1
|
Prusaczyk B, Tilmon S, Landman J, Seibert D, Colston DC, Westergaard R, Cooper H, Feinberg J, Friedmann PD, Go VF, Khoury D, Korthius T, Mixson S, Moellner A, Nolte K, Smith G, Young A, Pho MT, Jenkins W. Barriers to Healthcare and Social Service Utilization Among Rural Older Adults Who Use Drugs. J Appl Gerontol 2024:7334648241258018. [PMID: 38839560 DOI: 10.1177/07334648241258018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Abstract
The objective of this study was to understand barriers to healthcare and social service utilization among older adults residing in rural areas who use drugs. A cross-sectional survey of persons who use opioids or inject drugs in rural counties with high overdose rates across ten states was conducted. For this analysis, participants were restricted to only the 375 individuals aged 50 and older. They were asked about barriers to utilizing healthcare and social services. Multivariate analyses were conducted. The most common barriers were a lack of transportation and a fear of stigma. The average number of barriers was 2.53. Those who were either uninsured or homeless endorsed 37% more barriers. For every five-year increase in age, the number of barriers reduced by 15%. Efforts to reduce these barriers may include expanding eligibility for transportation and housing services and leveraging trusted community members to broker linkages to providers to overcome stigma.
Collapse
Affiliation(s)
- Beth Prusaczyk
- Division of General Medical Sciences, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
- Institute for Informatics, Data Science, and Biostatistics, Center for Population Health Informatics, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Sandra Tilmon
- Biological Sciences Division, University of Chicago, Chicago, IL, USA
| | - Joshua Landman
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Drake Seibert
- Medical School, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David C Colston
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
- Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA
| | - Ryan Westergaard
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Hannah Cooper
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Judith Feinberg
- Department of Medicine, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Peter D Friedmann
- Department of Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA, USA
| | - Vivian F Go
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Dalia Khoury
- RTI International, Research Triangle Park, NC, USA
| | - Todd Korthius
- Department of Medicine, Oregon Health and Sciences University, Portland, OR, USA
| | - Sarah Mixson
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - Alexandria Moellner
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Kerry Nolte
- College of Health and Human Services, University of New Hampshire, Durham, NH, USA
| | - Gordon Smith
- School of Public Health, West Virginia University, Morgantown, WV, USA
| | - April Young
- College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Mai T Pho
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago Medical Center, Chicago, IL, USA
| | - Wiley Jenkins
- Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, IL, USA
| |
Collapse
|
2
|
Baker R, Fredericksen RJ, Rudolph AE, Stopka TJ, Walters SM, Fadanelli M, Bolinski RS, Sibley AL, Stack E, Crane HM, Korthuis PT, Seal DW. Overdose responses among rural people who use drugs: A multi-regional qualitative study. Harm Reduct J 2024; 21:107. [PMID: 38822387 PMCID: PMC11140975 DOI: 10.1186/s12954-024-01007-9] [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: 08/29/2023] [Accepted: 04/16/2024] [Indexed: 06/03/2024] Open
Abstract
BACKGROUND Efforts to distribute naloxone have equipped more people with the ability to reverse opioid overdoses but people who use drugs are often reluctant to call 911 due to concerns for legal repercussions. Rural communities face unique challenges in reducing overdose deaths compared to urban communities, including limited access to harm reduction services as well as greater concerns about stigma and privacy. METHODS The Rural Opioid Initiative was funded in 2017 to better understand the health-related harms associated with the opioid crisis in rural US communities and consists of eight studies spanning ten states and 65 counties. Each study conducted semi-structured qualitative interviews with people who use drugs to understand contextual factors influencing drug use and health behaviors. We analyzed qualitative data from seven studies with data available at the time of analysis to understand peer response to overdose. RESULTS Of the 304 participants interviewed, 55% were men, 70% were white, 80% reported current injection drug use, and 60% reported methamphetamine use. Similar to what has been found in studies focused on urban settings, people who use drugs in rural communities use a range of strategies to reverse overdoses, including non-evidence-based approaches. Several reported that multiple doses of naloxone are needed to reverse overdose. Three themes emerged around the willingness to call 911, including (1) hesitancy to call 911 for fear of legal consequences, (2) negative perceptions or experiences with law enforcement officers, and (3) efforts to obtain medical intervention while avoiding identification/law enforcement involvement. CONCLUSION People who use drugs employ multiple strategies to attempt overdose reversal, including non-evidence-based approaches. Greater education about the most effective and least harmful strategies is needed. Reluctance to call 911 is rooted in concerns about potential legal consequences as well as perceptions about law enforcement officers, which may be heightened in rural communities where people who use drugs are more easily identified by law enforcement. People who use drugs will go to great strides to connect their peers to needed medical services, suggesting that comprehensive interventions to reduce interactions with law enforcement officers and eliminate legal consequences for reporting overdoses are critical.
Collapse
Affiliation(s)
- Robin Baker
- OHSU-PSU School of Public Health, Portland, OR, USA.
- Learning Design & Innovation, 37 Dewey Field Rd, Suite 201-205, 03755, Hanover, NH, USA.
| | | | - Abby E Rudolph
- Department of Epidemiology and Biostatistics, Temple University College of Public Health, Philadelphia, PA, USA
| | - Thomas J Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Suzan M Walters
- Department of Epidemiology, School of Global Public Health, New York University, New York, NY, USA
| | - Monica Fadanelli
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Adams L Sibley
- The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | | | - P Todd Korthuis
- School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - David W Seal
- Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| |
Collapse
|
3
|
McNeely J, McLeman B, Gardner T, Nesin N, Amarendran V, Farkas S, Wahle A, Pitts S, Kline M, King J, Rosa C, Marsch L, Rotrosen J, Hamilton L. Implementation of substance use screening in rural federally-qualified health center clinics identified high rates of unhealthy alcohol and cannabis use among adult primary care patients. Addict Sci Clin Pract 2023; 18:56. [PMID: 37726839 PMCID: PMC10510292 DOI: 10.1186/s13722-023-00404-y] [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: 01/03/2023] [Accepted: 07/31/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Screening for substance use in rural primary care clinics faces unique challenges due to limited resources, high patient volumes, and multiple demands on providers. To explore the potential for electronic health record (EHR)-integrated screening in this context, we conducted an implementation feasibility study with a rural federally-qualified health center (FQHC) in Maine. This was an ancillary study to a NIDA Clinical Trials Network study of screening in urban primary care clinics (CTN-0062). METHODS Researchers worked with stakeholders from three FQHC clinics to define and implement their optimal screening approach. Clinics used the Tobacco, Alcohol, Prescription Medication, and Other Substance (TAPS) Tool, completed on tablet computers in the waiting room, and results were immediately recorded in the EHR. Adult patients presenting for annual preventive care visits, but not those with other visit types, were eligible for screening. Data were analyzed for the first 12 months following implementation at each clinic to assess screening rates and prevalence of reported unhealthy substance use, and documentation of counseling using an EHR-integrated clinical decision support tool, for patients screening positive for moderate-high risk alcohol or drug use. RESULTS Screening was completed by 3749 patients, representing 93.4% of those with screening-eligible annual preventive care visits, and 18.5% of adult patients presenting for any type of primary care visit. Screening was self-administered in 92.9% of cases. The prevalence of moderate-high risk substance use detected on screening was 14.6% for tobacco, 30.4% for alcohol, 10.8% for cannabis, 0.3% for illicit drugs, and 0.6% for non-medical use of prescription drugs. Brief substance use counseling was documented for 17.4% of patients with any moderate-high risk alcohol or drug use. CONCLUSIONS Self-administered EHR-integrated screening was feasible to implement, and detected substantial alcohol, cannabis, and tobacco use in rural FQHC clinics. Counseling was documented for a minority of patients with moderate-high risk use, possibly indicating a need for better support of primary care providers in addressing substance use. There is potential to broaden the reach of screening by offering it at routine medical visits rather than restricting to annual preventive care visits, within these and other rural primary care clinics.
Collapse
Affiliation(s)
- Jennifer McNeely
- Department of Population Health, Section on Tobacco, Alcohol and Drug Use, New York University Grossman School of Medicine, 180 Madison Ave., 17th Floor, New York, NY, 10016, USA.
| | - Bethany McLeman
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Parkway, Evergreen Center, Suite 315, Lebanon, NH, 03766, USA
| | - Trip Gardner
- Penobscot Community Health Care (PCHC), 103 Maine Avenue, Bangor, ME, 04401, USA
| | - Noah Nesin
- Penobscot Community Health Care (PCHC), 103 Maine Avenue, Bangor, ME, 04401, USA
| | - Vijay Amarendran
- Penobscot Community Health Care (PCHC), 103 Maine Avenue, Bangor, ME, 04401, USA
| | - Sarah Farkas
- Department of Psychiatry, New York University Grossman School of Medicine, 1 Park Ave, New York, NY, 10016, USA
| | - Aimee Wahle
- The Emmes Company, 401 N. Washington St., Rockville, MD, 20850, USA
| | - Seth Pitts
- The Emmes Company, 401 N. Washington St., Rockville, MD, 20850, USA
| | - Margaret Kline
- The Emmes Company, 401 N. Washington St., Rockville, MD, 20850, USA
| | - Jacquie King
- The Emmes Company, 401 N. Washington St., Rockville, MD, 20850, USA
| | - Carmen Rosa
- National Institute on Drug Abuse, c/o NIH Mail Center, NIDA 3@FN MSC 6022, 16071 Industrial Drive-Dock 11, Gaithersburg, MD, 20892, USA
| | - Lisa Marsch
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Parkway, Evergreen Center, Suite 315, Lebanon, NH, 03766, USA
| | - John Rotrosen
- Department of Psychiatry, New York University Grossman School of Medicine, 1 Park Ave, New York, NY, 10016, USA
| | - Leah Hamilton
- Department of Population Health, Section on Tobacco, Alcohol and Drug Use, New York University Grossman School of Medicine, 180 Madison Ave., 17th Floor, New York, NY, 10016, USA
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Seattle, WA, 98101, USA
| |
Collapse
|
4
|
Batty EJ, Ibragimov U, Fadanelli M, Gross S, Cooper K, Klein E, Ballard AM, Young AM, Lockard AS, Oser CB, Cooper HLF. A qualitative analysis of rural syringe service program fidelity in Appalachian Kentucky: Staff and participant perspectives. J Rural Health 2023; 39:328-337. [PMID: 36117151 PMCID: PMC10484119 DOI: 10.1111/jrh.12715] [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] [Indexed: 11/29/2022]
Abstract
PURPOSE As drug-related epidemics have expanded from cities to rural areas, syringe service programs (SSPs) and other harm reduction programs have been slow to follow. The recent implementation of SSPs in rural areas demands attention to program fidelity based on core components of SSP success. METHODS Semistructured interviews conducted with clients and staff at 5 SSPs in 5 counties within 2 Central Appalachian health districts. Interviews covered fidelity of SSP implementation to 6 core components: (1) meet needs for harm reduction supplies; (2) education and counseling for sexual, injection, and overdose risks; (3) cooperation between SSPs and local law enforcement; (4) provide other health and social services; (5) ensure low threshold access to services; and (6) promote dignity, the impact of poor fidelity on vulnerability to drug-related harms, and the risk environment's influence on program fidelity. We applied thematic methods to analyze the data. FINDINGS Rural SSPs were mostly faithful to the 6 core components. Deviations from core components can be attributed to certain characteristics of the local rural risk environment outlined in the risk environment model, including geographic remoteness, lack of resources and underdeveloped infrastructure, and stigma against people who inject drugs (PWID) CONCLUSIONS: As drug-related epidemics continue to expand outside cities, scaling up SSPs to serve rural PWID is essential. Future research should explore whether the risk environment features identified also influence SSP fidelity in other rural areas and develop and test strategies to strengthen core components in these vulnerable areas.
Collapse
Affiliation(s)
- E J Batty
- Department of Sociology, University of Kentucky, Lexington, Kentucky, USA
| | - U Ibragimov
- Department of Behavioral, Social, and Health Education Sciences, Emory University, Atlanta, Georgia, USA
| | - M Fadanelli
- Department of Behavioral, Social, and Health Education Sciences, Emory University, Atlanta, Georgia, USA
| | - S Gross
- Department of Epidemiology, Emory University, Atlanta, Georgia, USA
| | - K Cooper
- Department of Behavioral, Social, and Health Education Sciences, Emory University, Atlanta, Georgia, USA
| | - E Klein
- Department of Epidemiology, Emory University, Atlanta, Georgia, USA
| | - A M Ballard
- Department of Environmental Health, Emory University, Atlanta, Georgia, USA
| | - A M Young
- Department of Epidemiology, University of Kentucky, Lexington, Kentucky, USA
| | - A S Lockard
- Kentucky River District Health Department, Hazard, Kentucky, USA
| | - C B Oser
- Department of Sociology, University of Kentucky, Lexington, Kentucky, USA
| | - H L F Cooper
- Department of Behavioral, Social, and Health Education Sciences, Emory University, Atlanta, Georgia, USA
| |
Collapse
|
5
|
Tempalski B, Williams LD, Kolak M, Ompad DC, Koschinsky J, McLafferty SL. Conceptualizing the Socio-Built Environment: An Expanded Theoretical Framework to Promote a Better Understanding of Risk for Nonmedical Opioid Overdose Outcomes in Urban and Non-Urban Settings. J Urban Health 2022; 99:701-716. [PMID: 35672547 PMCID: PMC9360264 DOI: 10.1007/s11524-022-00645-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/06/2022] [Indexed: 01/31/2023]
Abstract
Nonmedical opioid (NMO) use has been linked to significant increases in rates of NMO morbidity and mortality in non-urban areas. While there has been a great deal of empirical evidence suggesting that physical features of built environments represent strong predictors of drug use and mental health outcomes in urban settings, there is a dearth of research assessing the physical, built environment features of non-urban settings in order to predict risk for NMO overdose outcomes. Likewise, there is strong extant literature suggesting that social characteristics of environments also predict NMO overdoses and other NMO use outcomes, but limited research that considers the combined effects of both physical and social characteristics of environments on NMO outcomes. As a result, important gaps in the scientific literature currently limit our understanding of how both physical and social features of environments shape risk for NMO overdose in rural and suburban settings and therefore limit our ability to intervene effectively. In order to foster a more holistic understanding of environmental features predicting the emerging epidemic of NMO overdose, this article presents a novel, expanded theoretical framework that conceptualizes "socio-built environments" as comprised of (a) environmental characteristics that are applicable to both non-urban and urban settings and (b) not only traditional features of environments as conceptualized by the extant built environment framework, but also social features of environments. This novel framework can help improve our ability to identify settings at highest risk for high rates of NMO overdose, in order to improve resource allocation, targeting, and implementation for interventions such as opioid treatment services, mental health services, and care and harm reduction services for people who use drugs.
Collapse
Affiliation(s)
- Barbara Tempalski
- Center for Community-Based Population Health Research, NDRI-USA, Inc., 31 West 34th Street, New York, NY 10001 USA
| | - Leslie D. Williams
- Division of Community Health Sciences, University of Illinois at Chicago School of Public Health, 1603 W. Taylor Street, Chicago, IL 60607 USA
| | - Marynia Kolak
- Center for Spatial Data Science, University of Chicago, 1155 East 60th Street, Chicago, IL 60637 USA
| | - Danielle C. Ompad
- Center for Drug Use and HIV/HCV Research, and the Department of Epidemiology, New York University School of Global Public Health, 708 Broadway, New York, NY 10003 USA
| | - Julia Koschinsky
- Center for Spatial Data Science, University of Chicago, 1155 East 60th Street, Chicago, IL 60637 USA
| | - Sara L. McLafferty
- Department of Geography and Geographic Information Science, University of Illinois at Urbana-Champaign, 1301 W Green Street, Urbana, IL 61801 USA
| |
Collapse
|
6
|
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: 26] [Impact Index Per Article: 13.0] [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.
Collapse
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
| |
Collapse
|
7
|
Greenwood GL, Wilson A, Bansal GP, Barnhart C, Barr E, Berzon R, Boyce CA, Elwood W, Gamble-George J, Glenshaw M, Henry R, Iida H, Jenkins RA, Lee S, Malekzadeh A, Morris K, Perrin P, Rice E, Sufian M, Weatherspoon D, Whitaker M, Williams M, Zwerski S, Gaist P. HIV-Related Stigma Research as a Priority at the National Institutes of Health. AIDS Behav 2022; 26:5-26. [PMID: 33886010 PMCID: PMC8060687 DOI: 10.1007/s10461-021-03260-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2021] [Indexed: 02/07/2023]
Abstract
The National Institutes of Health (NIH) recognizes that, despite HIV scientific advances, stigma and discrimination continue to be critical barriers to the uptake of evidence-based HIV interventions. Achieving the Ending the HIV Epidemic: A Plan for America (EHE) goals will require eliminating HIV-related stigma. NIH has a significant history of supporting HIV stigma research across its Institutes, Centers, and Offices (ICOs) as a research priority. This article provides an overview of NIH HIV stigma research efforts. Each ICO articulates how their mission shapes their interest in HIV stigma research and provides a summary of ICO-relevant scientific findings. Research gaps and/or future opportunities are identified throughout, with key research themes and approaches noted. Taken together, the collective actions on the part of the NIH, in tandem with a whole of government and whole of society approach, will contribute to achieving EHE's milestones.
Collapse
Affiliation(s)
- Gregory L Greenwood
- Division of AIDS Research, National Institute of Mental Health, National Institutes of Health, 5601 Fishers Lane, 9G19, Bethesda, MD, 20852, USA.
| | - Amber Wilson
- Office of AIDS Research, National Institutes of Health, Bethesda, MD, 20852, USA
| | - Geetha P Bansal
- Division of International Training and Research, Fogarty International Center, Bethesda, MD, 20814, USA
| | - Christopher Barnhart
- Sexual and Gender Minority Research Office, National Institutes of Health, Bethesda, MD, 20814, USA
| | - Elizabeth Barr
- Office of Research on Women's Health, National Institutes of Health, Bethesda, MD, 20814, USA
| | - Rick Berzon
- Division of Scientific Programs, National Institute of Minority Health and Health Disparities, Bethesda, MD, 20892, USA
| | - Cheryl Anne Boyce
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, Bethesda, MD, 20892, USA
| | - William Elwood
- Office of Behavioral and Social Sciences Research, National Institutes of Health, Bethesda, MD, 20814, USA
| | | | - Mary Glenshaw
- Office of AIDS Research, National Institutes of Health, Bethesda, MD, 20852, USA
| | - Rebecca Henry
- Division of Extramural Science Programs, National Institute of Nursing Research, Bethesda, MD, 20892, USA
| | - Hiroko Iida
- Division of Extramural Research, National Institute of Dental and Craniofacial Research, Bethesda, MD, 20892, USA
| | - Richard A Jenkins
- Division of Epidemiology, Services and Prevention Research, National Institute on Drug Abuse, Bethesda, MD, 20852, USA
| | - Sonia Lee
- Division of Extramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, 20817, USA
| | - Arianne Malekzadeh
- Division of International Science Policy, Planning and Evaluation, Fogarty International Center, Bethesda, MD, 20814, USA
| | - Kathryn Morris
- Office of Behavioral and Social Sciences Research, National Institutes of Health, Bethesda, MD, 20814, USA
| | - Peter Perrin
- Division of Digestive Diseases & Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 20892, USA
| | - Elise Rice
- Division of Extramural Research, National Institute of Dental and Craniofacial Research, Bethesda, MD, 20892, USA
| | - Meryl Sufian
- Office of AIDS Research, National Institutes of Health, Bethesda, MD, 20852, USA
| | - Darien Weatherspoon
- Division of Extramural Research, National Institute of Dental and Craniofacial Research, Bethesda, MD, 20892, USA
| | - Miya Whitaker
- Office of Research on Women's Health, National Institutes of Health, Bethesda, MD, 20814, USA
| | - Makeda Williams
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, Bethesda, MD, 20892, USA
| | - Sheryl Zwerski
- Division of AIDS, National Institute of Allergy and Infectious Diseases, Bethesda, MD, 20852, USA
| | - Paul Gaist
- Office of AIDS Research, National Institutes of Health, Bethesda, MD, 20852, USA
| |
Collapse
|
8
|
Watson DP, Staton MD, Gastala N. Identifying unique barriers to implementing rural emergency department-based peer services for opioid use disorder through qualitative comparison with urban sites. Addict Sci Clin Pract 2022; 17:41. [PMID: 35902890 PMCID: PMC9331574 DOI: 10.1186/s13722-022-00324-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 07/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In an effort to address the current opioid epidemic, a number of hospitals across the United States have implemented emergency department-based interventions for engaging patients presenting with opioid use disorder. The current study seeks to address gaps in knowledge regarding implementation of a sub-type of such interventions, emergency department-based peer support services, in rural areas by comparing implementation of rural and urban programs that participated in Indiana's Recovery Coach and Peer Support Initiative (RCPSI). METHODS We conducted a secondary analysis of qualitative semi-structured implementation interviews collected as part of an evaluation of 10 programs (4 rural and 6 urban) participating in the RCPSI. We conducted interviews with representatives from each program at 3 time points over the course of the first year of implementation. Our deductive coding process was guided by the Consolidated Framework for Implementation Research (CFIR) and an external context taxonomy. RESULTS We identified key differences for rural programs corresponding to each of the 5 primary constructs in the coding scheme. (1) Intervention characteristics: rural sites questioned intervention fit with their context, required more adaptations, and encountered unexpected costs. (2) External context: rural sites were not appropriately staffed to meet patient needs, encountered logistical and legal barriers regarding patient privacy, and had limited patient transportation options. (3) Inner setting: rural sites lacked strong mechanisms for internal communication and difficulties integrating with pre-existing culture and climate. (4) Characteristics of individuals: some rural providers resisted working with peers due to pre-existing attitudes and beliefs. (5) Implementation process: rural sites spent more time identifying external partners and abandoned more components of their initial implementation plans. CONCLUSIONS Findings demonstrate how rural programs faced greater challenges implementing emergency department-based peer services over time. These challenges required flexible adaptations to originally intended plans. Rural programs likely require flexibility to adapt interventions that were developed in urban settings to ensure success considering local contextual constraints that were identified by our analysis.
Collapse
Affiliation(s)
- Dennis P. Watson
- grid.413870.90000 0004 0418 6295Chestnut Health Systems, 221 W. Walton St, Chicago, IL 60610 USA ,grid.185648.60000 0001 2175 0319Center for Dissemination and Implementation Science, Department of Medicine, University of Illinois College of Medicine at Chicago, Chicago, IL USA
| | - Monte D. Staton
- grid.185648.60000 0001 2175 0319Center for Dissemination and Implementation Science, Department of Medicine, University of Illinois College of Medicine at Chicago, Chicago, IL USA
| | - Nicole Gastala
- grid.185648.60000 0001 2175 0319Mile Square Health Centers, Department of Family Medicine, University of Illinois College of Medicine at Chicago, Chicago, IL USA
| |
Collapse
|
9
|
Jenkins RA. The fourth wave of the US opioid epidemic and its implications for the rural US: A federal perspective. Prev Med 2021; 152:106541. [PMID: 34482994 DOI: 10.1016/j.ypmed.2021.106541] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 10/20/2022]
Abstract
The current opioid epidemic in the United States has been characterized as having three waves: prescription opioid use, followed by heroin use, and then use of synthetic opioids (e.g., fentanyl), with early waves affecting a population that was younger, less predominantly male, and more likely to be Caucasian and rural than in past opioid epidemics. A variety of recent data suggest that we have entered a fourth wave which can be characterized as a stimulant/opioid epidemic, with mental illness co-morbidities being more evident than in the past. Stimulant use has introduced new complexities in terms of behavioral consequences (e.g., neurological deficits, suicidal ideation, psychosis, hostility, violence), available treatments, and engagement into services. These compound existing issues in addressing the opioid epidemic in rural areas, including the low density of populations and the scarcity of behavioral health resources (e.g., fewer credentialed behavioral health professionals, particularly those able to prescribe Buprenorphine). Considerations for addressing this new wave are discussed, along with the drawbacks of a wave perspective and persistent concerns in confronting drug abuse such as stigma.
Collapse
Affiliation(s)
- Richard A Jenkins
- National Institute on Drug Abuse, Bethesda, MD, United States of America.
| |
Collapse
|
10
|
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.
Collapse
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
| | | |
Collapse
|
11
|
Grabowska W, Holden S, Wayne PM, Kilgore K. An ethnographic study of opioid use disorder in rural Maine: The problem of pain. QUALITATIVE RESEARCH IN MEDICINE & HEALTHCARE 2021. [DOI: 10.4081/qrmh.2020.9175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
This qualitative study was conducted to more fully understand health care providers and community leaders’ perceptions of the opioid crisis in rural Maine. In 2017, Maine continued to have one of the highest opioid overdose death rates in the country, more than double the national average. I (first author) visited eight treatment centers in Maine providing support and treatment to people recovering form Opioid Use Disorder (OUD), shadowing health care providers. I also attended OUD-related meetings held with community leaders. I conducted a total of 33 semi-structured interviews with health care providers, community leaders, and NGOs in the state of Maine. Three themes emerged integrating observations with semi-structured interviews: i) Impact of emergence of new extended release opioids, their prescription patterns, and culture around them; ii) Subjectivity of pain and importance of understanding psychic injury in OUD treatment; iii) Socio-political context and perception of OUD in Maine. Our society’s perception of pain has deep historical and cultural sources that influence the way that pain has been perceived and treated in the medical setting. Resources beyond the medical environment are needed to address pain adequately.
Collapse
|
12
|
Ibragimov U, Young AM, Cooper HLF. Understanding rural risk environments for drug-related harms: Progress, challenges, and steps forward. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 85:102926. [PMID: 32912825 PMCID: PMC8215764 DOI: 10.1016/j.drugpo.2020.102926] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/09/2020] [Accepted: 08/13/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Umedjon Ibragimov
- Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, United States.
| | - April M Young
- Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY, United States
| | - Hannah L F Cooper
- Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| |
Collapse
|
13
|
Intersectional structural vulnerability to abusive policing among people who inject drugs: A mixed methods assessment in California's central valley. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 87:102981. [PMID: 33129133 DOI: 10.1016/j.drugpo.2020.102981] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/07/2020] [Accepted: 10/08/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Abusive and violent policing is an important determinant of health for people who inject drugs (PWID), which has been linked to structural vulnerability. However, further exploration of the intersectional nature of this vulnerability is warranted. California's Central Valley is a largely rural/suburban and politically conservative area, with high rates of injection drug use and overdose mortality, where rates of abusive policing of PWID have not been characterized. METHODS We assessed self-reported experiences of abusive policing using a sequential mixed-methods approach, consisting of n = 54 in-depth qualitative interviews followed by a respondent driven survey of n = 494 PWID. Qualitative conclusions were used to guide the development a novel quantitative framework to explore intersectional structural vulnerability, drawing on UpSet visualization and multivariable logistic regression. RESULTS Qualitative analysis suggests that abusive policing is not random or isolated; instead it can be understood in the context of routinized police harassment of PWID, which can escalate into physical or other forms of violence. These cycles are mediated by various forms of social disadvantage-often articulated through the frame of "looking like a drug user"-with deep connections to markers of race, class, gender, occupation and other elements of personal identity. Quantitative results confirm high frequency of abusive encounters with police, including physical violence (42%), verbal abuse (62%), sexual violence (9%), and the confiscation of new/unused syringes (39%). Females report higher rates of sexual violence and exploitation (aOR= 4.2; 95% CI: 2.1-9.0) and males report higher rates of physical violence (aOR=3.6; 95% CI: 2.4-5.6) and all other outcomes. Experiencing homelessness, having traded sex, and living in a rural zip code, are independently associated with numerous forms of police abuse. Intersectional analysis reveals clusters of individuals with highly elevated vulnerability, and in general, having a greater number of vulnerability factors was associated with increased odds of police abuse. CONCLUSIONS We find that structural vulnerability is linked-in a highly intersectional manner-with experiencing abusive police encounters among PWID in California's Central Valley. Monitoring, prevention, and response to deleterious law enforcement practices must be integrated into structural interventions to protect vulnerable groups. Reform is especially urgent in rural/suburban areas that are increasingly important focal points to reduce social and health harms associated with injection drug use.
Collapse
|