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

Postmortem screening of opioids, benzodiazepines, and alcohol among rural and urban suicide decedents

PURPOSE

Fatal suicides involving opioids are increasingly common, particularly in rural areas. As co-use of opioids with other substances contributes significantly to mortality risk, we examined whether positive screens for opioids with other substances is more prevalent among rural versus urban suicide deaths, as this could have implications for public health strategies to reduce overdose suicides.

METHODS

Data from all states reporting opioid-related overdose suicides in the National Violent Death Reporting System from 2012 to 2015 were used. Relative risk ratios were obtained using multinomial logistic regression, comparing opioid-only to (1) opioid and alcohol, (2) opioid and benzodiazepines, and (3) opioid, alcohol, and benzodiazepines suicides across rurality. Models were fit using robust standard errors and fixed effects for year of death, adjusting for individual, county, and state-level covariates.

FINDINGS

There were 3,781 opioid-overdose suicide decedents (42% female) tested for all 3 substances during the study period. Unadjusted prevalence of positive screens in decedents varied across rurality (P = .022). Urban decedents were more likely to test positive for opioids alone, while rural decedents were more to likely test positive for opioids and benzodiazepines.

CONCLUSIONS

Rural suicides are associated with increased opioid and benzodiazepine positive screens. These findings suggest the need for rural-focused interventions to support appropriate co-prescribing, better health education for providers about risks associated with drug mixing, and more linkages with mental health services.

Utilization of a poison control center by critical access hospitals-one state's experience

PURPOSE

Critical access hospitals (CAH) are an important source of exposures for poison control centers (PCC), yet there is a paucity of literature on how these calls differ from larger, more urban hospitals (UH). This study aimed to compare call characteristics from CAH and UH received by a regional PCC.

METHODS

This retrospective chart review used the Toxicall^® database of the Kansas PCC. All cases involving calls from a health care facility from 1 January 2012 to 31 December 2017 were identified. Cases were then identified as either from a CAH or from one of the four largest UH in Kansas for comparison. CAH were defined using the criteria from the Centers for Medicare & Medicaid Services. All information was de-identified in REDCAPS and analyzed in Microsoft Excel.

FINDINGS

A total of 12,469 unique patient cases were identified, including 6392 CAH and 6077 UH cases. Patients at UH were more likely to have longer duration of medical effects and experience more severe medical effects. Significant differences in the unique exposures, rates of intentional overdose, routes, and number of exposures were found. Patients at CAH were more likely to receive activated charcoal, flumazenil, and be transferred to another healthcare facility, but were less likely to have been referred by the PCC, need an ICU admission, or require consultation with a toxicologist.

CONCLUSIONS

PCC calls from CAHs were common and resulted in significant differences when compared to UH calls. Future research is warranted to optimize PCC services for rural hospitals.

Rural adults' perceived role of family members in prescription opioid misuse prevention: Implications for family-based approaches

PURPOSE

This study explored and documented rural adults' perceptions of family roles in prescription opioid misuse prevention and the predisposing, reinforcing, and enabling factors that influence family members from taking those roles.

METHODS

Nine focus groups with rural adults (n = 55) were conducted to evoke discussion about family roles in prescription opioid misuse prevention. Transcripts were coded based on common ideas that arose during the focus groups, previous literature, and the PRECEDE-PROCEED program planning model.

FINDINGS

Findings suggest that rural adults perceive the opioid epidemic as partially a family problem. Additionally, rural adults perceive themselves as having a critical role in preventing prescription opioid misuse among family members. Participants identified specific predisposing, reinforcing, and enabling factors that influence whether or not family members take responsibility in preventing prescription opioid misuse within their families. Rural adults also perceive that family-based education is important in preventing prescription opioid misuse.

CONCLUSIONS

These results suggest that there is an interest in family-based approaches that enable or foster the skills and resources necessary to engage in prescription opioid misuse prevention behaviors. Specifically, family-based prevention programming should include efforts to shape knowledge and attitudes about prescription opioid misuse, increase resources to facilitate prevention behaviors, and build skills related to prevention.

Nudging patients and surgeons to change ambulatory surgery pain management: Results from an opioid buyback program

BACKGROUND

Optimal postoperative opioid stewardship combines adequate pain medication to control expected discomfort while avoiding abuse and community diversion of unused prescribed opioids. We hypothesized that an opioid buyback program would motivate patients to return unused opioids, and surgeons will use that data to calibrate prescribing.

METHODS

Prospective cohort study of postambulatory surgery pain management at a level II Veterans Affairs rural hospital (2017-2019). Eligible patients were offered $5/unused opioid pill ($50 limit) returned to our Veterans Affairs hospital for proper disposal. After 6 months, buyback data was shared with each surgical specialty.

RESULTS

Overall, 934 of 1,880 (49.7%) eligible ambulatory surgery patients were prescribed opioids and invited to participate in the opioid buyback. We had 281 patients (30%) return 3,165 unused opioid pills; this return rate remained constant over the study period. In 2017, 62.4% of patients were prescribed an opioid; after data was shared with providers, prescriptions for opioids were reduced to 50.7% and 38.3% of eligible patients in 2018 and 2019, respectively (P < .0001). The median morphine milligram equivalents prescribed also decreased from 108.8 morphine milligram equivalents in 2017 to 75.0 morphine milligram equivalents in 2018 and sustained at 75.0 morphine milligram equivalents in 2019 (P < .001). Surgical providers, surgeries performed, patient characteristics, and 30-day refill rates were similar throughout the study period.

CONCLUSION

A small financial incentive resulted in patients returning unused opioids after ambulatory surgery. Feedback to surgeons regarding opioids returned reduced the proportion of patients prescribed an opioid and the amount of opioid after ambulatory surgery without an increase in refills.

Willingness to Participate in At-Home HIV Testing Among Young Adults Who Use Opioids in Rural Appalachia

New HIV infections associated with injection drug use are of major concern in rural US communities. This study explores acceptability of, consent for, and uptake of free at-home HIV testing among people who use drugs (PWUD) in one of the nation’s epicenters for drug-related harms and HIV vulnerability: Rural Central Appalachia. Eligible participants were 18–35 years old, lived in Appalachian Kentucky, and reported using opioids to get high in the previous 30 days. A majority reported being likely (63.6%, 96/151) to take a free at-home HIV tests and 66.9% (101/151) consented to receive one. Among those who were randomly selected to receive a Home Access HIV-1 test kit (n = 37), 37.8% mailed in blood spots and 21.6% called to receive results. This study provides evidence that PWUD may be willing to take an at-home test, but other barriers may inhibit actual completion.

Income inequality and opioid prescribing rates: Exploring rural/urban differences in pathways via residential stability and social isolation

While opioid prescribing rates have drawn researchers' attention, little is known about the mechanisms through which income inequality affects opioid prescribing rates and even less focuses on whether there is a rural/urban difference in mediating pathways. Applying mediation analysis techniques to a unique ZIP code level dataset from several sources maintained by the Centers for Medicare and Medicaid Services, we explicitly examine two mechanisms through residential stability and social isolation by rural/urban status and find that (1) income inequality is not directly related to opioid prescribing rates, but it exerts its influence on opioid prescribing via poor residential stability and elevated social isolation; (2) social isolation accounts for two-thirds of the mediating effect of income inequality on opioid prescribing rates among urban ZIP codes, but the proportion halves among rural ZIP codes; (3) residential stability plays a larger role in understanding how income inequality matters in rural than in urban ZIP codes; and (4) beneficiary characteristics only matter in urban ZIP codes. These findings offer nuanced insight into how income inequality affects opioid prescribing rates and suggests that the determinants of opioid prescribing rates vary by rural/urban status. Future research may benefit from identifying place-specific factors for opioid prescribing rates.

Effect of an mHealth Intervention on Hepatitis C Testing Uptake Among People With Opioid Use Disorder: Randomized Controlled Trial

Background

The growing epidemic of opioid use disorder (OUD) and associated injection drug use has resulted in a surge of new hepatitis C virus (HCV) infections. Approximately half of the people with HCV infection are unaware of their HCV status. Improving HCV awareness and increasing screening among people with OUD are critical. Addiction-Comprehensive Health Enhancement Support System (A-CHESS) is an evidence-based, smartphone-delivered relapse prevention system that has been implemented among people with OUD who are receiving medications for addiction treatment (MAT) to improve long-term recovery.

Objective

We incorporated HCV-related content and functionality into A-CHESS to characterize the HCV care continuum among people in early remission and receiving MAT for OUD and to determine whether incorporating such content and functionality into A-CHESS increases HCV testing.

Methods

HCV intervention content, including dissemination of educational information, private messages tailored to individuals’ stage of HCV care, and a public discussion forum, was implemented into the A-CHESS platform. Between April 2016 and April 2020, 416 participants with OUD were enrolled in this study. Participants were randomly assigned to receive MAT alone (control arm) or MAT+A-CHESS (experimental arm). Quarterly telephone interviews were conducted from baseline to month 24 to assess risk behaviors and HCV testing history. Cox proportional hazards regression was used to assess whether participants who used A-CHESS were tested for HCV (either antibody [Ab] or RNA testing) at a higher rate than those in the control arm. To assess the effect of A-CHESS on subsets of participants at the highest risk for HCV, additional analyses were performed to examine the effect of the intervention among participants who injected drugs and shared injection equipment.

Results

Overall, 44.2% (184/416) of the study participants were HCV Ab positive, 30.3% (126/416) were HCV Ab negative, and 25.5% (106/416) were considered untested at baseline. At month 24, there was no overall difference in HCV testing uptake between the intervention and control participants. However, among the subset of 109 participants who engaged in injection drug use, there was a slight trend toward increased HCV testing uptake among those who used A-CHESS (89% vs 85%; hazard ratio: 1.34; 95% CI 0.87-2.05; P=.18), and a stronger trend was observed when focusing on the subset of 32 participants who reported sharing injection equipment (87% vs 56%; hazard ratio: 2.92; 95% CI 0.959-8.86; P=.06).

Conclusions

Incorporating HCV prevention and care information into A-CHESS may increase the uptake of HCV testing while preventing opioid relapse when implemented among populations who engage in high-risk behaviors such as sharing contaminated injection equipment. However, more studies that are powered to detect differences in HCV testing among high-risk groups are needed.

Trial Registration

ClinicalTrials.gov NCT02712034; https://clinicaltrials.gov/ct2/show/NCT02712034

International Registered Report Identifier (IRRID)

RR2-10.2196/12620

Changes in opioid-related deaths following increased access to opioid substitution treatment

BACKGROUND

Opioid-related mortality is high and increasing in the Western world, and interventions aimed at reducing opioid-related deaths represent an important area of study. In Skåne County, Sweden, a patient choice reform resulted in increased access to opioid substitution treatment (OST). In addition, a gradual shift towards less restrictive terms for exclusion from OST has been implemented. The aim of this study was to assess the impact of these policy changes on opioid-related deaths.

METHODS

Detailed data on opioid-related deaths in Skåne during the 2 years prior to and following the policy change were obtained from forensic records and from health care services. Data on overdose deaths for Skåne and the rest of Sweden were obtained using publicly available national register data. Time periods were used as the predictor for opioid-related deaths in the forensic data. The national level data were used in a natural experiment design in which rates of overdose deaths were compared between Skåne and the rest of Sweden before and after the intervention.

RESULTS

There was no significant difference in the number of deaths in Skåne between the data collection periods (RR: 1.18 95% CI:0.89-1.57, p= 0.251). The proportion of deaths among patients enrolled in OST increased between the two periods (2.61, 1.12-6.10, p= 0.026). There was no change in deaths related to methadone or buprenorphine in relation to deaths due to the other opioids included in the study (0.92, 0.51-1.63, p= 0.764). An analysis of national mortality data showed an annual relative decrease in unintentional drug deaths in Skåne compared to the rest of Sweden following the onset of the reform (0.90, 0.84-0,97, p= 0.004).

CONCLUSIONS

Opioid-related deaths, as assessed using forensic data, has not changed significantly in Skåne following a change to lower-threshold OST. By contrast, national level data indicate that the policy change has been associated with decreased overdose deaths. The discrepancy between these results highlights the need for more research to elucidate this issue. The result that more patients die during ongoing OST following an increase in access to treatment underlines the need for further preventive interventions within the OST treatment setting.

Modeling the role of incarceration in HCV transmission and prevention amongst people who inject drugs in rural Kentucky

BACKGROUND

People who inject drugs (PWID) experience high incarceration rates, with current/recent incarceration being associated with increased hepatitis C virus (HCV) transmission. We assess the contribution of incarceration to HCV transmission amongst PWID in Perry County (PC), Kentucky, USA, and the impact of scaling-up community and in-prison opioid substitution therapy (OST), including the potential for reducing incarceration.

METHODS

A dynamic model of incarceration and HCV transmission amongst PWID was calibrated in a Bayesian framework to epidemiological and incarceration data from PC, incorporating an empirically estimated 2.8-fold (95%CI: 1.36-5.77) elevated HCV acquisition risk amongst currently incarcerated or recently released (<6 months) PWID compared to other PWID. We projected the percentage of new HCV infections that would be prevented among PWID over 2020-2030 if incarceration no longer elevated HCV transmission risk, if needle and syringe programmes (NSP) and OST are scaled-up, and/or if drug use was decriminalized (incarceration/reincarceration rates are halved) with 50% of PWID that would have been imprisoned being diverted onto OST. We assume OST reduces reincarceration by 10-42%.

RESULTS

Over 2020-2030, removing the effect of incarceration on HCV transmission could prevent 42.7% (95% credibility interval: 15.0-67.4%) of new HCV infections amongst PWID. Conversely, scaling-up community OST and NSP to 50% coverage could prevent 28.5% (20.0-37.4%) of new infections, with this increasing to 32.7% (24.5-41.2%) if PWID are retained on OST upon incarceration, 36.4% (27.7-44.9%) if PWID initiate OST in prison, and 45.3% (35.9-54.1%) if PWID are retained on OST upon release. decriminalization (with diversion to OST) could further increase this impact, preventing 56.8% (45.3-64.5%) of new infections. The impact of these OST interventions decreases by 2.1-28.6% if OST does not reduce incarceration.

CONCLUSION

Incarceration is likely to be an important contributor to HCV transmission amongst PWID in PC. Prison-based OST could be an important intervention for reducing this risk.

Patient Satisfaction With Medications for Opioid Use Disorder Treatment via Telemedicine: Brief Literature Review and Development of a New Assessment

Telemedicine is increasingly being used to treat patients with opioid use disorder (OUD). It has particular value in rural areas of the United States impacted by the opioid crisis as these areas have a shortage of trained addiction medicine providers. Patient satisfaction significantly impacts positive clinical outcomes in OUD treatment and thus is of great clinical interest. Yet little is known regarding patient satisfaction with the increasingly important platform of telemedicine-delivered medications for opioid use disorder (tMOUD). The goal of this review is to provide a summary of the existing literature regarding patient satisfaction with tMOUD. We also submit a novel survey based on an existing framework designed to assess tMOUD satisfaction, and present pilot data (N = 14) acquired from patients engaged in rural tMOUD care. Telemedicine provides a feasible method for delivering MOUD in rural areas, and our survey provides a useful assessment to measure patient satisfaction with tMOUD. In light of the pressing need for innovative and technology-driven solutions to the opioid epidemic (especially in light of the COVID-19 pandemic), future research should focus on the development and refinement of tools to assess the important implementation goal of patient satisfaction.

Contribution of Social Determinant of Health Factors to Rural-Urban Preventive Care Differences Among Medicaid Enrollees

OBJECTIVE

1) Assess whether rural-urban disparities are present in pediatric preventive health care utilization; and 2) use regression decomposition to measure the contribution of social determinants of health (SDH) to those disparities.

METHODS

With an Ohio Medicaid population served by a pediatric Accountable Care Organization, Partners For Kids, between 2017 and 2019, we used regression decomposition (a nonlinear multivariate regression decomposition model) to analyze the contribution of patient, provider, and SDH factors to the rural-urban well-child visit gap among children in Ohio.

RESULTS

Among the 453,519 eligible Medicaid enrollees, 61.2% of urban children received a well-child visit. Well-child visit receipt among children from large rural cities/towns and small/isolated towns was 58.2% and 55.5%, respectively. Comparing large rural towns to urban centers, 55.8% of the 3.0 percentage-point difference was explained by patient, provider, and community-level SDH factors. In comparing small/isolated town to urban centers, 89.8% of the 5.7 percentage-point difference was explained by these characteristics. Of provider characteristics, pediatrician providers were associated with increased well visit receipt. Of the SDH factors, unemployment and education contributed the most to the explained difference in large rural towns while unemployment, education, and food deserts contributed significantly to the small/isolated town difference.

CONCLUSIONS

The receipt of pediatric preventive care is slightly lower in rural communities. While modest, the largest part of the rural-urban preventive care gap can be explained by differences in provider type, poverty, unemployment, and education levels. More could be done to improve pediatric preventive care in all communities.

Factors Associated with Sterile Syringe Acquisition among People Who Inject Drugs in West Virginia

BACKGROUND

Syringe services programs (SSPs) are evidence-based interventions that provide essential overdose and infectious disease prevention resources to people who inject drugs (PWID). Little research has examined factors associated with sterile syringe acquisition at SSPs among rural PWID populations.

OBJECTIVES

We aim to identify factors associated with PWID in a rural county in West Virginia having recently acquired sterile syringes at an SSP.

METHODS

PWID (n = 420) completed a survey that included measures related to sociodemographics, structural vulnerabilities, and substance use. We used multivariable Poisson regression with robust variance estimation to examine independent associations with sterile syringe acquisition at an SSP.

RESULTS

Sixty-five percent of our sample reported having recently acquired sterile syringes at an SSP. Factors associated with recent sterile syringes acquisition at an SSP included: being older (aPR [adjusted prevalence ratio]: 1.011, 95% CI: 1.003-1.019), single (aPR: 0.862, 95% CI: 0.755-0.984), experiencing food insecurity (aPR: 1.233, 95% CI: 1.062-1.431), recently injecting fentanyl (aPR: 1.178, 95% CI: 1.010-1.375) and prescription opioid pain relievers (aPR: 0.681, 95% CI: 0.551-0.842), and recent naloxone acquisition (aPR: 1.360; 95% CI: 1.178-1.569). Receptive syringe sharing was inversely associated with acquiring sterile syringes at an SSP (aPR: 0.852; 95% CI: 0.741-0.979).

CONCLUSION

PWID accessing sterile syringes at an SSP was associated with several sociodemographic, structural, and substance use factors. Ensuring rural SSP operations are tailored to local PWID population-level needs is paramount to the prevention of infectious disease outbreaks and overdose fatalities.

Outcomes for patients receiving telemedicine-delivered medication-based treatment for Opioid Use Disorder: A retrospective chart review

This report builds on a previous study that describes the collaboration between an urban academic medical center and a rural drug treatment center, the goal of which is to provide medication-based treatment to individuals with OUD via videoconferencing. We describe results of a retrospective chart review of 472 patients treated in the program between August 2015 and April 2019. We examined several demographic and substance use variables for individuals who consented to telemedicine treatment, retention in treatment over time, and opioid use over time to understand further the impact of prescribing buprenorphine and naltrexone via telemedicine to patients in a rural OUD treatment setting. Our findings support the effectiveness of prescribing medications via telemedicine. The inclusion of more than three times as many patients as in our prior report revealed retention rates and toxicology results that are comparable to face-to-face treatment. These findings have implications for policymakers and clinicians considering implementation of similar programs.

Community-engaged research in translational science: Innovations to improve health in Appalachia

Health disparities between Appalachia and the rest of the country are widening. To address this, the Appalachian Translational Research Network (ATRN) organizes an annual ATRN Health Summit. The most recent Summit was held online September 22–23, 2020, and hosted by Wake Forest Clinical and Translational Science Institute in partnership with the Northwest Area Health Education Center. The Summit, titled “Community-Engaged Research in Translational Science: Innovations to Improve Health in Appalachia,” brought together a diverse group of 141 stakeholders from communities, academic institutions, and the National Center for Advancing Translational Science (NCATS) to highlight current research, identify innovative approaches to translational science and community-engaged research, develop cross-regional research partnerships, and establish and disseminate priorities for future Appalachian-focused research. The Summit included three plenary presentations and 39 presentations within 12 concurrent breakout sessions. Here, we describe the Summit planning process and implementation, highlight some of the research presented, and outline nine emergent themes to guide future Appalachian-focused research.

Distribution of Physician Specialties by Rurality

PURPOSE

Physicians of all specialties are more likely to live and work in urban areas than in rural areas. Physician availability affects the health and economy of rural communities. This study aimed to measure and update the availability of physician specialties in rural counties.

METHODS

This analysis included all counties with a Rural-Urban Continuum Code (RUCC) between 4 and 9. Geographically identified physician data from the 2019 American Medical Association Masterfile was merged with 2019 County Health Rankings, the Census Bureau's 2010 county-level population data, and 2010 Topologically Integrated Geographic Encoding and Referencing shapefiles. Multivariate logistic regression was performed to assess the availability of physicians by specialty in rural counties.

FINDINGS

Of the 1,947 rural counties in our sample, 1,825 had at least 1 physician. Specialties including emergency medicine, cardiology, psychiatry, diagnostic radiology, general surgery, anesthesiology, and OB/GYN were less available than primary care physicians (PCPs) in all rural counties. The probability of a rural county having a PCP was the highest in RUCC 4 (1.0) and lowest in RUCC 8 (0.93). Of all primary care specialties, family medicine was the most evenly distributed across the rural continuum, with a probability of 1.0 in RUCC 4 and 0.88 in RUCC 9.

CONCLUSIONS

Family medicine is the physician specialty most likely to be present in rural counties. Policy efforts should focus on maintaining the training and scope of practice of family physicians to serve the health care needs of rural communities where other specialties are less likely to practice.

Estimates of opioid use disorder prevalence from a regression-based multi-sample stratified capture-recapture analysis

BACKGROUND

An epidemic of opioid overdose has spread across North America, with illicit drug-related overdose emerging as a leading cause of death in recent years. Estimates of opioid use disorder (OUD) prevalence at the level of the public health service delivery area are needed to project resource needs and identify priority areas for targeted intervention. Our objective is to estimate the annual prevalence of OUD in British Columbia (BC), Canada, from 2000 to 2017.

METHODS

We performed a multi-sample stratified capture-recapture analysis to estimate OUD prevalence in BC. The analysis included individuals identified from 3 administrative databases for 2000-2011 and 4 databases for 2012-2017, linked at the individual level. Negative binomial regression models on the counts of individuals within these strata were used to estimate prevalence, adjusting for dependency between databases.

RESULTS

OUD prevalence in BC among people aged 12 years or older was 1.00 % (N = 34,663 individuals) in 2000 and increased to 1.54 % (N = 61,080) in 2011. Between 2013 and 2017 prevalence increased from 1.57 % (95 % confidence interval: 1.56-1.58) to 1.92 % (1.89-1.95; N = 83,760; 82,492-84,855). The greatest increases in prevalence were observed among males 12-30 years old and 31-44 years old, with 43.2 % and 40.2 % increases from 2013 to 2017.

CONCLUSIONS

In BC, the OUD prevalence was 1.92 % among people 12 years or older in 2017. We estimated that prevalence has nearly doubled since 2000, with the highest increases in prevalence observed among males under 45.

Examining opioid prescribing trends for non-cancer pain using an estimated oral morphine equivalence measure: a retrospective cohort study between 2005 and 2015

Background

Over the past 20 years prescription of opioid medicines has markedly increased in the UK, despite a lack of supporting evidence for use in commonly occurring, painful conditions. Prescribing is often monitored by counting numbers of prescriptions dispensed, but this may not provide an accurate picture of clinical practice.

Aim

To use an estimated oral morphine equivalent (OMEQ_e) dose to describe trends in opioid prescribing in non-cancer pain, and explore if opioid burden differed by deprivation status.

Design & setting

A retrospective cohort study using cross-sectional and longitudinal trend analyses of opioid prescribing data from Welsh Primary Care General Practices (PCGP) took place. Data were used from the Secure Anonymised Information Linkage (SAIL) databank.

Method

An OMEQ_e measure was developed and used to describe trends in opioid burden over the study period. OMEQ_e burden was stratified by eight drug groups, which was based on usage and deprivation.

Results

An estimated 643 436 843 milligrams (mg) OMEQ_e was issued during the study. Annual number of prescriptions increased 44% between 2005 and 2015, while total daily OMEQ_e per 1000 population increased by 95%. The most deprived areas of Wales had 100 711 696 mg more OMEQ_e prescribed than the least deprived over the study period.

Conclusion

Over the study period, OMEQ_e burden nearly doubled, with disproportionate OMEQ_e prescribed in the most deprived communities. Using OMEQ_e provides an alternative measure of prescribing and allows easier comparison of the contribution different drugs make to the overall opioid burden.

The Opioid/Overdose Crisis as a Dialectics of Pain, Despair, and One-Sided Struggle

The opioid/overdose crisis in the United States and Canada has claimed hundreds of thousands of lives and has become a major field for research and interventions. It has embroiled pharmaceutical companies in lawsuits and possible bankruptcy filings. Effective interventions and policies toward this and future drug-related outbreaks may be improved by understanding the sociostructural roots of this outbreak. Much of the literature on roots of the opioid/overdose outbreak focuses on (1) the actions of pharmaceutical companies in inappropriately promoting the use of prescription opioids; (2) "deaths of despair" based on the deindustrialization of much of rural and urban Canada and the United States, and on the related marginalization and demoralization of those facing lifetimes of joblessness or precarious employment in poorly paid, often dangerous work; and (3) increase in occupationally-induced pain and injuries in the population. All three of these roots of the crisis-pharmaceutical misconduct and unethical marketing practices, despair based on deindustrialization and increased occupational pain-can be traced back, in part, to what has been called the "one-sided class war" that became prominent in the 1970s, became institutionalized as neo-liberalism in and since the 1980s, and may now be beginning to be challenged. We describe this one-sided class war, and how processes it sparked enabled pharmaceutical corporations in their misconduct, nurtured individualistic ideologies that fed into despair and drug use, weakened institutions that created social support in communities, and reduced barriers against injuries and other occupational pain at workplaces by reducing unionization, weakening surviving unions, and weakening the enforcement of rules about workplace safety and health. We then briefly discuss the implications of this analysis for programs and policies to mitigate or reverse the opioid/overdose outbreak.

Higher and Higher? Drug and Alcohol Use and Misuse among HIV-Vulnerable Men, Trans Men, and Trans Women Who Have Sex with Men in the United States

BACKGROUND

Substance use (SU) and misuse are disproportionately more common among sexual and gender minority (SGM) individuals compared to their heterosexual peers. Yet, little is known about regional and demographic differences in use and misuse among SGM. In this study, we investigated regional and demographic differences in SU and misuse in a U.S. national, internet-based cohort (n = 6,280) of men and trans persons who have sex with men. Methods: Data collected included the WHO ASSIST (substance) and AUDIT (alcohol) SU scales to estimate recent (≤ 3 months) non-problematic use (≤ 3 ASSIST, ≤ 10 AUDIT) and misuse (≥4 ASSIST, ≥11 AUDIT). We used bivariate and multivariable logistic models to examine demographic and regional factors associated with SU and misuse. Results: Participants reported using alcohol (85.6%), cannabis (53.9%), and inhalants (39.1%) in the past three months. More than one-third self-reported misuse of cannabis, Gamma-Hydroxybutyrate (GHB), inhalants, methamphetamines, and prescription sedatives. We observed regional differences in substance use for cannabis (Southeast aOR = 0.76, 95% CI: 0.63-0.93; West aOR = 1.27, 95% CI: 1.02-1.59, ref. Northeast) and prescription Stimulants (Midwest aOR = 1.39, 95% CI: 1.00-1.93), as well as for cannabis misuse (Southeast aOR = 0.83, 95% CI: 0.69-0.99). We also observed significant associations between socioeconomic factors with use and misuse. Conclusions: Findings suggest geographic differences in misuse of certain substances among men and trans persons who have sex with men in the US, and that socio-economic factors, also play a key role in indicating risk.

Suicide, overdose and worker exit in a cohort of Michigan autoworkers

BACKGROUND

In recent decades, suicide and fatal overdose rates have increased in the US, particularly for working-age adults with no college education. The coincident decline in manufacturing has limited stable employment options for this population. Erosion of the Michigan automobile industry provides a striking case study.

METHODS

We used individual-level data from a retrospective cohort study of 26 804 autoworkers in the United Autoworkers-General Motors cohort, using employment records from 1970 to 1994 and mortality follow-up from 1970 to 2015. We estimated HRs for suicide or fatal overdose in relation to leaving work, measured as active or inactive employment status and age at worker exit.

RESULTS

There were 257 deaths due to either suicide (n=202) or overdose (n=55); all but 21 events occurred after leaving work. The hazard rate for suicide was 16.1 times higher for inactive versus active workers (95% CI 9.8 to 26.5). HRs for suicide were elevated for all younger age groups relative to those leaving work after age 55. Those 30-39 years old at exit had the highest HR for suicide, 1.9 (95% CI 1.2 to 3.0). When overdose was included, the rate increased by twofold for both 19- to 29-year-olds and 30- to 39-year-olds at exit. Risks remained elevated when follow-up was restricted to 5 years after exit.

CONCLUSIONS

Autoworkers who left work had a higher risk of suicide or overdose than active employees. Those who left before retirement age had higher rates than those who left after, suggesting that leaving work early may increase the risk.

Patterns, contexts, and motivations for polysubstance use among people who inject drugs in non-urban settings in the U.S. Northeast

BACKGROUND

Polysubstance use (i.e., using ≥2 psychoactive substances concomitantly) is associated with increased morbidity and mortality and complicates drug treatment needs among people who inject drugs (PWID). We explored patterns, contexts, motivations, and perceived consequences of polysubstance use among PWID in small cities and towns in the U.S. Northeast.

METHODS

Between October 2018 and March 2019, we conducted semi-structured interviews with 45 PWID living outside of the capital cities of Rhode Island and Massachusetts recruited online and through community-based organizations. Written transcripts were coded inductively and deductively using a team-based approach and analyzed thematically.

RESULTS

All participants reported recent polysubstance use, with most using five or more classes of substances in the past three months. Polysubstance use often followed long personal drug use histories (i.e., years or decades of occasional drug use). Reasons for polysubstance use included obtaining synergistic psychoactive effects as a result of mixing drugs (i.e., using drugs to potentiate effects of other drugs) and managing undesirable effects of particular drugs (e.g., offsetting the depressant effects of opioids with stimulants or vice-versa). Polysubstance use to self-medicate poorly managed physical and mental health conditions (e.g., chronic pain, anxiety, and depression) was also reported. Inadequately managed cravings and withdrawal symptoms prompted concomitant use of heroin and medications for opioid use disorder, including among individuals reporting cocaine or crack as their primary "issue" drugs. Polysubstance use was perceived to increase overdose risks and to be a barrier to accessing healthcare and drug treatment services.

CONCLUSION

Healthcare services and clinicians should acknowledge, assess, and account for polysubstance use among patients and promote harm reduction approaches for individuals who may be using multiple drugs. Comprehensive healthcare that meets the social, physical, mental health, and drug treatment needs of PWID may decrease the perceived need for polysubstance use to self-medicate poorly managed health conditions and symptoms.

Rural risk environments, opioid-related overdose, and infectious diseases: A multidimensional, spatial perspective

BACKGROUND

Much remains unknown in rural risk environments, despite a growing crisis in these areas. We adapt a risk environment framework to characterize rural southern Illinois and describe the relations of risk environments, opioid-related overdose, HIV, Hepatitis C, and sexually transmitted infection rates between 2015 and 2017.

METHODS

Over two dozen risk environment variables are summarized across zip-code (n = 128) or county levels (n = 16) based on availability and theoretical relevance. We calculate data attribute associations and characterize spatial and temporal dimensions of longitudinal health outcomes and the rural risk environment. We then use a "regional typology analysis" to generate data-driven risk regions and compare health outcomes.

RESULTS

Pervasive risk hotspots were identified in more populated locales with higher rates of overdose and HCV incidence, whereas emerging risk areas were isolated to more rural locales that had experienced an increase in analgesic opiate overdoses and generally lacked harm-reduction resources. At-risk areas were characterized with underlying socioeconomic vulnerability but in differing ways, reflecting a nuanced and shifting structural risk landscape.

CONCLUSIONS

Rural risk environment vulnerabilities and associated opioid-related health outcomes are multifaceted and spatially heterogeneous. More research is needed to better understand how refining geographies to more precisely define risk can support intervention efforts and further enrich investigations of the opioid epidemic.

Opioid-related overdose deaths among African Americans: Implications for research, practice and policy

Opioid-related overdose deaths among African Americans have only recently received national attention despite evidence of increase in death rates among this population spanning the past decade. Numerous authors have highlighted how the 'opioid epidemic' has largely been portrayed as a problem mostly affecting White America. The purpose of this commentary is to provide a synthesis spotlighting the unique structural and cultural considerations involved in research, practice and policy related to opioid use and treatment for opioid use disorders among African Americans. The commentary concludes with considerations for future research and practice intended to reduce deaths among this group.

Stigmatize the use, not the user? Attitudes on opioid use, drug injection, treatment, and overdose prevention in rural communities

Stigma is a known barrier to treating substance use disorders and dramatically diminishes the quality of life of people who use drugs (PWUD) nonmedically. Stigma against PWUD may be especially pronounced in rural areas due to their decreased anonymity and residents' limited access, or resistance, to "neutralizing" information on factors associated with drug use. Stigma often manifests in the attitudes of professionals whom stigmatized individuals regularly interact with and often materially impact. We analyzed interviews conducted between July 2018 and February 2019 with professional stakeholders in rural southern Illinois who interact with PWUD, specifically those who use opioids nonmedically or who inject drugs (n = 30). We further analyzed interview data from a complementary PWUD sample (n = 22). Interviews addressed perspectives around nonmedical drug use and treatment/harm reduction, with analysis centered around the Framework Integrating Normative Influences on Stigma and its focus on micro, meso and macro level stigmatization processes. Stakeholder participants included professionals from local law enforcement, courts, healthcare organizations, emergency management services, and faith-based and social services organizations. Most stakeholders, particularly law enforcement, negatively perceived PWUD and nonmedical drug use in general, questioned the character, agency and extrinsic value of PWUD, and used labels (e.g. "addict," "abuser," etc.) that may be regarded as stigmatizing. Further, most respondents, including PWUD, characterized their communities as largely unaware or dismissive of the bio-medical and sociocultural explanations for opioid use, drug injection and towards harm reduction services (e.g., syringe exchanges) and naloxone, which were frequently framed as undeserved usages of taxpayer funds. In conclusion, rural stigma against PWUD manifested and was framed as a substantial issue, notably activating at micro, meso and macro levels. Stigma prevention efforts in these communities should aim to improve public knowledge on the intricate factors contributing to opioid use and drug injection and harm reduction programming's moral and fiscal value.

The Intersection of the "Opioid Crisis" with Changes in US Immigration Policy: Contextual Barriers to Substance Abuse Research with Latinx Communities

One of the 12 Grand Challenges facing contemporary social work is to close the health gap experienced by those in historically marginalized communities (Uehara et al., 2013). As social workers, we seek to understand the individual, interpersonal, social, and environmental factors along with the structural inequities leading to initiation and continuation of substance misuse. We are constantly contextualizing the circumstances under which substance misuse occurs, as well as contextualizing our approaches to addressing this issue from both a public health and social justice perspective. In order to adequately meet this challenge, considerably more research-based knowledge on the substance use treatment needs and preferences of America's largest ethnic/cultural group, Latinx, is needed. This brief report outlines current challenges associated with substance use research focusing on active Latinx heroin users living in a border state in a time of rapidly evolving social policy related to immigration, substance regulation, and public health.

The relationship of opioid prescriptions and the educational performance of children

One of the more salient aspects of the opioid crisis in America has been the disparate impact it has had on communities. This paper considers the possibility that opioid abuse might have negative spillovers onto student performance in schools within the communities most affected. We use administrative data on individual children's test scores (grades 3 through 8) in South Carolina from the 2005-06 to 2016-17 academic years. These data are then linked to county-level changes in opioid prescriptions rates. Findings show that an increase in the opioid prescription rate in a county is associated with a statistically significant reduction in white student test scores, but no such decline was found among non-white students. This relationship is robust to controls for changing county-level economic conditions, time-varying controls for student-level poverty, county characteristics, and county time trends. Among white students, the association is strongest among rural students in households that are not receiving SNAP or TANF benefits. Given the importance of educational attainment, this reduction in test scores associated with high rates of opioid prescriptions may indicate that there will be long-lasting spillover effects of the opioid crisis.

Hostility, compassion and role reversal in West Virginia's long opioid overdose emergency

Background

West Virginia is a largely rural state with strong ties of kinship, mutual systems of support and charitable giving. At the same time, wealth inequalities are extreme and the state’s drug overdose fatality rate stands above all others in the USA at 51.5/100,000 in 2018, largely opioid-related. In recent years, harm reduction services have been active in the state but in 2018 Charleston’s needle and syringe program was forced to close. This paper considers the risk environment in which the state’s drug-related loss of life, and those attempting to prevent it, exist.

Methods

This rapid ethnographic study involved semi-structured interviews (n = 21), observation and video recordings of injection sequences (n = 5), initially recruiting people who inject heroin/fentanyl (PWIH) at the Charleston needle and syringe program. Snowball sampling led the research team to surrounding towns in southern West Virginia. Telephone interviews (n = 2) with individuals involved in service provision were also carried out.

Results

PWIH in southern West Virginia described an often unsupportive, at times hostile risk environment that may increase the risk of overdose fatalities. Negative experiences, including from some emergency responders, and fears of punitive legal consequences from calling these services may deter PWIH from seeking essential help. Compassion fatigue and burnout may play a part in this, along with resentment regarding high demands placed by the overdose crisis on impoverished state resources. We also found low levels of knowledge about safe injection practices among PWIH.

Conclusions

Hostility faced by PWIH may increase their risk of overdose fatalities, injection-related injury and the risk of HIV and hepatitis C transmission by deterring help-seeking and limiting the range of harm reduction services provided locally. Greater provision of overdose prevention education and naloxone for peer distribution could help PWIH to reverse overdoses while alleviating the burden on emergency services. Although essential for reducing mortality, measures that address drug use alone are not enough to safeguard longer-term public health. The new wave of psychostimulant-related deaths underline the urgency of addressing the deeper causes that feed high-risk patterns of drug use beyond drugs and drug use.

Characteristics and outcomes of hospitalizations and readmissions for opioid dependence and overdose: nationally representative data

BACKGROUND

Despite the increasing rates of morbidity, mortality, and costs from the opioid addiction crisis, there is a paucity of literature on nationwide patterns of opioid abuse and dependence admissions and readmissions. We sought to investigate common comorbidities, readmission rates, and variables associated with readmission following index admission for opioid overdose or dependence. Methods: The 2013 Nationwide Readmission Database is a national database including data on more than 14 million US admissions. We used International Classification of Disease, Ninth Revision, Clinical Modification codes to identify index opioid abuse or dependence admissions, readmissions, and medical co-morbidities. We summarized all-cause readmission rates and reasons for readmission following index opioid dependence or overdose admission. We performed multivariable logistic regression, testing the association between characteristics of index admission and readmission. Results: 64,426 individuals were admitted for drug overdose or dependence during 2013. Of those, 30.1% were readmitted for all causes within one year and 8.7% were readmitted for opioid overdose or dependence within that year. The most common primary diagnoses on the readmission record were infection, kidney failure, drug related admission, and psychiatric admission. Predictors of readmission were smoking, male sex, younger age, alcohol, bipolar disorder, non-opioid drug use, admission to teaching hospitals in metropolitan areas, and discharge against medical advice. Conclusion: There is a high all-cause readmission rate following index admission for opioid overdose or dependence and a greater likelihood of readmission among young males with psychiatric comorbidities in metropolitan areas. Targeted interventions to address psychiatric comorbidities and transitions of care may be needed for the high-risk opioid dependence and overdose population.

Enhancing Staffing In Rural Community Health Centers Can Help Improve Behavioral Health Care

Community health centers are a vital part of the primary and behavioral health care systems in rural areas. We compared behavioral health care staffing and services in rural and urban centers. In the period 2013-17 the overall staff-to-patient ratio in behavioral health rose by 66 percent in rural centers, faster than growth in urban centers (49 percent). Growth in both settings was mostly driven by clinical social workers and other licensed mental health providers; staffing by psychiatrists and psychologists changed only slightly. In rural centers the average adjusted increase in annual visits per additional behavioral health staff member was 411 for substance use disorders, slightly higher than at urban centers. Additional annual visits per additional staff member in rural centers were 539 for depression, 466 for anxiety, and 300 for other mental disorders, similar to the numbers in urban centers. Behavioral health staff currently participating in the National Health Service Corps (NHSC) contributed more to visits for depression and anxiety in rural centers, compared to both their urban counterparts and non-NHSC staff in rural centers. Enhancing behavioral health staffing in rural community health centers could help reduce the urban-rural gap in the availability of behavioral health services, but still more could be done.

Identifying Predictive Characteristics of Opioid Medication Use among a Nationally Representative Sample of United States Older Adults with Pain and Comorbid Hypertension or Hypercholesterolemia

The prevalence of older adults with pain and comorbid cardiovascular conditions is increasing in the United States (U.S.). This retrospective, cross-sectional database study used 2017 Medical Expenditure Panel Survey data and hierarchical logistic regression models to identify predictive characteristics of opioid use among a nationally representative sample of older U.S. adults (aged ≥50 years) with pain in the past four weeks and comorbid hypertension (pain-hypertension group) or hypercholesterolemia (pain-hypercholesterolemia group). The pain-hypertension group included 2733 subjects (n = 803 opioid users) and the pain-hypercholesterolemia group included 2796 subjects (n = 795 opioid users). In both groups, predictors of opioid use included: White race versus others, Hispanic versus non-Hispanic ethnicity, 1 versus ≥5 chronic conditions, little/moderate versus quite a bit/extreme pain, good versus fair/poor perceived mental health, functional limitation versus no functional limitation, smoker versus non-smoker, and Northeast versus West census region. In addition, Midwest versus West census region was a predictor in the pain-hypertension group, and 4 versus ≥5 chronic conditions was a predictor in the pain-hypercholesterolemia group. In conclusion, several characteristics of older U.S. adults with pain and comorbid hypertension or hypercholesterolemia were predictive of opioid use. These characteristics could be addressed to optimize individuals' pain management and help address the opioid overdose epidemic.

The Opioid Hydra: Understanding Overdose Mortality Epidemics and Syndemics Across the Rural-Urban Continuum

The rapid increase of fatal opioid overdoses over the past two decades is a major U.S. public health problem, especially in non-metropolitan communities. The crisis has transitioned from pharmaceuticals to illicit synthetic opioids and street mixtures, especially in urban areas. Using latent profile analysis, we classify n = 3,079 counties into distinct classes using CDC fatal overdose rates for specific opioids in 2002-2004, 2008-2012, and 2014-2016. We identify three distinct epidemics (prescription opioids, heroin, and prescription-synthetic opioid mixtures) and one syndemic involving all opioids. We find that prescription-related epidemic counties, whether rural or urban, have been "left behind" the rest of the nation. These communities are less populated and more remote, older and mostly white, have a history of drug abuse, and are former farm and factory communities that have been in decline since the 1990s. Overdoses in these places exemplify the "deaths of despair" narrative. By contrast, heroin and opioid syndemic counties tend to be more urban, connected to interstates, ethnically diverse, and in general more economically secure. The urban opioid crisis follows the path of previous drug epidemics, affecting a disadvantaged subpopulation that has been left behind rather than the entire community. County data on opioid epidemic class membership are provided.

Social norms associated with nonmedical opioid use in rural communities: a systematic review

Prescription and illicit opioids were involved in over 42,000 deaths in the USA in 2016. Rural counties experience higher rates of opioid prescribing and, although opioid prescribing rates have fallen in recent years, the rate of decline is less in rural areas. The sociocultural context of rural life may impact opioid misuse in important ways; however, little research directly explores this possibility. We performed a systematic review of English-language manuscripts in U.S. context to determine what is known about social networks, norms, and stigma in relation to rural opioid misuse. Of nine articles identified and reviewed, two had only primary findings associated with social networks, norms, or stigma, five had only secondary findings, and two had both primary and secondary findings. The normalization of prescription opioid use along with environmental factors likely impacts the prevalence of opioid misuse in rural communities. Discordant findings exist regarding the extent to which social networks facilitate or protect against nonmedical opioid use. Lastly, isolation, lack of treatment options, social norms, and stigma create barriers to substance use treatment for rural residents. Although we were able to identify important themes across multiple studies, discordant findings exist and, in some cases, findings rely on single studies. The paucity of research examining the role of social networks, norms, and stigma in relation to nonmedical opioid use in rural communities is evident in this review. Scholarship aimed at exploring the relationship and impact of rurality on nonmedical opioid use is warranted.

Community Meetings on the Rural Opioid Crisis: Setting a Path Forward by Learning from Others

Objectives:

This study implemented a series of meetings in one rural community struggling with the opioid crisis. Set in the town of Ardmore, Oklahoma, these meetings presented local residents who dealt with the crisis as part of their jobs with four categories of programs aimed at preventing and treating opioid-related issues. The ultimate goal was for the participants to develop a consensus about where resources should be appropriated in the future, based off the needs of the area.

Methods:

Three community meetings were held over a six-week period, with an average of 40 attendees. Data was collected through surveys, study circles, and a participant voting exercise. Surveys were distributed at the beginning and end of the meetings to determine if participant views changed over the course of the study. Study circles broke participants into small groups and prompted them with questions regarding the crisis to encourage group discussion. The participant voting exercise allowed participants to note where they would like future resources to be directed.

Findings:

Listening to experts and holding group discussions led to changes in opinions for some participants. Most felt that the most pressing need was to provide accessible opioid treatment options in their community. Youth-based prevention efforts were also noted as being a program that the community should focus on.

Conclusions:

Local perceptions of the most appropriate strategies for combatting the rural opioid crisis can change with group discussions alongside others who are actively involved with this issue. Future research should actively involve affected communities in order to develop relevant and accepted action plans.

Optimizing the Distribution of Pharmacy-Dispensed Naloxone Using Spatial Mapping Techniques in Rural Areas

With the worsening opioid epidemic, recent changes allow pharmacies to sell naloxone through standing orders to reverse opioid overdoses. This study assesses direct dispensed naloxone availability through pharmacy chains in California in 2016, and utilizes spatial analysis techniques to suggest optimal stocking of naloxone. Rural counties were less likely to have a pharmacy selling naloxone even though overdose death rates were higher in rural counties (odds ratio [OR] = 0.225; 95% confidence interval [CI] = [0.059, 0.854]). Pharmacies closest to the center of the population in these rural counties were identified as ideal stocking locations. Rural counties with high overdose death rates have the lowest rates of naloxone, but spatial analysis can determine pre-existing chain pharmacies that can stock naloxone.

The opioid crisis: a contextual, social-ecological framework

The prevalence of opioid use and misuse has provoked a staggering number of deaths over the past two and a half decades. Much attention has focused on individual risks according to various characteristics and experiences. However, broader social and contextual domains are also essential contributors to the opioid crisis such as interpersonal relationships and the conditions of the community and society that people live in. Despite efforts to tackle the issue, the rates of opioid misuse and non-fatal and fatal overdose remain high. Many call for a broad public health approach, but articulation of what such a strategy could entail has not been fully realised. In order to improve the awareness surrounding opioid misuse, we developed a social-ecological framework that helps conceptualise the multivariable risk factors of opioid misuse and facilitates reviewing them in individual, interpersonal, communal and societal levels. Our framework illustrates the multi-layer complexity of the opioid crisis that more completely captures the crisis as a multidimensional issue requiring a broader and integrated approach to prevention and treatment.

Community Attitudes Toward Opioid Use Disorder and Medication for Opioid Use Disorder in a Rural Appalachian County

PURPOSE

To evaluate community attitudes concerning opioid use disorder (OUD) and medication for opioid use disorder (MOUD) in a rural community, and to plan educational initiatives to reduce stigma surrounding OUD and treatment.

METHODS

Dissemination of a 24-question survey to people living in a rural community followed by comparative analysis of survey results between 2 groups classified by recognition of OUD as a real illness.

FINDINGS

Three hundred sixty-one individuals responded. Overall, 69% agreed that OUD is a real illness. Respondents recognizing OUD as a real illness were less likely to agree that individuals with OUD are dangerous (P = .014), more likely to agree that MOUD is effective (P < .001), that individuals with OUD should have the same right to a job (P < .001), and that naloxone should be administered for every overdose every time (P = .002).

CONCLUSIONS

Significant stigma exists toward individuals with OUD in rural communities, and recognizing OUD as a real illness is associated with less stigmatizing attitudes and better understanding of MOUD. Further study should focus on how to effectively convince communities that OUD is a real illness.

Rural/Urban Differences in the Predictors of Opioid Prescribing Rates Among Medicare Part D Beneficiaries 65 Years of Age and Older

PURPOSE

While research has been done comparing rural/urban differences in opioid prescribing to the disabled Medicare Part D population, research on opioid prescribing among the aged Medicare Part D population is lacking. This study aims to fill this gap by exploring the predictors of opioid prescribing to aged Medicare Part D beneficiaries and investigating whether these predictors vary across rural and urban areas.

METHODS

This is an analysis of ZIP Codes in the continental United States (18,126 ZIP Codes) utilizing 2017 data from Centers for Medicare & Medicaid Services. The analytic approach includes aspatial descriptive analysis, exploratory spatial analysis with geographically weighted regression, and explanatory analysis with spatial error regime modeling.

FINDINGS

Both beneficiary and prescriber characteristics play an important role in determining opioid prescribing rates in urban ZIP Codes, but most of them fail to explain the opioid prescribing rates in rural ZIP Codes.

CONCLUSION

We identify potential spatial nonstationarity in opioid prescribing rates, indicating the complex nature of opioid-related issues. This means that the same stimulus may not lead to the same change in opioid prescribing rates, because the change may be place specific. By understanding the rural/urban differences in the predictors of opioid prescribing, place-specific policies can be developed that can guide more informed opioid prescribing practices and necessary interventions.

Polysubstance Use Patterns among Justice-Involved Individuals Who Use Opioids

AIM

The current study explores pre-incarceration polysubstance use patterns among a justice-involved population who use opioids. Design: Setting: Data from prison and jail substance use programing in the state of Kentucky from 2015-2017 was examined. Participants: A cohort of 6,569 individuals who reported both pre-incarceration use of opioids and reported the use of more than one substance per day. Measurements: To determine the different typologies of polysubstance use involving opioids, latent profile analysis of the pre-incarceration thirty-day drug use of eight substances was conducted. Multinomial logistic regression predicted latent profile membership. Findings: Six unique profiles of polysubstance use involving opioids and other substances were found; Primarily Alcohol (9.4%), Primarily Heroin (19.0%), Less Polysubstance Use (34.3%), Tranquilizer Polysubstance Use (16.3%), Primarily Buprenorphine (7.8%), and Stimulant-Opioid (13.2%). Profiles differed by rural/urban geography, injection drug use, physical, and mental health symptoms. Conclusion: Findings indicate the heterogeneity of opioid use among a justice-involved population. More diverse polysubstance patterns may serve as a proxy to identifying individuals with competing physical and mental health needs. Future interventions could be tailored to polysubstance patterns during the period of justice-involvement.

Urban-Rural Disparities in Opioid Use Disorder Prevention and Response Activities: A Cross-Sectional Analysis

PURPOSE

Urban and rural areas have been differentially impacted by opioid use disorder (OUD) and related adverse outcomes, yet little systematic study of the urban-rural divide in OUD prevention and response activities exists. This study compares policy and programmatic activities to tackle the opioid crisis in metropolitan versus nonmetropolitan areas, and within their subclassifications.

METHODS

All county governments in 5 purposively selected states were surveyed. Metropolitan and nonmetropolitan counties, and their subclassifications, were compared in their reported implementation of 19 opioid policy and programmatic activities, using 2-sample proportion and 1-way analysis of variance (ANOVA) tests with Bonferroni-corrected multiple comparisons.

FINDINGS

Of the 358 counties surveyed, 171 (response rate = 48%) responses were obtained. The implementation rate of nonmetropolitan counties was lower than that of metropolitan counties for all activities, although not all differences were statistically significant. Within nonmetropolitan areas, the implementation rate of noncore counties was lower than that of micropolitan counties for all activities, and statistically significant differences were found for providing treatment and rehabilitation facilities, allowing arrest alternatives for opioid offenses, and providing opioid detection and treatment training to first responders, among other activities.

CONCLUSIONS

The results of this study corroborate claims that nonmetropolitan areas, and particularly noncore areas, face greater barriers to implementing opioid policy and programmatic activities. This study identifies activity areas where rural counties are especially lacking and federal and state governments could support efforts for bending the curve of the opioid crisis.

Racial/ethnic differences in opioid-involved overdose deaths across metropolitan and non-metropolitan areas in the United States, 1999-2017

BACKGROUND

From 1999 to 2017, more than 400,000 Americans died from a drug overdose death involving an opioid. Early surveillance studies have observed large variations in opioid-involved overdose deaths among different geographic regions and racial/ethnic groups. The purpose of this study was to characterize trends in racial/ethnic opioid-involved overdose deaths across metropolitan and non-metropolitan areas in the United States from 1999 to 2017.

METHODS

The analysis used National Vital Statistics System data from 1999 to 2017 that were accessed through the CDC WONDER online database. Drug overdose deaths involving any opioid were identified using the International Classification of Diseases, Tenth Revision, codes and were represented as age-adjusted rates per 100,000 population. Joinpoint regression was used to examine trends in opioid-involved overdose deaths among racial/ethnic groups (non-Hispanic white, non-Hispanic black, Hispanic, non-Hispanic other) by metropolitan and non-metropolitan status (large metropolitan areas, medium-small metropolitan areas, and non-metropolitan areas).

RESULTS

The annual age-adjusted death rates for drug overdose deaths that involved any opioid significantly increased for all racial/ethnic groups in metropolitan and non-metropolitan areas from 1999 to 2017. The largest average annual increases in rates occurred among non-Hispanic whites in non-metropolitan areas (13.6% increase per year) and medium-small metropolitan areas (12.3% increase per year), followed by non-Hispanic blacks in medium-small metropolitan areas (11.3% increase per year).

CONCLUSIONS

The variations in opioid-involved overdose deaths among different racial/ethnic groups across geographic regions support the existence of multiple sub-epidemics in the current opioid overdose crisis and provide directions for targeted intervention efforts.

Contraceptive use in Appalachian women who use drugs and were recruited from rural jails

This study describes a secondary data analysis of contraceptive use across the lifetime and within the six months prior to incarceration in a sample of 400 currently incarcerated women recruited from rural, Appalachian jails, who were using drugs prior to incarceration. Phase 1 (baseline) data from an NIH funded study were used to examine rates of contraceptive use, reasons for nonuse of condoms, and correlates of condom use. Results indicate that the majority (96.5%) of respondents reported lifetime use of contraceptives, and most (70.5%) had a history of using multiple methods, with male condoms, oral contraceptive pills, and contraceptive injections being the most commonly used methods. Almost 69% of respondents reported nonuse of contraceptives within the last six months, despite high rates of involvement in risky, intimate male partnerships prior to incarceration. Contraceptive use was found to be historically acceptable in this sample, in stark contrast to rates of use within the last six months prior to incarceration, suggesting that reproductive justice-informed, social work interventions to help improve current contraceptive use are warranted as a harm-reduction approach.

Examining Factors Associated with Non-Fatal Overdose among People Who Inject Drugs in Rural Appalachia

BACKGROUND

Overdose (OD) deaths have continued to rise in the United States posing a critical public health challenge. Various factors have been associated with increased likelihood of OD, including history of injection drug use. Purpose: This study examined multi-level factors associated with non-fatal OD among current people who inject drugs (PWID) in Appalachian Kentucky. Methods: This cross-sectional study utilized data from 324 PWID recruited via Respondent-Driven Sampling techniques in three Appalachian counties. The analysis focused on correlates of overdose history among people who inject drugs (PWID). Findings: Approximately 36.7% of our sample reported having overdosed in their lifetime, with only 21.4% currently having access to a naloxone kit for OD reversal. Respondents who had injected fentanyl alone or in combination with another drug (OR = 4.26, 95% CI= 2.31,7.86) had 4 times higher odds of an OD than those who did not. Our study found those who injected buprenorphine as primary drug (OR = 0.29, 95% CI = 0.10,0.81) had lower odds of OD compared to those who injected heroin. Conclusions/Importance: Given an increase in OD prevalence among PWID in the U.S, and especially among people living in the Appalachian region of Kentucky, assessing factors associated with OD is critical in development of tailored public health interventions to address the disparate rates of non-fatal OD in this vulnerable population.

The Impact of Policy Changes on Heroin and Nonmedical Prescription Opioid Use among an Incarcerated Population in Kentucky, 2008-2016

In response to the opioid epidemic, there have been several national and state-level policies enacted. Consideration of how criminal justice-involved individuals are affected by such policies has received limited attention, despite disproportionately higher use among this population. Bivariate statistics examined yearly trends and logistic regressiosns examined demographic correlates of nonmedical prescription opioid and heroin use among Kentucky inmates over an eight-year time-span of important national and local policy changes (n=34,542). Results indicate that among incarcerated individuals, prior use of heroin increased 204% from 2008 to 2016, with increases possibly linked to key policy changes associated with OxyContin reformulation and state implementation of a prescription drug monitoring program. The current incarcerated population had more severe use patterns when considering general population research. Consideration of criminal justice-involved populations is crucial to understanding and treating the opioid epidemic.

A spatial partial differential equation approach to addressing unit misalignments in Bayesian poisson space-time models

Spatial analyses using data from geographic areas that change shape and location over time, like US ZIP codes, produce biased results to the extent that unit misalignments are related to covariate effects. To address this issue, one method has incorporated a fixed effect measure of population shifts and a spatial structure as a block-diagonal neighborhood adjacency matrix within a Besag-York-Mollié (BYM) model. However, this approach assumes that spatial relationships among units change with time and precludes the assessment of temporal dynamic effects. Here, we assume that a continuous Gaussian random field underlies misaligned data and apply a stochastic partial differential equation (SPDE) approach to modeling area outcomes. We compare SPDE and BYM methods and show that both provide similar estimates of covariate effects. Importantly, we demonstrate that the SPDE approach can additionally identify autoregressive processes underlying the development of problematic health outcomes using data observed across Pennsylvania over 11 years.

The Self-Compassion Scale Arabic version for baccalaureate nursing students: A validation study

BACKGROUND

The Self-Compassion Scale is an extensively used tool to measure self-compassion among different groups of population, including nurses. The tool has been translated and tested for its psychometric properties in previous studies. Assessing self-compassion among Saudi nursing students is critical as self-compassion is suggested to create a positive effect on one's wellbeing, coping, emotions, and other personal outcomes.

OBJECTIVES

This study determined the validity and reliability of the Self-Compassion Scale Arabic version (SCS-A) for nursing students. It also identified the demographic factors associated with the students' self-compassion.

DESIGN

A quantitative, cross-sectional design.

SETTINGS

The investigation was carried-out in two government universities in Saudi Arabia.

PARTICIPANTS

A sample of 322 Saudi nursing students in the 2nd to 4th year, as well as nurse interns was surveyed (mean age = 21.27, range = 18-27).

METHODS

The Self-Compassion Scale was culturally adapted to come up with the SCS-A. Content validity was established. Exploratory Factor Analysis (EFA) was used to establish the construct validity; whereas for reliability, internal consistency and test-retest reliability were established. Pearson's product correlation, t-test, and One-way Analysis of Variance were used to examine the demographic factors associated with self-compassion, accordingly.

RESULTS

A panel of experts rated content validity as excellent. The EFA revealed six dimensions namely "self-judgment," "self-kindness," "common humanity," "mindfulness," "isolation," and "over-identification", with total variance of 64.1%. Cronbach's alpha values for the six factors were from 0.76 to 0.85, with an overall α of the whole scale at 0.86. Computation revealed ICC values ranging from 0.84 to 0.92, whereas the ICC for the entire SCS-A was 0.81.

CONCLUSION

SCS-A shown satisfactory validity as well as good reliability. SCS-A can be used to collect baseline data on self-compassion, which could be used in developing policies in the universities and training hospitals to ensure that nurse interns and nursing students have compassion toward self. The study also opens opportunities for multi-country and cross-cultural studies on self-compassion among nursing students.

Spatial heterogeneity and socioeconomic determinants of opioid prescribing in England between 2015 and 2018

BACKGROUND

Opioid overdoses have had a serious impact on the public health systems and socioeconomic welfare of several countries. Within this broader context, we focus our study on primary care opioid prescribing in England from 2015 to 2018, particularly the patterns of spatial variations at the community level and the socioeconomic and environmental factors that drive consumption.

METHODS

Leveraging open data sources, we combine prescription records with aggregated data on patient provenance and build highly granular maps of Oral Morphine Equivalent (OME) prescribing rates for Lower Layer Super Output Areas (LSOA). We quantify the strength of spatial associations by means of the Empirical Bayes Index (EBI) that accounts for geographical variations in population density. We explore the interplay between socioeconomic and environmental determinants and prescribing rates by implementing a multivariate logistic regression model across different temporal snapshots and spatial scales.

RESULTS

We observe, across time and geographical resolutions, a significant spatial association with the presence of localized hot and cold spots that group neighboring areas with homogeneous prescribing rates (e.g., EBI = 0.727 at LSOA level for 2018). Accounting for spatial dependency effects, we find that LSOA with both higher employment deprivation (OR = 62.6, CI 52.8-74.3) and a higher percentage of ethnically white (OR = 30.1, CI 25.4-35.7) inhabitants correspond to higher prescribing rates. Looking at educational attainment, we find LSOA with the prevalent degree of education being apprenticeship (OR = 2.33, CI 1.96-2.76) a risk factor and those with level 4+ (OR = 0.41, CI 0.35-0.48) a protective factor. Focusing on environmental determinants, housing (OR = 0.18, CI 0.15-0.21) and outdoor environment deprivation (OR = 0.62, CI 0.53-0.72) indices capture the bi-modal behavior observed in the literature concerning rural/urban areas. The results are consistent across time and spatial aggregations.

CONCLUSIONS

Failing to account for local variations in opioid prescribing rates smooths out spatial dependency effects that result in underestimating/overestimating the impact on public health policies at the community level. Our study suggests a novel approach to inform more targeted interventions toward the most vulnerable population strata.

Pharmacies and features of the built environment associated with opioid overdose: A geospatial comparison of rural and urban regions in Alabama, USA

BACKGROUND

Elements of the physical environment have been shown to influence health behaviors including drug use and overdose mortality. Throughout the opioid epidemic in the United States, rural regions have been disproportionately affected by opioid overdose. Although the relationship between the urban built environment and opioid overdose has been established, little is known as to how trends may differ in rural areas.

METHODS

Risk terrain modeling was used as a spatial analytical approach to assess environmental features that significantly increase the risk of opioid overdose in Jefferson County, Alabama. Spatial risk assessments were conducted for urban and rural regions as well as for the county as a whole. Criminogenic, opioid-related, and community variables were included and compared across spatial risk models.

RESULTS

The geographic context, rural or urban, influenced the relationship between environmental features and opioid overdose. In rural areas, community features such as bus stops and public schools were related to the occurrence of opioid overdose. In urban areas, inpatient treatment centers, transitional living facilities, express loan establishments, and liquor vendors were significantly related to the locations of opioid overdose.

CONCLUSION

Risk terrain modeling can be used to locate high-risk areas for opioid overdose while identifying factors that are contributing to the risk of events occurring in communities. The patterns of overdose risk differ in rural and urban contexts and may be used to inform the placement of treatment and prevention resources.

Risk factors for heroin use following release from jail or prison in adults in a Central Appalachian state between 2012-2017

Background

Corrections-involved adults with a history of opioid use disorder are at elevated risk of opioid overdose following release from correctional settings. Increased opioid prescribing restrictions and monitoring during a time when heroin is becoming cheaper and ubiquitous means that adults who misused prescription opioids prior to incarceration may be reentering communities at greater risk for heroin exposure and use.

Objectives

Determine risk factors of post-release heroin use among a sample of adults who participated in corrections-based drug treatment in Kentucky released between 2012 and 2017.

Methods

Survey data obtained as part of an ongoing evaluation of corrections-based drug treatment were examined.

Results

The final sample (N = 1,563) was majority male (80.9%). Nearly 11.0% reported past-year heroin use following their release. Depressive symptoms, polydrug use, and urban proximity were more common among participants reporting post-release heroin use. Heroin use 30 days prior to incarceration was associated with a 432.1% increase in odds of heroin use subsequent to incarceration. Post-release suicidal ideation increased odds of heroin use by 154.2%, whereas reporting satisfaction from social interactions decreased odds of use by nearly 60%. Post-release use of cocaine and diverted buprenorphine were associated with increased likelihood of heroin use during this time period, increasing odds by 469.1% and 265.9%, respectively. Residing in Central Appalachia subsequent to incarceration was associated with decreased likelihood of use.

Conclusions

In this sample, post-release heroin use was associated with concerning features, such as polydrug use, lack of social satisfaction, and suicidal ideation. These features can serve as clear targets for clinical intervention.