Kentucky

BACKGROUND

Previous research suggests gender differences exist in types of substances used and age of first use. Recent studies exploring contextual differences in substance use between rural Appalachian and urban environments show different patterns of substance use in rural environments.

OBJECTIVE

This study explores whether previously established differences in gender and age of first use exist within a rural Appalachian environment.

METHODS

Data are from a community-based study of drug users in rural Appalachia (N=400). Self-reported substance use was recorded using an interviewer-administered questionnaire with questions from the Addiction Severity Index (ASI).

RESULTS

On average, participants were 32 years old (X=32.33; median=31.00; interquartile range (IQR)=12) and the majority were male (59%). Examining the past 30-day substance use, more males reported alcohol (adjusted odds ratio (AOR): 2.11, 95% CI: 1.36, 3.23; p=.001) and any illegal drug use (AOR: 1.85, 95% CI: 1.16, 2.95; p=.010), which included heroin, cocaine, crack cocaine, methamphetamine, marijuana, and hallucinogens, after controlling for sociodemographic characteristics. ANCOVA analyses showed that males reported the use of alcohol (p=.000), marijuana (p=.007), and hallucinogens (p=.009) at a significantly younger age than females.

CONCLUSION

Findings suggest more men report the use of alcohol and "street" drugs, including heroin, crack cocaine, methamphetamine, marijuana, and hallucinogens. Furthermore, males report the use of alcohol, marijuana, and hallucinogens at a significantly younger age.

SCIENTIFIC SIGNIFICANCE

Understanding gender differences in substance use as well as other differences among individuals living in rural Appalachia presents important opportunities to incorporate this knowledge into substance abuse early intervention, prevention, and treatment efforts.

Nonmedical prescription drug use in a nationally representative sample of adolescents: evidence of greater use among rural adolescents

OBJECTIVES

To compare the prevalence of nonmedical prescription drug use among adolescents residing in urban, suburban, and rural areas of the United States and to determine factors independently associated with rural nonmedical prescription drug use among adolescents aged 12 to 17 years.

DESIGN

Cross-sectional, population-based survey.

SETTING

Noninstitutionalized residents in the United States.

PARTICIPANTS

Participants included adolescents aged 12 to 17 years (N = 17 872), most of whom were residing in urban areas (53.2%), male (51%), and white (59%).

MAIN EXPOSURE

Living in rural compared with urban area.

MAIN OUTCOME MEASURES

Nonmedical use of prescription drugs (pain relievers, tranquilizers, sedatives, and stimulants). Data were from the 2008 National Survey on Drug Use and Health.

RESULTS

Rural adolescents were 26% more likely than urban adolescents to have used prescription drugs nonmedically (adjusted odds ratio, 1.26; 95% confidence interval, 1.01-1.57) even after adjustment for race, health, and other drug and alcohol use. When examining the rural adolescents in particular, factors positively associated with nonmedical use of prescription drugs included decreased health status, major depressive episode(s), and other drug (marijuana, cocaine, hallucinogens, and inhalants) and alcohol use. Protective factors for nonmedical prescription drug use among rural adolescents included school enrollment and living in a 2-parent household.

CONCLUSIONS

Rural adolescents were significantly more likely than urban adolescents to report nonmedical prescription drug use. However, these results suggest there are multiple potential points of intervention to prevent initiation or progression of use among rural adolescents including preventing school dropout, increased parental involvement, and increased access to health, mental health, and substance abuse treatment.

Route of administration for illicit prescription opioids: a comparison of rural and urban drug users

Background

Nonmedical prescription opioid use has emerged as a major public health concern in recent years, particularly in rural Appalachia. Little is known about the routes of administration (ROA) involved in nonmedical prescription opioid use among rural and urban drug users. The purpose of this study was to describe rural-urban differences in ROA for nonmedical prescription opioid use.

Methods

A purposive sample of 212 prescription drug users was recruited from a rural Appalachian county (n = 101) and a major metropolitan area (n = 111) in Kentucky. Consenting participants were given an interviewer-administered questionnaire examining sociodemographics, psychiatric disorders, and self-reported nonmedical use and ROA (swallowing, snorting, injecting) for the following prescription drugs: buprenorphine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, OxyContin^® and other oxycodone.

Results

Among urban participants, swallowing was the most common ROA, contrasting sharply with substance-specific variation in ROA among rural participants. Among rural participants, snorting was the most frequent ROA for hydrocodone, methadone, OxyContin^®, and oxycodone, while injection was most common for hydromorphone and morphine. In age-, gender-, and race-adjusted analyses, rural participants had significantly higher odds of snorting hydrocodone, OxyContin^®, and oxycodone than urban participants. Urban participants had significantly higher odds of swallowing hydrocodone and oxycodone than did rural participants. Notably, among rural participants, 67% of hydromorphone users and 63% of morphine users had injected the drugs.

Conclusions

Alternative ROA are common among rural drug users. This finding has implications for rural substance abuse treatment and harm reduction, in which interventions should incorporate methods to prevent and reduce route-specific health complications of drug use.

Examining differences in substance use among rural and urban pregnant women

Substance use during pregnancy is a major public health concern. This study examined differences in substance use among pregnant women from rural and urban areas. Participants were 114 pregnant women entering a hospital-based inpatient detoxification unit primarily for Opiate Dependence who voluntarily agreed to a face-to-face interview. Substance use measures were based on the Addiction Severity Index gathering information about lifetime, past 12 months, and 30 days prior to admission. Rural pregnant women had higher rates of illicit opiate use, illicit sedative/benzodiazepine use, and injection drug use (IDU) in the 30 days prior to admission. Additionally, a greater proportion of rural pregnant women reported the use of multiple illegal/illicit substances in the 30 days prior to entering detoxification. More specifically, pregnant women from rural areas were 8.4 times more likely to report illicit opiate use, 5.9 times more likely to report IDU, 3.3 times more likely to report illicit sedative/benzodiazepine use, and 2.8 times more likely to report the use of multiple illegal/illicit substances in the 30 days prior to entering inpatient detoxification, after adjustment for socio-demographic characteristics (including education and income), pregnancy characteristics, physical and mental health indicators, and criminal justice system involvement. The increased rates of prescription opiate and benzodiazepine use as well as IDU among rural pregnant women are concerning. In order to begin to understand the elevated rates of substance abuse among rural pregnant women, substance use must be considered within the context of demographic, geographic, social, and economic conditions of the region.

Drug use and criminal activity among rural probationers with DUI histories

The present study examined whether ever being arrested for driving under the influence (DUI) was associated with higher levels of substance use and criminal activity in a sample of 800 probationers. Lifetime and 30-day histories of substance use and criminal activity were compared across three groups of probationers from rural Kentucky: those with a single DUI arrest, those with two or more DUI arrests, and those with no DUI arrests. A larger percentage of probationers with a DUI arrest reported lifetime and 30-day substance use than non-DUI offenders in almost all drug and alcohol categories. Higher prevalence of criminal activity was limited primarily to the multiple DUI arrest group. Findings add to the literature on rural substance abusers and indicate that DUI may be used as a marker to help identify opportunities for targeted substance abuse interventions.

Inmate Pre-Release Assessment (IPASS) Aftercare Placement Recommendation as a Predictor of Rural Inmate's 12-Step Attendance and Treatment Entry Post-Release

The purpose of this study is to use the Criminal Justice Drug Abuse Treatment Studies' (CJ-DATS) Inmate Pre-Release Assessment (IPASS), which recommends either intensive or non-intensive treatment after release, to predict rural offenders'12-step attendance and treatment entry within 6 months of release from prison. IPASS scores indicated that 52% of rural offenders needed intensive treatment upon community re-entry. In bivariate analyses, rural offenders with an intensive aftercare placement recommendation were significantly younger, more likely to have been employed more months in the year prior to incarceration, to have ever injected drugs, and to have ever received outpatient substance abuse treatment. The variables which were significant at the bivariate level were entered into two logistic multivariate models predicting 12-step attendance and treatment entry within 6 months of being released from prison. Age and having ever injected drugs were positive predictors of having attended a 12-step meeting, while the number of months legally employed was negatively related to 12-step attendance. In the treatment entry model, age increased the odds of entering formal treatment while having ever injected a drug decreased the odds. IPASS aftercare placement recommendation was not significant in either of the multivariate models. Findings from this study suggest that offenders re-entering rural communities may receive limited community-based continued care and future studies should explore geographic-specific treatment barriers. Implications for rural substance abuse treatment are provided.

Examination of an interventionist-led HIV intervention among criminal justice-involved female prisoners

The purpose of this study was to examine the implementation, adherence and protocol fidelity for the Reducing Risky Relationships for HIV (RRR-HIV) study. The RRR-HIV study is a phase III trial of a randomized intervention to reduce human immunodeficiency virus (HIV) risk behaviors among incarcerated women in four US states: Connecticut, Delaware, Kentucky and Rhode Island. The intervention consists of five interventionist-led prison-based group sessions and a sixth individual community-based session. Data on adherence, implementation, acceptability and fidelity of the intervention were obtained from forms completed after the five prison-based sessions by both the interventionist and participant. Data from the sixth session were collected by the interventionist. Of the 363 women recruited to date, 173 (47.6%) have been randomly allocated to the experimental RRR intervention, of which implementation measures were available for 162 (93.6%). Almost three-quarters of women attended all five sessions, each of which lasted a median of 90 minutes, indicating successful implementation of the protocol across multiple study sites. Interventionists and participants alike reported that all of the topics for each session were discussed, suggesting adherence to the protocol. In addition, protocol interventionists indicated that more than 95% of the women were engaged/involved, interested, and understood the materials presented, indicating high levels of acceptability among the participants and fidelity to the intervention protocols. The majority of participants also answered all of the post-test questions correctly, which is another strong indicator of the fidelity to the intervention. Results suggest that the RRR-HIV study has been successfully implemented across multiple study sites. Adherence to the protocol, as well as protocol fidelity and acceptability, were also strong, which is essential to establish prior to examining outcome data.

Adherence to Scheduled Sessions in a Randomized Field Trial of Case Management: The Criminal Justice-Drug Abuse Treatment Studies Transitional Case Management Study

The Transitional Case Management (TCM) study, one of the projects of the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) cooperative, was a multi-site randomized test of whether a strengths-based case management intervention provided during an inmate's transition from incarceration to the community increases participation in community substance abuse treatment, enhances access to needed social services, and improves drug use and crime outcomes. As in many intervention studies, TCM experienced a relatively large percentage of treatment-group participants who attended few or no scheduled sessions. The paper discusses issues with regard to participation in community case management sessions, examines patterns of session attendance among TCM participants, and analyzes client and case manager characteristics that are associated with number of sessions attended and with patterns of attendance. The average number of sessions (out of 12) attended was 5.7. Few client or case manager characteristics were found to be significantly related to session attendance. Clinical and research implications of the findings and of adherence in case management generally are discussed.

Gender-specific factors associated with community substance abuse treatment utilization among incarcerated substance users

This article describes the independent correlates of preincarceration community substance abuse treatment utilization for male and female offenders currently participating in prison-based treatment. As part of the National Institute on Drug Abuse-funded Criminal Justice Drug Abuse Treatment Studies cooperative agreement, this protocol was implemented by four collaborating research centers. Males with a history of treatment utilization were more likely to be older, to have used crack, and to have had a greater number of arrests, and they were less likely to be arrested for a violent charge. Females with previous treatment were more likely to have been hospitalized for a health condition and were significantly more likely to have lived with someone else before prison rather than in their own home. These findings suggest that factors associated with preincarceration treatment utilization differ by gender, which may have important implications for correctional-based treatment assessment, reentry planning, and transitional case management.