The opioid and related drug epidemics in rural Appalachia: A systematic review of populations affected, risk factors, and infectious diseases

The Association Between Employment in Coal Mining and History of Injury, Current Pain, and Prescription Opioid Use

BACKGROUND

Coal mining involves heavy physical demand, which is associated with increased risk of injury and long-term musculoskeletal health disorders and chronic pain. Management of chronic or recurrent pain is in turn associated with prescription opioid use and risk of opioid use disorder (OUD).

METHODS

We analyzed clinical data from 5463 coal miners evaluated between 2004 and 2015. Using an iterative text mining procedure, we analyzed structured clinical notes to extract information on occupational histories and clinical data. We evaluated associations along the causal chain using a series of multivariable logistic regression models to determine the relationship between (1) specific mining occupations and history of traumatic injury, (2) history of traumatic injury and current pain, and (3) current pain and current prescription opioid use.

RESULTS

Among these mostly-former coal miners (mean age 62.4 years), the average coal mining tenure was 27.3 years; 88.4% reported being previously injured, 92.3% reported suffering from current pain and 39.2% reported current prescription opioid use. Occupations involving the most strenuous mining work were associated with a history of traumatic injury. A history of traumatic injury to body regions of the head/neck/back/spine was associated with current pain involving the head/neck/back/spine (adjusted OR = 5.04; CI 95%: 4.46, 5.70; p < 0.001). In a separate model, reported current pain of the head/neck/back/spine was associated with current prescription opioid use (aOR = 2.66; CI 95%: 2.35, 3.01; p < 0.001).

CONCLUSIONS

These miners had a high prevalence of self-reported current pain, and certain specific mining occupations were more strongly associated with a history of injury, pain, and prescription opioid use.

I Don't Want to Shoot up the Meth Anymore: Pipe Distribution as a Harm Reduction Service for People Who Use Methamphetamine

BACKGROUND

Methamphetamine use is disproportionately high in rural settings, with rates increasing during the COVID-19 pandemic. While syringe service programs reduce disease transmission among people who inject drugs, limited research exists around the value of smoking equipment, specifically pipes, in minimizing harms associated with rural methamphetamine use.

METHODS

We conducted semi-structured interviews with people who use methamphetamine in rural southern Illinois. Inclusion criteria involved methamphetamine use in the past 30 days. Interview guides explored attitudes and behaviors regarding pipe use practices and pipe access. Interviews were recorded, transcribed, and coded. The data were analyzed for emergent themes using a sequential, deductive process.

RESULTS

Nineteen participants, average age 37.1 (SD + 8.7), were interviewed. 53% were women, and 89% were white. All reported smoking methamphetamine, and 84% reported injecting. Participants reported engaging in smoking instead of injection to decrease wounds, pain, and infections. Smoking enabled some to use socially as opposed to alone, as was typically the case when they injected. Participants expressed interest in pipe distribution through a harm reduction agency. They shared that, were a harm reduction agency to distribute pipes, it would connect people to other services such as HIV testing, naloxone, and safer sex supplies.

CONCLUSIONS

Pipe distribution may function as a harm reduction strategy by decreasing injection and solitary drug use and linking patients to additional services. Given disproportionate methamphetamine use in rural regions, this intervention could specifically address drug-related harms that impact rural populations.

Managing Pain in an Era of Opioid Addiction

Managing pain, whether acute or chronic, has taken a whole new look during the past 3 decades. Pain management continues to be a long-standing public health concern. The ongoing opioid epidemic has changed how the term pain is not only treated but viewed throughout all lenses of society. The following content will focus on pain management of clients aged 18 years or older with acute and/or chronic pain in the outpatient setting. As advocates and gatekeepers, primary care providers must have knowledge of evidence-based guidelines and recommendations of pain management to provide the competent, holistic care and education clients deserve.

Rural houselessness among people who use drugs in the United States: Results from the National Rural Opioid Initiative

BACKGROUND

Over the last two decades, houselessness and drug-related epidemics both have expanded from urban to rural regions across the United States (US). However, our understanding of the relationship between rural houselessness, drug use, and drug-related harms has not kept pace. The current study addresses this gap by describing houselessness among a large cohort of people who use drugs (PWUD) from rural communities across 10 states.

DESIGN

PWUD were recruited using modified chain-referral sampling for a cross-sectional survey capturing houselessness in the prior six months, drug use, drug-related harms, stigma, health service access, and sociodemographic characteristics. Using bivariate logistic regressions, we assessed associations between houselessness and participant characteristics. We also compare site-specific houselessness prevalence to Housing and Urban Development Point-in-Time (PIT) estimates, which are based on counts of sheltered and unsheltered people experiencing houselessness on a single night.

RESULTS

Among 3000 PWUD, 53.7 % reported experiencing houselessness. Houselessness was associated with multiple drug-related behaviors that increase the risk of overdose and acquisition of bloodborne infections. Houselessness prevalence was comparable and exceeded PIT estimates for several sites, even though study participants constituted <1 % of each site's adult population and were restricted to PWUD.

CONCLUSIONS

Our findings highlight that houselessness - historically considered an urban issue - is a significant public health concern for PWUD in rural areas. This demonstrates that addressing drug-related HIV, hepatitis C, and overdose epidemics, among others, in the rural US will require the provision of stable housing and harm reduction services as a pathway to treatment and recovery.

Facilitating factors and barriers for use of medications to treat opioid use disorder (MOUD) among justice-involved individuals in rural Appalachia

The purpose of this qualitative study is to assess facilitating factors and barriers for medications to treat opioid use disorder (MOUD) initiation among justice-involved individuals in one rural Appalachian community, as well as how those factors may differ across the three types of Food and Drug Administration (FDA) approved medications. Qualitative interviews were conducted with rural justice-involved individuals (N = 10) with a history of opioid use in the target community. Overall, participants demonstrated knowledge of the different types of MOUD and their pharmacological properties, but limited overall health literacy around opioid use disorder and MOUD treatment. Treatment access was hampered by transportation, time burdens, and costs. Findings call for research into improving health literacy education, training, and resources to decrease stigma and increase access to MOUD, particularly in light of the ongoing opioid crisis. State policies also need to increase access to all FDA medications among justice-involved individuals, as well as supporting a care continuum from facility entry, release, and community re-entry.

The War on Drugs, Racialized Capitalism, and Health Care Utilization Among White People Who Use Drugs in 22 Rural Appalachian Counties

Objectives. To analyze War on Drugs encounters and their relationships to health care utilization among White people who use drugs (PWUD) in 22 Appalachian rural counties in Kentucky, West Virginia, Ohio, and North Carolina. Methods. We recruited White PWUD using chain referral sampling in 2018 to 2020. Surveys asked about criminal-legal encounters, unmet health care needs, and other covariates. We used generalized estimating equations to regress unmet need on criminal-legal encounters in multivariable models. Results. In this sample (n = 957), rates of stop and search, arrest, incarceration, and community supervision were high (44.0%, 26.8%, 36.3%, and 31.1%, respectively), as was unmet need (68.5%). Criminal-legal encounters were unrelated to unmet need (stops: adjusted prevalence ratio [APR] = 1.13; 95% confidence interval [CI] = 0.97, 1.32; arrest: APR = 0.95; 95% CI = 0.78, 1.15; incarceration: APR = 1.01; 95% CI = 0.89, 1.14; community supervision: APR = 0.99; 95% CI = 0.90, 1.09). Conclusions. Contrasting with findings from predominantly Black urban areas, criminal-legal encounters and unmet need were unrelated among White Appalachian PWUD. Research should explore whether and under what conditions White supremacy's benefits might buffer adverse impacts of the War on Drugs in Appalachia. (Am J Public Health. 2024;114(10):1086-1096. https://doi.org/10.2105/AJPH.2024.307744).

Correlates of overdose among 2711 people who use drugs and live in 7 rural US sites

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.

Opioid Overdoses and Take-Home Naloxone Interventions: Ethnographic Evidence for Individual-Level Barriers to Treatment of Opioid Use Disorders in Rural Appalachia

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.

The relationship between felt stigma and non-fatal overdose among rural people who use drugs

BACKGROUND

Drug overdose deaths in the United States exceeded 100,000 in 2021 and 2022. Substance use stigma is a major barrier to treatment and harm reduction utilization and is a priority target in ending the overdose epidemic. However, little is known about the relationship between stigma and overdose, especially in rural areas. We aimed to characterize the association between felt stigma and non-fatal overdose in a multi-state sample of rural-dwelling people who use drugs.

METHODS

Between January 2018 and March 2020, 2,608 people reporting past 30-day opioid use were recruited via modified chain-referral sampling in rural areas across 10 states. Participants completed a computer-assisted survey of substance use and substance-related attitudes, behaviors, and experiences. We used multivariable logistic regression with generalized estimating equations to test the association between felt stigma and recent non-fatal overdose.

RESULTS

6.6% of participants (n = 173) reported an overdose in the past 30 days. Recent non-fatal overdose was significantly associated with felt stigma after adjusting for demographic and substance use-related covariates (aOR: 1.47, 95% CI: 1.20-1.81). The association remained significant in sensitivity analyses on component fear of enacted stigma items (aOR: 1.48, 95% CI: 1.20-1.83) and an internalized stigma item (aOR: 1.51, 95% CI: 1.07-2.14).

CONCLUSIONS

Felt stigma related to substance use is associated with higher risk of non-fatal overdose in rural-dwelling people who use drugs. Stigma reduction interventions and tailored services for those experiencing high stigma are underutilized approaches that may mitigate overdose risk.

Telling the story of the opioid crisis: A narrative analysis of the TV series Dopesick

Dopesick (2021) is the first TV series whose plot deals exclusively with the opioid crisis in the United States. The current study uses narrative analysis and framing theory to explore this series, discussing its portrayal of the people and themes involved in the opioid crisis. Our analysis found that although Dopesick attempts to portray multiple dimensions of the opioid crisis, its narrative oversimplifies the story in attributing the cause of the problem almost exclusively to Purdue Pharma and its director Richard Sackler, while downplaying other factors that contributed to the opioid crisis. Thus, the narrative in this TV series tends to offer simple explanations to a complex problem for which simple solutions are likely to be inadequate.

Willingness to utilize a mobile treatment unit in five counties at the epicenter of the US rural opioid epidemic

INTRODUCTION

US federal policies are evolving to expand the provision of mobile treatment units (MTUs) offering medications for opioid use disorder (MOUD). Mobile MOUD services are critical for rural areas with poor geographic access to fixed-site treatment providers. This study explored willingness to utilize an MTU among a sample of people who use opioids in rural Eastern Kentucky counties at the epicenter of the US opioid epidemic.

METHODS

The study analyzed Cross-sectional survey data from the Kentucky Communities and Researchers Engaging to Halt the Opioid Epidemic (CARE2HOPE) study covering five rural counties in the state. Logistic regression models investigated the association between willingness to utilize an MTU providing buprenorphine and naltrexone and potential correlates of willingness, identified using the Behavioral Model for Vulnerable Populations.

RESULTS

The analytic sample comprised 174 people who used opioids within the past six months. Willingness to utilize an MTU was high; 76.5 % of participants endorsed being willing. Those who had recently received MOUD treatment, compared to those who had not received any form of treatment or recovery support services, had six-fold higher odds of willingness to use an MTU. However, odds of being willing to utilize an MTU were 73 % lower among those who were under community supervision (e.g., parole, probation) and 81 % lower among participants who experienced an overdose within the past six months.

CONCLUSIONS

There was high acceptability of MTUs offering buprenorphine and naltrexone within this sample, highlighting the potential for MTUs to alleviate opioid-related harms in underserved rural areas. However, the finding that people who were recently under community supervision or had overdosed were significantly less willing to seek mobile MOUD treatment suggest barriers (e.g., stigma) to mobile MOUD at individual and systemic levels, which may prevent improving opioid-related outcomes in these rural communities given their high rates of criminal-legal involvement and overdose.

"They either leave you or they get involved in it": Familial factors influencing drug use amongst Appalachian people

West Virginia, the only state entirely in Appalachia, is considered the epicenter of the opioid crisis. Children raised in families affected by opioid use disorder can develop their own substance use disorder later in life. The continuing opioid crisis coupled with social and health disparities suggest families in West Virginia are vulnerable to generational cycles of substance misuse. This qualitative study uses content analysis to present emergent themes discerned from participant interviews on the opioid epidemic and impacts of a restrictive opioid prescribing law in West Virginia. Participants in this study described how using opioids has impacted their lives, their family, and community. They recognized drug use was embedded along familial groups and influenced by significant others such as partners or peers. Parents described how children were a strong motivator for recovery and how they felt remorse for exposing their children to their drug use. This study highlights the importance of community engagement, parental support, and early identification of vulnerable young people to lessen the intergenerational continuance of substance use.

Epidemiology of substance and opium use among adult residents of Tehran; a comprehensive report from Tehran cohort study (TeCS)

BACKGROUND

The prevalence and burden of substance and opium use have increased worldwide over the past decades. In light of rapid population changes in Tehran, we aimed to evaluate the prevalence of opium and other substance use among adult residents in Tehran, Iran.

METHOD

From March 2016 to March 2019, we utilized data from 8 296 participants in the Tehran Cohort Study recruitment phase (TeCS). We calculated the age-sex-weighted prevalence of substance use and the geographic distribution of substance use in Tehran. We also used logistic regression analysis to determine possible determinants of opium use.

RESULT

We analyzed data from 8 259 eligible participants with complete substance use data and the average age of participants was 53.7 ± 12.75 years. The prevalence of substance use was 5.6% (95% confidence interval [CI]: 4.6- 7.1%). Substance use was more common in males than females (Prevalence: 10.5% [95% CI: 8.6- 12.6%] vs. 0.5% [95% CI: 0.2- 1.2%], respectively). The age-sex weighted prevalence of substance use was 5.4% (95% CI: 4.6-7.1%). Moreover, opium was the most frequently used substance by 95.8% of substance users. Additionally, we found that male gender (Odds ratio [OR]: 12.1, P < 0.001), alcohol intake (OR: 1.3, P = 0.016), and smoking (OR: 8.5, P < 0.001) were independently associated with opium use.

CONCLUSIONS

We found that the prevalence of substance use in Tehran was 5.6%, and opium was the most frequently used substance. In addition, male gender, lower levels of education, alcohol, and tobacco consumption are the main risk factors for substance use in Tehran. Healthcare providers and policymakers can utilize our results to implement preventive strategies to minimize substance use in Tehran.

Understanding Regional Patterns of Overdose Deaths Related to Opioids and Psychostimulants

BACKGROUND

As overdose rates increase for multiple substances, policymakers need to identify geographic patterns of substance-specific deaths. In this study, we describe county-level opioid and psychostimulant overdose patterns and how they correlate with county-level social vulnerability measures.

METHODS

A cross-sectional observational study, we used nationwide 2016-2018 restricted access Centers for Disease Prevention and Control county-level mortality files for 1,024 counties. We estimated quartiles of opioid and psychostimulant overdose mortality and provided estimates of their association with county-level Social Vulnerability Index (SVI) percentile.

RESULTS

There was high opioid and psychostimulant overdose mortality in the Middle Atlantic, South Atlantic, East North Central, and Mountain regions. The Central US had the lowest opioid and psychostimulant overdose mortality rates. Counties with higher SVI scores (i.e. higher social vulnerability) were significantly more likely to experience high opioid and high psychostimulant overdose (high-high) mortality. A 10-percentile increase in SVI score was associated with a 3.1 percentage point increase in the likelihood of being a high-high county (p < 0.001) in unadjusted models and a 1.5 percentage point increase (p < 0.05) in models adjusting for region.

CONCLUSION

Our results illustrated the heterogenous geographic distribution of the growing concurrent opioid and psychostimulant overdose crisis. The substantial regional variation we identified highlights the need for local data to guide policymaking and treatment planning. The association of opioid-psychostimulant overdose mortality with social vulnerability demonstrates the critical need in impacted counties for tailored treatment that addresses the complex medical and social needs of people who use both opioids and psychostimulants.

Depression and Anxiety Symptoms and Treatment Utilization, and Associated HIV Outcomes among Adults with HIV in Rural Florida

Persons living with HIV (PLWH) and depression or anxiety in the rural South may have suboptimal HIV outcomes. We sought to examine the proportion of PLWH from rural Florida with symptoms of depression or anxiety, the proportion who received depression or anxiety treatment, and the relationship between untreated and treated symptoms of depression or anxiety and HIV outcomes. Cross-sectional survey data collected between 2014 and 2018 were analyzed. Among 187 PLWH residing in rural Florida (median age 49 years, 61.5%, male 45.5% Black), 127 (67.9%) met criteria for symptoms of depression and/or anxiety. Among these 127 participants, 60 (47.2%) were not on depression or anxiety treatment. Participants with untreated symptoms of depression and anxiety (OR 3.2, 95% CI 1.2-9.2, p = 0.03) and treated depression and anxiety with uncontrolled symptoms (OR 1.4, 95% CI 0.5-4.0, p = 0.52) were more likely to have viral non-suppression compared to those without depression or anxiety in an unadjusted bivariate analysis. Only the association between untreated symptoms of depression and anxiety and viral non-suppression was statistically significant, and when adjusting for social and structural confounders the association was attenuated and was no longer statistically significant. This suggests that social and structural barriers impact both mental health and HIV outcomes. Our findings support the need for increased mental health services and resources that address the social and structural barriers to care for PLWH in the rural South.

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.

Disparities in Mortality Between Appalachian and non-Appalachian Regions of Kentucky

Introduction

In the opioid epidemic, the U.S. faces a significant public health crisis, with some areas of the country, such as rural and Appalachian regions, suffering more than others. The differential regional impact of the crisis in Kentucky-a state with both non-metropolitan/metropolitan and Appalachian/Non-Appalachian statuses-has not yet been documented despite such knowledge being essential to the success of overdose prevention efforts.

Purpose

This study compares all-cause, drug- and opioid-related mortality between counties in different regions of Kentucky: Appalachian non-metropolitan, Appalachian metropolitan, non-Appalachian non-metropolitan, and non-Appalachian metropolitan.

Methods

Age-adjusted mortality data from the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research (CDC WONDER, 2000-2019) were used. County-level demographic and socioeconomic data were obtained from the U.S. Census Bureau, 2010 American Community Survey. Statistical analyses were performed with negative binomial regression models with a log link.

Results

The Appalachian non-metropolitan region of Kentucky had a significantly higher (p < .05) all-cause mortality (1,076/100,000) compared to the state's non-Appalachian metropolitan (904/100,000), non-Appalachian non-metropolitan (959/100,000), and Appalachian metropolitan (938/100,000) regions. Within non-Appalachian regions, non-metropolitan rates were higher than metropolitan (p = .0006). For drug- and opioid-related mortality, non-metropolitan and metropolitan regions had comparable rates within non-Appalachia, as well as within Appalachia. Appalachian regions had twice the mortality rates of non-Appalachian regions of the state (p < .05). Among the Appalachian counties, non-metropolitan counties had higher all-cause mortality than metropolitan counties.

Implications

The findings from this study can help healthcare practitioners and public health officials develop interventions addressing drug-related and opioid-related mortality in Kentucky targeted to the regions where rates are significantly higher. Also, the information on geographic, demographic, and socioeconomic factors related to these types of mortality can be used to design interventions specific to the target population's socio-demographics.

Identifying barriers and facilitators to COVID-19 vaccination uptake among People Who Use Drugs in Canada: a National Qualitative Study

BACKGROUND

People Who Use Drugs (PWUD) have lower vaccination uptake than the general population, and disproportionately experience the burden of harms from vaccine-preventable diseases. We conducted a national qualitative study to: (1) identify the barriers and facilitators to receiving COVID-19 vaccinations among PWUD; and (2) identify interventions to support PWUD in their decision-making.

METHODS

Between March and October 2022, semi-structured interviews with PWUD across Canada were conducted. Fully vaccinated (2 or more doses) and partially or unvaccinated (1 dose or less) participants were recruited from a convenience sample to participate in telephone interviews to discuss facilitators, barriers, and concerns about receiving COVID-19 vaccines and subsequent boosters, and ways to address concerns. A total of 78 PWUD participated in the study, with 50 participants being fully vaccinated and 28 participants partially or unvaccinated. Using thematic analysis, interviews were coded based on the capability, opportunity, and motivation-behavior (COM-B) framework.

RESULTS

Many partially or unvaccinated participants reported lacking knowledge about the COVID-19 vaccine, particularly in terms of its usefulness and benefits. Some participants reported lacking knowledge around potential long-term side effects of the vaccine, and the differences of the various vaccine brands. Distrust toward government and healthcare agencies, the unprecedented rapidity of vaccine development and skepticism of vaccine effectiveness were also noted as barriers. Facilitators for vaccination included a desire to protect oneself or others and compliance with government mandates which required individuals to get vaccinated in order to access services, attend work or travel. To improve vaccination uptake, the most trusted and appropriate avenues for vaccination information sharing were identified by participants to be people with lived and living experience with drug use (PWLLE), harm reduction workers, or healthcare providers working within settings commonly visited by PWUD.

CONCLUSION

PWLLE should be supported to design tailored information to reduce barriers and address mistrust. Resources addressing knowledge gaps should be disseminated in areas and through organizations where PWUD frequently access, such as harm reduction services and social media platforms.

A Prospective Study of Injection Drug Use and Jail Readmission in Two Western North Carolina Counties

Background

Injection drug use among people admitted to rural jails has significant implications for both infectious disease transmission and incarceration patterns. This study examines the relationship between injection drug use, jail readmission, and detention duration to inform interventions designed specifically for this understudied correctional setting.

Methods

The Comprehensive Addiction and Psychological Evaluation-5 (CAAPE-5) was administered to a random sample of adults admitted to two county detention centers in Western North Carolina. Data regarding readmission and the length of detention were obtained for the 12-month study period.

Results

Participants included 420 adults, aged 18-66 years. Nearly three-quarters (70.9%) met criteria for at least one substance use disorder (SUD) and almost half (45.7%) met criteria for multiple SUDs. Approximately half (45.2%) reported injecting drugs, with the majority (71.6%) reporting injecting methamphetamine, followed by 51.1% who injected opioids. People who injected drugs were 1.83 times more likely (95% CI = 1.17-2.87) than those who did not inject to be admitted on multiple occasions and also spent a significantly longer amount of time detained (IRR = 1.34, 95% CI = 1.02-1.77) during the 12-month follow-up period.

Limitations

The study was limited to jails in two counties and injection-related factors may vary from other facilities.

Conclusions

The association between drug injection and longer detention periods presents an opportunity to engage people with infectious disease screening and substance use services in jails. Connection to stable primary and behavioral health care after release is a high priority in enhancing community health.

The Opioid Epidemic: A Review of the Contributing Factors, Negative Consequences, and Best Practices

The opioid epidemic is a significant public health crisis that has caused extensive harm and devastation in the United States. This literature review aimed to identify the contributing factors and negative consequences of the epidemic, as well as best practices for healthcare providers in managing the epidemic. Overprescribing opiates and opioids, lack of education and opportunity, and being unmarried or divorced were some of the identified contributing factors to dependence on opioids. The epidemic's negative consequences are substantial, leading to increased access to opioids for vulnerable populations, which consequently cause accidental death among men and the degradation of rural community health services. As part of the literature review, we also analyzed the best practices for healthcare providers, including implementing prescription drug monitoring programs (PDMPs). However, we found that while PDMPs resulted in a decrease in opioid overprescription and an increase in provider confidence when prescribing medication, the evidence for their effectiveness in improving rural community health services or reducing opioid overdoses and opioid-related deaths was inconclusive. Our review highlights that the greatest challenge to overcome is a lack of legal mandates and proper education for healthcare providers on best practices for addressing the epidemic. To regulate and control opioids effectively, tracking and standardizing prescription models by federal agencies and medical institutions is necessary but not enough. Legal action is vital for the successful containment of the opioid crisis.

Violence Exposure, Mental Distress, Substance Use Behaviors, and Overdose Experiences Among People who Inject Drugs

Rates of exposure to traumatic events are up to two times higher among people with substance use disorders (SUDs) compared to the US general population. Overdoses (OD) and overdose fatalities have continued to increase nationally and in Kentucky and are associated with elevated trauma symptoms. This paper examines the impacts of witnessing and experiencing OD among people who inject drugs (PWID) in Kentucky. Data were derived from a NIDA-funded study of people who inject drugs (PWID) in three Appalachian counties. Study participants were recruited via Respondent-Driven Sampling techniques supplemented with direct community outreach. Utilizing a multinomial logistic regression analysis, we examined the interconnections between demographics, physical and mental health related factors, substance use behaviors, and violence experience with OD exposure. Our findings showed that participants reporting past year severe mental health distress and lifetime violence exposure had higher odds of both witnessing and experiencing OD. Additionally, participants who reported early abuse had higher odds of both witnessing and experiencing OD as did participants with early onset injection drug use. The findings highlight the high risk of repeated exposure to violence victimization and OD-related traumas among PWID. This suggests the need for incorporating knowledge about trauma into policies, procedures, and practices in treating SUD among PWID, as well as employing strategies that prevent re-traumatization in treating SUDs among PWIDs.

Reliving it All Over Again: Uncanny Temporalities of Injection Drug Use and Hepatitis C Diagnosis in Southwest Virginia, USA

Clinicians typically view the intersection between hepatitis C and injection drug use in terms of simultaneity - with transmission occurring via shared needles - or sequentially - with some states requiring that people stop using drugs prior to treatment. Yet, for patients, the connection between substance use and HCV infection can follow a more complex temporal pathway. In this article, we explore the non-linear temporality of "reliving" as it shapes HCV illness experience, its complex intersection with injection drug use, and the barriers patients face as they reckon with existing healthcare system responses and treatment modalities.

Over the Hills and Through the Hollers: How One Program is Assisting Residents of Appalachian with Opioid Use Recovery

Introduction

The consequences of increasing opioid misuse in the U.S. over the last two decades have been severe, contributing to hundreds of thousands of lives lost and heavy tolls on individuals, families, and society. The Appalachian Region has been hit particularly hard, with its predominantly rural landscape seeing disproportionate increases in opioid misuse and overdoses. These cases have been difficult to address due to poor treatment access and capacity constraints in many areas of Appalachia.

Purpose

The current study focuses on evaluating The Kentucky Access to Recovery Program (KATR), which provides services to individuals recovering from opioid addiction residing in several counties in Eastern Kentucky. Its purpose is to understand the impact of KATR on service recipients' access to recovery services and supports.

Methods

Semi-structured interviews were conducted with 12 service recipients, three service providers, and four vendors of support services related to housing, transportation, medical/dental care, employment, and childcare. Qualitative data were analyzed using thematic analysis.

Results

Themes related to individual-level impacts were identified and discussed, including behavioral changes related to recovery, physical and mental health improvements, relationship repair, regaining custody of children, provision of needed supports, and ability to gain employment and improve finances. Study findings showed that KATR had meaningful impacts on the lives of service recipients by helping meet needs and reducing barriers to their ongoing recovery.

Implications

Through its use of vouchers for support services and basic-needs provision, KATR demonstrates a potentially effective strategy for increasing access to health-related social services for persons in recovery in predominantly rural areas.

The association between grandparents as caregivers and overdose mortality in Appalachia and non-Appalachia counties

Objective

To assess the association of drug overdose mortality with grandparents serving as caregivers of children in Appalachia and non-Appalachia in the U.S.

Methods

This study used a cross-sectional design, with percent of grandparents as caregivers and overdose mortality rates being of primary interest. County-level data were combined, and descriptive, bivariate, and multivariable statistics were applied. Multiple sociodemographic and geographic variables were included: median age of the population, percent of the population that is uninsured, percent of the population that is non-Hispanic white, teen birth rate, percent of high school dropouts, and rurality.

Results

The percent of grandparents as caregivers increased as the overdose mortality rate increased (p < 0.01). For every 1% increase in the overdose mortality rate, the percent of grandparents as caregivers increased by 56% in Appalachian counties compared to 24% in non-Appalachian counties. After adjusting for sociodemographic characteristics, the interaction between overdose mortality and Appalachian vs. non-Appalachian counties was no longer significant (p = 0.3).

Conclusions

Counties with higher overdose mortality rates had greater rates of grandparents as caregivers, with Appalachian counties experiencing greater rates of grandparents as caregivers than non-Appalachian counties. Sociodemographic characteristics that are often more prevalent in Appalachia may be driving the observed differences.

Policy implications

Policies and programs are needed to support grandparents providing caregiving for children impacted by substance use disorders including reform to federal child welfare financing to support children, parents, and grandparent caregivers such as kinship navigation, substance use treatment and prevention services, mental health services and in-home supports.

Feasibility of using Facebook for HIV prevention: Implications for translational research among justice-involved women who use drugs in rural Appalachia

Background

Justice-involved women from rural Appalachia face significant barriers to the utilization of evidence-based HIV prevention interventions in spite of high rates of injection drug use and risky sexual practices. Adapting evidence-based practices to incorporate the cultural uniqueness of the target population is needed in order to advance translational and clinical science in this area. This study provides a descriptive overview of indicators of feasibility and acceptability of an adapted version of the National Institute on Drug Abuse Standard HIV prevention intervention for delivery using Facebook through a small randomized controlled pilot study with rural Appalachian women.

Method

Study methods include the random selection of rural Appalachian women from two local jails, screening for study eligibility, baseline data collection, random assignment to study interventions, and follow-up in the community three months post-release.

Results

Results indicate that the feasibility of the approach was supported through study enrollment of the target population who reported regular Facebook use and HIV risk behaviors including drug use and sex. Acceptability of the intervention was demonstrated through enrollment in the study intervention, engagement in the intervention through Facebook, and indicators of HIV/HCV knowledge.

Conclusions

Study findings contribute to the critical and unmet need to advance translational science on the delivery of evidence-based prevention interventions in real-world rural Appalachian settings to understudied, vulnerable individuals who are often overlooked in targeted prevention efforts.

Impacts of the COVID-19 Pandemic on a Rural Opioid Support Services Program

During 2020, Kentucky saw the third highest increase in overdose deaths in the U.S. Employment issues, inadequate housing, transportation problems, and childcare needs present barriers to accessing treatment in rural areas. These barriers and others (e.g., technology) arose during the pandemic negatively affecting individuals in recovery and service providers as they adjusted services to provide primarily telehealth and remote services. This study examines the impact of COVID-19 in its early stages on an opioid use disorder (OUD) support services program in a nonprofit located in rural eastern Kentucky, part of the central Appalachia region. A qualitative design was applied, employing semi-structured interviews in early fall 2020. Participants were associated with one OUD support services program, including service recipients, program coordinators, and business vendors. Guided by the Social Determinants of Health framework, two-cycle coding-descriptive coding and pattern coding-was utilized. Codes were sorted into three patterns: changes to daily life; financial impacts; and service access and provision. Overall, early stages of COVID-19 brought increased stress for individuals in recovery, as they were taking on more responsibility and navigating a changing environment. Coordinators were under pressure to provide services in a safe, timely manner. Vendors vocalized their struggles and successes related to finances. These findings can help organizations make realistic adjustments and policymakers set reasonable expectations and consider additional financial support.

The Rural Opioid Initiative Consortium description: providing evidence to Understand the Fourth Wave of the Opioid Crisis

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.

Substance Use Disorder Treatment Providers' Knowledge and Opinions Toward Testing and Treatment of Chronic Hepatitis C in Rural North Carolina

Poor access to care has made western North Carolina vulnerable to an outbreak of hepatitis C viral infection (HCV), particularly among persons who inject drugs (PWID). As substance use disorder (SUD) treatment providers could potentially improve linkage to HCV testing and treatment, we sought to understand SUD providers, clinic and client characteristics; referral patterns; HCV knowledge; willingness to participate in additional trainings; and local linkage-to-care pathways for treatment of substance use and HCV. Online survey data were collected from 78 SUD providers serving PWID in eight western rural North Carolina counties. Providers' attitudes toward working with HCV+ clients were very positive. One-third of providers reported a low fund of knowledge regarding HCV, HCV treatment, and financial assistance opportunities. Non-prescribing providers rarely initiated discussions about HCV testing/treatment, but were receptive to training. Respondents indicated that HCV testing and treatment were best delivered at local health departments or primary care clinics but were open to other venues where PWID access care. The vast majority of prescribing and non-prescribing providers expressed interest in obtaining training in HCV treatments, how to obtain HCV medications and topics on advanced liver disease. Data from prescribing and non-prescribing SUD providers suggest opportunities to develop or expand integrated care models for HCV testing/treatment in PWID in rural Appalachian North Carolina.

Substance Abuse and Rural Appalachian Pediatric Trauma in West Virginia

Introduction. Rural Appalachia is endemic to issues such as substance abuse, poverty, and lack of community support, all of which negatively influence health outcomes. The incidence of pediatric trauma as it relates to substance abuse is of concern in the region, where the rate of positive drug screens in pediatric trauma cases is higher than national average. Methods. The West Virginia statewide pediatric trauma database was analyzed in a retrospective cohort study for the years 2009-2019. Variables of interest included injury severity (assessed using Abbreviated Injury Scale (AIS)), drug screening results, and various measures of patient outcome. Results. The sample was divided into 2009-2016 presentations ( $n=\mathrm{3,356}$ ) and 2017-2019 presentations ( $n=\mathrm{1,182}$ ). Incidence of critical (AIS 5) head injuries ( $p=0.007$ ) and serious (AIS 3) neck injuries ( $p=0.001$ ) increased as time progressed. Days requiring ventilation increased from 3.1 in 2009–2016 to 6.3 in 2017–2019 ( $p<0.001$ ). Drug screens were obtained at a rate of 6.9% in 2009–2016 versus 23.3% in 2017–2019 ( $p<0.001$ ). Benzodiazepine use increased from 0.8% to 1.8% ( $p<0.001$ ), and opioid use increased from 1% to 4.9% ( $p<0.001$ ). Conclusion. The increasing severity of pediatric trauma and substance abuse in Appalachia is of significant concern. The use of respiratory drive-depressing drugs has risen, just as the severity of head and neck traumas has increased. These results emphasize the importance of targeted interventions in the rural pediatric population.

Substance Use Disorder, Bail Reform, and Failure to Appear in Court: Results From a Naturalistic Study

Most adults processed through local correctional facilities report symptoms consistent with substance use disorder and there is growing interest in bail reform to reduce or eliminate financial conditions as a requirement for release from detention in local jails. These practices are endorsed for their ability to reduce jail populations and enhance judicial efficiency, but failure to appear in court has become a major area of concern under these new procedures. The current study examined the associations between substance use disorder, financial release conditions, and failure to appear in court in the context of a naturalistic study of bail reform in one judicial district. Multivariate logistic regression results demonstrate significantly higher odds of failure to appear in court among adults with substance use disorder who received a nonfinancial release from jail. Findings suggest bail reform initiatives must address substance use disorder and provide person-centered services during the pretrial release period to become effective.

Polysubstance use and re-incarceration in the 12-months after release from jail: a latent transition analysis of rural Appalachian women

Background: Rural areas have high rates of opioid and stimulant involved polysubstance use which are known to contribute to overdose. Justice-involved women are likely to have multiple substance use disorders and are particularly vulnerable in rural areas where treatment is limited.Objectives: The research had three aims to (1) identify the patterns of polysubstance use of rural Appalachian justice-involved women, (2) examine how women's engagement in polysubstance use changed in the 12-months following initial release from jail, and (3) determine if women's changes in substance use patterns were associated with re-incarceration during the 12-months of post-release follow-up.Methods: A total of 339 women with recent substance use histories were randomly recruited from three rural jails. Latent transition analysis of women's substance use from baseline (in jail) to 6 and 12-months was examined, including the effect of re-incarceration on transitions (changes in substance use patterns).Results: Three latent classes were found: High Polysubstance/injection drug use (IDU) (36.3% baseline), Opioid/Benzo (Benzodiazepine) Involved Polysubstance Use (57.3% baseline), and Low Use (6.4% baseline). Polysubstance use classes were characterized by use of opioids and benzodiazepines; the High Polysubstance/IDU class was distinct in co-use and injection use of methamphetamine. Post-release, women transitioned to latent classes of reduced substance use and/or reduced injection drug use, particularly in the first six months. Women who were re-incarcerated during follow-up were likely to remain engaged in, or transition to, the High Polysubstance/IDU class (ORs: 3.14-46.56).Conclusion: Justice-involved women in Appalachia reported risky polysubstance use. The first six-months post-release were a critical period for changes in substance use.

Community Strengths and Challenges Related to Opioid Use Disorder in Rural Counties of East Tennessee

INTRODUCTION

Appalachia, particularly Rural East Tennessee, has been and continues to be disproportionately impacted by opioid use disorder and its many tragic ramifications.

PURPOSE

Community-engaged strategies can inform and support the development of relevant prevention efforts. Hence, people connected to a ten-county rural Appalachian region in East Tennessee were asked to identify and prioritize strengths and challenges related to opioid use disorder (OUD).

METHODS

Adult community members (n=577) completed a brief survey administered across 11 days in 2019.

RESULTS

Of the respondents, 85.3% never had been addicted to opioids, but 74.0% had someone close to them with OUD. The most frequently selected community strength was support for people with OUD to seek help and the most frequently selected challenge was lack of treatment and recovery services. People with personal OUD experience reported significantly higher mean levels of OUD-related stigma compared to persons without such experience.

IMPLICATIONS

The number of respondents indicates a local concern and commitment related to OUD in rural Appalachia. The findings prioritized areas of focus-both in needs to be addressed and strengths on which to capitalize. These community insights will guide the selection and development of OUD-related overdose prevention for this region.

Discriminant Function Analyses: Classifying Drugs/Violence Victimization Typologies Among Incarcerated Rural Women

This study examined the relationship between drug use and violence victimization among incarcerated women in Appalachian Kentucky. The purpose of this study was to test the utility of Goldstein's tripartite conceptual framework among rural incarcerated women, by examining whether distinct drugs/violence nexus groups could be classified based on psychopharmacological, economic-compulsive, and systemic factors. This study used secondary data from a National Institute on Drug Abuse (NIDA)-funded grant focused on risk reduction among high-risk incarcerated women in Appalachia (N = 400). Predicted drugs/violence groups were developed using a series of discriminant function analyses. The data yielded three statistically significant discriminant models. Findings of the classified groupings indicated support for three distinct drugs/violence victimization subgroups. The psychopharmacological group showed the greatest prevalence (n = 181; Wilks's λ = .389, F = 3.94, p < .001), followed by the economic-compulsive group (n = 77; Wilks's λ = .584, F = 11.86, p < .001) and systemic group (n = 55) significant (Wilks's λ = .994, F = 2.247, p < .035). To date, this is the first study to report a relationship between systemic violence victimization among rural communities. These findings could offer novel considerations for theory development and implications for clinical practice regarding the drug-related risks for violence victimization among rural incarcerated women.

A cross-sectional survey of potential factors, motivations, and barriers influencing research participation and retention among people who use drugs in the rural USA

BACKGROUND

Despite high morbidity and mortality among people who use drugs (PWUD) in rural America, most research is conducted within urban areas. Our objective was to describe influencing factors, motivations, and barriers to research participation and retention among rural PWUD.

METHODS

We recruited 255 eligible participants from community outreach and community-based, epidemiologic research cohorts from April to July 2019 to participate in a cross-sectional survey. Eligible participants reported opioid or injection drug use to get high within 30 days and resided in high-needs rural counties in Oregon, Kentucky, and Ohio. We aggregated response rankings to identify salient influences, motivations, and barriers. We estimated prevalence ratios to assess for gender, preferred drug use, and geographic differences using log-binomial models.

RESULTS

Most participants were male (55%) and preferred methamphetamine (36%) over heroin (35%). Participants reported confidentiality, amount of financial compensation, and time required as primary influential factors for research participation. Primary motivations for participation include financial compensation, free HIV/HCV testing, and contribution to research. Changed or false participant contact information and transportation are principal barriers to retention. Respondents who prefer methamphetamines over heroin reported being influenced by the purpose and use of their information (PR = 1.12; 95% CI: 1.00, 1.26). Females and Oregonians (versus Appalachians) reported knowing and wanting to help the research team as participation motivation (PR = 1.57; 95% CI: 1.09, 2.26 and PR = 2.12; 95% CI: 1.51, 2.99).

CONCLUSIONS

Beyond financial compensation, researchers should emphasize confidentiality, offer testing and linkage with care, use several contact methods, aid transportation, and accommodate demographic differences to improve research participation and retention among rural PWUD.

Behavior change, health, and health disparities 2021: Rural addiction and health

This Special Issue of Preventive Medicine (PM) is the 8th in a series on behavior change, health, and health disparities. This is a topic of critical importance to improving U.S. population health. There is broad consensus that personal behavior patterns or lifestyle such as substance abuse, poor food choices, physical inactivity, and non-adherence with medical regimens are among the most important modifiable causes of chronic disease and premature death and contributors to recent decreases in U.S. longevity. While no U.S region is free of these problems, they disproportionately impact rural communities. As in prior Special Issues in this series, we devote considerable space to the ongoing U.S. opioid epidemic while also examining selected issues in rural health disparities involving tobacco use, cancer, and cardiovascular disease. Across each of these topics we have recruited contributions from accomplished investigators, clinicians, and policymakers to acquaint readers with recent advances while also noting knowledge gaps and unresolved challenges.

Perceived Changes in Mood and Anxiety Among Male Youth During the COVID-19 Pandemic: Findings From a Mixed-Methods Study

PURPOSE

The coronavirus disease 2019 (COVID-19) pandemic has changed almost every aspect of our lives. Young adults are vulnerable to pandemic-related adverse mental health outcomes, but little is known about the impact on adolescents. We examined factors associated with perceived changes in mood and anxiety among male youth in urban and Appalachian Ohio.

METHODS

In June 2020, participants in an ongoing male youth cohort study were invited to participate in an online survey that included questions about changes in mood, anxiety, closeness to friends and family, and the major impacts of the pandemic. Weighted log-binomial regression models were used to assess the risk of worsened mood and increased anxiety. Chi-square tests were used to examine the association between perceived changes in mood and anxiety and perceived changes in closeness to friends and family and open-ended responses to a question about COVID-19's impact on participants.

RESULTS

Perceived worsened mood and increased anxiety during the pandemic were associated with higher household socioeconomic status, older age, feeling less close to friends and family, and reporting that COVID-19 negatively affected mental health. A perceived increase in anxiety was also associated with a history of symptoms of depression or anxiety.

CONCLUSIONS

Specific subgroups of male youth may be at heightened risk of worsening mental health during the COVID-19 pandemic. Interventions should target vulnerable adolescents and seek to increase closeness to social contacts. Such efforts could involve novel programs that allow youth to stay connected to friends, which might mitigate the negative impact on mental health.

Eliminating hepatitis C in a rural Appalachian county: protocol for the Kentucky Viral Hepatitis Treatment Study (KeY Treat), a phase IV, single-arm, open-label trial of sofosbuvir/velpatasvir for the treatment of hepatitis C

OBJECTIVES

The overall goal of the Kentucky Viral Hepatitis Treatment Study (KeY Treat) is to eliminate hepatitis C transmission from a county in Appalachian Kentucky by removing the barriers to accessing hepatitis C virus (HCV) treatment.

METHODS/ANALYSIS

KeY Treat is a phase IV, open-label, single-arm clinical trial of sofosbuvir/velpatasvir (SOF/VEL) for the treatment of viraemic HCV infections. Those eligible for KeY Treat are at least 18 years of age, viraemic and are residents of the target county. Pregnant women are not eligible. Rapid HCV RNA screening is used to determine eligibility, and those with a quantifiable viral load (VL) consenting to participate initiate SOF/VEL on the same day. All pharmacologic treatment and related medical care is provided free of charge using a non-specialist provider model. Follow-up visits occur at 2, 6 and 12 weeks during treatment to assess medication adherence (measured via VL and self-report), side effects and engagement in risk behaviours. Post-treatment visits occur at 12 weeks (sustained virologic response (SVR12) visit), 6 months and 12 months post-treatment completion to assess re-infection. A control county has also been identified, and prevalence and incidence of chronic HCV infections will be compared with the target community longitudinally. The primary outcome to assess elimination is SVR12. However, several outcomes will be measured to assess the effectiveness of removing the barriers to HCV treatment, including treatment entry, completion and re-infection. Analyses will be conducted via a generalised linear model framework that can incorporate flexible covariate adjustment and multiple outcome types with a compatible link function. Mathematical modelling will be completed assessing the impact and cost-effectiveness of the intervention.

ETHICS AND DISSEMINATION

KeY Treat has been approved by the Institutional Review Board at the University of Kentucky. Results from KeY Treat will be presented at conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03949764.

Spatiotemporal Trends in Opioid Overdose Deaths by Race for Counties in Ohio

BACKGROUND

The opioid epidemic continues to be an ongoing public health crisis in the United States. Initially, large increases in overdose death rates were observed in largely rural, White communities, leading to the initial perception that the opioid epidemic was primarily a problem for the White population. Recent findings have shown increasing rates of overdose death among Blacks. We compare overdose rates between Blacks and Whites and explore county-level spatiotemporal heterogeneity in Ohio.

METHODS

We obtained county-level opioid overdose death counts for Whites and Blacks from 2007 to 2018 in Ohio. We fit a Bayesian multivariate spatial rates model to estimate annual standardized mortality ratios for Whites and Blacks for each county. We accounted for correlation between racial groups in the same county and across space and time. We also estimated differences in the mean trends between urban and rural counties for each racial group.

RESULTS

The overall overdose death rate in the state was increasing until 2018. County-level death rates for Whites were higher than Blacks throughout the state early in the study period. Death rates for Blacks increased throughout the study period and were comparable to the rates for Whites by the end of the study in many counties.

CONCLUSIONS

County-level opioid overdose death rates increased faster for Blacks than Whites during the study. By 2018, death rates were comparable for Blacks and Whites in many counties. The opioid epidemic spans racial groups in Ohio and trends indicate that overdose is a growing problem among Blacks.

A Vulnerability Assessment for a Future HIV Outbreak Associated With Injection Drug Use in Illinois, 2017-2018

The current opioid crisis and the increase in injection drug use (IDU) have led to outbreaks of HIV in communities across the country. These outbreaks have prompted country and statewide examination into identifying factors to determine areas at risk of a future HIV outbreak. Based on methodology used in a prior nationwide county-level analysis by the US Centers for Disease Control and Prevention (CDC), we examined Illinois at the ZIP code level (n = 1,383). Combined acute and chronic hepatitis C virus (HCV) infection among persons <40 years of age was used as an outcome proxy measure for IDU. Local and statewide data sources were used to identify variables that are potentially predictive of high risk for HIV/HCV transmission that fell within three main groups: health outcomes, access/resources, and the social/economic/physical environment. A multivariable negative binomial regression was performed with population as an offset. The vulnerability score for each ZIP code was created using the final regression model that consisted of 11 factors, six risk factors, and five protective factors. ZIP codes identified with the highest vulnerability ranking (top 10%) were distributed across the state yet focused in the rural southern region. The most populous county, Cook County, had only one vulnerable ZIP code. This analysis reveals more areas vulnerable to future outbreaks compared to past national analyses and provides more precise indications of vulnerability at the ZIP code level. The ability to assess the risk at sub-county level allows local jurisdictions to more finely tune surveillance and preventive measures and target activities in these high-risk areas. The final model contained a mix of protective and risk factors revealing a heightened level of complexity underlying the relationship between characteristics that impact HCV risk. Following this analysis, Illinois prioritized recommendations to include increasing access to harm reduction services, specifically sterile syringe services, naloxone access, infectious disease screening and increased linkage to care for HCV and opioid use disorder.

Icelandic Prevention Model for Rural Youth: A Feasibility Study in Central Appalachia

The purpose of this study was to assess the feasibility of implementing the Icelandic model for Primary Substance Use Prevention (IPM) in rural Central Appalachia. Guided by the IPM's theoretical framework, 26 stakeholders from a single county in West Virginia were purposefully recruited during the spring of 2019 and divided into four focus groups. Interviews were recorded and transcribed verbatim and analyzed into themes based on IPM premises. Focus group material produced seven themes: Drug use overall, Drug treatment and other service needs, Poverty, Parenting/Caregiver practices, Transportation, Downtime/Leisure time activities, and Opportunities for solutions. General support was found for the potential of the IPM in the region. Preferably, the implementation of the model should coincide with attention to the adult population as drug use was reported to be plaguing the whole community. Treatment options were few and mostly far away. General poverty and lack of public transportation further stifled progress and potential for change. Organized leisure time activities and programs for youth were scarce and mostly seasonal. Suggested solutions for the adult community included workforce and skill training, coupled with increased opportunities for organized leisure activities for youth, and access to healthy role models via schools and faith-based organizations. We conclude that implementation of the IPM would be feasible to prevent substance use initiation and progression among youth in the rural Central Appalachia. We present several specific recommendations for policy and practice that address factors unique to this environment to initiate the IPM implementation development and suggest initial model application strategies.

Identifying Missed Opportunities for Routine Vaccination among People Who Use Drugs

In the US, adult immunization coverage remains low, especially among vulnerable populations, as recent hepatitis A outbreaks have demonstrated. We studied the vaccination history variation among the US adults who use drugs by implementing a community-engaged research survey to identify reported immunization coverage, missed opportunities (MO), and places where immunizations might be delivered. Our analysis of a sample of 1127 participants recruited at community syringe exchanges in three cities identified higher overall vaccination receipt in Los Angeles compared to Atlanta or Las Vegas (e.g., HAV receipt 52.2% LA, 42.1% LV, 41.4% Atlanta). Overall, fewer participants reported having received HAV (45.9%), HBV (47.5%), or influenza (47.6%) vaccines than MMR (57.1%) or Td/Tdap (61.1%). Across sites, HAV receipt was higher for participants incarcerated ≥ 5 years (54.2% vs. 43.6% for those incarcerated < 5 years, 49.4% no incarceration history, p = 0.02). HBV receipt was higher among participants who were not intravenous drug users (56.1% vs. 46.0%, p = 0.03). Additionally, income >$20k predicted higher rates of MMR receipt (67.0% vs. 56.5%, p = 0.009), as did stable housing (62.8% vs. 54.3%, p = 0.01). To address the need to expand vaccine coverage among vulnerable adults, delivering vaccine at sites where persons who use drugs access services, or in correctional facilities, may be warranted.

The next wave? Mental health comorbidities and patients with substance use disorders in under-resourced and rural areas

The rapid spread of the coronavirus disease (COVID-19) has impacted the lives of millions around the globe. The COVID-19 pandemic has caused increasing concern among treatment professionals about mental health and risky substance use, especially among those who are struggling with a substance use disorder (SUD). The pandemic's impact on those with an SUD may be heightened in vulnerable communities, such as those living in under-resourced and rural areas. Despite policies loosening restrictions on treatment requirements, unintended mental health consequences may arise among this population. We discuss challenges that under-resourced areas face and propose strategies that may improve outcomes for those seeking treatment for SUDs in these areas.

Novel Recruitment Methods for Research Among Young Adults in Rural Areas Who Use Opioids: Cookouts, Coupons, and Community-Based Staff

OBJECTIVES

Rural communities in the United States are increasingly becoming epicenters of substance use and related harms. However, best practices for recruiting rural people who use drugs (PWUD) for epidemiologic research are unknown, because such strategies were developed in cities. This study explores the feasibility of web- and community-based strategies to recruit rural, young adult PWUD into epidemiologic research.

MATERIALS AND METHODS

We recruited PWUD from rural Kentucky to participate in a web-based survey about opioid use using web-based peer referral and community-based strategies, including cookouts, flyers, street outreach, and invitations to PWUD enrolled in a concurrent substance use study. Staff members labeled recruitment materials with unique codes to enable tracking. We assessed eligibility and fraud through online eligibility screening and a fraud detection algorithm, respectively. Eligibility criteria included being aged 18-35, recently using opioids to get high, and residing in the study area.

RESULTS

Recruitment yielded 410 complete screening entries, of which 234 were eligible and 151 provided complete, nonfraudulent surveys (ie, surveys that passed a fraud-detection algorithm designed to identify duplicate, nonlocal, and/or bot-generated entries). Cookouts and subsequent web-based peer referrals accounted for the highest proportion of screening entries (37.1%, n = 152), but only 29.6% (n = 45) of entries from cookouts and subsequent web-based peer referrals resulted in eligible, nonfraudulent surveys. Recruitment and subsequent web-based peer referral from the concurrent study yielded the second most screening entries (27.8%, n = 114), 77.2% (n = 88) of which resulted in valid surveys. Other recruitment strategies combined to yield 35.1% (n = 144) of screening entries and 11.9% (n = 18) of valid surveys.

CONCLUSIONS

Web-based methods need to be complemented by context-tailored, street-outreach activities to recruit rural PWUD.

In Their Own Words: How Opioids Have Impacted the Lives of "Everyday" People Living in Appalachia

Introduction

The opioid epidemic is ravaging people, families, and communities in Appalachia. However, limited research has examined how "everyday" people (e.g., not chronic pain patients, not medical professionals) living in these communities how opioids have impacted their lives.

Objective

Identify the perception of the opioid epidemic on individuals, families, and communities from people living in region most impacted regions.

Methods

Patients were recruited at Remote Area Medical clinics throughout Central and Southern Appalachia to complete interviews online (N = 169) or over the phone (N = 26), including one open-ended question about how opioids have impacted their lives.

Results

Using the qualitative method content analysis, several themes were identified, including both the positive and negative impact of opioids from the online interviews. Additionally, resiliency was found to be a common theme and a theme not often emphasized by scholars and the media. These themes also highlight the importance of social support in these communities. Further, in the phone interviews, we were able to replicate the themes, and an additional theme was identified: Systemic Cause of Opioids.

Conclusion

Opioid intervention must be comprehensive and include the cultural context that recognizes community ties, family and kinship support, resilience, and systemic barriers to addressing the opioid epidemic. Future interventions must harness the existing resiliency and social support in these communities to effectively combat the opioid crisis in Appalachia. Otherwise, opioids will remain the insider and further insulate Appalachian communities from systemic recovery.

Characterization of diverted buprenorphine use among adults entering corrections-based drug treatment in Kentucky

BACKGROUND

Illicit, medically unsupervised use of buprenorphine (i.e., "diverted use") among vulnerable and underserved populations, such as corrections-involved adults, remains underexplored.

METHODS

Survey data (2016-2017) collected as part of a clinical assessment of incarcerated adults entering corrections-based substance use treatment in Kentucky were analyzed. For years examined, 12,915 completed the survey. Removing cases for participants who did not reside in Kentucky for >6 months during the one-year pre-incarceration period (n = 908) resulted in a final sample size of 12,007.

RESULTS

Over a quarter of the sample reported past-year diverted buprenorphine use prior to incarceration and 21.8 % reported use during the 30-days prior to incarceration, using 6.5 months and 14.3 days on average, respectively. A greater proportion of participants who reported diverted buprenorphine use had previously been engaged with some substance use treatment (77.0 %) and reported greater perceived need for treatment (79.4 %) compared to those who did not report use. Use was more likely among participants who were younger, white, male, and who reported rural or Appalachian residence. Diverted buprenorphine users also evidenced extensive polydrug use and presented with greater substance use disorder severity. Non-medical prescription opioid, heroin, and diverted methadone use were associated with increased odds of diverted buprenorphine use while kratom was not. Diverted methadone use was associated with a 252.9 % increased likelihood of diverted buprenorphine use.

CONCLUSIONS

Diverted buprenorphine use among participants in this sample was associated with concerning high-risk behaviors and may indicate barriers to accessing opioid agonist therapies for corrections-involved Kentucky residents, particularly those in rural Appalachia.