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Zhu L, Thompson WW, Hagan L, Randall LM, Rudolph AE, Young AM, Havens JR, Salomon JA, Linas BP. Potential impact of curative and preventive interventions toward hepatitis C elimination in people who inject drugs-A network modeling study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 130:104539. [PMID: 39033645 PMCID: PMC11347083 DOI: 10.1016/j.drugpo.2024.104539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 07/09/2024] [Accepted: 07/11/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Injection-equipment-sharing networks play an important role in hepatitis C virus (HCV) transmission among people who inject drugs (PWID). Direct-acting antiviral (DAA) treatments for HCV infection and interventions to prevent HCV transmission are critical components of an overall hepatitis C elimination strategy, but how they contribute to the elimination outcomes in different PWID network settings are unclear. METHODS We developed an agent-based network model of HCV transmission through the sharing of injection equipment among PWID and parameterized and calibrated the model with rural PWID data in the United States. We modeled curative and preventive interventions at annual coverage levels of 12.5 %, 25 %, or 37.5 % (cumulative percentage of eligible individuals engaged), and two allocation approaches: random vs targeting PWID with more injection partners (hereafter 'degree-based'). We compared the impact of these intervention strategies on prevalence and incidence of HCV infections. We conducted sensitivity analysis on key parameters governing the effects of curative and preventive interventions and PWID network characteristics. RESULTS Combining curative and preventive interventions at 37.5 % annual coverage with degree-based allocation decreased prevalence and incidence of HCV infection by 67 % and 70 % over two years, respectively. Curative interventions decreased prevalence by six to 12 times more than preventive interventions, while curative and preventive interventions had comparable effectiveness on reducing incidence. Intervention impact increased with coverage almost linearly across all intervention strategies, and degree-based allocation was always more effective than random allocation, especially for preventive interventions. Results were sensitive to parameter values defining intervention effects and network mean degree. CONCLUSION DAA treatments are effective in reducing both prevalence and incidence of HCV infection in PWID, but preventive interventions play a significant role in reducing incidence when intervention coverage is low. Increasing coverage, including efforts in reaching individuals with the most injection partners, preventing reinfection, and improving compliance and retention in preventive services can substantially improve the outcomes. PWID network characteristics should be considered when designing hepatitis C elimination programs.
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Affiliation(s)
- Lin Zhu
- Department of Global Health and Population, Harvard T. H. Chan School of Public, Boston, MA, USA; Department of Health Policy, School of Medicine, Stanford University, Stanford, CA, USA.
| | - William W Thompson
- Prevention Branch, Division of Viral Hepatitis, Centers for Disease Control and Prevention, GA, USA
| | - Liesl Hagan
- Prevention Branch, Division of Viral Hepatitis, Centers for Disease Control and Prevention, GA, USA
| | - Liisa M Randall
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, Boston, MA, USA
| | - Abby E Rudolph
- Department of Epidemiology and Biostatistics, Temple University College of Public Health, Philadelphia, PA, USA
| | - April M Young
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, KY, USA; Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Jennifer R Havens
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, KY, USA
| | - Joshua A Salomon
- Department of Health Policy, School of Medicine, Stanford University, Stanford, CA, USA
| | - Benjamin P Linas
- Section of Infectious Disease, Department of Medicine, Boston Medical Center, Boston, MA, USA; Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
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López-Castro T, Sohler N, Riback L, Bravo G, Ohlendorf E, Ghiroli M, Fox AD. Posttraumatic stress disorder in people who use drugs: syringe services program utilization, treatment need, and preferences for onsite mental health care. Harm Reduct J 2024; 21:108. [PMID: 38824597 PMCID: PMC11143655 DOI: 10.1186/s12954-024-01019-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 05/09/2024] [Indexed: 06/03/2024] Open
Abstract
BACKGROUND Syringe services programs (SSPs) are critical healthcare access points for people with opioid use disorder (OUD) who face treatment utilization barriers. Co-locating care for common psychiatric comorbidities, like posttraumatic stress disorder (PTSD), at SSPs may reduce harms and enhance the health of individuals with OUD. To guide the development of onsite psychiatric care at SSPs, we collected quantitative survey data on the prevalence of PTSD, drug use patterns, treatment experiences associated with a probable PTSD diagnosis, and attitudes regarding onsite PTSD care in a convenience sample of registered SSP clients in New York City. METHODS Study participants were administered the PTSD Checklist for the DSM-5 (PCL-5) and asked about sociodemographic characteristics, current drug use, OUD and PTSD treatment histories, and desire for future SSP services using a structured interview. Probable PTSD diagnosis was defined as a PCL-5 score ≥ 31. RESULTS Of the 139 participants surveyed, 138 experienced at least one potentially traumatic event and were included in the present analysis. The sample was primarily male (n = 108, 78.3%), of Hispanic or Latinx ethnicity (n = 76, 55.1%), and middle-aged (M = 45.0 years, SD = 10.6). The mean PCL-5 score was 35.2 (SD = 21.0) and 79 participants (57.2%) had a probable PTSD diagnosis. We documented frequent SSP utilization, significant unmet PTSD treatment need, and high interest in onsite PTSD treatment. CONCLUSIONS Study findings point to the ubiquity of PTSD in people with OUD who visit SSPs, large gaps in PTSD care, and the potential for harm reduction settings like SSPs to reach people underserved by the healthcare system who have co-occurring OUD and PTSD.
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Affiliation(s)
- Teresa López-Castro
- Department of Psychology, The City College of New York, City University of New York, 160 Convent Avenue, New York, NY, 10031, USA.
| | - Nancy Sohler
- The City University of New York School of Medicine, 160 Convent Avenue, New York, NY, 10031, USA
| | - Lindsey Riback
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, 10461, USA
- Montefiore Medical Center, 111 East 210th Street, Bronx, NY, 10467, USA
| | - Gina Bravo
- Department of Psychology, The City College of New York, City University of New York, 160 Convent Avenue, New York, NY, 10031, USA
| | - Eric Ohlendorf
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, 10461, USA
| | - Megan Ghiroli
- Montefiore Medical Center, 111 East 210th Street, Bronx, NY, 10467, USA
| | - Aaron D Fox
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY, 10461, USA
- Montefiore Medical Center, 111 East 210th Street, Bronx, NY, 10467, USA
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Havens JR, Lofwall MR, Young AM, Staton M, Schaninger T, Fraser H, Vickerman P, Walsh SL. Predictors of engagement in screening for a hepatitis C virus (HCV) treatment trial in a rural Appalachian community. J Viral Hepat 2024; 31:293-299. [PMID: 38436098 PMCID: PMC11102319 DOI: 10.1111/jvh.13933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 01/29/2024] [Accepted: 02/21/2024] [Indexed: 03/05/2024]
Abstract
An HCV treatment trial was initiated in September 2019 to address the opioid/hepatitis C virus (HCV) syndemic in rural Kentucky. The focus of the current analysis is on participation in diagnostic screening for the trial. Initial eligibility (≥18 years of age, county resident) was established by phone followed by in-person HCV viremia testing. 900 rural residents met the inclusion criteria and comprised the analytic sample. Generalized linear models were specified to estimate the relative risk of non-attendance at the in-person visit determining HCV eligibility. Approximately one-quarter (22.1%) of scheduled participants were no-shows. People who inject drugs were no more likely than people not injecting drugs to be a no-show; however, participants ≤35 years of age were significantly less likely to attend. While the median time between phone screening and scheduled in-person screening was only 2 days, each additional day increased the odds of no-show by 3% (95% confidence interval: 2%-3%). Finally, unknown HCV status predicted no-show even after adjustment for age, gender, days between screenings and injection status. We found that drug injection did not predict no-show, further justifying expanded access to HCV treatment among people who inject drugs. Those 35 years and younger were more likely to no-show, suggesting that younger individuals may require targeted strategies for increasing testing and treatment uptake. Finally, streamlining the treatment cascade may also improve outcomes, as participants in the current study were more likely to attend if there were fewer days between phone screening and scheduled in-person screening.
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Affiliation(s)
- Jennifer R. Havens
- Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, KY USA
| | - Michelle R. Lofwall
- Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, KY USA
| | - April M. Young
- Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, KY USA
- Department of Epidemiology, University of Kentucky College of Public Health, Lexington, KY USA
| | - Michele Staton
- Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, KY USA
| | - Takako Schaninger
- Division of Infectious Disease, Department of Internal Medicine, University of Kentucky College of Medicine, Lexington, KY USA
| | - Hannah Fraser
- Bristol Population Health Sciences Institute, Bristol Medical School, Bristol, United Kingdom
| | - Peter Vickerman
- Bristol Population Health Sciences Institute, Bristol Medical School, Bristol, United Kingdom
| | - Sharon L. Walsh
- Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, KY USA
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M FM, Doug LM, Peter F, Vivian F G, Wiley J, P Todd K, William M, Mai P, David S, Tom S, Ryan W, William Z, M YA, Lf CH. Correlates of overdose among 2711 people who use drugs and live in 7 rural US sites. Drug Alcohol Depend 2024; 258:111261. [PMID: 38581919 DOI: 10.1016/j.drugalcdep.2024.111261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 02/29/2024] [Accepted: 03/03/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Overdose rates in rural areas have been increasing globally, with large increases in the United States. Few studies, however, have identified correlates of non-fatal overdose among rural people who use drugs (PWUD). The present analysis describes correlates of nonfatal overdose among a large multistate sample of rural PWUD. METHODS This is a cross-sectional analysis of data gathered via surveys with PWUD recruited through seven Rural Opioid Initiative (ROI) sites. Descriptive analyses were conducted to assess the prevalence of past 30-day overdose. Generalized estimating equations were used to estimate a series of multivariable models quantifying relationships of select factors to past-month overdose; factors were selected using the Risk Environment Framework. RESULTS The multisite sample included 2711 PWUD, 6% of whom reported overdosing in the past 30 days. In the fully adjusted model, houselessness (AOR=2.27, 95%CI[1.48, 3.48]), a positive test result for Hepatitis C infection (AOR=1.73 95%CI[1.18, 2.52]) and heroin/fentanyl use (AOR= 8.58 95%CI [3.01, 24.50]) were associated with an increased risk of reporting past 30-day overdose, while having a high-school education or less was associated with reduced odds of overdose (AOR=0.52, 95% CI[0.37, 0.74]). CONCLUSION As in urban areas, houselessness, Hepatitis C infection, and the use of heroin and fentanyl were significant correlates of overdose. Widespread access to overdose prevention interventions - including fentanyl test strips and naloxone - is critical in this rural context, with particular outreach needed to unhoused populations, people living with Hepatitis C, and people using opioids.
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Affiliation(s)
- Fadanelli Monica M
- Rollins School of Public Health, 1518 Clifton Dr, Atlanta, GA 30329, USA.
| | | | - Friedmann Peter
- UMass Chan Medical School - Baystate, 3601 Main Street, Springfield, MA 01199, USA
| | - Go Vivian F
- Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC 27599, USA
| | - Jenkins Wiley
- SIU School of Medicine, 801 N Rutledge St., Springfield, IL 62702, USA
| | - Korthuis P Todd
- Oregon Health & Science University, School of Medicine, 3266 SW Research Dr, Portland, OR 97239, USA
| | - Miller William
- Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC 27599, USA
| | - Pho Mai
- The University of Chicago Medicine, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
| | - Seal David
- Tulane School of Public Health & Tropical Medicine, 1440 Canal St, New Orleans, LA 70112, USA
| | - Stopka Tom
- Tufts University School of Medicine, Public Health and Community Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Westergaard Ryan
- University of Wisconsin, School of Medicine and Public Health, 1685 Highland Ave, Madison, WI 53705-2281, USA
| | - Zule William
- Research Triangle Park, 3040 East Cornwallis Road, P.O. Box 12194, NC 27709-2194, USA
| | - Young April M
- University of Kentucky, College of Public Health, 111 Washington Ave., Lexington, KY 40536, USA
| | - Cooper Hannah Lf
- Rollins School of Public Health, 1518 Clifton Dr, Atlanta, GA 30329, USA
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Garcia V, McCann L, Lauber E, Vaccaro C, Swauger M, Heckert DA. Opioid Overdoses and Take-Home Naloxone Interventions: Ethnographic Evidence for Individual-Level Barriers to Treatment of Opioid Use Disorders in Rural Appalachia. Subst Use Misuse 2024; 59:1313-1322. [PMID: 38635977 DOI: 10.1080/10826084.2024.2340986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
Introduction: Research indicates that take-home naloxone (THN) is saving lives across rural Appalachia, but whether it also results in treatment for opioid use disorders (OUDs) remains unclear. This study involves a detailed qualitative analysis of interviews with 16 individuals who had overdosed on opioids 61 times to understand why a THN intervention does not routinely lead to OUD treatment. Methods: This study builds upon a one-year (2018) qualitative study on community responses to opioid overdose fatalities in four adjacent rural counties in Western Pennsylvania. Using a semi-structured interview guide, 16 individuals who had experienced one or more overdoses were interviewed. Using NVivo, the transcribed audio-recorded interviews were coded, and a thematic analysis of the coded text was conducted. Findings: Findings reveal that of the 29 overdoses that included a THN intervention, only eight resulted in treatment. The analysis derives five individual-level barriers to treatment: (1) opioid dependence, (2) denial/readiness, (3) opioid withdrawal fears, (4) incarceration concerns, and (5) stigma and shame. These barriers impeded treatment, even though all the interviewees knew of treatment programs, how to access them, and in some cases had undergone treatment previously. Discussion and Conclusion: findings indicate that there is evidence that the five barriers make entering treatment after a THN intervention challenging and seemingly insurmountable at times. Recommendations based on the findings include increasing efforts to reduce stigma of OUDs in the community, including self-stigma resulting from misusing opioids, increasing informational efforts about Good Samaritan Laws, and increasing familiarity with medication-assisted treatments for OUDS.
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Affiliation(s)
- Victor Garcia
- Research Scientist, Prevention Research Center, Berkeley, California, USA
| | - Lisa McCann
- Department of Sociology, Indiana University of Pennsylvania, Indiana, Pennsylvania, USA
| | - Erick Lauber
- Department of Communications Media, Indiana University of Pennsylvania, Indiana, Pennsylvania, USA
| | - Christian Vaccaro
- Department of Sociology Associate Director Mid Atlantic Research and, Training Institute Indiana University of Pennsylvania, Indiana, Pennsylvania, USA
| | - Melissa Swauger
- Nonprofit Management, Empowerment and Diversity Studies (new address), Slippery Rock University of Pennsylvania Slippery Rock, Pennsylvania, USA
| | - Daniel Alex Heckert
- Department of Sociology Director Mid Atlantic Research and Training Center, Indiana University of Pennsylvania, Indiana, Pennsylvania, USA
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Byrne CJ, Sani F, Thain D, Fletcher EH, Malaguti A. Psychosocial factors associated with overdose subsequent to Illicit Drug use: a systematic review and narrative synthesis. Harm Reduct J 2024; 21:81. [PMID: 38622647 PMCID: PMC11017611 DOI: 10.1186/s12954-024-00999-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 04/03/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND AND AIMS Psychological and social status, and environmental context, may mediate the likelihood of experiencing overdose subsequent to illicit drug use. The aim of this systematic review was to identify and synthesise psychosocial factors associated with overdose among people who use drugs. METHODS This review was registered on Prospero (CRD42021242495). Systematic record searches were undertaken in databases of peer-reviewed literature (Medline, Embase, PsycINFO, and Cinahl) and grey literature sources (Google Scholar) for work published up to and including 14 February 2023. Reference lists of selected full-text papers were searched for additional records. Studies were eligible if they included people who use drugs with a focus on relationships between psychosocial factors and overdose subsequent to illicit drug use. Results were tabulated and narratively synthesised. RESULTS Twenty-six studies were included in the review, with 150,625 participants: of those 3,383-4072 (3%) experienced overdose. Twenty-one (81%) studies were conducted in North America and 23 (89%) reported polydrug use. Psychosocial factors associated with risk of overdose (n = 103) were identified and thematically organised into ten groups. These were: income; housing instability; incarceration; traumatic experiences; overdose risk perception and past experience; healthcare experiences; perception of own drug use and injecting skills; injecting setting; conditions with physical environment; and social network traits. CONCLUSIONS Global rates of overdose continue to increase, and many guidelines recommend psychosocial interventions for dependent drug use. The factors identified here provide useful targets for practitioners to focus on at the individual level, but many identified will require wider policy changes to affect positive change. Future research should seek to develop and trial interventions targeting factors identified, whilst advocacy for key policy reforms to reduce harm must continue.
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Affiliation(s)
- Christopher J Byrne
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK.
- Directorate of Public Health, NHS Tayside, Kings Cross Hospital, Dundee, UK.
| | - Fabio Sani
- Division of Psychology, School of Humanities, Social Sciences and Law, University of Dundee, Scrymgeour Building, Dundee, UK
| | - Donna Thain
- Directorate of Public Health, NHS Tayside, Kings Cross Hospital, Dundee, UK
| | - Emma H Fletcher
- Directorate of Public Health, NHS Tayside, Kings Cross Hospital, Dundee, UK
| | - Amy Malaguti
- Division of Psychology, School of Humanities, Social Sciences and Law, University of Dundee, Scrymgeour Building, Dundee, UK
- Tayside Drug and Alcohol Recovery Psychology Service, NHS Tayside, Dundee, UK
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Young AM, Havens JR, Cooper HLF, Fallin-Bennett A, Fanucchi L, Freeman PR, Knudsen H, Livingston MD, McCollister KE, Stone J, Vickerman P, Freeman E, Jahangir T, Larimore E, White CR, Cheatom C, Community Staff K, Design Team K. Kentucky Outreach Service Kiosk (KyOSK) Study protocol: a community-level, controlled quasi-experimental, type 1 hybrid effectiveness study to assess implementation, effectiveness and cost-effectiveness of a community-tailored harm reduction kiosk on HIV, HCV and overdose risk in rural Appalachia. BMJ Open 2024; 14:e083983. [PMID: 38431295 PMCID: PMC10910671 DOI: 10.1136/bmjopen-2024-083983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 02/13/2024] [Indexed: 03/05/2024] Open
Abstract
INTRODUCTION Many rural communities bear a disproportionate share of drug-related harms. Innovative harm reduction service models, such as vending machines or kiosks, can expand access to services that reduce drug-related harms. However, few kiosks operate in the USA, and their implementation, impact and cost-effectiveness have not been adequately evaluated in rural settings. This paper describes the Kentucky Outreach Service Kiosk (KyOSK) Study protocol to test the effectiveness, implementation outcomes and cost-effectiveness of a community-tailored, harm reduction kiosk in reducing HIV, hepatitis C and overdose risk in rural Appalachia. METHODS AND ANALYSIS KyOSK is a community-level, controlled quasi-experimental, non-randomised trial. KyOSK involves two cohorts of people who use drugs, one in an intervention county (n=425) and one in a control county (n=325). People who are 18 years or older, are community-dwelling residents in the target counties and have used drugs to get high in the past 6 months are eligible. The trial compares the effectiveness of a fixed-site, staffed syringe service programme (standard of care) with the standard of care supplemented with a kiosk. The kiosk will contain various harm reduction supplies accessible to participants upon valid code entry, allowing dispensing data to be linked to participant survey data. The kiosk will include a call-back feature that allows participants to select needed services and receive linkage-to-care services from a peer recovery coach. The cohorts complete follow-up surveys every 6 months for 36 months (three preceding kiosk implementation and four post-implementation). The study will test the effectiveness of the kiosk on reducing risk behaviours associated with overdose, HIV and hepatitis C, as well as implementation outcomes and cost-effectiveness. ETHICS AND DISSEMINATION The University of Kentucky Institutional Review Board approved the protocol. Results will be disseminated in academic conferences and peer-reviewed journals, online and print media, and community meetings. TRIAL REGISTRATION NUMBER NCT05657106.
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Affiliation(s)
- April M Young
- Department of Epidemiology and Environmental Health, University of Kentucky, Lexington, Kentucky, USA
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
| | - Jennifer R Havens
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Hannah L F Cooper
- Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | | | - Laura Fanucchi
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Patricia R Freeman
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky, Lexington, Kentucky, USA
| | - Hannah Knudsen
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Melvin D Livingston
- Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Kathryn E McCollister
- Division of Health Services Research and Policy, University of Miami, Coral Gables, Florida, USA
| | - Jack Stone
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Peter Vickerman
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Edward Freeman
- Department of Epidemiology and Environmental Health, University of Kentucky, Lexington, Kentucky, USA
| | - Tasfia Jahangir
- Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Elizabeth Larimore
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
| | - Carol R White
- Department of Epidemiology and Environmental Health, University of Kentucky, Lexington, Kentucky, USA
| | | | - KyOSK Community Staff
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
- College of Public Health, University of Kentucky, Lexington, Kentucky, USA
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Kesich Z, Ibragimov U, Komro K, Lane K, Livingston M, Young A, Cooper H. "I'm not going to lay back and watch somebody die": A qualitative study of how people who use drugs' naloxone experiences are shaped by rural risk environment and naloxone distribution/overdose education intervention. RESEARCH SQUARE 2023:rs.3.rs-3310319. [PMID: 37720025 PMCID: PMC10503866 DOI: 10.21203/rs.3.rs-3310319/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Background Overdoses have surged in rural areas in the U.S. and globally for years, but harm reduction interventions have lagged. Overdose education and naloxone distribution (OEND) programs are highly effective to prevent overdose mortality, but little is known about people who use drugs' (PWUD) experience with these interventions in rural areas. Here, we analyze qualitative data with rural PWUD to learn about their experiences with an OEND intervention, and about how their perceptions of their rural risk environments influenced the interventions' effects. Methods Twenty-nine one-on-one, semi-structured qualitative interviews were conducted with rural PWUD engaged in the CARE2HOPE OEND intervention in Appalachian Kentucky. Interviews were conducted via Zoom, audio-recorded, and transcribed verbatim. Thematic analysis was conducted, guided by the Rural Risk Environment Framework. Results The OEND intervention transformed participants' roles locally, so they became an essential component of the local rural healthcare environment. The intervention provided access to naloxone and information, thereby increasing PWUD's confidence in naloxone administration. Through the intervention, over half of participants gained knowledge on naloxone (access points, administration technique) and on the criminal-legal environment as it pertained to naloxone. Most participants opted to accept and carry naloxone, citing factors related to the social environment (sense of responsibility to their community) and physical/healthcare environments (high overdose prevalence, suboptimal emergency response systems). Over half of participants described recent experiences administering intervention-provided naloxone. These experiences were shaped by features of the local rural social environment (anticipated negative reaction from recipients, prior naloxone conversations). Conclusions By providing naloxone paired with non-stigmatizing health and policy information, the OEND intervention offered the material and informational support that allowed participants to become a part of the healthcare environment. Findings highlight need for more outreach to rural PWUD on local policy that impacts them; tailored strategies to help rural PWUD engage in productive dialogue with peers about naloxone and navigate interpersonal conflict associated with overdose reversal; and opportunities for rural PWUD to formally participate in emergency response systems as peer overdose responders. Trial registration The ClinicalTrials.gov ID for the CARE2HOPE intervention is NCT04134767. The registration date was October 19th, 2019.
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Affiliation(s)
- Zora Kesich
- Emory University Rollins School of Public Health
| | | | - Kelli Komro
- Emory University Rollins School of Public Health
| | | | | | - April Young
- University of Kentucky College of Public Health
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Guarino H, Frank D, Quinn K, Kim D, Gile K, Ruggles K, Friedman SR, Mateu-Gelabert P. Syndemic factors associated with non-fatal overdose among young opioid users in New York City. Front Public Health 2023; 11:1195657. [PMID: 37435512 PMCID: PMC10332320 DOI: 10.3389/fpubh.2023.1195657] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/07/2023] [Indexed: 07/13/2023] Open
Abstract
Introduction Rates of illicit opioid use are particularly high among young adults, yet research on overdose experience and factors associated with overdose in this population remains limited. This study examines the experiences and correlates of non-fatal overdose among young adults using illicit opioids in New York City (NYC). Methods 539 participants were recruited via Respondent-Driven Sampling in 2014-2016. Eligibility criteria included: aged 18-29 years old; current residence in NYC; and nonmedical prescription opioid (PO) use and/or heroin use in the past 30 days. Participants completed structured interviews to assess their socio-demographics, drug use trajectories, current substance use and lifetime and most recent overdose experiences, and were tested on-site for hepatitis C virus (HCV) antibodies. Results 43.9% of participants reported lifetime overdose experience; of these, 58.8% had experienced two or more overdose events. The majority of participants' most recent overdoses (63.5%) were due to polysubstance use. In bivariable analyses, after RDS adjustment, having ever overdosed was correlated with: household income of >$100,00 growing up (vs. $51,000-100,000); lifetime homelessness; HCV antibody-positive status; lifetime engagement in regular nonmedical benzodiazepine use, regular heroin injection and regular PO injection; and using a non-sterile syringe in the past 12 months. Multivariable logistic regression identified childhood household income >$100,00 (AOR=1.88), HCV-positive status (AOR=2.64), benzodiazepine use (AOR=2.15), PO injection (AOR=1.96) and non-sterile syringe use (AOR=1.70) as significant independent correlates of lifetime overdose. A multivariable model with multiple overdoses (vs. one) found only lifetime regular heroin use and PO injection to be strong correlates. Discussion Results indicate a high prevalence of lifetime and repeated overdose among opioid-using young adults in NYC, highlighting a need for intensified overdose prevention efforts for this population. The strong associations of HCV and indices of polydrug use with overdose suggest that prevention efforts should address the complex risk environment in which overdose occurs, attending to the overlapping nature of disease-related risk behavior and overdose risk behavior among young people who inject opioids. Overdose prevention efforts tailored for this group may find it useful to adopt a syndemic conception of overdose that understands such events as resulting from multiple, and often interrelated, risk factors.
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Affiliation(s)
- Honoria Guarino
- Institute for Implementation Science in Population Health, CUNY Graduate School of Public Health & Health Policy, New York, NY, United States
| | - David Frank
- Behavioral Science Training Program in Drug Abuse Research, NYU Rory Myers College of Nursing, New York University, New York, NY, United States
| | - Kelly Quinn
- Behavioral Science Training Program in Drug Abuse Research, NYU Rory Myers College of Nursing, New York University, New York, NY, United States
- Department of Population Health, New York University School of Medicine, New York, NY, United States
| | - Dongah Kim
- Department of Mathematics and Statistics, University of Massachusetts Amherst, Amherst, MA, United States
| | - Krista Gile
- Department of Mathematics and Statistics, University of Massachusetts Amherst, Amherst, MA, United States
| | - Kelly Ruggles
- Department of Population Health, New York University School of Medicine, New York, NY, United States
| | - Samuel R. Friedman
- Department of Population Health, New York University School of Medicine, New York, NY, United States
| | - Pedro Mateu-Gelabert
- Institute for Implementation Science in Population Health, CUNY Graduate School of Public Health & Health Policy, New York, NY, United States
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10
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Oser CB, Batty E, Booty M, Eddens K, Knudsen HK, Perry B, Rockett M, Staton M. Social ecological factors and medication treatment for opioid use disorder among justice-involved rural and urban persons: the Geographic variation in Addiction Treatment Experiences (GATE) longitudinal cohort study protocol. BMJ Open 2023; 13:e066068. [PMID: 36940952 PMCID: PMC10030549 DOI: 10.1136/bmjopen-2022-066068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2023] Open
Abstract
INTRODUCTION Three medications are Food and Drug Administration approved for the treatment of opioid use disorder (OUD); however, these medications are underused within prisons, which elevates the risk of relapse and overdose when persons with opioid use disorder (POUD) are released. Research is scant regarding the multilevel factors associated with POUDs' willingness to initiate medication treatment for opioid use disorder (MOUD) while in prison and their continued engagement in treatment after release. Furthermore, rural and urban populations have not been compared. The Geographic variation in Addiction Treatment Experiences (GATE) study seeks to identify multilevel factors (ie, individual, personal network, and structural factors) influencing prison-based extended-release injectable naltrexone (XR-NTX) and buprenorphine initiation and will examine predictors of postrelease MOUD use and adverse outcomes (ie, relapse, overdose, recidivism) among both rural and urban POUDs. METHODS AND ANALYSIS This mixed methods study employs a social ecological framework. A prospective observational longitudinal cohort study is being conducted with 450 POUDs using survey and social network data collected in prison, immediately postrelease, 6 months postrelease and 12 months postrelease to identify multilevel rural-urban variation in key outcomes. In-depth qualitative interviews are being conducted with POUDs, prison-based treatment staff and social service clinicians. To maximise rigour and reproducibility, we employ a concurrent triangulation strategy, whereby qualitative and quantitative data contribute equally to the analysis and are used for cross-validation when examining scientific aims. ETHICS AND DISSEMINATION The GATE study was reviewed and approved by the University of Kentucky's Institutional Review Board prior to implementation. Findings will be disseminated through presentations at scientific and professional association conferences, peer-reviewed journal publications and a summary aggregate report submitted to the Kentucky Department of Corrections.
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Affiliation(s)
- Carrie B Oser
- Department of Sociology, Center on Drug & Alcohol Research, Center for Health Equity Transformation, University of Kentucky, Lexington, Kentucky, USA
| | - Evan Batty
- Department of Sociology, Center on Drug & Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
| | - Marisa Booty
- Department of Sociology, Center on Drug & Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
| | - Kate Eddens
- Department of Epidemiology & Biostatistics, School of Public Health, Indiana University, Bloomington, Indiana, USA
| | - Hannah K Knudsen
- Department of Behavioral Science, Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
| | - Brea Perry
- Department of Sociology, Irsay Family Research Institute, Indiana University, Bloomington, Indiana, USA
| | - Maria Rockett
- Department of Sociology, Center on Drug & Alcohol Research, Center for Health Equity Transformation, University of Kentucky, Lexington, Kentucky, USA
| | - Michele Staton
- Department of Behavioral Science, Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
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11
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Macmadu A, Gurka KK, Linn HI, Smith GS, Feinberg J. Factors Associated with Non-Evidence-Based Overdose Responses among People Who Use Prescription Opioids Non-Medically in Rural Appalachia. Subst Use Misuse 2023; 58:163-170. [PMID: 36546533 DOI: 10.1080/10826084.2022.2135967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: Opioid-related overdose deaths recently accelerated. In response, overdose education and naloxone distribution (OEND) has been implemented widely, though access remains sparse in rural Appalachia. Despite increasing OEND, risk factors for non-evidence-based overdose responses among the training-naïve remain unknown. Methods: We enrolled 169 adults who use prescription opioids non-medically and reside in rural West Virginia (August 2014-March 2015). Participants were interviewed about witnessing overdose (lifetime and prior-year), characteristics of the most recent overdose, responses to the overdose, and OEND acceptability. Logistic regression was used to assess factors associated with non-evidence-based responses to overdose. Results: Among the 73 participants who witnessed an opioid-related overdose, the majority (n = 53, 73%) reported any non-evidence-based responses. Participants were significantly more likely to report a non-evidence-based response when victims were unresponsive (OR = 3.36; 95% CI = 1.07, 10.58). Common evidence-based responses included staying with the victim until help arrived (n = 66, 90%) and calling 911 (n = 63, 86%), while the most common non-evidence-based responses were hitting or slapping the victim (n = 37, 51%) and rubbing the victim with ice or placing them in a cold shower or bath (n = 14, 19%). While most (n = 60, 82%) had never heard of OEND, the majority (n = 69, 95%) were willing to train, particularly those reporting non-evidence-based responses (n = 52, 98%). Conclusions: These findings underscore the need to expand access to OEND in rural communities and indicate OEND is acceptable to training-naïve individuals who use opioids in rural Appalachia. Given the "harm reduction deserts" in the region, approaches to expand OEND should be pursued.
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Affiliation(s)
- Alexandria Macmadu
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Kelly K Gurka
- Department of Epidemiology, University of Florida Colleges of Public Health & Health Professions and Medicine, Gainesville, Florida, USA
| | - Herbert I Linn
- Office of Health Affairs, Health Sciences Center, West Virginia University, Morgantown, West Virginia, USA
| | - Gordon S Smith
- Department of Epidemiology and Biostatistics, School of Public Health, West Virginia University, Morgantown, West Virginia, USA
| | - Judith Feinberg
- Department of Behavioral Medicine & Psychiatry, West Virginia University, Morgantown, West Virginia, USA
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12
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Nolte K, Romo E, Stopka TJ, Drew A, Dowd P, Del Toro-Mejias L, Bianchet E, Friedmann PD. "I've been to more of my friends' funerals than I've been to my friends' weddings": Witnessing and responding to overdose in rural Northern New England. J Rural Health 2023; 39:197-211. [PMID: 35301749 PMCID: PMC9481744 DOI: 10.1111/jrh.12660] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE Overdose is a leading cause of death among people who use drugs (PWUDs), but policies to reduce fatal overdose have had mixed results. Summaries of naloxone access and Good Samaritan Laws (GSLs) in prior studies provide limited information about local context. Witnessing overdoses may also be an important consideration in providing services to PWUDs, as it contributes to post traumatic stress disorder (PTSD) symptoms, which complicate substance use disorder treatment. METHODS We aim to estimate the prevalence and correlates of witnessing and responding to an overdose, while exploring overdose context among rural PWUD. The Drug Injection Surveillance and Care Enhancement for Rural Northern New England (DISCERNNE) mixed-methods study characterized substance use and risk behaviors in 11 rural Massachusetts, Vermont, and New Hampshire counties between 2018 and 2019. PWUD completed surveys (n = 589) and in-depth interviews (n = 22). FINDINGS Among the survey participants, 84% had ever witnessed an overdose, which was associated with probable PTSD symptoms. Overall, 51% had ever called 911 for an overdose, though some experienced criminal legal system consequences despite GSL. Although naloxone access varied, 43% had ever used naloxone to reverse an overdose. CONCLUSIONS PWUD in Northern New England commonly witnessed an overdose, which they experienced as traumatic. Participants were willing to respond to overdoses, but faced barriers to effective overdose response, including limited naloxone access and criminal legal system consequences. Equipping PWUDs with effective overdose response tools (education and naloxone) and enacting policies that further protect PWUDs from criminal legal system consequences could reduce overdose mortality.
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Affiliation(s)
- Kerry Nolte
- Department of Nursing, College of Health and Human Services, University of New Hampshire, Hewitt Hall, 4 Library Way, Durham, NH, 03824, USA
| | - Eric Romo
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Thomas J. Stopka
- Department of Public Health and Community Medicine, Tufts University School of Public Health, 136 Harrison Ave., Boston, MA
| | - Aurora Drew
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, 1 Medical Center Drive, Lebanon, NH, 03756, USA
| | - Patrick Dowd
- Office of Research, University of Massachusetts Medical School-Baystate, 3601 Main Street, 3 Floor, Springfield, MA, 01199, USA
| | - Lizbeth Del Toro-Mejias
- Office of Research, University of Massachusetts Medical School-Baystate, 3601 Main Street, 3 Floor, Springfield, MA, 01199, USA
| | - Elyse Bianchet
- Office of Research, University of Massachusetts Medical School-Baystate, 3601 Main Street, 3 Floor, Springfield, MA, 01199, USA
| | - Peter D. Friedmann
- Office of Research, University of Massachusetts Medical School-Baystate, 3601 Main Street, 3 Floor, Springfield, MA, 01199, USA
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13
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Macmadu A, Frueh L, Collins AB, Newman R, Barnett NP, Rich JD, Clark MA, Marshall BDL. Drug use behaviors, trauma, and emotional affect following the overdose of a social network member: A qualitative investigation. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 107:103792. [PMID: 35816791 PMCID: PMC9462427 DOI: 10.1016/j.drugpo.2022.103792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/03/2022] [Accepted: 07/04/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Scant research has examined the influence of overdoses occurring in social networks (i.e., knowing someone who has overdosed) on individual overdose risk. We sought to characterize drug use behaviors of individuals following the overdose of someone in their social network. METHODS We conducted semi-structured interviews with 25 people who use drugs and knew someone who overdosed in the prior 90 days. All interviews were conducted in person in Rhode Island from July to October 2021. Data were stratified by drug use behaviors following the overdose of a network member (i.e., risk behaviors, protective behaviors, no change; selected a priori) and analyzed using a thematic analysis variation to identify salient themes. RESULTS We identified variation in the effect of knowing someone who overdosed on subsequent drug use behaviors and emotional affect. Several participants described increasing their drug use or using more types of drugs than usual to manage feelings of bereavement and trauma, and a subset of these participants described increased drug use with suicidal intention and increased suicidal ideations following the overdose event. Other participants described reducing their drug use and engaging in protective behaviors in response to heightened perceived overdose risk, protection motivation (i.e., increased motivation to protect oneself), and concern for others. Additionally, some participants reported no change in drug use behaviors, and these participants described already engaging in harm reduction practices, feeling desensitized due to frequent or repeated exposure to overdose, and ambivalence about living. CONCLUSIONS Findings suggest a need for enhanced investment in network-based overdose prevention interventions, as well as more robust integration of bereavement support and mental health services in settings that serve people who use drugs. The findings also suggest a need for future research to identify mediators of the effect of overdose occurring in social networks on individual overdose risk.
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Affiliation(s)
- Alexandria Macmadu
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Providence, RI, USA
| | - Lisa Frueh
- Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, USA
| | - Alexandra B Collins
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Providence, RI, USA
| | - Roxxanne Newman
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Providence, RI, USA
| | - Nancy P Barnett
- Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 South Main Street, Providence, RI, USA
| | - Josiah D Rich
- The Center for Health + Justice Transformation, The Miriam Hospital, 1125 North Main Street, Providence, RI, USA
| | - Melissa A Clark
- Department of Health Services, Policy & Practice, Brown University School of Public Health, 121 South Main Street, Providence, RI, USA
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Providence, RI, USA.
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14
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Prevalence of mental disorders among people with opioid use disorder: A systematic review and meta-analysis. Drug Alcohol Depend 2022; 238:109551. [PMID: 35797876 DOI: 10.1016/j.drugalcdep.2022.109551] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/12/2022] [Accepted: 06/26/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Opioid use disorder (OUD) and mental disorders are major public health issues and comorbidity is common. Among people with OUD, comorbid mental disorders are associated with poorer health outcomes. To our knowledge, this is the first systematic review and meta-analysis to estimate prevalence of specific mental disorders among people with OUD. METHODS We searched Embase, MEDLINE, and PsycInfo from 1990 to 2021 for observational studies of depression, anxiety, post-traumatic stress disorder (PTSD), bipolar, personality, and other pre-specified mental disorders among people with OUD. We pooled current and lifetime estimates of each disorder using random-effects meta-analyses with 95% Confidence Intervals (CIs). Meta-regressions and stratified analyses were used to assess heterogeneity of prevalence estimates by methodological factors and sample characteristics. FINDINGS Of the 36,971 publications identified, we included data from 345 studies and 104,135 people with OUD in at least one pooled estimate. Among people with OUD, the prevalence of current depression was 36.1% (95%CI 32.4-39.7%), anxiety was 29.1% (95%CI 24.0-33.3%), attention-deficit/hyperactivity disorder was 20.9% (95%CI 15.7-26.2%), PTSD was 18.1% (95%CI 15.4-20.9%), and bipolar disorder was 8.7% (95%CI 6.7-10.7%). Lifetime prevalence of anti-social personality disorder was 33.6% (95%CI 29.1-38.0%) and borderline personality disorder was 18.2% (95% CI 13.4-23.1%). Sample characteristics and methodological factors, including sex, were associated with variance of multiple prevalence estimates. INTERPRETATION Our findings emphasise the need for access to mental disorder treatment among people with OUD. Specific mental disorder estimates may inform clinical guidelines, treatment services, and future research for people with OUD, including subpopulations with distinct treatment needs.
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15
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Jenkins RA, Whitney BM, Nance RM, Allen TM, Cooper HLF, Feinberg J, Fredericksen R, Friedmann PD, Go VF, Jenkins WD, Korthuis PT, Miller WC, Pho MT, Rudolph AE, Seal DW, Smith GS, Stopka TJ, Westergaard RP, Young AM, Zule WA, Delaney JAC, Tsui JI, Crane HM. The Rural Opioid Initiative Consortium description: providing evidence to Understand the Fourth Wave of the Opioid Crisis. Addict Sci Clin Pract 2022; 17:38. [PMID: 35883197 PMCID: PMC9321271 DOI: 10.1186/s13722-022-00322-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 07/11/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To characterize and address the opioid crisis disproportionately impacting rural U.S. regions. METHODS The Rural Opioid Initiative (ROI) is a two-phase project to collect and harmonize quantitative and qualitative data and develop tailored interventions to address rural opioid use. The baseline quantitative survey data from people who use drugs (PWUD) characterizes the current opioid epidemic (2018-2020) in eight geographically diverse regions. RESULTS Among 3,084 PWUD, 92% reported ever injecting drugs, 86% reported using opioids (most often heroin) and 74% reported using methamphetamine to get high in the past 30 days; 53% experienced homelessness in the prior 6 months; and 49% had ever overdosed. Syringe service program use varied by region and 53% had ever received an overdose kit or naloxone prescription. Less than half (48%) ever received medication for opioid use disorder (MOUD). CONCLUSIONS The ROI combines data across eight rural regions to better understand drug use including drivers and potential interventions in rural areas with limited resources. Baseline ROI data demonstrate extensive overlap between opioid and methamphetamine use, high homelessness rates, inadequate access to MOUD, and other unmet needs among PWUD in the rural U.S. By combining data across studies, the ROI provides much greater statistical power to address research questions and better understand the syndemic of infectious diseases and drug use in rural settings including unmet treatment needs.
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Affiliation(s)
- Richard A. Jenkins
- Prevention Research Branch, National Institute on Drug Abuse, 3WFN MSC 6024, 301 North Stonestreet Ave, Bethesda, MD 20892 USA
| | - Bridget M. Whitney
- University of Washington Harborview Medical Center, 325 9th Ave, Box 359931, Seattle, WA 98106 USA
| | - Robin M. Nance
- University of Washington Harborview Medical Center, 325 9th Ave, Box 359931, Seattle, WA 98106 USA
| | - Todd M. Allen
- Ragon Institute of MGH, MIT and Harvard, Rm 764 400 Technology Square, Cambridge, MA 02139 USA
| | - Hannah L. F. Cooper
- Rollins School of Public Health, Emory University, Grace Crum Rollins Building 1518 Clifton Road, Atlanta, GA 30322 USA
| | - Judith Feinberg
- West Virginia University, 930 Chestnut Ridge Road, PO Box 9156, Morgantown, WV 26505 USA
| | - Rob Fredericksen
- University of Washington Harborview Medical Center, 325 9th Ave, Box 359931, Seattle, WA 98106 USA
| | - Peter D. Friedmann
- Baystate Medical Center—University of Massachusetts, Office of Research, UMass Chan Medical School - Baystate, 3601 Main Street, 3rd Floor, Springfield, MA 01199 USA
| | - Vivian F. Go
- University of North Carolina—Chapel Hill, 363 Rosenau Hall CB# 7440, Chapel Hill, NC 27599 USA
| | - Wiley D. Jenkins
- Southern Illinois University, 201 E Madison Street, Springfield, IL 62702 USA
| | - P. Todd Korthuis
- Oregon Health & Science University, 3270 Southwest Pavilion Loop OHSU Physicians Pavilion, Suite 350, Portland, OR 97239 USA
| | - William C. Miller
- The Ohio State University, 302 Cunz Hall 1841 Neil Ave, Columbus, OH 43210 USA
| | - Mai T. Pho
- University of Chicago, 5841 S. Maryland Avenue, Chicago, IL 60637 USA
| | - Abby E. Rudolph
- Department of Epidemiology and Biostatistics, Temple University College of Public Health, 1301 Cecil B Moore Avenue, Ritter Annex 905, Philadelphia, PA USA
| | - David W. Seal
- Tulane University, 1440 Canal Street, Suite 2210, New Orleans, LA 70112 USA
| | - Gordon S. Smith
- West Virginia University, 930 Chestnut Ridge Road, PO Box 9156, Morgantown, WV 26505 USA
- College of Pharmacy, University of Manitoba, Apotex Centre, 750 McDermot Ave. W, Winnipeg, MB R3E 0T5 Canada
| | - Thomas J. Stopka
- Tufts University School of Medicine Public Health and Community Medicine, 136 Harrison Avenue, Boston, MA 02111 USA
| | - Ryan P. Westergaard
- University of Wisconsin-Madison, 1685 Highland Avenue, 5th Floor, Madison, WI 53705-2281 USA
| | - April M. Young
- University of Kentucky, 760 Press Avenue Suite 280, Lexington, KY 40536 USA
| | - William A. Zule
- RTI International, 3040 E. Cornwallis Road, PO Box 12194, Research Triangle Park, NC 2709-2194 USA
| | - Joseph A. C. Delaney
- College of Pharmacy, University of Manitoba, Apotex Centre, 750 McDermot Ave. W, Winnipeg, MB R3E 0T5 Canada
| | - Judith I. Tsui
- University of Washington Harborview Medical Center, 325 9th Ave, Box 359931, Seattle, WA 98106 USA
| | - Heidi M. Crane
- University of Washington Harborview Medical Center, 325 9th Ave, Box 359931, Seattle, WA 98106 USA
| | - the Rural Opioid Initiative
- Prevention Research Branch, National Institute on Drug Abuse, 3WFN MSC 6024, 301 North Stonestreet Ave, Bethesda, MD 20892 USA
- University of Washington Harborview Medical Center, 325 9th Ave, Box 359931, Seattle, WA 98106 USA
- Ragon Institute of MGH, MIT and Harvard, Rm 764 400 Technology Square, Cambridge, MA 02139 USA
- Rollins School of Public Health, Emory University, Grace Crum Rollins Building 1518 Clifton Road, Atlanta, GA 30322 USA
- West Virginia University, 930 Chestnut Ridge Road, PO Box 9156, Morgantown, WV 26505 USA
- Baystate Medical Center—University of Massachusetts, Office of Research, UMass Chan Medical School - Baystate, 3601 Main Street, 3rd Floor, Springfield, MA 01199 USA
- University of North Carolina—Chapel Hill, 363 Rosenau Hall CB# 7440, Chapel Hill, NC 27599 USA
- Southern Illinois University, 201 E Madison Street, Springfield, IL 62702 USA
- Oregon Health & Science University, 3270 Southwest Pavilion Loop OHSU Physicians Pavilion, Suite 350, Portland, OR 97239 USA
- The Ohio State University, 302 Cunz Hall 1841 Neil Ave, Columbus, OH 43210 USA
- University of Chicago, 5841 S. Maryland Avenue, Chicago, IL 60637 USA
- Department of Epidemiology and Biostatistics, Temple University College of Public Health, 1301 Cecil B Moore Avenue, Ritter Annex 905, Philadelphia, PA USA
- Tulane University, 1440 Canal Street, Suite 2210, New Orleans, LA 70112 USA
- Tufts University School of Medicine Public Health and Community Medicine, 136 Harrison Avenue, Boston, MA 02111 USA
- University of Wisconsin-Madison, 1685 Highland Avenue, 5th Floor, Madison, WI 53705-2281 USA
- University of Kentucky, 760 Press Avenue Suite 280, Lexington, KY 40536 USA
- RTI International, 3040 E. Cornwallis Road, PO Box 12194, Research Triangle Park, NC 2709-2194 USA
- College of Pharmacy, University of Manitoba, Apotex Centre, 750 McDermot Ave. W, Winnipeg, MB R3E 0T5 Canada
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16
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Modeling of overdose and naloxone distribution in the setting of fentanyl compared to heroin. Drug Alcohol Depend 2022; 236:109478. [PMID: 35588609 PMCID: PMC9235402 DOI: 10.1016/j.drugalcdep.2022.109478] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/22/2022] [Accepted: 04/25/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Fentanyl has replaced most other non-prescribed opioids in much of North America. There is controversy over whether a hypothetical reduced efficacy of naloxone in reversing fentanyl is a major contributor to the coincident rising overdose mortality. METHODS We modified an existing Markov decision analytic model of heroin overdose and naloxone distribution to account for known risks of fentanyl by adjusting overdose risk, the likelihood of death in the event of overdose, and the proportion of cases in which available naloxone was administered in time to prevent death. We assumed near-universal survival when naloxone was administered promptly for heroin or fentanyl overdose, but allowed that to decline in sensitivity analyses for fentanyl. We varied the proportion of use that was fentanyl and adjusted the modified parameters accordingly to estimate mortality as the dominant opioid shifted. RESULTS Absent naloxone, the annual overdose death rate was 1.0% and 4.1% for heroin and fentanyl, respectively. With naloxone reaching 80% of those at risk, the overdose death rate was 0.7% and 3.6% for heroin and fentanyl, respectively, representing reductions of 26.4% and 12.0%. Monte Carlo simulations resulted in overdose mortality with fentanyl of 3.3-5.2% without naloxone and 2.6-4.9% with naloxone, with 95% certainty. Positing reduced efficacy for naloxone in reversing fentanyl resulted in 3.6% of fentanyl overdose deaths being prevented by naloxone. CONCLUSIONS Heightened risk for overdose and subsequent death, alongside the time-sensitive need for naloxone administration, fully account for increased mortality when fentanyl replaces heroin, assuming optimal pharmacologic efficacy of naloxone.
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Werb D, Scheim AI, Soipe A, Aeby S, Rammohan I, Fischer B, Hadland SE, Marshall BDL. Health harms of non-medical prescription opioid use: A systematic review. Drug Alcohol Rev 2022; 41:941-952. [PMID: 35437841 PMCID: PMC9064965 DOI: 10.1111/dar.13441] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 01/06/2022] [Accepted: 01/08/2022] [Indexed: 11/30/2022]
Abstract
ISSUES Non-medical prescription opioid use (NMPOU) contributes substantially to the global burden of morbidity. However, no systematic assessment of the scientific literature on the associations between NMPOU and health outcomes has yet been undertaken. APPROACH We undertook a systematic review evaluating health outcomes related to NMPOU based on ICD-10 clinical domains. We searched 13 electronic databases for original research articles until 1 July 2021. We employed an adaptation of the Oxford Centre for Evidence-Based Medicine 'Levels of Evidence' scale to assess study quality. KEY FINDINGS Overall, 182 studies were included. The evidence base was largest on the association between NMPOU and mental and behavioural disorders; 71% (129) studies reported on these outcomes. Less evidence exists on the association of NMPOU with infectious disease outcomes (26; 14%), and on external causes of morbidity and mortality, with 13 (7%) studies assessing its association with intentional self-harm and 1 study assessing its association with assault (<1%). IMPLICATIONS A large body of evidence has identified associations between NMPOU and opioid use disorder as well as on fatal and non-fatal overdose. We found equivocal evidence on the association between NMPOU and the acquisition of HIV, hepatitis C and other infectious diseases. We identified weak evidence regarding the potential association between NMPOU and intentional self-harm, suicidal ideation and assault. DISCUSSION AND CONCLUSIONS Findings may inform the prevention of harms associated with NMPOU, although higher-quality research is needed to characterise the association between NMPOU and the full spectrum of physical and mental health disorders.
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Affiliation(s)
- Dan Werb
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, USA.,Centre on Drug Policy Evaluation, St. Michael's Hospital, Toronto, Canada
| | - Ayden I Scheim
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Toronto, Canada.,Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, USA
| | - Ayorinde Soipe
- Department of Epidemiology, Brown University School of Public Health, Providence, USA.,Division of Nephrology, Department of Medicine, State University of New York, New York, USA
| | - Samantha Aeby
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Canada
| | - Indhu Rammohan
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Toronto, Canada
| | - Benedikt Fischer
- Schools of Population Health and Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.,Department of Psychiatry, University of Toronto, Toronto, Canada.,Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Vancouver, Canada.,Department of Psychiatry, Federal University of Sao Paulo, São Paulo, Brazil
| | - Scott E Hadland
- Grayken Center for Addiction and Department of Pediatrics, Boston Medical Center, Boston, USA.,Division of General Pediatrics, Department of Pediatrics, Boston University School of Medicine, Boston, USA
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, USA
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18
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Ataiants J, Mazzella S, Roth AM, Robinson LF, Sell RL, Lankenau SE. Multiple Victimizations and Overdose Among Women With a History of Illicit Drug Use. JOURNAL OF INTERPERSONAL VIOLENCE 2022; 37:NP1588-NP1613. [PMID: 32536256 PMCID: PMC7808297 DOI: 10.1177/0886260520927501] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
The experiences of violence and overdose are highly prevalent among women who use illicit drugs. This study sought to ascertain whether multiple victimizations during adulthood increase the frequency of women's overdose. The sample comprised 218 women recruited at Philadelphia harm reduction sites during 2016-2017. Victimization was assessed as exposure to 16 types of adulthood violence. Three measures were constructed for multiple victimizations: continuous and categorical polyvictimization, and predominant violence domain. Negative binomial regression estimated the incidence rate ratio (IRR) of lifetime overdoses from multiple victimizations. Lifetime history of opioid use (88.6%) and drug injection (79.5%) were common. Among overdose survivors (68.5%), the median of lifetime overdoses was 3. The majority of participants (58.7%) were victims of predominantly sexual violence, 26.1% experienced predominantly physical abuse/assault, and 3.7% were victims of predominantly verbal aggression/coercive control. Participants reported a mean of seven violence types; the higher-score category of polyvictimization (9-16 violence types) comprised 41.7% of the total sample. In multivariable models, one-unit increase in continuous polyvictimization was associated with 4% higher overdose rates (IRR: 1.04, 95% confidence interval [CI]: [1.00, 1.08]). Compared to women who were not victimized (11.5%), those in the higher-score category of polyvictimization (IRR: 2.01; 95% CI: [1.06, 3.80]) and exposed to predominantly sexual violence (IRR: 2.10, 95% CI: [1.13, 3.91]) were expected to have higher overdose rates. Polyvictimization and sexual violence amplified the risk of repeated overdose among drug-involved women. Female overdose survivors need to be screened for exposure to multiple forms of violence, especially sexual violence. Findings underscore the need to scale-up victimization support and overdose prevention services for disenfranchised women.
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Peck KR, Moxley-Kelly N, Badger GJ, Sigmon SC. Posttraumatic stress disorder in individuals seeking treatment for opioid use disorder in Vermont. Prev Med 2021; 152:106817. [PMID: 34599919 PMCID: PMC8641000 DOI: 10.1016/j.ypmed.2021.106817] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/30/2021] [Accepted: 09/26/2021] [Indexed: 11/27/2022]
Abstract
Posttraumatic stress disorder (PTSD) and opioid use disorder (OUD) may be associated with poor outcomes in rural areas where access to mental health services and opioid agonist treatment (OAT) is limited. This study examined the characteristics associated with a history of PTSD among a sample of individuals seeking buprenorphine treatment for OUD in Vermont, the second-most rural state in the US. Participants were 89 adults with OUD who participated in one of two ongoing randomized clinical trials examining the efficacy of an interim buprenorphine dosing protocol for reducing illicit opioid use during waitlist delays to OAT. Thirty-one percent of participants reported a history of PTSD. Those who did (PTSD+; n = 28) and did not (PTSD-; n = 61) report a history of PTSD were similar on sociodemographic and drug use characteristics. However, the PTSD+ group was less likely to have received prior OUD treatment compared to the PTSD- group (p = .02) despite being more likely to have a primary care physician (p = .009) and medical insurance (p = .002). PTSD+ individuals also reported greater mental health service utilization, more severe psychiatric, medical and drug use consequences, and greater pain severity and interference vs. PTSD- individuals (ps < 0.05). These findings indicate that a history of PTSD is prevalent and associated with worse outcomes among individuals seeking treatment for OUD in Vermont. Dissemination of screening measures and targeted interventions may help address the psychiatric and medical needs of rural individuals with OUD and a history of PTSD.
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Affiliation(s)
- Kelly R Peck
- The Vermont Center on Behavior and Health, University of Vermont, Burlington, VT, USA.
| | | | - Gary J Badger
- Department of Medical Biostatistics, University of Vermont, Burlington, VT, USA.
| | - Stacey C Sigmon
- The Vermont Center on Behavior and Health, University of Vermont, Burlington, VT, USA.
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Creasy SL, Thompson JR, Mair CF, Burke JG. Understanding Polarizing Community Perspectives on Harm Reduction Strategies: Challenges to Addressing the Opioid Crisis in Appalachian Pennsylvania. JOURNAL OF APPALACHIAN HEALTH 2021; 3:74-88. [PMID: 35769820 PMCID: PMC9183794 DOI: 10.13023/jah.0304.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Rural communities face barriers to opioid treatment and overdose prevention including concerns about stigma and lack of harm reduction services. Purpose The aim of this study was to explore community perspectives and understanding of harm reduction approaches to opioid use and overdose in a high-risk Northern Appalachian case community in Pennsylvania. Methods A small town approximately 10 miles from Pittsburgh was identified as the community with the greatest predicted probabilities of epidemic outbreak using posteriors from spatial models of hospitalizations for opioid use disorders. We interviewed 20 key stakeholders in the case community in using a semi-structured interview guide and analyzed the qualitative data using an inductive grounded theory approach. Results Our findings illustrate how conflicting perspectives about opioid dependence lay the foundation for the polarizing community perspectives on addressing opioid use and overdose and general disagreement regarding the legitimacy of harm reduction approaches versus abstinence-based recovery plans. Community members shared varying perspectives on multiple aspects of the opioid epidemic, including appropriate strategies, treatment, and overdose prevention methods and how community leaders and organizations should respond. Implications Opinions, coupled with a general lack of education regarding opioid use and harm reduction options, make it challenging for small communities with limited resources to create comprehensive plans to address the opioid crisis.
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Affiliation(s)
- Stephanie L Creasy
- Department of Behavioral and Community Health Sciences, Center for Social Dynamics and Community Health, University of Pittsburgh Graduate School of Public Health, Pittsburgh PA
| | - Jessica R Thompson
- Department of Behavioral and Community Health Sciences, Center for Social Dynamics and Community Health, University of Pittsburgh Graduate School of Public Health, Pittsburgh PA
| | - Christina F Mair
- Department of Behavioral and Community Health Sciences, Center for Social Dynamics and Community Health, University of Pittsburgh Graduate School of Public Health, Pittsburgh PA
| | - Jessica G Burke
- Department of Behavioral and Community Health Sciences, Center for Social Dynamics and Community Health, University of Pittsburgh Graduate School of Public Health, Pittsburgh PA
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21
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Surratt HL, Otachi J, McLouth C, Vundi N. Healthcare stigma and HIV risk among rural people who inject drugs. Drug Alcohol Depend 2021; 226:108878. [PMID: 34214880 PMCID: PMC8355211 DOI: 10.1016/j.drugalcdep.2021.108878] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/25/2021] [Accepted: 06/01/2021] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The HIV epidemic is increasingly penetrating rural areas of the U.S. due to evolving epidemics of injection drug use. Many rural areas experience deficits in availability of HIV prevention, testing and harm reduction services, and confront significant stigma that inhibits care seeking. This paper examines enacted stigma in healthcare settings among rural people who inject drugs (PWID) and explores associations of stigma with continuing high-risk behaviors for HIV. METHODS PWID participants (n = 324) were recruited into the study in three county health department syringe service programs (SSPs), as well as in local community-based organizations. Trained interviewers completed a standardized baseline interview lasting approximately 40 min. Bivariate logistic regression models examined the associations between enacted healthcare stigma, health conditions, and injection risk behaviors, and a mediation analysis was conducted. RESULTS Stigmatizing health conditions were common in this sample of PWID, and 201 (62.0 %) reported experiencing stigma from healthcare providers. Injection risk behaviors were uniformly associated with higher odds of enacted healthcare stigma, including sharing injection equipment at most recent injection (OR = 2.76; CI 1.55, 4.91), and lifetime receptive needle sharing (OR = 2.27; CI 1.42, 3.63). Enacted healthcare stigma partially mediated the relationship between having a stigmatizing health condition and engagement in high-risk injection behaviors. DISCUSSION Rural PWID are vulnerable to stigma in healthcare settings, which contributes to high-risk injection behaviors for HIV. These findings have critical public health implications, including the importance of tailored interventions to decrease enacted stigma in care settings, and structural changes to expand the provision of healthcare services within SSP settings.
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Affiliation(s)
| | | | - Chris McLouth
- University of Kentucky, Department of Behavioral Science
| | - Nikita Vundi
- University of Kentucky, Center for Health Services Research
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22
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Ibragimov U, Cooper KE, Batty E, Ballard AM, Fadanelli M, Gross SB, Klein EM, Lockard S, Young AM, Cooper HLF. Factors that influence enrollment in syringe services programs in rural areas: a qualitative study among program clients in Appalachian Kentucky. Harm Reduct J 2021; 18:68. [PMID: 34193165 PMCID: PMC8244225 DOI: 10.1186/s12954-021-00518-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/17/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Enrolling sufficient number of people who inject drugs (PWID) into syringe services programs (SSP) is important to curtail outbreaks of drug-related harms. Still, little is known about barriers and facilitators to SSP enrollment in rural areas with no history of such programs. This study's purpose was to develop a grounded theory of the role of the risk environment and individual characteristics of PWID in shaping SSP enrollment in rural Kentucky. METHODS We conducted one-on-one semi-structured interviews with 41 clients of 5 SSPs that were established in rural counties in Appalachian Kentucky in 2017-2018. Interviews covered PWID needs, the process of becoming aware of SSPs, and barriers and facilitators to SSP enrollment. Applying constructivist grounded theory methods and guided by the Intersectional Risk Environment Framework (IREF), we applied open, axial and selective coding to develop the grounded theory. RESULTS Stigma, a feature of IREF's meso-level social domain, is the main factor hampering SSP enrollment. PWID hesitated to visit SSPs because of internalized stigma and because of anticipated stigma from police, friends, family and healthcare providers. Fear of stigma was often mitigated or amplified by a constellation of meso-level environmental factors related to healthcare (e.g., SSPs) and social (PWID networks) domains and by PWID's individual characteristics. SSPs mitigated stigma as a barrier to enrollment by providing low threshold services in a friendly atmosphere, and by offering their clients program IDs to protect them from paraphernalia charges. SSP clients spread positive information about the program within PWID networks and helped their hesitant peers to enroll by accompanying them to SSPs. Individual characteristics, including child custody, employment or high social status, made certain PWID more susceptible to drug-related stigma and hence more likely to delay SSP enrollment. CONCLUSIONS Features of the social and healthcare environments operating at the meso-level, as well as PWID's individual characteristics, appear to enhance or mitigate the effect of stigma as a barrier to SSP enrollment. SSPs opening in locations with high stigma against PWID need to ensure low threshold and friendly services, protect their clients from police and mobilize PWID networks to promote enrollment.
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Affiliation(s)
| | | | - Evan Batty
- University of Kentucky College of Public Health, Lexington, KY, USA
| | - April M Ballard
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Monica Fadanelli
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Skylar B Gross
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Emma M Klein
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Scott Lockard
- Kentucky River District Health Department, Hazard, KY, USA
| | - April M Young
- University of Kentucky College of Public Health, Lexington, KY, USA
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Kline A, Mattern D, Cooperman N, Williams JM, Dooley-Budsock P, Foglia R, Borys S. Opioid overdose in the age of fentanyl: Risk factor differences among subpopulations of overdose survivors. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 90:103051. [PMID: 33321284 DOI: 10.1016/j.drugpo.2020.103051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/06/2020] [Accepted: 11/20/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although fentanyl is the drug most frequently implicated in overdose deaths, the association between overdose risk and attitudes and behaviors surrounding fentanyl in opioid-using communities has remained understudied. Possible subpopulation differences in fentanyl-related overdose risk remain equally unexamined. This paper addresses these gaps by exploring the association between overdose and fentanyl-related attitudes/behaviors in three subpopulations of overdose survivors. METHODS In this cross-sectional study, we sampled 432 individuals who currently or recently used opioids from New Jersey methadone and acute residential detoxification programs. Using multinomial regression analysis, we compared overdose risk factors, including fentanyl-related attitudes/behaviors, of those who never overdosed with three subgroups of overdose survivors who experienced: 1. recent overdoses occurring after, but not before, fentanyl expansion; 2. past overdoses occurring before, but not after, fentanyl expansion; 3. persistent overdoses occurring before and after fentanyl expansion. RESULTS Forty percent of respondents had knowingly used fentanyl and 38% deliberately sought overdose-implicated drugs. Respondents with persistent overdoses represented under 10% of the sample but accounted for 44% of all lifetime overdoses (x̅ =8.03 vs. 1.71 for the full sample). This was also the only subgroup for whom PTSD (AOR=3.84; 95%CI=1.45-10.16; p=.01) and fentanyl-seeking (AOR=1.50; 95% CI=1.16-1.94; p=.01) were significant overdose risk factors. Those with recent overdoses engaged in frequent drug combining (AOR=2.28; 95% CI=1.19-6.98; p=.05), which could have led to inadvertent fentanyl use. Those with past overdoses were not at overdose risk from fentanyl-seeking or drug combining and had rates of methadone treatment comparable to rates of those with no overdoses. CONCLUSION Harm reduction strategies will need to address consumers' evolving drug preferences as fentanyl continues to saturate local drug markets. Targeting comprehensive interventions, including mental health treatment, to the small group of opioid users with longstanding overdose histories may reduce the burden of overdose in opioid-using communities.
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Affiliation(s)
- Anna Kline
- Rutgers-Robert Wood Johnson Medical School, Division of Addiction Psychiatry, 317 George Street, New Brunswick, NJ 08901 United States.
| | - Dina Mattern
- Rutgers-Robert Wood Johnson Medical School, Division of Addiction Psychiatry, 317 George Street, New Brunswick, NJ 08901 United States
| | - Nina Cooperman
- Rutgers-Robert Wood Johnson Medical School, Division of Addiction Psychiatry, 317 George Street, New Brunswick, NJ 08901 United States
| | - Jill M Williams
- Rutgers-Robert Wood Johnson Medical School, Division of Addiction Psychiatry, 317 George Street, New Brunswick, NJ 08901 United States
| | - Patricia Dooley-Budsock
- Rutgers-Robert Wood Johnson Medical School, Division of Addiction Psychiatry, 317 George Street, New Brunswick, NJ 08901 United States
| | - Ralph Foglia
- Rutgers-Robert Wood Johnson Medical School, Division of Addiction Psychiatry, 317 George Street, New Brunswick, NJ 08901 United States
| | - Suzanne Borys
- New Jersey Department of Human Services, Division of Addiction Services, 222 South Warren Street, PO Box 700, Trenton, NJ 08625-0700 United States
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Ezell JM, Walters S, Friedman SR, Bolinski R, Jenkins WD, Schneider J, Link B, Pho MT. Stigmatize the use, not the user? Attitudes on opioid use, drug injection, treatment, and overdose prevention in rural communities. Soc Sci Med 2020; 268:113470. [PMID: 33253992 DOI: 10.1016/j.socscimed.2020.113470] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 10/08/2020] [Accepted: 10/19/2020] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Jerel M Ezell
- Africana Studies and Research Center, Cornell University, Ithaca, NY, USA; Cornell Center for Health Equity, Cornell University, Ithaca, NY, USA.
| | - Suzan Walters
- Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Samuel R Friedman
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Rebecca Bolinski
- Department of Sociology, Southern Illinois University, Carbondale, IL, USA
| | - Wiley D Jenkins
- Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - John Schneider
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago Medicine, Chicago, IL, USA; Chicago Center for HIV Elimination, University of Chicago, Chicago, IL, USA
| | - Bruce Link
- Department of Sociology, University of California, Riverside, CA, USA
| | - Mai T Pho
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago Medicine, Chicago, IL, USA
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Ondocsin J, Mars SG, Howe M, Ciccarone D. Hostility, compassion and role reversal in West Virginia's long opioid overdose emergency. Harm Reduct J 2020; 17:74. [PMID: 33046092 PMCID: PMC7549084 DOI: 10.1186/s12954-020-00416-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 09/24/2020] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Jeff Ondocsin
- Heroin in Transition Study, UCSF Department of Family and Community Medicine, University of California, 500 Parnassus Avenue, Milberry Union East, 3rd Floor, San Francisco, CA, 94143, USA
| | - Sarah G Mars
- Heroin in Transition Study, UCSF Department of Family and Community Medicine, University of California, 500 Parnassus Avenue, Milberry Union East, 3rd Floor, San Francisco, CA, 94143, USA
| | - Mary Howe
- Homeless Youth Alliance, PO Box 170427, San Francisco, CA, 94117, USA
| | - Daniel Ciccarone
- Heroin in Transition Study, UCSF Department of Family and Community Medicine, University of California, 500 Parnassus Avenue, Milberry Union East, 3rd Floor, San Francisco, CA, 94143, USA.
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PARK JUNYEONG, ROUHANI SABA, BELETSKY LEO, VINCENT LOUISE, SALONER BRENDAN, SHERMAN SUSANG. Situating the Continuum of Overdose Risk in the Social Determinants of Health: A New Conceptual Framework. Milbank Q 2020; 98:700-746. [PMID: 32808709 PMCID: PMC7482387 DOI: 10.1111/1468-0009.12470] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Policy Points This article reconceptualizes our understanding of the opioid epidemic and proposes six strategies that address the epidemic's social roots. In order to successfully reduce drug-related mortality over the long term, policymakers and public health leaders should develop partnerships with people who use drugs, incorporate harm reduction interventions, and reverse decades of drug criminalization policies. CONTEXT Drug overdose is the leading cause of injury-related death in the United States. Synthetic opioids, predominantly illicit fentanyl and its analogs, surpassed prescription opioids and heroin in associated mortality rates in 2016. Unfortunately, interventions fail to fully address the current wave of the opioid epidemic and often omit the voices of people with lived experiences regarding drug use. Every overdose death is a culmination of a long series of policy failures and lost opportunities for harm reduction. METHODS In this article, we conducted a scoping review of the opioid literature to propose a novel framework designed to foreground social determinants more directly into our understanding of this national emergency. The "continuum of overdose risk" framework is our synthesis of the global evidence base and is grounded in contemporary theories, models, and policies that have been successfully applied both domestically and internationally. FINDINGS De-escalating overdose risk in the long term will require scaling up innovative and comprehensive solutions that have been designed through partnerships with people who use drugs and are rooted in harm reduction. CONCLUSIONS Without recognizing the full drug-use continuum and the role of social determinants, the current responses to drug overdose will continue to aggravate the problem they are trying to solve.
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Affiliation(s)
| | | | - LEO BELETSKY
- School of Law and Bouvé College of Health SciencesNortheastern University
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Bolinski R, Ellis K, Zahnd WE, Walters S, McLuckie C, Schneider J, Rodriguez C, Ezell J, Friedman SR, Pho M, Jenkins WD. Social norms associated with nonmedical opioid use in rural communities: a systematic review. Transl Behav Med 2020; 9:1224-1232. [PMID: 31504988 DOI: 10.1093/tbm/ibz129] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Rebecca Bolinski
- Department of Sociology, Southern Illinois University, Carbondale, IL, USA
| | - Kaitlin Ellis
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Whitney E Zahnd
- Rural and Minority Health Research Center, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Suzan Walters
- Rory Meyers College of Nursing, New York University, New York, NY, USA
| | - Colleen McLuckie
- School of Public Health, University of Illinois at Chicago, Chicago, IL, USA
| | - John Schneider
- Medicine and Epidemiology, Chicago Center for HIV Elimination, Howard Brown Health, Departments of Medicine and Public Health Sciences, University of Chicago, Chicago, IL, USA
| | - Christofer Rodriguez
- Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Jerel Ezell
- Department of Sociology and Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Samuel R Friedman
- Institute for Infectious Disease Research, National Research and Development Institutes, Inc, New York, NY, USA
| | - Mai Pho
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago, Chicago, IL, USA
| | - Wiley D Jenkins
- Epidemiology and Biostatistics, Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, IL, USA
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Macmadu A, Adams JW, Bessey SE, Brinkley-Rubinstein L, Martin RA, Clarke JG, Green TC, Rich JD, Marshall BDL. Optimizing the impact of medications for opioid use disorder at release from prison and jail settings: A microsimulation modeling study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 91:102841. [PMID: 32712165 DOI: 10.1016/j.drugpo.2020.102841] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 06/09/2020] [Accepted: 06/11/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND We examined the impact of expanded access to medications for opioid use disorder (MOUD) in a unified prison and jail system on post-release, opioid-related overdose mortality. METHODS We developed a microsimulation model to simulate a population of 55,000 persons at risk of opioid-related overdose mortality in Rhode Island. The effect of an extended-release (XR) naltrexone only intervention and the effect of providing access to all three MOUD (i.e., methadone, buprenorphine, and XR-naltrexone) at release from incarceration on cumulative overdose death over eight years (2017-2024) were compared to the standard of care (i.e., limited access to MOUD). RESULTS In the standard of care scenario, the model predicted 2385 opioid-related overdose deaths between 2017 and 2024. An XR-naltrexone intervention averted 103 deaths (4.3% reduction), and access to all three MOUD averted 139 deaths (5.8% reduction). Among those with prior year incarceration, an XR-naltrexone only intervention and access to all three MOUD reduced overdose deaths by 22.8% and 31.6%, respectively. CONCLUSIONS Expanded access to MOUD in prison and jail settings can reduce overdose mortality in a general, at-risk population. However, the real-world impact of this approach will vary by levels of incarceration, treatment enrollment, and post-release retention.
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Affiliation(s)
- Alexandria Macmadu
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Providence, RI 02903, USA; The Center for Prisoner Health and Human Rights, The Miriam Hospital, 8 Third Street, Providence, RI 02906, USA
| | - Joëlla W Adams
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Providence, RI 02903, USA
| | - S E Bessey
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Providence, RI 02903, USA
| | - Lauren Brinkley-Rubinstein
- Department of Social Medicine, University of North Carolina at Chapel Hill, 333 South Columbia Street, Chapel Hill, NC 27516, USA; Center for Health Equity Research, University of North Carolina at Chapel Hill, 335 South Columbia Street, Chapel Hill, NC 27514, USA
| | - Rosemarie A Martin
- Department of Behavioral and Social Science, Brown University School of Public Health, 121 South Main Street, Providence, RI 02903, USA
| | - Jennifer G Clarke
- Rhode Island Department of Corrections, 40 Howard Avenue, Cranston, RI 02920, USA
| | - Traci C Green
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Providence, RI 02903, USA; Department of Emergency Medicine, The Warren Alpert School of Medicine of Brown University, Rhode Island Hospital, 55 Claverick Street, Providence, RI 02903, USA
| | - Josiah D Rich
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Providence, RI 02903, USA; The Center for Prisoner Health and Human Rights, The Miriam Hospital, 8 Third Street, Providence, RI 02906, USA
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Providence, RI 02903, USA.
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Mateu-Gelabert P, Guarino H, Zibbell JE, Teubl J, Fong C, Goodbody E, Edlin B, Salvati C, Friedman SR. Prescription opioid injection among young people who inject drugs in New York City: a mixed-methods description and associations with hepatitis C virus infection and overdose. Harm Reduct J 2020; 17:22. [PMID: 32228700 PMCID: PMC7106794 DOI: 10.1186/s12954-020-00367-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 03/13/2020] [Indexed: 01/02/2023] Open
Abstract
Aim Evidence is emerging that prescription opioid (PO) injection is associated with increased health risks. This mixed-methods study compares the mechanics of PO and heroin injection and examines the demographic and drug-related correlates of lifetime PO injection in a sample of young people who inject drugs (PWID) in New York City (NYC). Methods Qualitative analysis of 46 semi-structured interviews with young adult opioid users ages 18–32. Interview segments describing PO injection were analyzed for common themes. Quantitative analysis of structured interviews with 539 young adult opioid users ages 18–29 recruited via respondent-driven sampling (RDS). Analyses are based on the subsample of 353 participants (65%) who reported having ever injected drugs. All variables were assessed via self-report, except hepatitis C virus status, which was established via rapid antibody testing. Results Participants described injecting POs and reported that preparing abuse-deterrent pills for injection is especially cumbersome, requiring extended manipulation and large amounts of water. Injecting POs, in contrast to injecting heroin, requires repeated injections per injection episode. Among RDS-recruited participants, the majority of injectors reported injecting POs, sporadically (33%) or regularly (26%), but often infrequently (≤ 7 days/month). In separate multivariable analyses controlling for syringe- and cooker-sharing, ever injecting POs was a significant predictor of testing HCV antibody-positive (AOR = 2.97) and lifetime experience of non-fatal overdose (AOR = 2.51). Ever injecting POs was independently associated with lifetime homelessness (AOR = 2.93) and having grown up in a middle-income ($51,000–100,000/year vs. ≤ $50,000/year; AOR = 1.86) or a high-income household (> $100,000/year vs. ≤ $50,000/year; AOR = 2.54). Conclusions Even in an urban environment like NYC with widespread heroin access, most young PWID have injected POs, although less frequently than heroin. PO injection involves practices that are known to increase risk for blood-borne viral infection (e.g., repeated injections) and predicted testing HCV-positive, as well as overdose. PO injection may also serve as a marker for a subgroup of PWID at elevated risk for multiple drug use-related comorbidities. Programs that provide prevention services to PWID need to tailor harm reduction measures and messaging to the specific practices and harms associated with the injection of POs.
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Affiliation(s)
- Pedro Mateu-Gelabert
- CUNY Graduate School of Public Health and Health Policy, Institute for Implementation Science in Population Health (ISPH), 55 West 125th Street, New York, NY, 10027, USA.
| | - Honoria Guarino
- CUNY Graduate School of Public Health and Health Policy, Institute for Implementation Science in Population Health (ISPH), 55 West 125th Street, New York, NY, 10027, USA
| | - Jon E Zibbell
- RTI International, 2987 Clairmont Road, Century Plaza 1, Suite 400, Atlanta, GA, 30329-4434, USA
| | - Jennifer Teubl
- National Development Research Institutes, Inc., 71 West 23rd St, New York, NY, 10010, USA
| | - Chunki Fong
- CUNY Graduate School of Public Health and Health Policy, Institute for Implementation Science in Population Health (ISPH), 55 West 125th Street, New York, NY, 10027, USA
| | - Elizabeth Goodbody
- CUNY Graduate School of Public Health and Health Policy, Institute for Implementation Science in Population Health (ISPH), 55 West 125th Street, New York, NY, 10027, USA
| | | | - Carli Salvati
- CUNY Graduate School of Public Health and Health Policy, Institute for Implementation Science in Population Health (ISPH), 55 West 125th Street, New York, NY, 10027, USA
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Linn BK, Ely GE, Staton M. Latent Profiles of Health and Reproductive Risk and Protective Factors among Women in Appalachia. JOURNAL OF SOCIAL WORK PRACTICE IN THE ADDICTIONS 2020; 20:155-167. [PMID: 33209100 PMCID: PMC7668409 DOI: 10.1080/1533256x.2020.1748976] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Women who use opiates and are involved in the criminal justice system in Appalachia may be prone to adverse health outcomes. In this study, we performed a latent class analysis of risk and protective factors on 400 drug-using women recruited from rural, Appalachian jails. A two-profile solution best fit the data. Both profiles evinced low levels of condom use, reproductive and physical health screens, and STD history. However, the primary substantive difference between the profiles was partner risk behavior: the higher risk class had main male partners with histories of injection drug use and incarceration. Results suggest that interventions need to be tailored to unique profiles of risk and protective factors, which should include taking partner risk into consideration.
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Affiliation(s)
- Braden K Linn
- Clinical and Research Institute on Addictions, University at Buffalo, The State University of New York, Buffalo, NY
| | - Gretchen E Ely
- School of Social Work, University at Buffalo, The State University of New York, Buffalo, NY
| | - Michele Staton
- University of Kentucky, College of Medicine, Medical Behavioral Science Building, Lexington, KY
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Thomas N, van de Ven K, Mulrooney KJD. The impact of rurality on opioid-related harms: A systematic review of qualitative research. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 85:102607. [PMID: 31864787 DOI: 10.1016/j.drugpo.2019.11.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 10/02/2019] [Accepted: 11/10/2019] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Over the past decade, there has been mounting recognition that opioid use and related mortality and morbidity is a significant public health problem in rural, non-urban areas across the globe. Taking what has been termed the 'opioid crisis' as a starting off point, this article aims to systematically review the qualitative literature on the ways in which rurality shapes the risk for opioid-related harm. METHODS A systematic review was undertaken using database searches and secondary reference list searches for qualitative literature on rural and non-urban opioid-related harms. A total of 32 qualitative studies met the inclusion criteria. Data extraction was performed in NVivo 12 using a codebook based on the 'risk environment' framework. RESULTS The findings explore how rurality shapes the risk environment for opioid-related harms through four environment influences: (1) economic conditions, including economic transition and deindustrialisation that has occurred in many rural areas, and the high levels of economic distress experienced by rural residents; (2) physical conditions, including a lack of infrastructure and recreation opportunities, larger geographic distances, and limited transportation; (3) social conditions, where social networks could be both protective but also amplify risk through a lack of knowledge about treatment and risk behaviours, a lack of anonymity and stigmatisation of people who use opioids in rural areas; and (4) policy conditions including limited coverage and availability of harm reduction and drug treatment services, and stigmatising service provider practices. CONCLUSIONS The impact of rurality on risk of opioid-related harm is multifaceted. We suggest that future research on rural opioid use would benefit from drawing on the theoretical toolkit of rural criminology to attend to the ways the 'rural crisis', and attendant insecurities, anxieties and strains, impacts upon rural communities and shapes risk, along with how socio-cultural characteristics of the rural 'organise' risks of drug use.
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Affiliation(s)
- Natalie Thomas
- Centre for Rural Criminology, University of New England, Armidale, New South Wales, Australia; School of Humanities, Arts, and Social Sciences, University of New England, Armidale, New South Wales, Australia.
| | - Katinka van de Ven
- Centre for Rural Criminology, University of New England, Armidale, New South Wales, Australia; Drug Policy Modelling Program, Social Policy Research Centre, UNSW, Sydney, NSW, Australia
| | - Kyle J D Mulrooney
- Centre for Rural Criminology, University of New England, Armidale, New South Wales, Australia; School of Humanities, Arts, and Social Sciences, University of New England, Armidale, New South Wales, Australia
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Fadanelli M, Cloud DH, Ibragimov U, Ballard AM, Prood N, Young AM, Cooper HLF. People, places, and stigma: A qualitative study exploring the overdose risk environment in rural Kentucky. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 85:102588. [PMID: 31753603 DOI: 10.1016/j.drugpo.2019.11.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/20/2019] [Accepted: 11/02/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Though overdose rates have been increasing in US rural areas for two decades, little is known about the rural risk environment for overdoses. This qualitative study explored the risk environment for overdoses among young adults in Eastern Kentucky, a rural epicenter of the US opioid epidemic. METHODS Participants were recruited via community-based outreach. Eligibility criteria included living in one of five rural Eastern Kentucky counties; being aged 18-35; and using opioids to get high in the past 30 days. Semi-structured interviews explored the rural risk environment, and strategies to prevent overdose and dying from an overdose. Interviews were transcribed verbatim and analyzed using constructivist grounded-theory methods. RESULTS In this sample (N = 19), participants reported using in a range of locations, including homes and outdoor settings; concerns about community stigma and law enforcement shaped the settings where participants used opioids and the strategies they deployed in these settings to prevent an overdose, and to survive an overdose. Almost half of participants reported using opioids in a "trap house" or other dealing locations, often to evade police after buying drugs, and reported that others present pressed them to use more than usual. If an overdose occurred in this setting, however, these same people might refuse to call EMS to protect themselves from arrest. Outdoor settings presented particular vulnerabilities to overdose and dying from an overdose. Most participants reported using opioids outdoors, where they skipped overdose prevention steps to reduce their risk of arrest; they worried that no one would find them if they overdosed, and that cell phone coverage would be too weak to summon EMS. CONCLUSION Findings suggest that initiatives to reduce overdoses in Eastern Kentucky would be strengthened by de-escalating the War on Drugs and engaging law enforcement in initiatives to protect the health of people who use opioids.
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Affiliation(s)
- Monica Fadanelli
- Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA 30322, USA.
| | - David H Cloud
- Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA 30322, USA
| | - Umedjon Ibragimov
- Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA 30322, USA
| | - April M Ballard
- Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA 30322, USA
| | - Nadya Prood
- Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA 30322, USA
| | - April M Young
- College of Public Health, University of Kentucky, 111 Washington Ave, Lexington, KY 40536, USA; Center on Drug and Alcohol Research, University of Kentucky, 845 Angliana Avenue, Lexington, KY 40508, USA
| | - Hannah L F Cooper
- Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA 30322, USA
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The prevalence of non-fatal overdose among people who inject drugs: A multi-stage systematic review and meta-analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 73:172-184. [DOI: 10.1016/j.drugpo.2019.07.030] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 07/15/2019] [Accepted: 07/15/2019] [Indexed: 12/13/2022]
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Lee WK, Hayashi K, DeBeck K, Milloy MJS, Grant C, Wood E, Kerr T. Association between posttraumatic stress disorder and nonfatal drug overdose. PSYCHOLOGICAL TRAUMA-THEORY RESEARCH PRACTICE AND POLICY 2019; 12:373-380. [PMID: 31524428 DOI: 10.1037/tra0000511] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE North America is in the midst of a growing drug overdose crisis. While prescription opioid misuse and synthetic opioids such as fentanyl have been implicated in the overdose crisis, less attention has been given to the role that posttraumatic stress disorder (PTSD) may play in this crisis. As such, this study sought to examine the relationship between PTSD and risk of nonfatal overdose among people who use drugs (PWUD). METHOD Data were derived from three prospective cohorts of PWUD in Vancouver, Canada. For each participant, PTSD was assessed using the PTSD Checklist for the DSM-5. Multivariate logistic regression analysis was used to estimate the relationship between PTSD and nonfatal overdose, adjusting for potential confounders. RESULTS Between 2016 and 2018 among 1,059 PWUD, including 363 (34%) nonmale participants, 171 (16%) experienced a nonfatal drug overdose in the past 6 months, and 414 (39%) met criteria for a provisional PTSD diagnosis. In multivariate analysis, PTSD (adjusted odds ratio = 1.98, 95% confidence interval [1.4, 2.79]) remained independently associated with nonfatal overdose after adjustment for a range of confounders. CONCLUSIONS Among participants in these community-recruited cohorts of PWUD, having a provisional PTSD diagnosis nearly doubled the risk of nonfatal overdose. The findings from this study support the need to incorporate a trauma-informed approach within the current overdose prevention framework. Education and training relating to trauma and PTSD should be prioritized for health care professionals who work with and treat PWUD. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
| | | | | | | | | | - Evan Wood
- British Columbia Centre on Substance Use
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Schalkoff CA, Lancaster KE, Gaynes BN, Wang V, Pence BW, Miller WC, Go VF. The opioid and related drug epidemics in rural Appalachia: A systematic review of populations affected, risk factors, and infectious diseases. Subst Abus 2019; 41:35-69. [PMID: 31403903 DOI: 10.1080/08897077.2019.1635555] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Background/aims: To examine trends in rural Appalachian opioid and related drug epidemics during the past 10 years, including at-risk populations, substance use shifts and correlates, and associated infections. Methods: We conducted this review in accordance with the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Seven databases were searched for quantitative studies, published between January 2006 and December 2017, of drug use, drug-related mortality, or associated infections in rural Appalachia. Results: Drug-related deaths increased in study states, and a high incidence of polydrug toxicity was noted. Rural substance use was most common among young, white males, with low education levels. A history of depression/anxiety was common among study populations. Prescription opioids were most commonly used, often in conjunction with sedatives. Women emerged as a distinct user subpopulation, with different routes of drug use initiation and drug sources. Injection drug use was accompanied by risky injection behaviors and was associated with hepatitis C. Conclusions: This review can help to inform substance use intervention development and implementation in rural Appalachian populations. Those at highest risk are young, white males who often engage in polysubstance use and have a history of mental health issues. Differences in risk factors among other groups and characteristics of drug use in rural Appalachian populations that are conducive to human immunodeficiency virus (HIV) spread also warrant consideration.
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Affiliation(s)
- Christine A Schalkoff
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Bradley N Gaynes
- Department of Psychiatry, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Vivian Wang
- College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Brian W Pence
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - William C Miller
- College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Vivian F Go
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Votaw VR, Geyer R, Rieselbach MM, McHugh RK. The epidemiology of benzodiazepine misuse: A systematic review. Drug Alcohol Depend 2019; 200:95-114. [PMID: 31121495 PMCID: PMC6639084 DOI: 10.1016/j.drugalcdep.2019.02.033] [Citation(s) in RCA: 216] [Impact Index Per Article: 43.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 02/22/2019] [Accepted: 02/27/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Benzodiazepine misuse is a growing public health problem, with increases in benzodiazepine-related overdose deaths and emergency room visits in recent years. However, relatively little attention has been paid to this emergent problem. We systematically reviewed epidemiological studies on benzodiazepine misuse to identify key findings, limitations, and future directions for research. METHODS PubMed and PsychINFO databases were searched through February 2019 for peer-reviewed publications on benzodiazepine misuse (e.g., use without a prescription; at a higher frequency or dose than prescribed). Eligibility criteria included human studies that focused on the prevalence, trends, correlates, motives, patterns, sources, and consequences of benzodiazepine misuse. RESULTS The search identified 1970 publications, and 351 articles were eligible for data extraction and inclusion. In 2017, benzodiazepines and other tranquilizers were the third most commonly misused illicit or prescription drug in the U.S. (approximately 2.2% of the population). Worldwide rates of misuse appear to be similar to those reported in the U.S. Factors associated with misuse include other substance use, receipt of a benzodiazepine prescription, and psychiatric symptoms and disorders. Benzodiazepine misuse encompasses heterogeneous presentations of motives, patterns, and sources. Moreover, misuse is associated with myriad poor outcomes, including mortality, HIV/HCV risk behaviors, poor self-reported quality of life, criminality, and continued substance use during treatment. CONCLUSIONS Benzodiazepine misuse is a worldwide public health concern that is associated with a number of concerning consequences. Findings from the present review have implications for identifying subgroups who could benefit from prevention and treatment efforts, critical points for intervention, and treatment targets.
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Affiliation(s)
- Victoria R. Votaw
- Department of Psychology, University of New Mexico, MSC 03-2220, Albuquerque, NM, USA,Corresponding author: Victoria R. Votaw, Clinical Psychology Ph.D. Student Department of Psychology, University of New Mexico, Logan Hall, 1 University of New Mexico, Albuquerque, NM 87131,
| | - Rachel Geyer
- Division of Alcohol and Drug Abuse, McLean Hospital, 115 Mill Street, Belmont, MA, USA
| | - Maya M. Rieselbach
- Department of Psychiatry, McLean Hospital, 115 Mill Street, Belmont, MA, USA
| | - R. Kathryn McHugh
- Division of Alcohol and Drug Abuse, McLean Hospital, 115 Mill Street, Belmont, MA, USA,Department of Psychiatry, Harvard Medical School, 401 Park Drive, Boston, MA, USA
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Young AM, Rudolph AE, Havens JR. Network-Based Research on Rural Opioid Use: an Overview of Methods and Lessons Learned. Curr HIV/AIDS Rep 2019; 15:113-119. [PMID: 29457200 DOI: 10.1007/s11904-018-0391-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW The purpose of this paper is to provide a thorough overview of methods used for recruitment, network data collection, and network data management in a network-based study of rural people who use drugs (PWUD) and to offer methodological recommendations for future research on rural drug use. RECENT FINDINGS The Social Networks among Appalachian People (SNAP) study recruited a cohort of 503 rural PWUD via respondent-driven sampling (RDS) and has retained more than 80% of eligible participants over 7-9 years. SNAP has yielded important methodological insights, including that (1) RDS referral was non-random and disproportionately involved kin and (2) interviewer-administered questionnaires were successful in eliciting accurate name and age information about network members. The SNAP experience suggests that RDS was a successful recruitment strategy for rural PWUD and questionnaires administered by community-based interviewers in the context of a Certificate of Confidentiality could elicit detailed data on PWUD risk networks.
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Affiliation(s)
- April M Young
- Department of Epidemiology, University of Kentucky College of Public Health, 111 Washington Avenue, Office 211C, Lexington, KY, 40536, USA. .,Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, KY, USA.
| | - Abby E Rudolph
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Jennifer R Havens
- Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, KY, USA
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Cloud DH, Ibragimov U, Prood N, Young AM, Cooper HLF. Rural risk environments for hepatitis c among young adults in appalachian kentucky. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 72:47-54. [PMID: 31113713 DOI: 10.1016/j.drugpo.2019.05.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/25/2019] [Accepted: 05/05/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Rural Kentucky is an epicenter of hepatitis C(HCV), especially among young adults who inject drugs. While the Risk Environment Framework (REF) has been used widely to study and address socio-ecological determinants of infectious disease among people who inject drugs (PWID), it has been almost exclusively applied to urban environments. Applying REF to rural environments can enhance our understanding of the drivers of HCV epidemics in these hard-hit areas, and inform the creation and implementation of harm reduction interventions in this local context. METHODS Participants were recruited between March and August 2017 via community-based outreach methods (e.g., cookouts, flyers) and peer referral. Individuals who met eligibility criteria (aged 18-35, recently used prescription opioids and/or heroin to get high, lived in one of the 5 target counties) participated indepth, semi-structured interviews. The interview guide was informed by the REF, and covered HCV-related risk behaviors and environmental features that shaped vulnerability to engaging in these behaviors. Interviews were transcribed and analyzed using constructivist grounded-theory methods. RESULTS Participants (N=19) described multiple intersecting risk environment features that shaped vulnerability to HCV transmission. Economic decline generated intergenerational poverty, dwindling employment prospects, and diminished social enrichment opportunities that collectively contributed to substance misuse and risky injection practices. Geographic isolation, lack of collective knowledge about HCV transmission risks, scarce harm reduction services, familial poverty, and fear of law enforcement interacted to increase the odds of people injecting in "trap houses" (akin to shooting galleries) or secluded areas, spaces in which they rushed to inject and shared injection equipment. Pervasive stigma was a structural barrier to adopting, expanding, and using harm reduction services. CONCLUSION This exploratory study identified features of rural risk environments that may contribute to significant HCV burdens in Appalachian Kentucky. Findings signal the importance of expanding proven harm reduction strategies and anti-stigma interventions tailored to rural contexts.
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Affiliation(s)
- David H Cloud
- Emory University, Rollins School of Public Health, United States.
| | | | - Nadya Prood
- Emory University, Rollins School of Public Health, United States
| | - April M Young
- University of Kentucky College of Public Health, United States
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Rudolph AE, Young AM, Havens JR. Using Network and Spatial Data to Better Target Overdose Prevention Strategies in Rural Appalachia. J Urban Health 2019; 96:27-37. [PMID: 30465260 PMCID: PMC6391296 DOI: 10.1007/s11524-018-00328-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This analysis uses network and spatial data to identify optimal individuals to target with overdose prevention interventions in rural Appalachia. Five hundred and three rural persons who use drugs were recruited to participate in the Social Networks among Appalachian People Study (2008-2010). Interviewer-administered surveys collected information on demographic characteristics, risk behaviors (including overdose history), network members, and residential addresses. We restricted the sample to individuals with at least one confirmed relationship to another study participant (N = 463). Using dyadic analyses (N = 1428 relationships), we identified relationship-level correlates of relationships with network members who have previously overdosed. We then examined individual- and network-level factors associated with (1) having at least one first-degree alter (i.e., network member) with a prior overdose and (2) each additional network member with a prior overdose (N = 463 study participants). Overall, 28% of the sample had previously overdosed and 57% were one-degree away from someone who previously overdosed. Relationships with those who had overdosed were characterized by closer residential proximity. Those with at least one network member who previously overdosed were more geographically central and occupied more central network positions. Further, the number of network members with an overdose history increased with decreasing distance to the town center, increasing network centrality, and prior enrollment in an alcohol detox program. Because fatal overdoses can be prevented through bystander intervention, these findings suggest that strategies that target more central individuals (both geographically and based on their network positions) and those who have previously enrolled in alcohol detox programs with overdose prevention training and naloxone may optimize intervention reach and have the potential to curb overdose fatalities in this region.
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Affiliation(s)
- Abby E Rudolph
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA. .,Department of Epidemiology and Biostatistics, Temple University College of Public Health, 1301 Cecil B Moore Avenue, Ritter Annex 905, Philadelphia, PA, 19122, USA.
| | - April M Young
- Department of Epidemiology, University of Kentucky College of Public Health, Lexington, KY, USA.,Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Jennifer R Havens
- Center on Drug and Alcohol Research, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington, KY, USA
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Palombi LC, St Hill CA, Lipsky MS, Swanoski MT, Lutfiyya MN. A scoping review of opioid misuse in the rural United States. Ann Epidemiol 2018; 28:641-652. [PMID: 29921551 DOI: 10.1016/j.annepidem.2018.05.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 04/09/2018] [Accepted: 05/24/2018] [Indexed: 11/18/2022]
Abstract
INTRODUCTION This study is a scoping review of the original research literature onthe misuse of opioids in the rural United States (US) and maps theliterature of interest to address the question: What does theoriginal research evidence reveal about the misuse of opioids inrural US communities? METHODS This study used a modified preferred reporting items for systematicreviews and meta-analyses (PRISMA) approach which is organized byfive distinct elements or steps: beginning with a clearly formulatedquestion, using the question to develop clear inclusion criteria toidentify relevant studies, using an approach to appraise the studiesor a subset of the studies, summarizing the evidence using anexplicit methodology, and interpreting the findings of the review. RESULTS The initial search yielded 119 peer reviewed articles and aftercoding, 41 papers met the inclusion criteria. Researcher generatedsurveys constituted the most frequent source of data. Most studieshad a significant quantitative dimension to them. All the studieswere observational or cross-sectional by design. CONCLUSIONS This analysis found an emerging research literature that hasgenerated evidence supporting the claim that rural US residents andcommunities suffer a disproportionate burden from the misuseof opioidscompared to their urban or metropolitan counterparts.
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Affiliation(s)
- Laura C Palombi
- Department of Pharmacy Practice and Pharmaceutical Sciences, College of Pharmacy, University of Minnesota, Minneapolis, MN
| | | | | | - Michael T Swanoski
- Department of Pharmacy Practice and Pharmaceutical Sciences, College of Pharmacy, University of Minnesota, Minneapolis, MN
| | - M Nawal Lutfiyya
- Department of Pharmacy Practice and Pharmaceutical Sciences, College of Pharmacy, University of Minnesota, Minneapolis, MN.
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Push and Pull: Migration Patterns and Links to Harm Reduction Services Among People Who Use Drugs. CANADIAN JOURNAL OF ADDICTION 2018. [DOI: 10.1097/cxa.0000000000000018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Victor G, Kheibari A, Staton M, Oser C. Appalachian Women's Use of Substance Abuse Treatment: Examining the Behavioral Model for Vulnerable Populations. JOURNAL OF SOCIAL WORK PRACTICE IN THE ADDICTIONS 2018; 18:192-213. [PMID: 30853861 PMCID: PMC6405208 DOI: 10.1080/1533256x.2018.1450264] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
The Gelberg-Andersen Behavioral Model for Vulnerable Populations was applied to understand vulnerable Appalachian women's (N = 400) utilization of addiction treatment. A secondary data analyses included multiple multivariate analyses. Strongest correlates of treatment utilization included ever injecting drugs (OR = 2.77), limited availability of substance abuse treatment facilities (OR = 2.03), and invalidated violence abuse claims (OR = 2.12). This study contributes theory-driven research to the greater social work addiction literature by confirming that vulnerable domains related to substance abuse treatment utilization warrant unique considerations compared to non-vulnerable domains. Findings also highlight the importance of understanding the unique role that cultural factors play in treatment utilization among Appalachian women. Inferences relevant to clinicians and policymakers are discussed.
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Affiliation(s)
- Grant Victor
- College of Social Work, University of Kentucky, Lexington, KY, USA
| | - Athena Kheibari
- College of Social Work, University of Kentucky, Lexington, KY, USA
| | - Michele Staton
- College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Carrie Oser
- College of Sociology, University of Kentucky, Lexington, KY, USA
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LANCASTER KATHRYNE, MALVESTUTTO CARLOSD, MILLER WILLIAMC, GO VIVIANF. Commentary on Fraser et al. (2018): Evidence base for harm reduction services-the urban-rural divide. Addiction 2018; 113:183-184. [PMID: 29226535 PMCID: PMC6715287 DOI: 10.1111/add.14052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 09/28/2017] [Accepted: 10/01/2017] [Indexed: 01/19/2023]
Abstract
The evidence base for scaling-up hepatitis C virus (HCV) treatment and harm reduction services within rural communities is limited, and requires a better understanding of the socio-cultural context and operational issues for these distinct settings. Best practices from US urban centers, where most implementation research has been focused, do not necessarily translate to sparsely populated rural areas, where HCV and harm reduction services are limited and fragmented.
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Affiliation(s)
- KATHRYN E. LANCASTER
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - CARLOS D. MALVESTUTTO
- Division of Infectious Diseases, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - WILLIAM C. MILLER
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - VIVIAN F. GO
- Department of Health Behavior, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Brady JE, Giglio R, Keyes KM, DiMaggio C, Li G. Risk markers for fatal and non-fatal prescription drug overdose: a meta-analysis. Inj Epidemiol 2017; 4:24. [PMID: 28762157 PMCID: PMC5545182 DOI: 10.1186/s40621-017-0118-7] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 06/20/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Drug overdose is a public health crisis in the United States, due in part to the unintended consequences of increases in prescribing of opioid analgesics. Many clinicians evaluate risk markers for opioid-related harms when prescribing opioids for chronic pain; however, more data on predictive risk markers are needed. Risk markers are attributes (modifiable and non-modifiable) that are associated with increased probability of an outcome. This review aims to identify risk markers associated with fatal and non-fatal prescription drug overdose by synthesizing findings in the existing peer-reviewed and grey literature. Eligible cohort, case-control, cross-sectional, and case-cohort studies were reviewed and data were extracted for qualitative and quantitative synthesis. FINDINGS Summary odds ratios (SOR) were estimated from 29 studies for six risk markers: sex, age, race, psychiatric disorders, substance use disorder (SUD), and urban/rural residence. Heterogeneity was assessed and effect estimates were stratified by study characteristics. Of the six risk markers identified, SUD had the strongest association with drug overdose death (SOR = 5.24, 95% confidence interval (CI) = 3.53 - 7.76), followed by psychiatric disorders (SOR = 3.94, 95% CI = 3.09 - 5.01), white race (SOR = 2.28, 95% CI = 1.93 - 2.70), the 35-44 year age group relative to the 25-34 year reference group (SOR = 1.52, 95% CI = 1.31 - 1.76), and male sex (SOR = 1.33, 95% CI = 1.17 - 1.51). CONCLUSIONS This review highlights fatal and non-fatal prescription drug risk markers most frequently assessed in peer-reviewed and grey literature. There is a need to better understand modifiable risk markers and underlying reasons for drug misuse in order to inform interventions that may prevent future drug overdoses.
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Affiliation(s)
- Joanne E. Brady
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY USA
| | - Rebecca Giglio
- Center for Injury Epidemiology and Prevention, Columbia University, New York, NY USA
| | - Katherine M. Keyes
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY USA
- Center for Injury Epidemiology and Prevention, Columbia University, New York, NY USA
| | - Charles DiMaggio
- Department of Surgery, Division of Trauma, New York University, New York, NY USA
| | - Guohua Li
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY USA
- Center for Injury Epidemiology and Prevention, Columbia University, New York, NY USA
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY USA
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Karamoozian A, Jahani Y, Shahesmaeili A, Mirzaee M. Relationship between a network's indicators and basic factors with high-risk behavior of injection among injecting drug users (IDU) via the multiple membership multilevel model. Electron Physician 2017; 9:5318-5324. [PMID: 29038716 PMCID: PMC5633232 DOI: 10.19082/5318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Accepted: 06/03/2017] [Indexed: 11/21/2022] Open
Abstract
Background Among various methods and types of drug abuse, injection receives a great deal of importance because of its related dangerous behavior and health consequences. It seemed that some of the network’s indicators affect dangerous behavior of injection. Objective To determine the relationship between a network’s indicators and basic factors with high-risk behavior of injection among injecting drug users (IDU) via the multiple memberships multilevel model. Methods In this cross-sectional study, the data related to 147 IDUs in Kerman province, who were interviewed from October 2013 through March 2014, were used, and these addicts were chosen for interview from specific resorts used for common injection. In this study, for analyzing data, multiple membership multilevel model and MLwiN 2.02 software were used. Results In this study, the mean age of people, who were mostly men, was 37.2±9.02. Based on the result, it becomes obvious that variables of in-degree with OR=1.49 (p=0.006) and the whole number of people related to the person with OR=1.18 (p=0.003) influences the high-risk behavior of injection. Also, none of the demographic variables influenced the high-risk behavior of injection. Conclusion Totally based on the results of this study, one can find a suitable method in the social network of IDUs in order to create essential strategies, reducing the risk throughout the country. In addition, in minimum time with fewer expenses, aggravation of dangerous behavior especially high-risk behavior of injection can be prevented.
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Affiliation(s)
- Ali Karamoozian
- M.Sc. of Biostatistics, Modeling in Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Yunes Jahani
- Ph.D. of Biostatistics, Assistant Professor, Modeling in Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.,Ph.D. of Biostatistics, Assistant Professor, Department of Biostatistics and Epidemiology, School of Public Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Armita Shahesmaeili
- Ph.D. of Epidemiology, Assistant Professor, HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Moghaddameh Mirzaee
- Ph.D. of Biostatistics, Assistant Professor, Modeling in Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.,Ph.D. of Biostatistics, Assistant Professor, Department of Biostatistics and Epidemiology, School of Public Health, Kerman University of Medical Sciences, Kerman, Iran
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Ho J, DeBeck K, Milloy MJ, Dong H, Wood E, Kerr T, Hayashi K. Increasing availability of illicit and prescription opioids among people who inject drugs in a Canadian setting, 2010-2014. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2017; 44:368-377. [PMID: 29048952 PMCID: PMC5882238 DOI: 10.1080/00952990.2017.1376678] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 08/29/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND Nonmedical use of prescription opioid and illicit opioid has been increasing at an alarming rate in North America over the past decade. OBJECTIVE We sought to examine the temporal trends and correlates of the availability of illicit and prescription opioids among people who inject drugs (PWID) in Vancouver, Canada. METHODS Data were derived from three prospective cohort studies of PWID in Vancouver between 2010 and 2014. In semiannual interviews, participants reported the availability of five sets of illicit and prescription opioids: (1) heroin; (2) Percocet (oxycodone/acetaminophen), Vicodin (hydrocodone/acetaminophen), or Demerol (meperidine); (3) Dilaudid (hydromorphone); (4) Morphine; (5) oxycontin/OxyNEO (controlled-release oxycodone). We defined perceived availability as immediate (e.g., available within 10 minutes) versus no availability/available after 10 minutes. The trend and correlation of immediate availability were identified by multivariable generalized estimating equations logistic regression. RESULTS Among 1584 participants, of which 564 (35.6%) were female, the immediate availability of all illicit and prescribed opioids (except for oxycontin/OxyNEO) increased over time, independent of potential confounders. The Adjusted Odds Ratios of immediate availability associated with every calendar year increase were between 1.09 (95% confidence interval 1.05-1.12) (morphine and Dilaudid) and 1.13 (95% confidence interval 1.09-1.17) (Percocet/Vicodin/Demerol) (all p-values <0.05). CONCLUSION The availability of most prescription opioids had continued to increase in recent years among our sample of PWID in Vancouver. Concurrent increases in the availability of heroin were also observed, raising concerns regarding combination of both illicit and prescription opioid use among PWID that could potentially increase the risk of overdose.
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Affiliation(s)
- Joel Ho
- Department of Medicine, University of Manitoba, Health Sciences Centre, GC425-820 Sherbrook Street, Winnipeg, MB, R3T 2N2
| | - Kora DeBeck
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
- School of Public Policy, Simon Fraser University, 515 West Hastings St –Suite 3271, Vancouver, BC, V6B 5K3 Canada
| | - M-J Milloy
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
- Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6
| | - Huiru Dong
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
- School of Population and Public Health, University of British Columbia,5804 Fairview Avenue, Vancouver, BC, Canada, V6T 1Z3
| | - Evan Wood
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
- Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6
| | - Thomas Kerr
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
- Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
- Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 11300, 8888 University Drive, Burnaby, BC V5A 1S6 Canada
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Cochran GT, Engel RJ, Hruschak VJ, Tarter RE. Prescription Opioid Misuse Among Rural Community Pharmacy Patients: Pilot Study for Screening and Implications for Future Practice and Research. J Pharm Pract 2017; 30:498-505. [PMID: 27402634 PMCID: PMC5219955 DOI: 10.1177/0897190016656673] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Opioid misuse imposes a disproportionately heavy burden on individuals living in rural areas. Community pharmacy has the potential to expand and coordinate with health professionals to identify and intervene with those who misuse opioids. OBJECTIVE Rural and urban community pharmacy patients were recruited in this pilot project to describe and compare patterns of opioid misuse. METHODS We administered a health screening survey in 4 community pharmacies among patients filling opioid medications. Univariate statistics were used to assess differences in health characteristics and opioid medication misuse behaviors between rural and urban respondents. Multivariable statistics were used to identify risk factors associated with rural and urban opioid misuse. RESULTS A total of 333 participants completed the survey. Participants in rural settings had poorer overall health, higher pain levels, lower education, and a higher rate of unemployment compared to patients in urban pharmacies. Rural respondents with illicit drug use (adjustable odds ratio [aOR]: 14.34, 95% confidence interval [CI] = 2.16-95.38), posttraumatic stress disorder (aOR: 5.44, 95% CI = 1.52-19.50), and ≤high school education (aOR: 6.68, 95% CI = 1.06-42.21) had increased risk for opioid misuse. CONCLUSIONS Community pharmacy represents a promising resource for potential identification of opioid misuse, particularly in rural communities. Continued research must extend these findings and work to establish collaborative services in rural settings.
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Affiliation(s)
- Gerald T Cochran
- 1 Department of Psychiatry, School of Medicine, University of Pittsburgh School of Social Work, Pittsburgh, PA, USA
| | - Rafael J Engel
- 2 University of Pittsburgh School of Social Work, Pittsburgh, PA, USA
| | | | - Ralph E Tarter
- 3 University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
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Al-Tayyib AA, Koester S, Riggs P. Prescription opioids prior to injection drug use: Comparisons and public health implications. Addict Behav 2017; 65:224-228. [PMID: 27569698 DOI: 10.1016/j.addbeh.2016.08.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 07/20/2016] [Accepted: 08/13/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The intertwining prescription opioid and heroin epidemic is a major public health problem in the United States, with increasing morbidity and mortality among persons who use these substances. We examined differences between persons who reported being hooked on prescription opioids prior to injecting for the first time and those who did not by demographics, injection and non-injection characteristics, and overdose. METHODS Between June and December 2015, persons who inject drugs were recruited using respondent-driven sampling as part of the National HIV Behavioral Surveillance system in Denver, Colorado. RESULTS Of 599 participants (median age, 40: IQR, 19-69; 71% male; 58% white, non-Hispanic), 192 (32%) reported being hooked on prescription opioids before they injected for the very first time. Compared to participants who were not hooked before they injected, participants who reported being hooked were significantly more likely to be younger, more recent injectors, report a slightly older age at first injection, and report heroin as the first drug injected as well as the drug most frequently injected. Those who reported being hooked were also more likely to be more frequent users of benzodiazepines, non-injection prescription opioids, and non-injection heroin as well as report injecting on a daily or more than daily basis. Being hooked on prescription opioids prior to injection drug use was associated with a 1.55 (95% CI: 1.14, 2.10) fold increase in the risk of at least one overdose in the past 12months. CONCLUSIONS Being hooked on prescription opioids prior to injection might result in a higher risk profile for persons who inject drugs.
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Affiliation(s)
- Alia A Al-Tayyib
- Denver Public Health, Denver Health and Hospital Authority, Denver, CO, USA; Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA.
| | - Stephen Koester
- Departments of Anthropology and Health and Behavioral Sciences, University of Colorado Denver, Denver, CO, USA
| | - Paula Riggs
- Division of Substance Dependence, University of Colorado School of Medicine, Aurora, CO, USA
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Rowe C, Santos GM, Raymond HF, Coffin PO. Social mixing and correlates of injection frequency among opioid use partnerships. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 41:80-88. [PMID: 28113118 DOI: 10.1016/j.drugpo.2016.11.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 11/17/2016] [Accepted: 11/18/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND As resources are deployed to address the opioid overdose epidemic in the USA, it is essential that we understand the correlates of more frequent opioid injections-which has been associated not only with HIV and HCV transmission, but also with overdose risk-to inform the development and targeting of effective intervention strategies like overdose prevention and naloxone distribution programs. However, no studies have explored how characteristics of opioid use partnerships may be associated within injection frequency with opioid partnerships. METHODS Using baseline data from a trial of a behavioural intervention to reduce overdose among opioid users in San Francisco, CA, we calculated assortativity among opioid use partnerships by race, gender, participant-reported HIV- and HCV-status, and opioids used using Newman's assortativity coefficient (NC). Multivariable generalized estimating equations linear regression was used to examine associations between individual- and partnership-level characteristics and injection frequency within opioid use partnerships. RESULTS Opioid use partnerships (n=134) reported by study participants (n=55) were assortative by race (NC=0.42, 95%CI=0.33-0.50) and participant-reported HCV-status (NC=0.42, 95%CI=0.31-0.52). In multivariable analyses, there were more monthly injections among sexual/romantic partnerships (β=114.4, 95%CI=60.2-168.7, p<0.001), racially concordant partnerships reported by white study participants (β=71.4, 95%CI=0.3-142.5, p=0.049), racially discordant partnerships reported by African American study participants (β=105.7, 95%CI=1.0-210.5, p=0.048), and partnerships in which either member had witnessed the other experience an overdose (β=81.8, 95%CI=38.9-124.6, p<0.001). CONCLUSION Social segregation by race and HCV-status should potentially be considered in efforts to reach networks of opioid users. Due to higher injection frequency and greater likelihood of witnessing their partners experience an overdose, individuals in sexual/romantic opioid use partnerships, white individuals in racially homogenous partnerships, and African American individuals in heterogeneous partnerships may warrant focused attention as part of peer- and network-based overdose prevention efforts, as well as broader HIV/HCV prevention strategies. Developing and targeting overdose prevention education programs that provide information on risk factors and ways to identify overdose, as well as effective responses, including naloxone use and rescue breathing, for more frequently injecting networks may help reduce opioid morbidity and mortality in these most at risk groups.
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Affiliation(s)
- Christopher Rowe
- San Francisco Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA 94102, USA.
| | - Glenn-Milo Santos
- San Francisco Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA 94102, USA; University of California, San Francisco, 500 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Henry F Raymond
- San Francisco Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA 94102, USA; University of California, San Francisco, 500 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Phillip O Coffin
- San Francisco Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA 94102, USA; University of California, San Francisco, 500 Parnassus Avenue, San Francisco, CA 94143, USA
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Iversen J, Dertadian G, Geddes L, Maher L. High risk injecting behaviour among people who inject pharmaceutical opioids in Australia. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 42:1-6. [PMID: 28104570 DOI: 10.1016/j.drugpo.2016.12.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 11/30/2016] [Accepted: 12/13/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Use of opioid analgesic medicines has doubled globally over the past decade, with a concomitant increase in prevalence of injection of pharmaceutical opioids (PO), including in Australia. This study investigates types of PO injected, methods used to prepare PO for injection and correlates of recent (last 6 months) PO injection among a large national sample of people who inject drugs (PWID). METHODS The Australian NSP Survey (ANSPS), conducted annually at ∼50 NSP services across Australia, consists of a brief self-administered questionnaire and provision of a capillary dried blood spot for HIV and hepatitis C antibody testing. Data from 2014 were used to conduct univariable and multivariable logistic regression analysis to determine factors independently associated with recent injection of PO. RESULTS Among 1488 ANSPS respondents who were identified as opioid injectors, 57% (n=848) reported injection of PO in the previous six months. The majority of PO injectors (85%) reported filtering PO prior to injection, although use of efficacious wheel filters was relatively rare (11%). Correlates of POs injection included daily injection (AOR=1.65, 95% CI 1.31-2.08), receptive sharing of syringes (AOR=2.00, 95% CI 1.43-2.78), receptive sharing of drug preparation equipment (AOR=1.55, 95% CI 1.19-2.01), drug overdose in the previous year (AOR=1.81, 95% CI 1.36-2.42) and residence in inner regional (AOR=3.27, 95% CI 2.21-5.23) or outer regional/remote (AOR=5.50, 95% CI 3.42-8.84) areas of Australia. CONCLUSION PO injection is geographically widespread among Australian PWID and takes place in the context of poly-drug use. People who inject POs are at high risk of overdose, injection related injury and disease and blood borne viral infections. Harm reduction services that target this group, including in non-urban areas, should deliver health education regarding PO-specific overdose risks, the requirement to adequately filter PO before injection and to ensure that both naloxone and specialist pill filters are readily accessible.
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Affiliation(s)
- Jenny Iversen
- Viral Hepatitis Epidemiology and Prevention Program, The Kirby Institute, UNSW Australia, Sydney, NSW 2052, Australia.
| | - George Dertadian
- Viral Hepatitis Epidemiology and Prevention Program, The Kirby Institute, UNSW Australia, Sydney, NSW 2052, Australia
| | - Louise Geddes
- Viral Hepatitis Epidemiology and Prevention Program, The Kirby Institute, UNSW Australia, Sydney, NSW 2052, Australia
| | - Lisa Maher
- Viral Hepatitis Epidemiology and Prevention Program, The Kirby Institute, UNSW Australia, Sydney, NSW 2052, Australia
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