Drivers of opioid use in Appalachian Pennsylvania: Cross-cutting social and community-level factors

Examining the relationship between social determinants of health, measures of structural racism and county-level overdose deaths from 2017-2020

INTRODUCTION

Despite being an important determinant of health outcomes, measures of structural racism are lacking in studies examining the relationship between the social determinants of health (SDOH) and overdose deaths. The aim of this study is to examine the association between per capita revenue generated from fines and forfeitures, a novel measure of structural racism, and other SDOH with county-level overdose deaths from 2017-2020.

METHODS

This longitudinal analysis of 2,846 counties from 2017-2020 used bivariate and multivariate Generalized Estimating Equations models to estimate associations between county overdose mortality rates and SDOH characteristics, including the fines and forfeitures measure.

RESULTS

In our multivariate model, higher per capita fine and forfeiture revenue (5.76; CI: 4.76, 6.78), households receiving food stamps (1.15; CI: 0.77, 1.53), residents that are veterans (1.07; CI: 0.52, 1.63), substance use treatment availability (4.69; CI: 3.03, 6.33) and lower population density (-0.002; CI: -0.004, -0.001) and percent of Black residents (-0.7`; CI: -1.01, -0.42) were significantly associated with higher overdose death rates. There was a significant additive interaction between the fines and forfeitures measure (0.10; CI: 0.03, 0.17) and the percent of Black residents.

CONCLUSIONS

Our findings suggest that structural racism, along with other SDOH, is associated with overdose deaths. Future research should focus on connecting individual-level data on fines and forfeitures to overdose deaths and other health outcomes, include measures of justice-related fines, such as court fees, and assess whether interventions aimed at increasing economic vitality in disadvantaged communities impact overdose deaths in a meaningful way.

Housing cost burden and external causes of mortality: Variations across housing regimes in high-income countries, 2010-2020

OBJECTIVES

While comparative studies reported that generous welfare state improves population health, they did not take into account the roles of housing as a cornerstone of welfare state. To reduce knowledge gaps, this study aims to estimate (a) the link between housing affordability stress and mortality rate due to external causes and (b) the moderating effects of housing regime on such association.

METHODS

Using country level panel data from the databases of the Organisation for Economic Co-operation and Development (OECD), fixed effects were performed to estimate the effects of housing costs to income ratio on mortality rates due to external causes (accidents, intentional self-harm, and assault). Also, we tested whether housing regimes moderate the association between housing cost burden and mortality rate.

RESULTS

An increased level of housing cost burden predicted mortality rates due to accidents and intentional self-harm. Such association was pronounced for countries with higher rates of homeownership and limited access to market self-help. In addition, when homeownership rates and debt-to-income ratios are taken into account as time-varying variables, the elevated mortality risks associated with both increased housing cost burden and higher homeownership are mitigated in countries where debt relative to income increases.

CONCLUSION

Our findings suggest that different housing systems shape divergent patterns of mortality risks associated with housing affordability stress. Future studies may wish to incorporate housing in macro comparative studies on population health.

High-risk Individuals and Naloxone Use: Implications for THN Programs in Rural Appalachian Communities

Introduction

Take-home naloxone (THN) is being made available across rural Appalachia to curb opioid overdose fatalities. Despite this initiative, some opioid users do not possess naloxone, and if they do, do not administer it to others.

Purpose

Research findings on risk factors that contribute to opioid overdose are presented. These factors, identified in a sample of 16 overdose cases, are (1) early onset age of opioid use; (2) progressive opioid use; (3) a transition from pain medication to heroin and fentanyl; (4) fears of being arrested at a naloxone intervention if first responders are contacted, and (5) limited knowledge of Good Samaritan Laws.

Methods

The findings are based on a subsample 16 overdose victims who were identified during a one-year (2018) qualitative study on the decline of overdose fatalities in four rural counties in Western Pennsylvania. They were recruited from a larger sample of 50 current and former substance users and were interviewed a second time using a semi-structured interview guide about their overdose experiences. All interview data were analyzed using thematic analysis via NVivo.

Results

Findings reveal that risk factors contribute to a severe opioid dependence that interferes with naloxone use. These factors also hinder adherence to proper naloxone protocol, designed to place overdose victims in contact with treatment providers.

Implications

Recommendations are made for additional research and for pursuing measures to increase efficacy of naloxone interventions. They include developing naloxone campaigns aimed at high-risk individuals, improving their knowledge of Good Samaritan Laws, increasing adherence to THN protocols that improve the possibility of treatment, and using community harm reduction specialists for community outreach.

Adverse Childhood Experiences and Overdose: Lessons From Overdose Data to Action

INTRODUCTION

Adverse childhood experiences and overdose are linked in a cycle that affects individuals and communities across generations. The Centers for Disease Control and Prevention's Overdose Data to Action cooperative agreement supports a comprehensive public health approach to overdose prevention and response activities across the U.S. Exposure to traumatic events during childhood can increase the risk for myriad health outcomes, including overdose; therefore, many Overdose Data to Action recipients leveraged funds to address adverse childhood experiences.

METHODS

In 2021, an inventory of Overdose Data to Action‒funded activities implemented in 2019 and 2020 showed that 34 of the 66 recipients proposed overdose prevention activities that support people who have experienced adverse childhood experiences or that focus on preventing the intergenerational transmission of adverse childhood experiences. Activities were coded by adverse childhood experience prevention strategy, level of the social ecology, and whether they focused on neonatal abstinence syndrome.

RESULTS

Most activities among Overdose Data to Action recipients occurred at the community level of the social‒ecologic model and under the intervene to lessen harms adverse childhood experience prevention strategy. Of the 84 adverse childhood experience‒related activities taking place across 34 jurisdictions, 44 are focused on neonatal abstinence syndrome.

CONCLUSIONS

Study results highlight the opportunities to expand the breadth of adverse childhood experience prevention strategies across the social ecology. Implementing cross-cutting overdose and adverse childhood experience‒related activities that span the social‒ecologic model are critical for population-level change and have the potential for the broadest impact. Focusing on neonatal abstinence syndrome also offers a unique intervention opportunity for both adverse childhood experience and overdose prevention.

A qualitative examination of recent increases in methamphetamine use in a cohort of rural people who use drugs

INTRODUCTION

Rising rates of methamphetamine use among populations using opioids is an escalating public health concern. The purpose of this manuscript is to identify socioecologic factors driving increases in methamphetamine use among Appalachian Kentucky adults with a history of opioid use.

METHODS

Semi-structured qualitative interviews were conducted among 20 Appalachian Kentuckians in the Social Network of Appalachian Peoples (SNAP) cohort who reported lifetime opioid use and past 30-day methamphetamine use. Interviews focused on initiation of methamphetamine use, factors that influence methamphetamine use at the individual, interpersonal, community and society levels.

RESULTS

Participants reported using methamphetamine to self-treat underlying issues, including withdrawal from opioids, chronic pain, and emotional distress. Initiation of use was most often facilitated through their drug networks. Participants reported that methamphetamine was widely available and affordable in their community. Several participants with extensive histories of non-medical prescription opioid (NMPO) use described transitioning to methamphetamine as their drug of choice as opioids became less available in their community. Participants also reported economic distress and lack of recreational opportunities as drivers of increased methamphetamine use.

DISCUSSION

Recent increases in methamphetamine use among those with a history of opioid use is facilitated by methamphetamine's relative availability and affordability. Methamphetamine use was also highly influenced by societal factors such as economic deprivation and policies that decreased availability of NMPOs. Surging methamphetamine use exacerbates inequities in addiction care brought to light by the opioid epidemic. Interventions aimed at addressing the socioecological drivers of methamphetamine use among people who use opioids are warranted.

Understanding Polarizing Community Perspectives on Harm Reduction Strategies: Challenges to Addressing the Opioid Crisis in Appalachian Pennsylvania

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.

Equity-oriented frameworks to inform responses to opioid overdoses: a scoping review

OBJECTIVE

The purpose of this scoping review was to systematically identify and describe literature that uses a health equity-oriented approach for preventing and reducing the harms of stigma or overdose for people who use illicit drugs or misuse prescription opioids.

INCLUSION CRITERIA

To be included, papers had to both: i) use a health equity-oriented approach, defined as a response that addresses health inequities and aims to reduce drug-related harms of stigma or overdose; and ii) include at least one of the following concepts: cultural safety, trauma- and violence-informed care, or harm reduction. We also looked for papers that included an Indigenous-informed perspective in addition to any of the three concepts.

METHODS

An a priori protocol was published and the JBI methodology for conducting scoping reviews was employed. Published and unpublished literature from January 1, 2000, to July 31, 2019, was included. The databases searched included CINAHL (EBSCOhost), MEDLINE (Ovid), Academic Search Premier (EBSCOhost), PsycINFO (EBSCOhost), Sociological Abstracts and Social Services Abstracts (ProQuest), JBI Database of Systematic Reviews and Implementation Reports, Cochrane Database of Systematic Reviews, PROSPERO, Aboriginal Health Abstract Database, First Nations Periodical Index, and the National Indigenous Studies Portal. The search for unpublished studies included ProQuest Dissertations and Theses, Google Scholar, and targeted web searches. Screening and data extraction were performed by two reviewers using templates developed by the authors. Data extraction included specific details about the population, concepts, context, and key findings or recommendations relevant to the review objectives.

RESULTS

A total of a total of 1065 articles were identified and screened, with a total of 148 articles included. The majority were published in the previous five years (73%) and were from North America (78%). Most articles only focused on one of the three health equity-oriented approaches, most often harm reduction (n = 79), with only 16 articles including all three. There were 14 articles identified that also included an Indigenous-informed perspective. Almost one-half of the papers were qualitative (n = 65; 44%) and 26 papers included a framework. Of these, seven papers described a framework that included all three approaches, but none included an Indigenous-informed perspective. Recommendations for health equity-oriented approaches are: i) inclusion of people with lived and living experience; ii) multifaceted approaches to reduce stigma and discrimination; iii) recognize and address inequities; iv) drug policy reform and decriminalization; v) ensure harm-reduction principles are applied within comprehensive responses; and vi) proportionate universalism. Gaps in knowledge and areas for future research are discussed.

CONCLUSIONS

We have identified few conceptual frameworks that are both health equity-oriented and incorporate multiple concepts that could enrich responses to the opioid poisoning emergency. More research is required to evaluate the impact of these integrated frameworks for action.

A comparison of methods for measuring spatial access to health care

OBJECTIVE

To compare measures of spatial access to care commonly used by policy makers and researchers with the more comprehensive enhanced two-step floating catchment area (E2SFCA) method.

STUDY SETTING

Fourteen southwestern Pennsylvania counties.

STUDY DESIGN

We estimated spatial access to buprenorphine-waivered prescribers using three commonly used measures-Euclidean travel distance to the closest prescriber, travel time to the closest provider, and provider-to-population ratios-and the E2SFCA. Unlike other measures, the E2SFCA captures provider capacity, potential patient volume, and travel time to prescribers.

DATA COLLECTION/EXTRACTION METHODS

We measured provider capacity as the number of buprenorphine prescribers listed at a given address in the Drug Enforcement Agency's 2020 Controlled Substances Act Registrants Database, and we measured potential patient volume as the number of nonelderly adults in a given census tract as reported by the 2018 American Community Survey. We estimated travel times between potential patients and prescribers with Bing Maps and Mapbox application programming interfaces. We then calculated each spatial access measure using the R programming language. We used each measure of spatial access to identify census tracts in the lowest quintile of spatial access to prescribers.

PRINCIPAL FINDINGS

The Euclidean distance, travel time, and provider-to-population ratio measures identified 48.3%, 47.2%, and 69.9% of the census tracts that the E2SFCA measure identified as being in the lowest quintile of spatial access to care, meaning that these measures misclassify 30%-52% of study area census tracts as having sufficient spatial access to buprenorphine prescribers.

CONCLUSIONS

Measures of spatial access commonly used by policy makers do not sufficiently accurately identify geographic areas with relatively low access to prescribers of buprenorphine. Using the E2SFCA in addition to the commonly used measures would allow policy makers to precisely target interventions to increase spatial access to opioid use disorder treatment and other types of health care services.

Social vulnerabilities for substance use: Stressors, socially toxic environments, and discrimination and racism

Applying a social determinants of health framework, this review brings attention to evidence from social sciences and neuroscience on the role of selected social factors in individual and population-level vulnerability to substance use and substance use disorders (SUDs). The understanding that social vulnerability to substance use and SUDs is multifaceted and occurs across different levels of influence (individual, interpersonal, community, and societal) is underscored. We propose that socially based stressors play a critical role in creating vulnerability to substance use and SUDs, and as such, deserve greater empirical attention to further understand how they "get under the skin." Current knowledge from social sciences and neuroscience on the relationships among vulnerability to substance use resulting from stressors, exposure to socially toxic childhood environments, and racism and discrimination are summarized and discussed, as are implications for future research, practice, and policy. Specifically, we propose using a top-down approach to the examination of known, yet often unexplored, relationships between vulnerability to substance use and SUDs, related inequities, and potential differential effects across demographic groups. Finally, research gaps and promising areas of research, practice, and policy focused on ameliorating social vulnerabilities associated with substance use and SUDs across the lifespan are presented. This article is part of the special issue on 'Vulnerabilities to Substance Abuse'.

Social Ecological Model of Problem Gambling: A Cross-National Survey Study of Young People in the United States, South Korea, Spain, and Finland

Problem gambling among young people is an emerging trend globally. The online environment in particular offers various possibilities for gambling engagement. This is the first cross-national survey study using the social ecological model to analyze problem gambling, especially in the online context. The study aimed to analyze how different social ecological spheres explain problem gambling. Participants were young people aged 15–25 in the United States (n = 1212), South Korea (n = 1192), Spain (n = 1212), and Finland (n = 1200). The South Oaks Gambling Screen (SOGS) instrument measured problem gambling. The regression models analyzed problem gambling with measures of intrapersonal, interpersonal, organizational, and societal spheres. Spanish participants had the highest SOGS score for problem gambling. In all countries, the variations in problem gambling were best explained by the organizational sphere measures (26%) when compared to the intrapersonal (11%), interpersonal (5%), and societal (3%) spheres. In the full model, the organizational sphere measures had strong associations with problem gambling. These included consumer debt, online gambling community participation, online casino participation, and exposure to online pop-up advertisements. Problem gambling was also associated with conformity to group norms in the interpersonal sphere, and male gender and impulsivity in the intrapersonal sphere. Cross-national results were similar in different countries. Within the final model, gambling community participation had the strongest association with problem gambling (β = 0.23, p < 0.001). The online context plays a major role in problem gambling behavior. The social ecological model is a useful tool for tackling problem gambling and developing preventative measures.

Examining the Relationship between Social Connection and Opioid Misuse: A Systematic Review

METHODS

We used a Boolean search strategy of PubMed, PsycINFO, and Embase to identify eligible publications from January 1990 to March 2020 and narrative analysis to synthesize the evidence.

RESULTS

The database search identified 1267 independent citations; 29 publications met inclusion criteria. Nearly all the studies demonstrated high risk of bias, most often due to selection and confounding bias. Most of the studies in the review (k = 20, 69%) found at least one significant association between social connection and opioid outcomes. Although no two studies included the same measures of social connection or opioid misuse, and social connection was both positively and negatively associated with opioid misuse, results support that social connection is an important correlate of opioid misuse.

CONCLUSIONS

This review highlights the importance of social connection as a correlate to opioid misuse. However, the extensive variability among research studies points to a need for standardization of measurement and larger studies with diverse populations to allow for consequential recommendations for prevention or treatment of opioid misuse. Evidence regarding the associations between social connection and opioid misuse or disorder is sparse. We provide suggestions for advancing this research, including clarification of the complex influences between social connections and opioid misuse.