The estimated impact of state-level support for expanded delivery of substance use disorder treatment during the COVID-19 pandemic

Provider perspectives on the impact of COVID-19 on treatment of substance use and opioid use disorders among American Indian and Alaska Native adults

Introduction

American Indian/Alaska Native (AI/AN) communities are more likely to suffer negative consequences related to substance misuse. The COVID-19 pandemic exacerbated the opioid poisoning crisis, in combination with ongoing treatment barriers resulting from settler-colonialism, systemic oppression and racial discrimination. AI/AN adults are at greatest risk of COVID-19 related serious illness and death. In collaboration with an Indigenous community advisory board and Tribal leadership, this study explored AI/AN treatment provider perceptions of client-relatives' (i.e., SUD treatment recipients) experiences during the pandemic from 2020 to 2022.

Methods

Providers who underwent screening and were eligible to participate (N = 25) represented 6 programs and organizations serving rural and urban areas in Washington, Utah, and Minnesota. Participants engaged in audio-recorded 60-90 min semi-structured individual interviews conducted virtually via Zoom. The interview guide included 15 questions covering regulatory changes, guidance for telemedicine, policy and procedures, staff communication, and client-relatives' reactions to implemented changes, service utilization, changes in treatment modality, and perceptions of impact on their roles and practice. Interview recordings were transcribed and de-identified. Members of the research team independently reviewed transcripts before reaching consensus. Coding was completed in Dedoose, followed by analyses informed by a qualitative descriptive approach.

Results

Five main domains were identified related to client-relative experiences during the COVID-19 pandemic, as observed by providers: (1) accessibility, (2) co-occurring mental health, (3) social determinants of health, (4) substance use, coping, and harm reduction strategies, and (5) community strengths. Providers reported the distinctive experiences of AI/AN communities, highlighting the impact on client-relatives, who faced challenges such as reduced income, heightened grief and loss, and elevated rates of substance use and opioid-related poisonings. Community and culturally informed programming promoting resilience and healing are outlined.

Conclusion

Findings underscore the impact on SUD among AI/AN communities during the COVID-19 pandemic. Identifying treatment barriers and mental health impacts on client-relatives during a global pandemic can inform ongoing and future culturally responsive SUD prevention and treatment strategies. Elevating collective voice to strengthen Indigenous informed systems of care to address the gap in culturally-and community-based services, can bolster holistic approaches and long-term service needs to promote SUD prevention efforts beyond emergency response efforts.

Mortality, incarceration and cost implications of fentanyl felonization laws: A modeling study

BACKGROUND

Opioid overdose continues to be a major cause of death in the United States. One effort to control opioid use has been to implement policies that enhance criminalization of opioid possession. Laws to further criminalize possession of fentanyl have been enacted or are under consideration across the country, including at the national level.

OBJECTIVE

Estimate the long-term effects on opioid death and incarceration resulting from increasingly strict fentanyl possession laws .

DESIGN

We built a Markov simulation model to explore the potential outcomes of a 2022 Colorado law which made possession of >1 g of drug with any amount of fentanyl a Level 4 drug felony (and escalation of the previous law, where >4 g of any drug with any amount of fentanyl in possession was considered a felony). The model simulates a cohort of people with fentanyl possession moving through the criminal justice system, exploring the probability of overdose and incarceration under different scenarios, including various fentanyl possession policies and potential interventions.

SETTING

Colorado PARTICIPANTS: A simulated cohort of people in possession of fentanyl.

MEASUREMENTS

Number of opioid overdose deaths, people incarcerated, and associated costs over 5 years.

RESULTS

When >4 g of a drug containing any amount of fentanyl is considered a felony in Colorado, the model predicts 5460 overdose deaths (95% CrI 410-9260) and 2,740 incarcerations for fentanyl possession (95% CrI: 230-10,500) over 5 years. When the policy changes so that >1 g possession of drug with fentanyl is considered a felony, opioid overdose deaths increase by 19% (95% CRI: 16-38%) and incarcerations for possession increase by 98% (CrI: 85-98%). Diversion programs and MOUD in prison help alleviate some of the increases in death and incarceration, but do not completely offset them.

LIMITATIONS

The mathematical model is meant to offer broad assessment of the impact of these policies, not forecast specific and exact numerical outcomes.

CONCLUSIONS

Our model shows that lowering thresholds for felony possession of fentanyl containing drugs can lead to more opioid overdose deaths and incarceration.

Barriers to Assessing and Treating Trauma in Primary Care and Opportunities for Improvement: Perspectives from Prescribers of Medications for Opioid Use Disorder

Background: Medication for Opioid Use Disorder (MOUD) is a best practice for treating individuals with opioid use disorder (OUD), and primary care-based MOUD management can reduce treatment barriers among OUD patients. Individuals with OUD experience disproportionately high rates of trauma and violence, highlighting the importance of addressing trauma, mental health, and substance use concurrently. However, clear guidelines for trauma-informed treatment in a primary care setting remain poorly established. Methods: A qualitative approach was engaged to explore primary care providers' perceptions of barriers and facilitators to assessing and treating trauma among MOUD patients. Twenty in-depth interviews were conducted in 2021 with Baltimore-based MOUD prescribers, including primary care physicians and nurse practitioners. Interview questions assessed experiences with identifying and treating trauma among MOUD patients, including challenges and opportunities. Results: Providers reported extensive histories of trauma experienced by MOUD patients. Barriers to addressing trauma include a lack of standardized protocols/procedures for identifying trauma, insufficient training/time to assess and treat trauma, and the limited availability of external mental health providers and specialty services. Opportunities included building strong, mutually respectful patient-provider relationships, providing individualized, person-centered care, and establishing connections to coordinated multidisciplinary treatment networks. Conclusions: MOUD treatment within primary care is an important way to increase OUD treatment access, but clearer standards are needed for the treatment of trauma within this patient population. These findings demonstrate opportunities to improve standards and systems such that primary care providers are better equipped to assess and treat the complex histories of trauma experienced by individuals with OUD.

A qualitative exploration of barriers and facilitators to drug treatment services among people who inject drugs in west Virginia

BACKGROUND

The opioid overdose crisis in the USA has called for expanding access to evidence-based substance use treatment programs, yet many barriers limit the ability of people who inject drugs (PWID) to engage in these programs. Predominantly rural states have been disproportionately affected by the opioid overdose crisis while simultaneously facing diminished access to drug treatment services. The purpose of this study is to explore barriers and facilitators to engagement in drug treatment among PWID residing in a rural county in West Virginia.

METHODS

From June to July 2018, in-depth interviews (n = 21) that explored drug treatment experiences among PWID were conducted in Cabell County, West Virginia. Participants were recruited from locations frequented by PWID such as local service providers and public parks. An iterative, modified constant comparison approach was used to code and synthesize interview data.

RESULTS

Participants reported experiencing a variety of barriers to engaging in drug treatment, including low thresholds for dismissal, a lack of comprehensive support services, financial barriers, and inadequate management of withdrawal symptoms. However, participants also described several facilitators of treatment engagement and sustained recovery. These included the use of medications for opioid use disorder and supportive health care workers/program staff.

CONCLUSIONS

Our findings suggest that a range of barriers exist that may limit the abilities of rural PWID to successfully access and remain engaged in drug treatment in West Virginia. Improving the public health of rural PWID populations will require expanding access to evidence-based drug treatment programs that are tailored to participants' individual needs.

A cyclic behavioral modeling aspect to understand the effects of vaccination and treatment on epidemic transmission dynamics

Evolutionary epidemiological models have played an active part in analyzing various contagious diseases and intervention policies in the biological sciences. The design in this effort is the addition of compartments for treatment and vaccination, so the system is designated as susceptible, vaccinated, infected, treated, and recovered (SVITR) epidemic dynamic. The contact of a susceptible individual with a vaccinated or an infected individual makes the individual either immunized or infected. Inventively, the assumption that infected individuals enter the treatment and recover state at different rates after a time interval is also deliberated through the presence of behavioral aspects. The rate of change from susceptible to vaccinated and infected to treatment is studied in a comprehensive evolutionary game theory with a cyclic epidemic model. We theoretically investigate the cyclic SVITR epidemic model framework for disease-free and endemic equilibrium to show stable conditions. Then, the embedded vaccination and treatment strategies are present using extensive evolutionary game theory aspects among the individuals in society through a ridiculous phase diagram. Extensive numerical simulation suggests that effective vaccination and treatment may implicitly reduce the community risk of infection when reliable and cheap. The results exhibited the dilemma and benefitted situation, in which the interplay between vaccination and treatment evolution and coexistence are investigated by the indicators of social efficiency deficit and socially benefited individuals.

"There's absolutely no downside to this, I mean, except community opposition:" A qualitative study of the acceptability of vending machines for harm reduction

BACKGROUND

Vending machines for harm reduction (VMHR) are an innovative approach to deliver life-saving materials, information, and treatment for hard-to-reach populations, particularly for persons who inject drugs. The current study explores stakeholders' perspectives on the feasibility and acceptability of VMHR in Philadelphia.

METHODS

From October 2021 to February 2022, we conducted 31 semi-structured interviews with potential end users, staff, and leadership at a local federally qualified health center, and community members. Trained coders extracted themes from interview transcripts across four key domains: materials and logistics, location, access, and community introduction.

RESULTS

Interviewees from all stakeholder groups endorsed using VMHR to provide supplies for wound care, fentanyl test strips, naloxone, and materials to connect individuals to treatment and other services. Dispensing syringes and medications for opioid use disorder were commonly endorsed by health center staff but were more controversial among potential end users. Even within stakeholder groups, views varied with respect to where to locate the machines, but most agreed that the machine should be placed in the highest drug use areas. Across stakeholder groups, interviewees suggested several strategies to introduce and gain community acceptance of VMHR, including community education, one-on-one conversations with community members, and coupling the machine with safe disposal of syringes and information to link individuals to treatment.

CONCLUSIONS

Stakeholders were generally receptive to VMHR. The current study findings are consistent with qualitative analyses from outside of the USA and contribute new ideas regarding the anticipated community response and best methods for introducing these machines to a community. With thoughtful planning and design, VMHR could be a feasible and acceptable modality to reduce death and disease transmission associated with the opioid and HIV epidemics in cities like Philadelphia.

The impact of COVID-19 on the treatment of opioid use disorder in carceral facilities: a cross-sectional study

While the COVID-19 pandemic disrupted healthcare delivery everywhere, persons with carceral system involvement and opioid use disorder (OUD) were disproportionately impacted and vulnerable to severe COVID-associated illness. Carceral settings and community treatment programs (CTPs) rapidly developed protocols to sustain healthcare delivery while reducing risk of COVID-19 transmission. This survey study assessed changes to OUD treatment, telemedicine use, and re-entry support services among carceral and CTPs participating in the National Institute on Drug Abuse (NIDA)-funded study, Long-Acting Buprenorphine vs. Naltrexone Opioid Treatments in Criminal Justice System-Involved Adults (EXIT-CJS) study. In December 2020, carceral sites (n = 6; median pre-COVID 2020 monthly census = 3468 people) and CTPs (n = 7; median pre-COVID 2020 monthly census = 550 patients) participating in EXIT-CJS completed a cross-sectional web-based survey. The survey assessed changes pre- (January-March 2020) and post- (April-September 2020) COVID-19 in OUD treatment, telemedicine use, re-entry supports and referral practices. Compared to January-March 2020, half of carceral sites (n = 3) increased the total number of persons initiating medication for opioid use disorder (MOUD) from April-September 2020, while a third (n = 2) decreased the number of persons initiated. Most CTPs (n = 4) reported a decrease in the number of new admissions from April-September 2020, with two programs stopping or pausing MOUD programs due to COVID-19. All carceral sites with pre-COVID telemedicine use (n = 5) increased or maintained telemedicine use, and all CTPs providing MOUD (n = 6) increased telemedicine use. While expansion of telemedicine services supported MOUD service delivery, the majority of sites experienced challenges providing community support post-release, including referrals to housing, employment, and transportation services. During the COVID-19 pandemic, this small sample of carceral and CTP sites innovated to continue delivery of treatment for OUD. Expansion of telemedicine services was critical to support MOUD service delivery. Despite these innovations, sites experienced challenges providing reintegration supports for persons in the community. Pre-COVID strategies for identifying and engaging individuals while incarcerated may be less effective since the pandemic. In addition to expanding research on the most effective telemedicine practices for carceral settings, research exploring strategies to expand housing and employment support during reintegration are critical.

Racial Discrimination, Mental Health and Behavioral Health During the COVID-19 Pandemic: a National Survey in the United States

BACKGROUND

While hate crimes rose during the COVID-19 pandemic, few studies examined whether this pandemic-time racial discrimination has led to negative health consequences at the population level.

OBJECTIVE

We examined whether experienced and perceived racial discrimination were associated with mental or behavioral health outcomes during the pandemic.

DESIGN

In October 2020, we conducted a national survey with minorities oversampled that covered respondents' sociodemographic background and health-related information.

PARTICIPANTS

A total of 2709 participants responded to the survey (response rate: 4.2%).

MAIN MEASURES

The exposure variables included (1) experienced and encountered racial discrimination, (2) experienced racial and ethnic cyberbullying, and (3) perceived racial bias. Mental health outcomes were measured by psychological distress and self-rated happiness. Measures for behavioral health included sleep quality, change in cigarette smoking, and change in alcohol consumption. Weighted logistic regressions were performed to estimate the associations between the exposure variables and the outcomes, controlling for age, gender, race and ethnicity, educational attainment, household income, eligibility to vote, political party, COVID-19 infection, and geographic region. Separate regressions were performed in the six racial and ethnic subgroups: non-Hispanic White, non-Hispanic Black, Hispanic, East Asian, South Asian, and Southeast Asian respondents.

KEY RESULTS

Experienced racial discrimination was associated with higher likelihood of psychological distress (adjusted odds ratio [AOR] = 2.18, 95% confidence interval [95% CI]: 1.34-3.55). Experienced racial discrimination (AOR = 2.31, 95% CI: 1.34-3.99) and perceived racial bias (AOR = 1.05, 95% CI: 1.00-1.09) were both associated with increased cigarette smoking. The associations between racial discrimination and mental distress and substance use were most salient among Black, East Asian, South Asian, and Hispanic respondents.

CONCLUSIONS

Racial discrimination may be associated with higher likelihood of distress, and cigarette smoking among racial and ethnic minorities. Addressing racial discrimination is important for mitigating negative mental and behavioral health ramifications of the pandemic.

Changes in Racial/Ethnic Disparities in Opioid-Related Outcomes in Urban Areas during the COVID-19 Pandemic: A Rapid Review of the Literature

Opioid use disorders (OUDs) are increasingly common among minoritized populations, who have historically experienced limited access to healthcare, a situation that may have worsened during the COVID-19 pandemic. Using a structured keyword search in Pubmed, we reviewed the literature to synthesize the evidence on changes in racial/ethnic disparities in OUD-related outcomes in urban areas during the COVID-19 pandemic in the US. Nine articles were included in the final analysis. Six found increases in OUD-related outcomes during the pandemic, with four showing a widening of disparities. Results also point to the worsening of opioid outcomes among Black and Latinx individuals related to shelter-in-place or stay-at-home orders. Studies examining the use of telehealth and access to OUD treatment showed that minoritized groups have benefited from telehealth programs. The limited number of studies in a small number of jurisdictions indicate a gap in research examining the intersection between COVID-19 and OUD-related outcomes with a focus on disparities. More research is needed to understand the impact of the COVID-19 pandemic and related policies on OUD outcomes among racial/ethnic minoritized groups, including examining the impact of service disruptions on vulnerable groups with OUD.

Barriers and poor telephone counseling experiences among patients receiving medication for opioid use disorders

OBJECTIVE

The COVID-19 pandemic catalyzed the relaxation of regulations surrounding Medication for Opioid Use Disorders (MOUD) treatment, including a shift from in-person to telehealth counseling services adjunct to MOUD treatment. We examine how patient-level barriers impact their counseling experiences.

METHODS

We examine data from n = 264 participants who completed a cross-sectional survey regarding their experiences with telephone counseling adjunct to MOUD between July to November 2020. Variables examined include: convenience and satisfaction with telephone counseling, comfort and change in relationship with counselor, and how telephone counseling helped with anxiety, depression, anger, substance use, and recovery. Participants also listed the barriers they faced when using telephone counseling.

RESULTS

Thirty-one percent of the sample (n = 81) reported experiencing one or more barriers to telephone counseling. Satisfaction with counseling, perceived convenience, comfort, and beneficial effects of counseling on substance use were associated with increased odds of reporting no barriers (range of p.038 to <0.001).

CONCLUSIONS

Many participants reported barriers to telehealth counseling, and these barriers were in turn associated with poorer counseling experiences.

PRACTICE IMPLICATIONS

Many treatment providers plan to integrate telehealth service provision in their healthcare delivery model, but more research on patient-level barriers and its impact on treatment is needed.

A cross-sectional study of factors associated with COVID-19 testing among people who inject drugs: missed opportunities for reaching those most at risk

BACKGROUND

People who inject drugs (PWID) are vulnerable to SARS-CoV-2 infection. We examined correlates of COVID-19 testing among PWID in the U.S.-Mexico border region and described encounters with services representing potential opportunities (i.e., 'touchpoints') where COVID-19 testing could have been offered.

METHODS

Between October, 2020 and September, 2021, participants aged ≥18 years from San Diego, California, USA and Tijuana, Baja California, Mexico who injected drugs within the last month completed surveys and SARS-CoV-2, HIV, and HCV serologic testing. Logistic regression identified factors associated with COVID-19 testing including potential touchpoints, comorbidities and COVID-19 related misinformation and disinformation.

RESULTS

Of 583 PWID, 30.5% previously had a COVID-19 test. Of 172 PWID who tested SARS-CoV-2 seropositive (30.1%), 50.3% encountered at least one touchpoint where COVID-19 testing could have been offered within the prior six months. Factors independently associated with at least two fold higher odds of COVID-19 testing were living in San Diego, recent incarceration, receiving substance use treatment, and experiencing ≥1 chronic health condition. Homelessness, having received ≥1 dose of COVID-19 vaccine, and having a HIV or HCV test since the COVID-19 epidemic began were also independently associated with having had a prior COVID-19 test.

CONCLUSION

We identified several factors independently associated with COVID-19 testing and multiple touchpoints where COVID-19 testing could be scaled up for PWID, such as SUD treatment programs and syringe service programs. Integrated health services are needed to improve access to rapid, free COVID-19 testing in this vulnerable population.

Factors Associated with COVID-19 Testing among People who Inject Drugs: Missed Opportunities for Reaching those Most at Risk

People who inject drugs (PWID) are vulnerable to SARS-CoV-2 infection. We examined correlates of COVID-19 testing among PWID in the U.S.-Mexico border region and described encounters with services or venues representing potential opportunities (i.e., 'touchpoints') where COVID-19 testing could have been offered. Between October, 2020 and September, 2021, participants aged ≥18 years from San Diego, California, USA and Tijuana, Baja California, Mexico who injected drugs within the last month completed surveys and SARS-CoV-2, HIV, and HCV serologic testing. Logistic regression was used to identify factors associated with COVID-19 testing prior to enrollment. Of 583 PWID, 30.5% previously had a COVID-19 test. Of 172 PWID who tested SARS-CoV-2 seropositive in our study (30.1%), 50.3% encountered at least one touchpoint within the prior six months where COVID-19 testing could have been offered. Factors independently associated with at least two fold higher odds of COVID-19 testing were living in San Diego (versus Tijuana), having recently been incarcerated or attending substance use disorder (SUD) treatment and having at least one chronic health condition. In addition, recent homelessness, having had at least one COVID-19 vaccine dose and having been tested for HIV or HCV since the pandemic began were independently associated with COVID-19 testing. We identified several factors independently associated with COVID-19 testing and multiple touchpoints where COVID-19 testing could be scaled up for PWID, such as SUD treatment programs and syringe service programs. Integrated health services are needed to improve access to rapid, free COVID-19 testing in this vulnerable population.