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M FM, Doug LM, Peter F, Vivian F G, Wiley J, P Todd K, William M, Mai P, David S, Tom S, Ryan W, William Z, M YA, Lf CH. Correlates of overdose among 2711 people who use drugs and live in 7 rural US sites. Drug Alcohol Depend 2024; 258:111261. [PMID: 38581919 DOI: 10.1016/j.drugalcdep.2024.111261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 02/29/2024] [Accepted: 03/03/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Overdose rates in rural areas have been increasing globally, with large increases in the United States. Few studies, however, have identified correlates of non-fatal overdose among rural people who use drugs (PWUD). The present analysis describes correlates of nonfatal overdose among a large multistate sample of rural PWUD. METHODS This is a cross-sectional analysis of data gathered via surveys with PWUD recruited through seven Rural Opioid Initiative (ROI) sites. Descriptive analyses were conducted to assess the prevalence of past 30-day overdose. Generalized estimating equations were used to estimate a series of multivariable models quantifying relationships of select factors to past-month overdose; factors were selected using the Risk Environment Framework. RESULTS The multisite sample included 2711 PWUD, 6% of whom reported overdosing in the past 30 days. In the fully adjusted model, houselessness (AOR=2.27, 95%CI[1.48, 3.48]), a positive test result for Hepatitis C infection (AOR=1.73 95%CI[1.18, 2.52]) and heroin/fentanyl use (AOR= 8.58 95%CI [3.01, 24.50]) were associated with an increased risk of reporting past 30-day overdose, while having a high-school education or less was associated with reduced odds of overdose (AOR=0.52, 95% CI[0.37, 0.74]). CONCLUSION As in urban areas, houselessness, Hepatitis C infection, and the use of heroin and fentanyl were significant correlates of overdose. Widespread access to overdose prevention interventions - including fentanyl test strips and naloxone - is critical in this rural context, with particular outreach needed to unhoused populations, people living with Hepatitis C, and people using opioids.
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Affiliation(s)
- Fadanelli Monica M
- Rollins School of Public Health, 1518 Clifton Dr, Atlanta, GA 30329, USA.
| | | | - Friedmann Peter
- UMass Chan Medical School - Baystate, 3601 Main Street, Springfield, MA 01199, USA
| | - Go Vivian F
- Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC 27599, USA
| | - Jenkins Wiley
- SIU School of Medicine, 801 N Rutledge St., Springfield, IL 62702, USA
| | - Korthuis P Todd
- Oregon Health & Science University, School of Medicine, 3266 SW Research Dr, Portland, OR 97239, USA
| | - Miller William
- Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC 27599, USA
| | - Pho Mai
- The University of Chicago Medicine, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
| | - Seal David
- Tulane School of Public Health & Tropical Medicine, 1440 Canal St, New Orleans, LA 70112, USA
| | - Stopka Tom
- Tufts University School of Medicine, Public Health and Community Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Westergaard Ryan
- University of Wisconsin, School of Medicine and Public Health, 1685 Highland Ave, Madison, WI 53705-2281, USA
| | - Zule William
- Research Triangle Park, 3040 East Cornwallis Road, P.O. Box 12194, NC 27709-2194, USA
| | - Young April M
- University of Kentucky, College of Public Health, 111 Washington Ave., Lexington, KY 40536, USA
| | - Cooper Hannah Lf
- Rollins School of Public Health, 1518 Clifton Dr, Atlanta, GA 30329, USA
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Garcia V, McCann L, Lauber E, Vaccaro C, Swauger M, Heckert DA. Opioid Overdoses and Take-Home Naloxone Interventions: Ethnographic Evidence for Individual-Level Barriers to Treatment of Opioid Use Disorders in Rural Appalachia. Subst Use Misuse 2024; 59:1313-1322. [PMID: 38635977 DOI: 10.1080/10826084.2024.2340986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
Introduction: Research indicates that take-home naloxone (THN) is saving lives across rural Appalachia, but whether it also results in treatment for opioid use disorders (OUDs) remains unclear. This study involves a detailed qualitative analysis of interviews with 16 individuals who had overdosed on opioids 61 times to understand why a THN intervention does not routinely lead to OUD treatment. Methods: This study builds upon a one-year (2018) qualitative study on community responses to opioid overdose fatalities in four adjacent rural counties in Western Pennsylvania. Using a semi-structured interview guide, 16 individuals who had experienced one or more overdoses were interviewed. Using NVivo, the transcribed audio-recorded interviews were coded, and a thematic analysis of the coded text was conducted. Findings: Findings reveal that of the 29 overdoses that included a THN intervention, only eight resulted in treatment. The analysis derives five individual-level barriers to treatment: (1) opioid dependence, (2) denial/readiness, (3) opioid withdrawal fears, (4) incarceration concerns, and (5) stigma and shame. These barriers impeded treatment, even though all the interviewees knew of treatment programs, how to access them, and in some cases had undergone treatment previously. Discussion and Conclusion: findings indicate that there is evidence that the five barriers make entering treatment after a THN intervention challenging and seemingly insurmountable at times. Recommendations based on the findings include increasing efforts to reduce stigma of OUDs in the community, including self-stigma resulting from misusing opioids, increasing informational efforts about Good Samaritan Laws, and increasing familiarity with medication-assisted treatments for OUDS.
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Affiliation(s)
- Victor Garcia
- Research Scientist, Prevention Research Center, Berkeley, California, USA
| | - Lisa McCann
- Department of Sociology, Indiana University of Pennsylvania, Indiana, Pennsylvania, USA
| | - Erick Lauber
- Department of Communications Media, Indiana University of Pennsylvania, Indiana, Pennsylvania, USA
| | - Christian Vaccaro
- Department of Sociology Associate Director Mid Atlantic Research and, Training Institute Indiana University of Pennsylvania, Indiana, Pennsylvania, USA
| | - Melissa Swauger
- Nonprofit Management, Empowerment and Diversity Studies (new address), Slippery Rock University of Pennsylvania Slippery Rock, Pennsylvania, USA
| | - Daniel Alex Heckert
- Department of Sociology Director Mid Atlantic Research and Training Center, Indiana University of Pennsylvania, Indiana, Pennsylvania, USA
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Garcia V, McCann L, Lauber E, Vaccaro C, Swauger M, Heckert AD. High-risk Individuals and Naloxone Use: Implications for THN Programs in Rural Appalachian Communities. JOURNAL OF APPALACHIAN HEALTH 2023; 5:9-21. [PMID: 38784143 PMCID: PMC11110902 DOI: 10.13023/jah.0503.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
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.
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Abstract
OBJECTIVES As opioid use increases, it remains important to assess factors that contribute to injection drug risk behaviors, as sharing needles and other drug use equipment contributes to the spread of human immunodeficiency virus and hepatitis C virus. Such risks may differ by sex and injecting with others. The current study examined factors that contribute to increased injection drug risk separately for men and women. METHODS People who inject drugs were recruited at an academic safety-net hospital that reported recent injection drug use. Two main injection outcomes were assessed: (1) human immunodeficiency virus drug risk behaviors as assessed by the Risk Assessment Battery and (2) the number of times participants injected drugs with a needle used by someone else. For each outcome, different models for women and men were conducted to detect differences by sex. RESULTS Both men and women were more likely to inject with a needle used by someone else if they used drugs within a sexual relationship (incidence rate ratio (IRR) = 14.61, P < 0.01; IRR = 7.17, P < 0.05). Being employed was associated with lower risk assessment battery scores among men, and lower mean rates of using a needle used by someone else among women (IRR = 0.22, P < 0.05). Women with post-traumatic stress disorder (PTSD) and men with higher depression scores had higher rates of injecting with a needle used by someone else. CONCLUSIONS People who inject drugs who are in intimate relationships report higher injection drug risk behaviors. We found benefits to employment among both men and women. Identifying factors associated with increased injection risk behaviors can be useful for creating interventions tailored by sex.
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Genberg BL, Gicquelais RE, Astemborski J, Knight J, Buresh M, Sun J, German D, Thomas DL, Kirk GD, Mehta SH. Trends in fatal and nonfatal overdose by race among people who inject drugs in Baltimore, Maryland from 1998 to 2019. Drug Alcohol Depend 2021; 229:109152. [PMID: 34749056 PMCID: PMC8665116 DOI: 10.1016/j.drugalcdep.2021.109152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/18/2021] [Accepted: 10/18/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The objective of this study was to examine trends in fatal and nonfatal overdose in a community-based sample of current and former people who inject drugs (PWID). METHODS Data from 4826 current and former PWID from the AIDS Linked to the IntraVenous Experience (ALIVE) observational cohort study in Baltimore, Maryland, were used to characterize fatal and nonfatal overdose rates from 1998 to 2019. Poisson regression was used to examine factors associated with nonfatal overdose and differences by race among 1052 PWID between 2014 and 2019. RESULTS Fatal overdose rates reached a high of 13 per 1000 person-years in 2018. Among 1052 current and former PWID, of whom 75% were Black and one-third were female, the nonfatal overdose rate of 529 per 1000 person-years in 2019 was 8 times higher than 2014 (incidence rate ratio [IRR]=7.76, 95% CI: 3.35, 18.0). The annual adjusted increase in nonfatal overdose rate was 53% among Black PWID (IRR=1.53, 95% CI: 1.34, 1.75), compared to 14% among White PWID (IRR=1.14, 95% CI: 0.88, 1.46). Urban residence, opioid use, depressive symptoms, and hepatitis C infection were positively associated with nonfatal overdose among Black PWID. Recent injection drug use and tranquilizer use was associated with increased overdose among Black and White PWID. CONCLUSIONS Rates of fatal and nonfatal overdose were high and increased from 2014 to 2019 among current and former PWID, with the most dramatic increases in nonfatal overdose observed among Black PWID. These findings highlight the urgent need for additional resources to reduce the differential harms associated with opioids by race.
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Affiliation(s)
- Becky L. Genberg
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe Street, Baltimore, MD 21205 USA
| | - Rachel E. Gicquelais
- University of Wisconsin-Madison School of Nursing, 701 Highland Ave, Madison, WI, 53705 USA
| | - Jacquie Astemborski
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe Street, Baltimore, MD 21205 USA
| | - Jennifer Knight
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe Street, Baltimore, MD 21205 USA
| | - Megan Buresh
- Johns Hopkins School of Medicine, Division of Addiction Medicine, 5200 Eastern Avenue, Mason Lord Building, East Tower, 2nd floor, Baltimore, MD 21224 USA
| | - Jing Sun
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe Street, Baltimore, MD 21205 USA
| | - Danielle German
- Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior and Society, 615 N. Wolfe Street, Baltimore, MD 21205 USA
| | - David L. Thomas
- Johns Hopkins University School of Medicine, Division of Infectious Diseases, Baltimore, MD 21205 USA
| | - Gregory D. Kirk
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe Street, Baltimore, MD 21205 USA, Johns Hopkins University School of Medicine, Division of Infectious Diseases, Baltimore, MD 21205 USA
| | - Shruti H. Mehta
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe Street, Baltimore, MD 21205 USA
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Armoon B, Bayani A, Griffiths MD, Bayat AH, Mohammadi R, Fattah Moghaddam L, Ahounbar E. Prevalence and high-risk behaviors associated with non-fatal overdose among people who use illicit opioids: A systematic review and meta-analysis. JOURNAL OF SUBSTANCE USE 2021. [DOI: 10.1080/14659891.2021.1978112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Bahram Armoon
- Research Center, Douglas Mental Health University Institute, Montreal, QC, Canada
- Department of Psychiatry, McGill University, Montreal, Qc, Canada
| | - Azadeh Bayani
- Student Research Committee, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mark D. Griffiths
- International Gaming Research Unit, Psychology Department, Nottingham Trent University, Nottingham, UK
| | - Amir-Hossein Bayat
- Social Determinants of Health Research Center, Saveh University of Medical Sciences, Saveh, Iran
| | - Rasool Mohammadi
- Department of Biostatistics and Epidemiology, School of Public Health and Nutrition, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Ladan Fattah Moghaddam
- Department of Nursing, Faculty of Nursing and Midwifery, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Elahe Ahounbar
- Substance Abuse and Dependence Research Center, The University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
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Surratt HL, Otachi J, McLouth C, Vundi N. Healthcare stigma and HIV risk among rural people who inject drugs. Drug Alcohol Depend 2021; 226:108878. [PMID: 34214880 PMCID: PMC8355211 DOI: 10.1016/j.drugalcdep.2021.108878] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/25/2021] [Accepted: 06/01/2021] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The HIV epidemic is increasingly penetrating rural areas of the U.S. due to evolving epidemics of injection drug use. Many rural areas experience deficits in availability of HIV prevention, testing and harm reduction services, and confront significant stigma that inhibits care seeking. This paper examines enacted stigma in healthcare settings among rural people who inject drugs (PWID) and explores associations of stigma with continuing high-risk behaviors for HIV. METHODS PWID participants (n = 324) were recruited into the study in three county health department syringe service programs (SSPs), as well as in local community-based organizations. Trained interviewers completed a standardized baseline interview lasting approximately 40 min. Bivariate logistic regression models examined the associations between enacted healthcare stigma, health conditions, and injection risk behaviors, and a mediation analysis was conducted. RESULTS Stigmatizing health conditions were common in this sample of PWID, and 201 (62.0 %) reported experiencing stigma from healthcare providers. Injection risk behaviors were uniformly associated with higher odds of enacted healthcare stigma, including sharing injection equipment at most recent injection (OR = 2.76; CI 1.55, 4.91), and lifetime receptive needle sharing (OR = 2.27; CI 1.42, 3.63). Enacted healthcare stigma partially mediated the relationship between having a stigmatizing health condition and engagement in high-risk injection behaviors. DISCUSSION Rural PWID are vulnerable to stigma in healthcare settings, which contributes to high-risk injection behaviors for HIV. These findings have critical public health implications, including the importance of tailored interventions to decrease enacted stigma in care settings, and structural changes to expand the provision of healthcare services within SSP settings.
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Affiliation(s)
| | | | - Chris McLouth
- University of Kentucky, Department of Behavioral Science
| | - Nikita Vundi
- University of Kentucky, Center for Health Services Research
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Shrestha S, Stopka TJ, Hughto JMW, Case P, Palacios WR, Reilly B, Green TC. Prevalence and correlates of non-fatal overdose among people who use drugs: findings from rapid assessments in Massachusetts, 2017-2019. Harm Reduct J 2021; 18:93. [PMID: 34461922 PMCID: PMC8404353 DOI: 10.1186/s12954-021-00538-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 08/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND People who experience non-fatal overdose (NFOD) are at high risk of subsequent overdose. With unprecedented increases in fentanyl in the US drug supply, many Massachusetts (MA) communities have seen a surge in opioid-related overdoses. The objective of this study was to determine factors associated with lifetime and past year NFOD in at-risk MA communities. METHODS We conducted multiple rapid assessments among people who use drugs (PWUD) in eight MA communities using non-probability sampling (purposive, chain referral, respondent-driven) methods. We collected sociodemographic, substance use, overdose history, substance use treatment, and harm reduction services utilization data. We examined the prevalence of NFOD (lifetime and past year) and identified factors associated with NFOD through multivariable logistic regression analyses in a subset of 469 study participants between 2017 and 2019. RESULTS The prevalence of lifetime and last year non-fatal opioid overdose was 62.5% and 36.9%, respectively. Many of the study participants reported heroin (64%) and fentanyl (45%) use during the 30 days preceding the survey. Nonprescription buprenorphine and fentanyl use were independently associated with higher odds of lifetime NFOD, while marijuana use was associated with lower odds of lifetime NFOD (p < 0.05). Injection as the route of administration, benzodiazepine, nonprescription buprenorphine, heroin, and fentanyl use were independently associated with higher odds, while methadone use was associated with lower odds of past year NFOD (p < 0.05). CONCLUSION We documented a high prevalence of past year and lifetime NFOD among PWUD in MA. Our findings provide indicators that can help inform interventions to prevent overdoses among PWUD, including overdose prevention, medication treatment, and naloxone distribution.
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Affiliation(s)
- Shikhar Shrestha
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Thomas J Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Jaclyn M W Hughto
- Departments of Behavioral and Social Sciences and Epidemiology, Brown University School of Public Health, Center for Health Promotion and Health Equity, Brown University, Providence, RI, USA
| | - Patricia Case
- Bouvé College of Health Sciences, Northeastern University, Boston, MA, USA
| | - Wilson R Palacios
- School of Criminology and Justice Studies, University of Massachusetts, Lowell, MA, USA
| | - Brittni Reilly
- Massachusetts Department of Public Health, Bureau of Substance Addiction Services, Boston, MA, USA
| | - Traci C Green
- Opioid Policy Research Collaborative, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA.
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