Research on rural residence and access to drug abuse services: where are we and where do we go?

Presenting Pattern and Psychiatric Comorbidities in Rural versus Urban Substance Dependent Patients: A Hospital-Based Cross-Sectional Study

Background

"Locality" is a significant factor in substance initiation, maintenance, and relapse. The pattern of substance dependence among rural and urban populations varies across studies and is scarcely studied, warranting further research. To compare presenting patterns (sociodemographic and drug-related variables), reasons for substance use, and psychiatric comorbidities (prevalence, type, and severity) between rural and urban substance-dependent groups.

Materials and Methods

This study was a cross-sectional analytical study in a government de-addiction center, including rural and urban patient groups aged 18-65. International Classification of Diseases, Tenth Revision (ICD-10) criteria, and severity of dependence scale were used for diagnosing substance dependence. After detoxification, psychiatric comorbidity was assessed using brief psychiatric rating scale, Young's mania rating scale, and patient health questionnaire - somatic, anxiety, and depression symptoms scale. Post-analysis was performed to assess socioeconomic variables and access to de-addiction services.

Results

The final sample was 500 (250 rural and 250 urban). The post-analysis sample size was 386 (211 rural and 175 urban). The mean age was 38.2 ± 12.4 years, mostly males (n = 495, 99%). Substance frequency was opioids (92%)> benzodiazepines (24.8%) > alcohol (22%) > cannabis (1.6%) for rural and opioids (91.2%) > alcohol (29.6%) > benzodiazepines (14.8%) > cannabis (2%) for urban patients. More than half of patients had comorbid nicotine dependence. Rural patients were more benzodiazepine dependent (P = 0.007), and urban were more opioid + alcohol dependent (P = 0.001). Rural patients had higher age (P = 0.012), less education (P < 0.001), positive family history of substance (P = 0.028), daily wagers, and farmers (P < 0.001) than urban patients who were younger, students (P = 0.002), businessmen and government employed (P < 0.001). Urban patients expended more on drugs (P < 0.001), had higher treatment attempts (P = 0.008), and had better availability and accessibility of de-addiction services (P < 0.001). More rural users initiated substances to "enhance performance," whereas urban ones initiated for "stress relief/novelty" (P < 0.001). For treatment seeking, "External pressure" was a more common reason in urban patients (P < 0.001), who also had more psychiatric comorbidities (P = 0.026).

Conclusion

Significant pattern differences exist between rural and urban substance dependents, warranting emphasis on locality-specific factors for appropriate intervention.

The Gendered Path for Girls in Rural Communities: The Impact of COVID-19 on Youth Presenting at Juvenile Detention Facilities

Prior to the COVID-19 pandemic, girls and women represented one of the fastest growing populations within the juvenile and criminal justice systems. Since the spread of COVID-19, suggestions were provided to juvenile justice bodies, encouraging a reduction of youth arrests, detainments, and quicker court processing. Yet, the research comparing peri-COVID-19 changes for girls and boys is lacking, with an oversight to gender trends and rural and urban differences. This study used Juvenile Intake and Assessment Center (JIAC) data from a rural Midwestern state to look at rural and urban location trends for both boys and girls. Results suggest rural communities are responding differently to girls' behaviors, revealing a slower decline in intakes compared to boys and youth in urban areas.

Pain management: A deeper look at rural and urban nurses' perceptions and experiences

PURPOSE

About 11.4 million individuals admitted to misusing an opioid in the past year. The purpose of this study was to determine if nurses' definitions of pain management differed by location, and to assess the challenges treating patients with pain management concerns. This study fills a gap by comparing quantitative and qualitative feedback from nurses on pain management concerns in their practice location.

METHODS

Data were collected using an electronic survey emailed to licensed nurses across the United States. The mixed methods survey used multiple choice, select all that apply, and open-ended responses to gather data on nurses' perceptions of pain management. One hundred and eighty nurses completed the survey and were included in the study. Sixty-six percent practiced in an urban hospital.

FINDINGS

Rural and urban nurses defined pain management as nonopioids and opioids. Seventy-one percent of urban nurses defined pain management as physical therapy compared to only 61% of rural nurses. Similarly, 62% of urban nurses identified homeopathic medicines and treatments as pain management techniques compared to 52% of rural nurses. From the qualitative data, 32% of rural nurses stated that patients with pain management concerns only want pain medications compared to 14% of urban nurses.

CONCLUSIONS

Nurses have a critical position in and valuable perspective on the opioid epidemic. Rural communities are relatively disadvantaged in combatting the opioid epidemic. The finding that rural residents only want pain medication instead of alternative pain management options further challenges the country's rural health care workforce.

A cohort study examining changes in treatment patterns for alcohol use disorder among commercially insured adults in the United States during the COVID-19 pandemic

INTRODUCTION

We know very little about how the pandemic impacted outpatient alcohol use disorder (AUD) care and the role of telemedicine.

METHODS

Using OptumLabs® Data Warehouse de-identified administrative claims, we identified AUD cohorts in 2018 (N = 23,204) and 2019 (N = 23,445) and examined outpatient visits the following year, focusing on week 12, corresponding to the March 2020 US COVID-19 emergency declaration, through week 52. Using multivariable logistic regression, we examined the association between patient demographic and clinical characteristics and receipt of any outpatient AUD visits in 2020 vs. 2019.

RESULTS

In 2020, weekly AUD visit utilization decreased maximally at the pandemic start (week 12) by 22.5 % (2019: 3.8 %, 2020: 3.0 %, percentage point change [95 % CI] = -0.86[-1.19, -0.05]) but was similar to 2019 utilization by mid-April 2020 (week 16). Telemedicine accounted for 50.1 % of AUD visits by early July 2020 (week 27). Individual therapy returned to 2019 levels within 1 week (i.e., week 13) whereas group therapy did not consistently do so until mid-August 2020 (week 31). Further, individual therapy exceeded 2019 levels by as much as 50 % starting mid-October 2020. The study found no substantial differences in visits by patient demographic or clinical characteristics.

CONCLUSIONS

Among patients with known AUD, initial outpatient care disruptions were relatively brief. However, substantial shifts occurred in care delivery-an embrace of telemedicine but also more pronounced, longer disruptions in group therapy vs. individual and an increase in individual therapy use. Further research needs to help us understand the implications of these findings for clinical outcomes.

The "goldfish bowl": a qualitative study of the effects of heightened surveillance on people who use drugs in a rural and coastal Canadian setting

BACKGROUND

A growing body of research has focused on contextual factors that shape health and well-being of people who use drugs (PWUD). However, most of this research focuses on large cities and less is known about the effects of social and structural contexts on drug use and associated risks in rural Canadian settings. Therefore, we undertook this study to examine rural-specific contextual factors that affect the day-to-day experiences of PWUD.

METHODS

Twenty-seven qualitative semi-structured interviews were conducted with PWUD in a rural and coastal setting in British Columbia, Canada. Participants had to be ≥ 19 years old, used illegal opioids and/or stimulants regularly, and lived in the qathet region. Interview transcripts were coded based on themes identified by the research team.

RESULTS

Participants described progressive shifts in politics and culture in the qathet region while also identifying resource scarcity, homelessness, and changes in the drug supply, where illicit drug contents have become highly toxic and unpredictable. Participants discussed the qualities of a small community where everyone knows each other and there is a lack of privacy and confidentiality around drug use, which resulted in experiences of stigma, discrimination, and surveillance. Participants also reported rural-specific policing issues and experiences of surveillance on ferries when traveling to larger cities to purchase drugs. This led to significantly higher drug prices for PWUD due to the time dedication and criminalized risks associated with drug possession and trafficking.

CONCLUSIONS

Our findings illustrate the unique experiences faced by PWUD in a rural and coastal setting. The "goldfish bowl" effect in this rural community created heightened social and structural surveillance of PWUD, which led to a variety of negative consequences. There is a clear need for interventions to address the larger contextual drivers affecting people who use drugs in rural settings, including decriminalization and peer-led anti-stigma strategies, in order to improve the lives of PWUD.

Prevalence and sociodemographic factors associated with polysubstance use: analysis of a population-based survey in Jamaica

BACKGROUND

In Latin America and the Caribbean, there is a dearth of research exploring polysubstance use. This study aims to determine the prevalence, varying combinations and associated sociodemographic characteristics of polysubstance use in Jamaica.

METHODS

This study involved a secondary data analysis of the Jamaica National Drug Prevalence Survey 2016 dataset where 4,623 participants between the age of 12 and 65 years from each household were randomly selected as respondents. Statistical analysis was performed to determine the prevalence and the sociodemographic correlates of polysubstance use among Jamaicans.

RESULTS

19.6% of respondents used two or more drugs in their lifetime. Of this amount 68.7% reported past year use and 61.9% reported past month use. Bivariate analyses reported polysubstance use was statistically significantly higher amongst males (U = 54,579, p = 0.000), those living in rural areas (U = 91,892, p = 0.003), non-Christian (U = 89,514, p = 0.014), and married persons (U = 74,672, p = 0.000). Past month polysubstance use was statistically significantly higher among employed persons than unemployed persons were (U = 81,342, p = 0.001). Surprisingly, there was a lack of significant differences between education level, household income and past month concurrent polysubstance use (p = 0.609; p = 0.115 respectively). Logistic regression model indicated males were 3.076 times more likely than females to report past month polysubstance use than females. Also, when compared to those 55-65 years old, participants 35-54 years were 2.922 times more likely and those 18-34 years were 4.914 times more likely to report past month polysubstance use. Additionally, those living in rural areas were 1.508 times more likely than participants living in urban areas to report past month polysubstance use. As it relates to occupational status, when compared to armed forces, skilled workers were 4.328 times more likely and unskilled workers were 7.146 times more likely to report past month polysubstance use.

CONCLUSIONS

One in five Jamaicans identified as polysubstance users, predominated by marijuana as the most common factor amongst the polysubstance combinations examined, signalling the need for early marijuana interventions.

Improving the Recruitment and Retention of Counselors in Rural Substance Use Disorder Treatment Programs

While access to drug treatment has increased in recent years, there is still a shortage of substance use disorder (SUD) treatment counselors in the United States, especially in rural areas. This study examined recruitment and retention issues for counselors in rural substance use disorder treatment programs. Qualitative interviews were conducted with 26 program, clinical, and/or human resource directors of SUD treatment programs. Almost all interviewees had problems recruiting high-quality counselors although only a small number saw retention as a significant issue. Improving educational opportunities and training related to addictions counseling could result in more people entering the SUD treatment field. Strategies for improving retention of counselors include more supportive and inclusive management practices. The stigma of SUD also contributed to recruitment and retention problems.

Measuring hospital spatial accessibility using the enhanced two-step floating catchment area method to assess the impact of spatial accessibility to hospital and non-hospital care on the length of hospital stay

Background

Optimal healthcare access improves the health status and decreases health inequalities. Many studies demonstrated the importance of spatial access to healthcare facilities in health outcomes, particularly using the enhanced two-step floating catchment area (E2SFCA) method. The study objectives were to build a hospital facility access indicator at a fine geographic scale, and then to assess the impact of spatial accessibility to inpatient hospital and non-hospital care services on the length of hospital stay (LOS).

Methods

Data concerning older adults (≥75 years) living in the Nord administrative region of France were used. Hospital spatial accessibility was computed with the E2SFCA method, and the LOS score was calculated from the French national hospital activity and patient discharge database. The relationship between LOS and spatial accessibility to inpatient hospital care and to three non-hospital care types (general practitioners, physiotherapists, and home-visiting nurses) was analyzed with linear regression models.

Results

The mean number (standard deviation) of beds per 10,000 inhabitants was 19.0 (10.69) in Medical, Surgical and Obstetrics (MCO) facilities and 5.58 (2.19) in Postoperative and Rehabilitation Care (SSR) facilities, highlighting important variations within the region. Accessibility to hospital services was higher in large urban areas, despite the dense population and higher demand. In 2014, the mean LOS scores were 0.26 for MCO and 0.85 for SSR, but their geographical repartition was non-homogeneous. The linear regression analysis revealed a strong negative and significant association between LOS and non-hospital care accessibility.

Conclusions

This is the first study to measure spatial accessibility to inpatient hospital care in France using the E2SFCA method, and to investigate the relationship between healthcare utilization (LOS score) and spatial accessibility to inpatient hospital care facilities and three types of non-hospital care services. Our findings might help to make decisions about deploying additional beds and to identify the best locations for non-hospital care services. They might also contribute to improve access, and to ensure the best coordination and sustainability of inpatient and outpatient services, in order to better cover the population’s healthcare needs. International studies using multiple consensual indicators of healthcare outcomes and accessibility and sophisticated modeling methods are needed.

"Could we have predicted this?" The association of a future mental health need in young people with a non-specific complaint and frequent emergency department visits

OBJECTIVE

Mental health emergencies among young people are increasing. There is growing pressure for emergency departments to screen patients for mental health needs even when it is not their chief complaint. We hypothesized that young people with an initial non-specific condition and emergency department (ED) revisits have increased mental health needs.

METHODS

Retrospective, observational study of the California Office of Statewide Health Planning and Development Emergency Department Discharge Dataset (2010-2014) of young people (11-24 years) with an index visit for International Classification of Diseases, Ninth Revision diagnostic codes of "Symptoms, signs, and ill-defined conditions" (Non-Specific); "Diseases of the respiratory system" (Respiratory) and "Unintentional injury" (Trauma) who were discharged from a California ED. Patients were excluded if they had a prior mental health visit, chronic disease, or were pregnant. ED visit frequency was counted over 12 months. Regression models were created to analyze characteristics associated with a mental health visit.

RESULTS

Patients in the Non-Specific category compared to the Respiratory category had 1.2 times the odds of a future mental health visit (OR 1.20; 95% CI 1.17-1.24). Patients with ≥1 ED revisit, regardless of diagnostic category, had 1.3 times the odds of a future mental health visit. Patients with both a Non-Specific index visit and 1, 2, and 3 or more revisits with non-specific diagnoses had increasing odds of a mental health visit (OR 1.38; 95% CI 1.29-1.47; OR 1.70; 95% CI 1.46-1.98; OR 2.20; 95% CI 1.70-2.87, respectively.).

CONCLUSIONS

Young people who go to the ED for non-specific conditions and revisits may benefit from targeted ED mental health screening.

Barriers and Motivators to Opioid Treatment Among Suburban Women Who Are Pregnant and Mothers in Caregiver Roles

Women of childbearing age who misuse opioids are a particularly vulnerable population, and their barriers to treatment are unique because of their caregiver roles. Research on treatment for opioid use generally draws from urban and rural areas. This study fills a gap in research that focuses on barriers and motivators to opioid treatment in suburban areas. The aim of this study was to give voice to suburban pregnant women and mothers caring for children while using opioids. Ethnographic methods were used for recruitment, and 58 in-depth interviews were analyzed using a modified grounded theory approach. Barriers to medication-assisted treatment (MAT) included stigma, staff attitudes, and perceptions the women had about MAT treatment. Barriers associated with all types of treatment included structural factors and access difficulties. Relationships with partners, friends, family, and providers could be barriers as well as motivators, depending on the social context of the women’s situation. Our findings suggest increasing treatment-seeking motivators for mothers and pregnant women by identifying lack of resources, more empathetic consideration of social environments, and implementing structural changes to overcome barriers. Findings provide a contemporary understanding of how suburban landscapes affect mothers’ treatment-seeking for opioid dependence and suggest the need for more focus on emotional and structural resources rather than strict surveillance of women with opioid dependence who are pregnant or caring for children.

Efficiency of fine scale and spatial regression in modelling associations between healthcare service spatial accessibility and their utilization

BACKGROUND

Healthcare accessibility, a key public health issue, includes potential (spatial accessibility) and realized access (healthcare utilization) dimensions. Moreover, the assessment of healthcare service potential access and utilization should take into account the care provided by primary and secondary services. Previous studies on the relationship between healthcare spatial accessibility and utilization often used conventional statistical methods without addressing the scale effect and spatial processes. This study investigated the impact of spatial accessibility to primary and secondary healthcare services on length of hospital stay (LOS), and the efficiency of using a geospatial approach to model this relationship.

METHODS

This study focused on the ≥ 75-year-old population of the Nord administrative region of France. Inpatient hospital spatial accessibility was computed with the E2SFCA method, and then the LOS was calculated from the French national hospital activity and patient discharge database. Ordinary least squares (OLS), spatial autoregressive (SAR), and geographically weighted regression (GWR) were used to analyse the relationship between LOS and spatial accessibility to inpatient hospital care and to three primary care service types (general practitioners, physiotherapists, and home-visiting nurses). Each model performance was assessed with measures of goodness of fit. Spatial statistical methods to reduce or eliminate spatial autocorrelation in the residuals were also explored.

RESULTS

GWR performed best (highest R2 and lowest Akaike information criterion). Depending on global model (OLS and SAR), LOS was negatively associated with spatial accessibility to general practitioners and physiotherapists. GWR highlighted local patterns of spatial variation in LOS estimates. The distribution of areas in which LOS was positively or negatively associated with spatial accessibility varied when considering accessibility to general practitioners and physiotherapists.

CONCLUSIONS

Our findings suggest that spatial regressions could be useful for analysing the relationship between healthcare spatial accessibility and utilization. In our case study, hospitalization of elderly people was shorter in areas with better accessibility to general practitioners and physiotherapists. This may be related to the presence of effective community healthcare services. GWR performed better than LOS and SAR. The identification by GWR of how these relationships vary spatially could bring important information for public healthcare policies, hospital decision-making, and healthcare resource allocation.

Early implementation of screening for substance use in rural primary care: A rapid analytic qualitative study

Background: Few primary care patients are screened for substance use. As part of a phased feasibility study examining the implementation of electronic health record-integrated screening with the Tobacco, Alcohol, and Prescription Medication Screening (TAPS) Tool and clinical decision support (CDS) in rural primary care clinics, focus groups were conducted to identify early indicators of success and challenges to screening implementation. Method: Focus groups (n = 6) were conducted with medical assistants (MAs: n = 3: 19 participants) and primary care providers (PCPs: n = 3: 13 participants) approximately one month following screening implementation in three Federally Qualified Health Centers in Maine. Rapid analysis and matrix analysis using Proctor's Taxonomy of Implementation Outcomes were used to explore implementation outcomes. Results: There was consensus that screening is being used, but use of the CDS was lower, in part due to limited positive screens. Fidelity was high among MAs, though discomfort with the CDS surfaced among PCPs, impacting adoption and fidelity. The TAPS Tool's content, credibility and ease of workflow integration were favorably assessed. Challenges include screening solely at annual visits and self-administered screening for certain patients. Conclusions: Results reveal indicators of implementation success and strategies to address challenges to screening for substance use in primary care.

Establishing cross-systems collaborations for implementation: protocol for a longitudinal mixed methods study

Background

Cross-system interventions can help integrate services across different service delivery systems but require organizations to establish strong collaborative relationships for implementation. Contingency theory suggests that the effectiveness of different collaborative strategies (i.e. specific ways organizations align operations and services) varies by context. This paper describes a study of different strategies for fostering collaboration between child welfare and substance abuse treatment agencies and the conditions under which they are effective for implementation. We also describe the development and piloting of the Collaborating Across Systems for Program Implementation (CASPI) tool—a decision-making guide intended to help researchers and organizational leaders identify and use appropriate collaborative strategies for their context.

Methods/design

This multisite longitudinal, mixed methods study, leverages a naturally occurring implementation initiative -- in up to 17 Ohio counties -- to implement Ohio START (Sobriety Treatment and Reducing Trauma). START is a child welfare model that requires strong collaboration with local substance use treatment organizations to promote integrated services. During the first two years, we will identify collaborative strategies associated with improved START implementation (penetration and fidelity) and service delivery outcomes (timeliness), given system, and organizational features. We will conduct a convergent mixed methods study drawing on worker surveys, agency documents, administrative data, formal partner agreements, and group interviews. Data will be integrated and analyzed using Qualitative Comparative Analysis (QCA). To develop the CASPI, an expert panel comprised of implementation experts, and community stakeholders will convene to synthesize our findings and develop contents (including a decision tree). During the final year of the study, we will assess the acceptability, appropriateness, and feasibility of the CASPI in a randomized vignette experiment, and a pilot-test with 3 child welfare agencies that have not yet implemented START.

Discussion

Our results will lay the groundwork for a larger controlled trial that will test the CASPI’s effectiveness for supporting effective and efficient implementation of cross-system interventions like START. The CASPI is expected to help leaders and researchers select and use collaboration strategies tailored to their context and be applicable in a wide range of settings including rural communities. Our work also advances system-level implementation strategies.

Trial registration

NCT03931005, Registered April 29, 2019.

"It's Took Over This Region": Patient Perspectives of Prescription Drug Abuse in Appalachia

Background: Prescription drug abuse is a public health problem in the United States and the region of Appalachia, specifically. Primary care and addiction medicine-as possible points of access for prescription drugs with abuse potential and points of intervention for prescription drug abuse-are among the medical fields at its forefront. Little is known, however, about perceptions of prescription drug abuse across the two patient populations. Objectives: The objective of this qualitative analysis was to explore perceptions of the scale and context of prescription drug abuse among primary care and addiction medicine patients in Appalachia. Methods: As part of a mixed methods study, semi-structured interviews were conducted with 20 patients from primary care and addiction medicine in Central and South Central Appalachia from 2014 to 2015. The interviews were audio-recorded and transcribed verbatim. Thematic analysis was used to identify themes. Results: Three themes were identified: (1) pervasiveness of prescription drug abuse, describing perceptions of its high prevalence and negative consequences; (2) routes and routine practices for prescription drug acquisition and distribution, describing perceptions of routes of access to prescription drugs and behaviors exhibited to acquire and distribute prescription drugs; and (3) rationales for prescription drug acquisition and distribution, describing perceptions of the two underlying reasons for these processes-tolerance/addiction and revenue source. Conclusions/Importance: Perceptions of prescription drug abuse among primary care and addiction medicine patients in Appalachia are multifaceted, especially regarding prescription drug acquisition and distribution. Clinical practice implications for mitigating prescription drug abuse are discussed.

Inpatient Addiction Medicine Consultation and Post-Hospital Substance Use Disorder Treatment Engagement: a Propensity-Matched Analysis

BACKGROUND

Hospitalizations due to medical and surgical complications of substance use disorder (SUD) are rising. Most hospitals lack systems to treat SUD, and most people with SUD do not engage in treatment after discharge.

OBJECTIVE

Determine the effect of a hospital-based addiction medicine consult service, the Improving Addiction Care Team (IMPACT), on post-hospital SUD treatment engagement.

DESIGN

Cohort study using multivariable analysis of Oregon Medicaid claims comparing IMPACT patients with propensity-matched controls.

PARTICIPANTS

18-64-year-old Oregon Medicaid beneficiaries with SUD, hospitalized at an Oregon hospital between July 1, 2015, and September 30, 2016. IMPACT patients (n = 208) were matched to controls (n = 416) using a propensity score that accounted for SUD, gender, age, race, residence region, and diagnoses.

INTERVENTIONS

IMPACT included hospital-based consultation care from an interdisciplinary team of addiction medicine physicians, social workers, and peers with lived experience in recovery. IMPACT met patients during hospitalization; offered pharmacotherapy, behavioral treatments, and harm reduction services; and supported linkages to SUD treatment after discharge.

OUTCOMES

Healthcare Effectiveness Data and Information Set (HEDIS) measure of SUD treatment engagement, defined as two or more claims on two separate days for SUD care within 34 days of discharge.

RESULTS

Only 17.2% of all patients were engaged in SUD treatment before hospitalization. IMPACT patients engaged in SUD treatment following discharge more frequently than controls (38.9% vs. 23.3%, p < 0.01; aOR 2.15, 95% confidence interval [CI] 1.29-3.58). IMPACT participation remained associated with SUD treatment engagement when limiting the sample to people who were not engaged in treatment prior to hospitalization (aOR 2.63; 95% CI 1.46-4.72).

CONCLUSIONS

Hospital-based addiction medicine consultation can improve SUD treatment engagement, which is associated with reduced substance use, mortality, and other important clinical outcomes. National expansion of such models represents an opportunity to address an enduring gap in the SUD treatment continuum.

Screening for Substance Use in Rural Primary Care: a Qualitative Study of Providers and Patients

BACKGROUND

Substance use frequently goes undetected in primary care. Though barriers to implementing systematic screening for alcohol and drug use have been examined in urban settings, less is known about screening in rural primary care.

OBJECTIVE

To identify current screening practices, barriers, facilitators, and recommendations for the implementation of substance use screening in rural federally qualified health centers (FQHCs).

DESIGN

As part of a multi-phase study implementing electronic health record-integrated screening, focus groups (n = 60: all stakeholder groups) and individual interviews (n = 10 primary care providers (PCPs)) were conducted.

PARTICIPANTS

Three stakeholder groups (PCPs, medical assistants (MAs), and patients) at three rural FQHCs in Maine.

APPROACH

Focus groups and interviews were recorded, transcribed, and content analyzed. Themes surrounding current substance use screening practices, barriers to screening, and recommendations for implementation were identified and organized by the Knowledge to Action (KTA) Framework.

KEY RESULTS

Identifying the problem: Stakeholders unanimously agreed that screening is important, and that universal screening is preferred to targeted approaches. Adapting to the local context: PCPs and MAs agreed that screening should be done annually. Views were mixed regarding the delivery of screening; patients preferred self-administered, tablet-based screening, while MAs and PCPs were divided between self-administered and face-to-face approaches. Assessing barriers: For patients, barriers to screening centered around a perceived lack of rapport with providers, which contributed to concerns about trust, judgment, and privacy. For PCPs and MAs, barriers included lack of comfort, training, and preparedness to address screening results and offer treatment.

CONCLUSIONS

Though stakeholders agree on the importance of implementing universal screening, concerns about the patient-provider relationship, the consequences of disclosure, and privacy appear heightened by the rural context. Findings highlight that strong relationships with providers are critical for patients, while in-clinic resources and training are needed to increase provider comfort and preparedness to address substance use.

Rural Location and Relative Location: Adding Community Context to the Study of Sexual Assault Survivor Time Until Presentation for Medical Care

Despite a strong empirical base linking community context and proximity to resources to individual health care access, studies examining predictors of sexual assault survivor time until presentation for medical care have not yet examined these relationships. This study addresses this gap. The data included retrospective records on a sample of 1,630 female survivors who reported their sexual assault to law enforcement and were subsequently seen by a sexual assault nurse examiner (SANE) in one of eight Alaskan communities between the years 1996 and 2006. Logistic regression models were used to determine whether delays in presentation (presentation 12 hr or more after assault) differed for women presenting in unique communities (rural location), and between those whose assault and exam occurred in different communities versus occurring in the same community (relative location). Although rural location did not seem to have a unique impact on time until presentation, differing locations (i.e., relative location) of assaults and exams increased the likelihood of delays in presentation. Non-American Indian/Alaska Native race/ethnicity and knowing one's assailant(s) also increased the likelihood of delays. These results indicate that in addition to a need for further research, there is a need for more appropriate and reliable sexual assault medical services across communities, and that survivors assaulted by known assailants should be targeted in efforts to reduce time until presentation.

Predicting Substance Use Patterns Among Rural Adults: The Roles of Mothers, Fathers, and Parenthood

This study examined the role of parenthood and parental influences on substance use patterns for 710 stimulant users age 18-61 living in the rural Midwest and Mid-south U.S. Longitudinal growth analyses showed that a maternal history of drug use was associated with increased baseline drug use severity, lesser declines in severity, and greater plateau of drug use severity over time. Parental conflict was associated with lesser declines in drug use severity, and drug use severity declined more steeply for participants who were themselves parents. Participants with two parents having a history of alcohol use had a greater baseline severity of alcohol use, with paternal history of drug use associated with lower baseline alcohol use severity. These findings demonstrate the importance of identifying parental influences in evaluating adult substance use, and point to the inclusion of parents in efforts to prevent and treat substance use disorders.

Patterns of Alcohol Use Among Patients Living With HIV in Urban, Large Rural, and Small Rural Areas

BACKGROUND

For people living with HIV (PLWH), alcohol use is harmful and may be influenced by unique challenges faced by PLWH living in rural areas. We describe patterns of alcohol use across rurality among PLWH.

METHODS

Veterans Aging Cohort Study electronic health record data were used to identify patients with HIV (ICD-9 codes for HIV or AIDS) who completed AUDIT-C alcohol screening between February 1, 2008, and September 30, 2014. Regression models estimated and compared 4 alcohol use outcomes (any use [AUDIT-C > 0] and alcohol use disorder [AUD; ICD-9 codes for abuse or dependence] diagnoses among all PLWH, and AUDIT-C risk categories: lower- [1-3 men/1-2 women], moderate- [4-5 men/3-5 women], higher- 6-7]), and severe-risk [8-12], and heavy episodic drinking (HED; ≥1 past-year occasion) among PLWH reporting use) across rurality (urban, large rural, small rural) and census-defined region.

FINDINGS

Among 32,699 PLWH (29,540 urban, 1,301 large rural, and 1,828 small rural), both any alcohol use and AUD were highest in urban areas, although this varied across region. Predicted prevalence of any alcohol use was 54.1% (53.5%-54.7%) in urban, 49.6% (46.9%-52.3%) in large rural, and 50.6% (48.3%-52.9%) in small rural areas (P < .01). Predicted prevalence of AUD was 14.4% (14.0%-14.8%) in urban, 11.8% (10.0%-13.5%) in large rural, and 12.3% (10.8%-13.8%) in small rural areas (P < .01). Approximately 12% and 25% had higher- or severe-risk drinking and HED, respectively, but neither differed across rurality.

CONCLUSION

Though some variation across rurality and region was observed, alcohol-related interventions are needed for PLWH across all geographic locations.

Acceptability of HIV Testing Sites Among Rural and Urban African Americans Who Use Cocaine

African Americans (AAs) who use cocaine in the Southern region of the U.S. have a relatively high risk of HIV and need for HIV testing. Among this group, those residing in rural areas may have less favorable opinions about common HIV testing sites, which could inhibit HIV testing. We examined rural/urban variations in their acceptability of multiple HIV testing sites (private physician clinic, local health department, community health center, community HIV fair, hospital emergency department, blood plasma donation center, drug abuse treatment facility, and mobile van or community outreach worker). Results from partial proportional odds and logistic regression analyses indicate that rural AA who use cocaine have lower odds of viewing local health departments (OR = 0.09, 95 % CI = 0.03-0.21), physician offices (OR = 0.19, 95 % CI = 0.09-0.42), and drug use treatment centers (OR = 0.49; 95 % CI = 0.30-0.80) as acceptable relative to their urban counterparts. The findings have implications for further targeting HIV testing toward AAs who use of cocaine, particularly those residing in the rural South.

Assessing Differences in the Availability of Opioid Addiction Therapy Options: Rural Versus Urban and American Indian Reservation Versus Nonreservation

BACKGROUND

Opioid misuse is a large public health problem in the United States. Residents of rural areas and American Indian (AI) reservation/trust lands represent traditionally underserved populations with regard to substance-use disorder therapy.

PURPOSE

Assess differences in the number of opioid agonist therapy (OAT) facilities and physicians with Drug Addiction Treatment Act (DATA) waivers for rural versus urban, and AI reservation/trust land versus non-AI reservation/trust land areas in Washington State.

METHODS

The unit of analysis was the ZIP code. The dependent variables were the number of OAT facilities and DATA-waivered physicians in a region per 10,000 residents aged 18-64 in a ZIP code. A region was defined as a ZIP code and its contiguous ZIP codes. The independent variables were binary measures of whether a ZIP code was classified as rural versus urban, or AI reservation/trust land versus non-AI reservation/trust land. Zero-inflated negative binomial regressions with robust standard errors were estimated.

RESULTS

The number of OAT clinics in a region per 10,000 ZIP-code residents was significantly lower in rural versus urban areas (P = .002). This did not differ significantly between AI reservation/trust land and non-AI reservation/trust land areas (P = .79). DATA-waivered physicians in a region per 10,000 ZIP-code residents was not significantly different between rural and urban (P = .08), or AI reservation/trust land versus non-AI reservation/trust land areas (P = .21).

CONCLUSIONS

It appears that the potential for Washington State residents of rural and AI reservation areas to receive OAT is similar to that of residents outside of those areas; however, difficulties in accessing therapy may remain, highlighting the importance of expanding health care insurance and providing support for DATA-waivered physicians.

Rural substance use treatment centers in the United States: an assessment of treatment quality by location

BACKGROUND

While previous research has added to the understanding of rural residents' unique health challenges, much remains to be learned about the provision of substance use disorder (SUD) treatment in rural areas. A key question is difference in structural resources and quality of care between rural and urban treatment centers.

OBJECTIVE

To examine differences in treatment quality in rural and urban centers and to determine if differences in treatment quality are contextualized by centers' structural resources.

METHODS

Utilizing combined data from two representative samples of SUD treatment centers (n = 591), we used a series of multivariate regressions to analyze the association between center rurality and various indicators of structural characteristics and treatment quality. Interaction effects were further examined between structural characteristics and treatment quality indicators.

RESULTS

We found that structural and quality differences between rural and urban treatment centers were present. Rural centers had reduced access to highly educated counselors, were more likely to be non-profit and dependent on public funding, offered fewer wraparound services, and had less diverse specialized treatment options. Our results also indicated that rural centers were less likely to prescribe buprenorphine as part of their treatment but were more likely to employ nursing staff and offer specialized treatment for adolescents. Rural center access to a physician contextualized the association between center rurality and the more limited provision of wraparound services.

CONCLUSION

Our findings suggest that treatment quality differs between urban and rural centers in complex ways that are subject to resource availability.

Understanding Treatment Gaps for Mental Health, Alcohol, and Drug Use in South Dakota: A Qualitative Study of Rural Perspectives

PURPOSE

More than 25% of US adults experience mental health or substance use conditions annually, yet less than half receive treatment. This study explored how rural participants with behavioral health conditions pursue and receive care, and it examined how these factors differed across American Indian (AI) and geographic subpopulations.

METHODS

We undertook a qualitative follow-up study from a statewide survey of unmet mental health and substance use needs in South Dakota. We conducted semistructured phone interviews with a purposive sample of key informants with varying perceptions of need for mental health and substance use treatment.

RESULTS

We interviewed 33 participants with mental health (n = 18), substance use (n = 9), and co-occurring disorders (n = 6). Twenty participants (61.0%) lived in rural communities that did not overlap with AI tribal land. Twelve participants (34.3%) were AI, 8 of whom lived on a reservation (24.2%). The discrepancy between actual and perceived treatment need was related to how participants defined mental health, alcohol, and drug use "problems." Mental health disorders and excessive alcohol consumption were seen as a normal part of life in rural and reservation communities; seeking mental health care or maintaining sobriety was viewed as the result of an individual's willpower and frequently related to a substantial life event (eg, childbirth). Participants recommended treatment gaps be addressed through multicomponent community-level interventions.

DISCUSSION

This study describes how rural populations view mental health, alcohol, and drug use. Enhancing access to care, addressing discordant perceptions, and improving community-based interventions may increase treatment uptake.

Disparities in Alcohol, Drug Use, and Mental Health Condition Prevalence and Access to Care in Rural, Isolated, and Reservation Areas: Findings From the South Dakota Health Survey

PURPOSE

Research on urban/rural disparities in alcohol, drug use, and mental health (ADM) conditions is inconsistent. This study describes ADM condition prevalence and access to care across diverse geographies in a predominantly rural state.

METHODS

Multimodal cross-sectional survey in South Dakota from November 2013 to October 2014, with oversampling in rural areas and American Indian reservations. Measures assessed demographic characteristics, ADM condition prevalence using clinical screenings and participant self-report, perceived need for treatment, health service usage, and barriers to obtaining care. We tested for differences among urban, rural, isolated, and reservation geographic areas, controlling for participant age and gender.

FINDINGS

We analyzed 7,675 surveys (48% response rate). Generally, ADM condition prevalence rates were not significantly different across geographies. However, respondents in isolated and reservation areas were significantly less likely to have access to primary care. Knowledge of treatment options was significantly lower in isolated regions and individuals in reservation areas had significantly lower odds of reporting receipt of all needed care. Across the sample there was substantial discordance between ADM clinical screenings and participant self-reported need; 98.1% of respondents who screened positive for alcohol or drug misuse and 63.8% of respondents who screened positive for a mental health condition did not perceive a need for care.

CONCLUSION

In a predominantly rural state, geographic disparities in ADM conditions are related to differences in access as opposed to prevalence, particularly for individuals in isolated and reservation areas. Educational interventions about ADM condition characteristics may be as important as improving access to care.

Factors Associated with Recidivism among Corrections-Based Treatment Participants in Rural and Urban Areas

The majority of corrections-based treatment outcome studies focus on individuals paroling to urban areas; thus there is a significant gap in the literature on outcomes, including recidivism, among individuals paroling to non-urban and rural communities. This study examines differences in factors associated with recidivism among former corrections-based treatment participants living in urban and rural communities following release. Analyses focused on secondary data collected from treatment participants in one southeastern state over a four year period between July 2006 and June 2010 including both baseline (treatment intake) and follow-up data (12-months post-release). Findings indicated that individuals in urban areas were 2.4 times more likely to recidivate than rural individuals. Other factors identified in separate rural and urban analyses also emerged as significant predictors in the overall model including age, gender, race, employment and drug use. Overall, these findings suggest that corrections-based treatment participants living in urban and rural areas following release may share similar risk factors for recidivism. However, rural areas may be protective for returning to custody despite the presence of some of these risks.

Barriers and Facilitators to Substance Use Treatment in the Rural South: A Qualitative Study

PURPOSE

Little qualitative research has examined factors associated with care in substance abuse treatment agencies in Southeastern rural communities. This study explored client- and agency stakeholder-perceived barriers and facilitators to substance use treatment delivery in southeastern rural communities.

METHODS

Group and individual interviews were conducted with 40 key stakeholders and 40 clients at 9 substance abuse agencies serving rural communities in a southeastern state. Qualitative thematic analysis was used to identify perceived barriers and facilitators to substance abuse services in rural communities.

FINDINGS

Four primary themes emerged from the client and stakeholder interviews as both barriers and facilitators: availability of services for individuals with substance use disorders; access to the current technology for client services and agency functioning; cost of services; and stigma.

CONCLUSIONS

This study identifies novel barriers and facilitators to substance use care in the rural South and highlights essential areas for consideration when developing and implementing substance use care in this geographic region. These findings can be used as guidelines to provide better care to individuals with substance use disorders living in rural communities.

The Effectiveness of Group Assertiveness Training on Happiness in Rural Adolescent Females With Substance Abusing Parents

Background:

Parental substance abuse confronts children with a variety of psychological, social, and behavioral problems. Children of substance abusing parents show higher levels of psychiatric disorders including anxiety and depression and exert lower levels of communication skills. Weak social skills in this group of adolescents put them at a higher risk for substance abuse. Many studies showed school based interventions such as life skill training can effective on future substance abusing in these high risk adolescences.

Materials and Methods:

The participants consisted of 57 middles schools girls, all living in rural areas and having both parents with substance dependency. The participants were randomly assigned to intervention (n=28) and control (n=29) groups. The data were collected before and six weeks after training in both group. The intervention group received eight sessions of group assertiveness training. Participants were compared in terms of changes in scores on the Oxford Happiness Questionnaire and the Gambrills-Richey Assertion Inventory.

Results:

The total score for happiness change from 43.68 ±17.62 to 51.57 ±16.35 and assertiveness score changed from 110.33±16.05 to 90.40±12.84. There was a significant difference in pretest-posttest change in scores for intervention (7.89±4.13) and control (-2.51±2.64) groups; t (55) =2.15, p = 0.049. These results suggest that intervention really does have an effect on happiness and assertiveness.

Conclusion:

Determining the effectiveness of these school based interventions on other life aspects such as substance abuse calls for further study on these rural adolescent girls.

Correlates of HIV testing among rural African American cocaine users

Andersen's Revised Behavioral Model of Health Services Use (RBM) was used as a framework in this correlational cross-sectional study to examine factors associated with HIV testing among a sample of 251 rural African American cocaine users. All participants reported using cocaine and being sexually active within the past 30 days. Independent variables were categorized according to the RBM as predisposing, enabling, need, or health behavior factors. Number of times tested for HIV (never, one time, two to four times, five or more times) was the outcome of interest. In ordered logistic regression analyses, HIV testing was strongly associated with being female, of younger age (predisposing factors); having been tested for sexually transmitted diseases or hepatitis, ever having been incarcerated in jail or prison (enabling factors); and having had one sex partner the past 30 days (health behavior factor). Other sexual risk behaviors, drug use, health status, and perception of risk were not associated with HIV testing. Our findings confirm the importance of routine testing in all healthcare settings rather than risk-based testing.

African American cocaine users' preferred treatment site: variations by rural/urban residence, stigma, and treatment effectiveness

To encourage access, policy makers and providers need information about variations in drug users' treatment preferences. This study examined how rural/urban residence, stigma surrounding drug use, and perceived treatment availability and effectiveness are associated with African American cocaine users' preferences for the site of treatment (local, or in one's home town; nearby, or in a town nearby; and distant, or in a town farther away). Two hundred rural and 200 urban cocaine users were recruited using respondent-driven sampling and completed in-person interviews. Multinomial logit regression analyses were conducted to estimate the relative odds of preferring local vs. nearby and local vs. distant treatment. Rural cocaine users preferred distant (58%), and urban users preferred local (57%) treatment. Rural residence and a lifetime history of treatment were associated with higher odds of preferring nearby vs. local treatment; older age and greater perceived local treatment effectiveness were associated with lower odds of preferring nearby vs. local treatment. Rural residence, access to an automobile, higher rejection/discrimination stigma scores, and higher Brief Symptom Inventory-Global Severity Index scores were associated with higher odds of preferring distant vs. local treatment; older age, lower educational attainment, and greater perceived discrimination after treatment were associated with lower odds of preferring distant vs. local treatment. The findings from this study suggest that a regional approach to organizing drug use treatment services could better satisfy the preferences of rural African American cocaine users, whereas local treatment services should be expanded to meet the needs of urban cocaine users.

Rural/urban residence, access, and perceived need for treatment among African American cocaine users

OBJECTIVE

To examine how rural/urban residence, perceived access, and other factors impede or facilitate perceived need for drug use treatment, a concept closely linked to treatment utilization.

STUDY DESIGN

Two hundred rural and 200 urban African American cocaine users who were not receiving treatment were recruited via Respondent-Driven Sampling and completed a structured in-person interview. Bivariate and multivariate analyses were conducted to test the associations between perceived need and rural/urban residence, perceived access, and other predisposing (eg, demographics), enabling (eg, insurance), and health factors (eg, psychiatric distress).

PRINCIPAL FINDINGS

In bivariate analyses, rural relative to urban cocaine users reported lower perceived treatment need (37% vs 48%), availability, affordability, overall ease of access, and effectiveness, as well as lower perceived acceptability of residential, outpatient, self-help, and hospital-based services. In multivariate analyses, there was a significant interaction between rural/urban residence and the acceptability of religious counseling. At the highest level of acceptability, rural users had lower odds of perceived need (OR = 0.21); at the lowest level, rural users had higher odds of perceived need (OR = 3.97) than urban users. Among rural users, the acceptability of religious counseling was negatively associated with perceived need (OR = 0.65). Ease of access was negatively associated (OR = 0.71) whereas local treatment effectiveness (OR = 1.47) and the acceptability of hospital-based treatment (OR = 1.29) were positively associated with perceived need among all users.

CONCLUSIONS

Our findings suggest rural/urban disparities in perceived need and access to drug use treatment. Among rural and urban cocaine users, improving perceptions of treatment effectiveness and expanding hospital-based services could promote treatment seeking.

Cognitive-behavioral therapy in depressed primary care patients with co-occurring problematic alcohol use: effect of telephone-administered vs. face-to-face treatment-a secondary analysis

This secondary analysis of a larger study compared adherence to telephone-administered cognitive-behavioral therapy (T-CBT) vs. face-to-face CBT and depression outcomes in depressed primary care patients with co-occurring problematic alcohol use. To our knowledge, T-CBT has never been directly compared to face-to-face CBT in such a sample of primary care patients. Participants were randomized in a 1:1 ratio to face-to-face CBT or T-CBT for depression. Participants receiving T-CBT (n = 50) and face-to-face CBT (n = 53) were compared at baseline, end of treatment (week 18), and three-month and six-month follow-ups. Face-to-face CBT and T-CBT groups did not significantly differ in age, sex, ethnicity, marital status, educational level, severity of depression, antidepressant use, and total score on the Alcohol Use Disorders Identification Test. Face-to-face CBT and T-CBT groups were similar on all treatment adherence outcomes and depression outcomes at all time points. T-CBT and face-to-face CBT had similar treatment adherence and efficacy for the treatment of depression in depressed primary care patients with co-occurring problematic alcohol use. When targeting patients who might have difficulties in accessing care, primary care clinicians may consider both types of CBT delivery when treating depression in patients with co-occurring problematic alcohol use.

Treatment outcomes for prescription drug misusers: the negative effect of geographic discordance

This is the first known study to examine geographic discordance (traveling from one's home residence to a county with a different socio-cultural context to receive substance abuse treatment) as a predictor of clinical and social functioning treatment outcomes (i.e., relapse, self-help attendance, anxiety, and incarceration) among a sample of prescription drug misusers. Treatment entry and 12-month follow-up client-level survey data were collected from 187 clients who misused prescription drugs, and center-level survey data were collected from the supervisors at treatment centers attended by the clients. Multivariate models reveal that geographic discordance significantly increased the odds that prescription drug misusers would report relapse to prescription opioid misuse, anxiety, and any incarceration at follow-up. Moreover, geographically discordant clients were significantly less likely to have attended a self-help group, net of the effect of other individual- and center-level factors. Implications for clinical practice and substance abuse treatment policy are provided.

Barriers to substance abuse treatment in rural and urban communities: counselor perspectives

The purpose of this study is to compare rural and urban substance abuse counselors' perceptions of barriers to providing effective treatment services. Data were collected from 28 substance abuse counselors in Kentucky during four focus group sessions in 2008. Line-by-line coding and memoing were used by two raters on the transcribed data to isolate findings. The results of this study suggest that, though rural and urban counselors encounter similar constraints that hamper successful treatment outcomes, rural counselors are subject to special circumstances within their communities that present unique challenges to treatment efficacy. Novel contributions, implications, and limitations are also discussed.

Effectiveness of A-CRA/ACC in treating adolescents with cannabis-use disorders

An evidence-based treatment for adolescent cannabis users, Adolescent Community Reinforcement Approach with Assertive Continuing Care, was implemented in a rural county and small city in the USA. A total of 147 adolescents, ages 12-18, were enrolled and assessed at baseline and three time points: 3, 6, and 12 months using the Global Appraisal of Individual Needs and related measures. Program effectiveness was confirmed. The treatment was equally effective for youth from the city versus the county. More than two-thirds (68.7%) of the adolescents reported quitting use of cannabis by 12 months. The days of cannabis use in the last 90 days decreased significantly from the first follow-up, controlling for age (p value < .01), and shows consistent decline until the end of the treatment. In addition to reduction in substance use, the average number of days missing school and expelled from school decreased significantly from baseline to the end of the treatment.

Risky sex in rural America: longitudinal changes in a community-based cohort of methamphetamine and cocaine users

BACKGROUND AND OBJECTIVES

This study examined the longitudinal associations between stimulant use and sexual behaviors.

METHODS

Data are from a 3-year community-based study of 710 rural stimulant users. Past 30-day crack cocaine, powder cocaine, and methamphetamine use and sexual behaviors (any sex, inconsistent condom use, and multiple sexual partners) were assessed through in-person interviews every 6 months.

RESULTS

GEE analyses revealed that the odds of having sex remained steady over time, with crack cocaine and methamphetamine use positively associated with having sex. The odds of multiple sexual partners declined, but the odds of inconsistent condom use remained steady over time. Crack cocaine use was positively associated with multiple sexual partners, whereas powder cocaine use was negatively associated with inconsistent condom use.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Many rural stimulant users could potentially benefit from safe sex educational programs. Such efforts could reduce the incidence of HIV and other STIs in rural America.

A qualitative analysis of provider barriers and solutions to HIV testing for substance users in a small, largely rural southern state

PURPOSE

Integrating HIV testing programs into substance use treatment is a promising avenue to help increase access to HIV testing for rural drug users. Yet few outpatient substance abuse treatment facilities in the United States provide HIV testing. The purpose of this study was to identify barriers to incorporating HIV testing with substance use treatment from the perspectives of treatment and testing providers in Arkansas.

METHODS

We used purposive sampling from state directories to recruit providers at state, organization, and individual levels to participate in this exploratory study. Using an interview guide, the first and second authors conducted semistructured individual interviews in each provider's office or by telephone. All interviews were recorded, transcribed verbatim, and entered into ATLAS.ti software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). We used constant comparison and content analysis techniques to identify codes, categories, and primary patterns in the data.

FINDINGS

The sample consisted of 28 providers throughout the state, 18 from the substance use system and 10 from the public/ community health system. We identified 7 categories of barriers: environmental constraints, policy constraints, funding constraints, organizational structure, limited inter- and intra-agency communication, burden of responsibility, and client fragility.

CONCLUSIONS

This study presents the practice-based realities of barriers to integrating HIV testing with substance use treatment in a small, largely rural state. Some system and/or organization leaders were either unaware of or not actively pursuing external funds available to them specifically for engaging substance users in HIV testing. However, funding does not address the system-level need for coordination of resources and services at the state level.

Prevalence and correlates for nonmedical use of prescription opioids among urban and rural residents

BACKGROUND

In the United States, rural areas have reported an increase in overdose deaths secondary to nonmedical use of prescription opioids. Little is known about the differences in nonmedical use of prescription opioids among urban and rural adults.

METHODS

Using the 2008-2009 National Survey on Drug Use and Health, we examined the prevalence of nonmedical use of prescription opioids in urban and rural counties and determined bivariate and multivariate associations, stratified by county. We also compared type of opioids, stratified by county.

RESULTS

Among 75,964 respondents, the prevalence of nonmedical use of prescriptions opioids was similar among residents in urban and rural counties (4.7% vs. 4.3%, p=0.15). Urban and rural residents with severe psychological distress and nonmedical use of other prescription medications were more likely to report nonmedical use of opioids. Urban residents whose first use of illicit drugs was between the age of 18 and 25 and who reported alcohol use were more likely to report nonmedical use. Black and Hispanic urban residents were less likely to use prescription opioids nonmedically compared to white urban residents. Rural residents were more likely than urban residents to use acetaminophen with propoxyphene (61.1% vs. 55.8%, p=0.02), methadone (14.8% vs. 9.1%, p=0.003) and acetaminophen with codeine (3.5% vs. 1.9%, p=0.05).

CONCLUSIONS

Prevalence and risk factors related to nonmedical use of opioids are similar between urban and rural residents; however rural residents report propoxyphene, codeine, and methadone use more than their urban counterparts. Prevention and treatment interventions may need to be tailored for specific communities.

Physical victimization of rural methamphetamine and cocaine users

Substance use and physical violence often coincide, but little has been published on the correlates associated with receipt of partner versus nonpartner physical violence for rural users of methamphetamine and/or cocaine. In this study, participants' substance use, depression and past-year physical victimization were assessed. In separate logistic regression models, received partner violence in females was associated with age; alcohol, cocaine, and methamphetamine abuse/dependence; and number of drugs used in the past 6 months. In males, received nonpartner violence was associated with age, cocaine abuse/dependence, and being Caucasian. Findings suggest a relationship between stimulant use and received violence among rural substance users and a need for victimization screenings in settings where such individuals seek health care.

Trajectories in use of substance abuse and mental health services among stimulant users in rural areas

OBJECTIVE

This study examined substance abuse and mental health service utilization during a three-year period among stimulant users living in rural areas.

METHODS

Participants (N=710) were interviewed at baseline and every six months for 36 months. One-step transition probabilities were constructed between the two types of service use for each consecutive pair of interviews to examine the resulting steady-state probabilities among multiple one-step transition matrices.

RESULTS

Most participants received no substance abuse or mental health services. On average, the probabilities of reporting use of the same types of services during the 36-month follow-up were 82% for receiving neither service, 9% for receiving only mental health treatment, 6% for receiving only substance abuse treatment, and 2% for receiving both services.

CONCLUSIONS

Further study is needed to determine factors that affect the decision to seek mental health or substance abuse treatment among residents of rural communities.

Distance traveled and cross-state commuting to opioid treatment programs in the United States

This study examined commuting patterns among 23,141 methadone patients enrolling in 84 opioid treatment programs (OTPs) in the United States. Patients completed an anonymous one-page survey. A linear mixed model analysis was used to predict distance traveled to the OTP. More than half (60%) the patients traveled < 10 miles and 6% travelled between 50 and 200 miles to attend an OTP; 8% travelled across a state border to attend an OTP. In the multivariate model (n = 17,792), factors significantly (P < .05) associated with distance were, residing in the Southeast or Midwest, low urbanicity, area of the patient's ZIP code, younger age, non-Hispanic white race/ethnicity, prescription opioid abuse, and no heroin use. A significant number of OTP patients travel considerable distances to access treatment. To reduce obstacles to OTP access, policy makers and treatment providers should be alert to patients' commuting patterns and to factors associated with them.

Outcomes following Prison and Jail-Based Treatment among Women Residing in Metro and Non-Metro Communities following Release

This study uses data from the Criminal Justice Kentucky Treatment Outcome Study (CJKTOS) to describe treatment outcomes following prison and jail-based treatment among women residing in metro and non-metro areas following release. The study takes an exploratory look at potential differences in sustained abstinence, community treatment utilization, and recidivism by geographic location (metro/non-metro) and treatment program (jail or prison). Baseline data was collected from women as they entered two prison and two jail-based treatment programs, and follow-up data was collected 12 months post-release in the community. Bivariate group differences were noted with a higher percentage of metro women who participated in prison-based treatment relapsing to cocaine use during the follow-up period compared to non-metro women. In multivariate models, females who participated in jail-based treatment and prison-based treatment fared similarly on study outcomes. There was, however a main effect of residence status in that women living in non-metro areas during the follow-up period were less likely to utilize community-based aftercare treatment and less likely to be re-incarcerated during the follow-up period than women living in metro areas. Findings are discussed with regard to future research and practice implications for women offenders transitioning to geographically different communities following release.