Rural and Appalachian Disparities in Neonatal Abstinence Syndrome Incidence and Access to Opioid Abuse Treatment

County-level neonatal opioid withdrawal syndrome rates and real-world access to buprenorphine during pregnancy: An audit ("secret shopper") study in Missouri

Background

Amid rising rates of neonatal opioid withdrawal syndrome (NOWS) worldwide and in many regions of the USA, we conducted an audit study ("secret shopper study") to evaluate the influence of county-level buprenorphine capacity and rurality on county-level NOWS rates.

Methods

In 2019, up to three phone calls were made to buprenorphine prescribers in the state of Missouri (USA). County-level buprenorphine capacity was defined as the number of clinicians (across all specialties) accepting pregnant people divided by the number of births. Multivariable negative binomial regression models estimated associations between buprenorphine capacity, rurality, and county-level NOWS rates, controlling for potential confounders (i.e., poverty, unemployment, and physician shortages) that may correspond to higher rates of NOWS and lower rates of buprenorphine prescribing. Analyses were stratified using tertiles of county-level overdose rates (top, middle, and lowest 1/3 of overdose rates).

Results

Of 115 Missouri counties, 81(70 %) had no buprenorphine capacity, 17(15 %) were low-capacity (<0.5-clinicians/1,000 births), and 17(15 %) were high-capacity (≥0.5/1,000 births). The mean NOWS rate was 6.5/1,000 births. In Missouri counties with both the highest and lowest opioid overdose rates, higher buprenorphine capacity did not correspond to decreases in NOWS rates (incidence rate ratio[IRR]=1.23[95 %-confidence-interval[CI]=0.65-2.32] and IRR=1.57[1.21-2.03] respectively). Rurality did not correspond to greater NOWS burden in both Missouri counties with highest and lowest opioid overdose rates.

Conclusions

The vast majority of counties in Missouri have no capacity for buprenorphine prescribing during pregnancy. Rurality and lower buprenorphine capacity did not significantly predict elevated rates of NOWS.

A case-control study comparing rates and diagnoses of hospital readmission in infants affected by neonatal abstinence syndrome

OBJECTIVE

Rates of neonatal abstinence syndrome/neonatal opioid withdrawal syndrome (NAS/NOWS), a withdrawal syndrome from opioids and other substances resulting from intrauterine exposure, have been increasing exponentially in the U.S. To improve health outcomes, it is important to understand population health risks, including rehospitalization and related diagnoses, using current data. This study will compare and describe the rates of rehospitalization, the demographic characteristics and the rehospitalization diagnoses and age at diagnosis between the infants affected by NAS/NOWS to those sampled who were unaffected. This study will also describe the frequency of NAS/NOWS births per year along with a yearly comparison of readmissions in those affected by NAS/NOWS to those who were not (2016-2020).

METHODS

Health claims data were used to conduct a case/control study. Diagnosis codes for neonatal withdrawal syndrome/NAS/NOWS (P04.49 or P96.1 and P96.1 alone) from 1 October 2015 to 1 June 2021 were extracted, and controls were case-matched based on month/year of birth. Rehospitalizations following birth and the related diagnoses were described and grouped using the Agency of Healthcare Research Quality Clinical Classifications Software Refined Frequency distribution. The chi-square test of association and generalized estimating equation modeling were used for data analysis.

RESULTS

Infants affected by NAS/NOWS are 2.7 times more likely to have a rehospitalization. White, non-Hispanic neonates (OR = 1.5; p = .007) and those infants residing in rural areas (OR = 1.9; p < .001) were disproportionately affected. We identified a host of admission diagnoses with increased prevalence in infants affected by NAS/NOWS when compared to those who were not affected (e.g. infectious diseases, feeding disorders).

CONCLUSIONS

Infants with NAS/NOWS are at increased risk of rehospitalization with a host of diagnoses, and specific demographic groups (White, rural) are more highly affected.

Recent and lifetime maternal substance use: Rurality and economic distress

Research on opioid use disorder (OUD) in pregnancy has mainly considered women in urban areas receiving treatment, with less known about women in rural areas. We sought to describe demographics and substance use characteristics of pregnant women with OUD and to compare the women based on urbanicity, in a state (Kentucky) with unfavorable economic conditions in many rural counties; we hypothesized that pregnant women in rural areas would have greater adversity, broadly defined, related to substance use. Using data collected from a larger project between 2017 and 2020, we analyzed characteristics of 93 pregnant women (59 rural and 34 urban) with OUD; we examined data in medical, employment, substance use, legal, family history, relationship, and psychiatric health domains, both overall and within rural (population <50,000) and urban (population ≥50,000) strata. Pregnant women with OUD from rural and urban areas were similar on almost all attributes. Among the few significant differences, 30% from urban areas perceived inadequate prenatal care versus 11% from rural areas (p = 0.024); 21% of urban women used amphetamines/methamphetamines in the month before delivery versus 0% of rural women (p < 0.001); and rural women had longer most recent abstinence from substance use than their urban counterparts (medians 7.0 and 2.8 months, p = 0.049). The few significant differences that were discovered favored rural women. These findings, contrary to our hypothesis, suggest that tailoring interventions may require more than focusing on geography. The participants in this study were pregnant women being treated for OUD, and as such there is patient contribution of data.

Inequities in the treatment of opioid use disorder: A scoping review

BACKGROUND

Given the lack of access to evidenced-based OUD treatment and the corresponding overdose crisis, researchers must evaluate and report health care inequities involving the treatment of OUD. Additionally, clinicians should be aware of these inequities in the treatment of patients.

METHODS

We carried out a scoping review of the literature regarding health inequities in treatment for OUD in July 2022. The study team retrieved articles published between 2016 and 2021 from MEDLINE and Ovid Embase. After authors received training, screening and data extraction were performed in masked, duplicate fashion. The team screened a total of 3673 titles and abstracts, followed by 172 articles for full-text review. The inequities that we examined were race/ethnicity, sex or gender, income, under-resourced/rural, occupational status, education level, and LGBTQ+. We used Stata 17.0 (StataCorp, LLC, College Station, TX) to summarize data and statistics of the studies within our sample.

RESULTS

A total of 44 studies evaluating inequities in OUD treatment met inclusion criteria. The most common inequity that studies examined was race/ethnicity (34/44 [77.27 %] studies), followed by under-resourced/rural (19/44 [43.18 %] studies), and sex or gender (18/44 [40.91 %] studies). LGBTQ+ (0/44 [0.0 %] studies) was not reported in the included studies. Our results indicate that many historically marginalized populations experience inequities related to access and outcomes in OUD treatment. The included studies in our scoping review occasionally demonstrated inconsistent findings.

CONCLUSIONS

Gaps exist within the literature on health inequities in treatment for OUD. The most examined inequities were race/ethnicity, under-resourced/rural and sex or gender, while studies did not examine LGBTQ+ status. Future research should aim to advance and supplement literature investigating health inequities in OUD treatment to ensure inclusive, patient-centered care.

Early Identification of Atypical Motor Performance of Infants With Prenatal Opioid Exposure

PURPOSE

To investigate the association between prenatal opioid exposure (POE) and newborn infants' motor performance to aid in the early identification of developmental delays.

METHODS

Nineteen infants with POE requiring pharmacological treatment, 27 infants with POE without pharmacological treatment, and 25 infants without POE were assessed via the Test of Infant Motor Performance (TIMP).

RESULTS

Infants in both groups with POE had lower TIMP scores than infants without POE. There was no difference between the TIMP scores of infants with POE who required pharmacological treatment and infants with POE who did not require pharmacological treatment.

CONCLUSIONS

The TIMP can detect differences in motor performance of infants with POE. Regardless of whether infants required pharmacological treatment, POE was associated with lower motor performance. Those working in hospital or early intervention settings can use the TIMP to identify early delays in infants with POE and refer for intervention.

Breastfeeding Experiences in Women from Ten States Reporting Opioid Use Before or During Pregnancy: PRAMS, Phase 8

INTRODUCTION

Evidence of opioid use at hospital delivery has increased over the past two decades, increasing risk of neonatal withdrawal. Breastfeeding may improve infant outcomes, but little is known about breastfeeding experiences of women who have a history of opioid use prior to or during pregnancy. This study aimed to determine if self-reported opioid use prior to or during pregnancy impacted breastfeeding, specifically attempt to breastfeed, duration of breastfeeding, assessment of prenatal breastfeeding intention, source of breastfeeding information, and early hospital experiences.

METHODS

Data from ten states (n = 10,550) that evaluated opioid use in the 2016 Pregnancy Risk Assessment Monitoring System survey were included. Weighted univariate and multivariate linear and logistic regression were calculated. The multivariate regression also included adjustment for covariates.

RESULTS

Among the overall sample, 939 participants reported opioid exposure before or during pregnancy. We found no significant difference in breastfeeding attempt. Breastfeeding for at least 6, 10, or 20 weeks was significantly less likely in participants reporting opioid exposure. Exposure correlated with lower odds of skin-to-skin contact, infant being fed in the first hour, exclusive breastfeeding in the hospital, and feeding on demand. Hospital pacifier use was associated with opioid exposure.

CONCLUSION

While we found no difference in breastfeeding attempt, we did observe significant differences in breastfeeding duration and early hospital experiences which may represent modifiable gaps in clinical practice. Future work should focus on optimizing early hospital experiences and support when breastfeeding is clinically indicated.

Access to tablet injectable opioid agonist therapy in rural and smaller urban settings in British Columbia, Canada: a qualitative study

BACKGROUND

Rural and smaller urban settings in Canada are disproportionately impacted by the overdose crisis, highlighting the need for novel public health interventions within these jurisdictions. Tablet injectable opioid agonist therapy (TiOAT) programs have been implemented in select rural communities as a means to address drug-related harms. However, little is known about the accessibility of these novel programs. Therefore, we conducted this study to understand the rural context and factors that affected access of TiOAT programs.

METHODS

Between October 2021 to April 2022, individual qualitative semi-structured interviews were conducted with 32 individuals enrolled in a TiOAT program at participating rural and smaller urban sites in British Columbia, Canada. Interview transcripts were coded using NVivo 12 and data were analyzed thematically.

RESULTS

TiOAT access varied considerably. TiOAT delivery in rural settings is complicated due to geographic challenges. Participants who were homeless and staying at a nearby shelter or those in centrally-located supportive housing had minimal issues compared to those living in more affordable housing on the outskirts of town with limited transportation options. Dispensing policies that required daily-witnessed ingestion multiple times daily were challenging for most. Only one site provided evening take-home doses whereas participants at the other site could only resort to the illicit opioid supply to address withdrawal outside of program hours. Participants described the clinics as providing a positive and familial social environment compared to experiences of stigma elsewhere. Medication interruptions did occur when participants were in hospital and custodial settings, leading to withdrawal, program discontinuation, and overdose risk.

CONCLUSIONS

This study highlights the beneficial ways in which health services tailored for people who use drugs can create a stigma-free environment with an emphasis on social bonds. Other factors such as transportation access, dispensing policies, and access in rural hospitals and custodial settings produced unique challenges for rural people who use drugs. Public health authorities in rural and smaller settings should consider these factors when designing, implementing, and scaling up future substance use services, including TiOAT programs.

Comparison of Nonprofit Hospital Community Benefit Substance Abuse Identification and Practice Implementation in Appalachian and Non-Appalachian Counties

CONTEXT

As substance use continues to be a public health crisis nationally, it disproportionately affects the Appalachian region.

OBJECTIVES

Our research seeks to explore whether there is a greater substance use burden in Appalachia and whether that burden is being prioritized in local hospital systems' community health needs assessments (CHNAs) and implementation strategies (ISs).

SETTING

The setting for this study is the 13 states that are represented within the Appalachian region.

PARTICIPANTS

This study examines CHNAs and ISs of a stratified random sample (n = 140) representing 20% of the hospital population within the identified states (those with counties within the Appalachian region). Each sampled hospital is labeled as Appalachian or non-Appalachian based on its county designation.

MAIN OUTCOME MEASURES

Our main outcome measures were the percentage of hospitals listing substance abuse in their CHNAs, with comparisons between Appalachian and non-Appalachian subgroups, and percent addressing substance use in their ISs in Appalachia and non-Appalachia.

DESIGN

Community health needs assessments and ISs produced between the years 2018 and 2021 were gathered for each hospital within the sample; each document was then coded for the inclusion of substance use. Chi-square tests and logistic regression were employed to conduct the analysis and draw conclusions.

RESULTS

Although all non-Appalachian Counties that had substance use listed as a need within a CHNA correspondingly addressed that need in their ISs, only 75% of Appalachian counties that listed substance use a need went on to prioritize substance use in an IS. In addition, logistic regression indicated no significant link between overdose rates and addressing substance use.

CONCLUSIONS

These findings further support other literature that suggests that lack of resources is limiting Appalachian health care organizations' ability to address substance use issues.

How the rural risk environment underpins hepatitis C risk: Qualitative findings from rural southern Illinois, United States

BACKGROUND

Hepatitis C virus (HCV) infection has increased among persons who inject drugs (PWID) in the United States with disproportionate burden in rural areas. We use the Risk Environment framework to explore potential economic, physical, social, and political determinants of hepatitis C in rural southern Illinois.

METHODS

Nineteen in-depth semi-structured interviews were conducted with PWID from August 2019 through February 2020 (i.e., pre-COVID-19 pandemic) and four with key informants who professionally worked with PWID. Interviews were recorded, professionally transcribed, and coded using qualitative software. We followed a grounded theory approach for coding and analyses.

RESULTS

We identify economic, physical, policy, and social factors that may influence HCV transmission risk and serve as barriers to HCV care. Economic instability and lack of economic opportunities, a lack of physically available HCV prevention and treatment services, structural stigma such as policies that criminalize drug use, and social stigma emerged in interviews as potential risks for transmission and barriers to care.

CONCLUSION

The rural risk environment framework acknowledges the importance of community and structural factors that influence HCV infection and other disease transmission and care. We find that larger structural factors produce vulnerabilities and reduce access to resources, which negatively impact hepatitis C disease outcomes.

Averting neonatal abstinence syndrome and treating addiction among rural, opioid-using young women

BACKGROUND AND OBJECTIVES

America's opioid epidemic has spawned an epidemic of neonatal abstinence syndrome (NAS). Studies have not tested approaches to promoting contraceptive services for women with opioid use disorder (OUD) along with treatment for this disorder. This pilot study examined the promotion of medication for OUD (MOUD) treatment and contraception use, primarily long-acting reversible contraception (LARC), for women with OUD.

METHODS

In Appalachia, a peer-delivered contraception and MOUD promotion intervention was delivered to a sample of 30 women with OUD. Primary outcomes were attendance of initial appointments to receive MOUD and counseling about contraceptive options. Peer recovery coaches also offered to help the women schedule appointments and attend the appointment with them or give them a ride if necessary and requested by the patients.

RESULTS

Two-thirds experienced all seven symptoms of opioid dependence. Within 30 days of a brief counseling session, over one-half of the women (56.7%) were referred to MOUD, with all of them initiating treatment within 30 days. Just under one-half of the women (46.7%) were referred to a contraception consultation, with 85.7% of those receiving a LARC implant.

DISCUSSIONS AND CONCLUSIONS

Study findings indicate the potential efficacy of a single-session, peer-delivered counseling intervention for linking women with OUD and at high risk of unintended pregnancy to MOUD and to services that provide women with highly reliable contraceptives.

SCIENTIFIC SIGNIFICANCE

This study is unique in exploring the efficacy of linking high-risk opioid-using women to contraceptive options and treatment for MOUD to prevent NAS.

Cumulative barriers to retention in methadone treatment among adults from rural and small urban communities

Background

Though methadone has been shown to effectively treat opioid use disorder, many barriers prevent individuals from accessing and maintaining treatment. Barriers are prevalent in less populated areas where treatment options are limited. This study examines barriers to retention in methadone treatment in a small Midwest community and identifies factors associated with greater endorsement of barriers.

Methods

Patients at an opioid treatment program (N = 267) were recruited to complete a computer-based survey onsite. Surveys assessed demographics, opioid misuse, depression and anxiety symptoms, trauma history and symptoms, social support, and barriers to retention in treatment (e.g., childcare, work, housing, transportation, legal obligations, cost, health). Descriptive statistics were used to examine individual barriers and multiple regression was calculated to identify demographic and psychosocial factors associated with greater cumulative barriers.

Results

Most participants reported at least one barrier to retention in treatment and more than half reported multiple barriers. Travel hardships and work conflicts were the most highly endorsed barriers. Past year return to use (B = 2.31, p = 0.004) and more severe mental health symptomology (B = 0.20, p = 0.038) were associated with greater cumulative barriers. Greater levels of social support were associated with fewer barriers (B = − 0.23, p < 0.001).

Conclusion

This study adds to the limited research on barriers to retention in methadone treatment among patients in rural and small urban communities. Findings suggest flexible regulations for dispensing methadone, co-location or care coordination, and family or peer support programs may further reduce opioid use and related harms in small communities. Individuals with past year return to use reported a greater number of barriers, highlighting the time following return to use as critical for wraparound services and support. Those with co-occurring mental health issues may be vulnerable to poor treatment outcomes, as evidenced by greater endorsement of barriers. As social support emerged as a protective factor, efforts to strengthen informal support networks should be explored as adjunctive services to methadone treatment.

Perceived Clinical Characteristics of Children With History of Opioid Exposure: A Speech-Language Pathology Perspective

PURPOSE

This research was conducted to describe the clinical characteristics of children with a history of opioid exposure as perceived by the speech-language pathologists (SLPs) treating them.

METHOD

Three focus groups were conducted. Participants consisted of 20 SLPs working in the schools in West Virginia who had experienced working with children with a confirmed or suspected history of opioid exposure. A thematic, qualitative analysis was conducted, whereby focus group sessions were transcribed verbatim and information was coded, organized into themes, and interpreted.

RESULTS

Themes of perceived clinical characteristics (speech, language, executive function, and other developmental delays) are reported to address the research question. Additionally, themes derived from the data regarding perceived significant differentiators (greater severity/needs, inconsistent performance, and atypical manifestation) and perceived confounding characteristics (safety and well-being, aspects of home environment, and effects on school environment) that are often reported in children with a history or suspected history of opioid exposure are presented.

CONCLUSIONS

Perceived clinical characteristics of this population, both intrinsic and situational, highlight the complex profile of this population and demonstrate the importance of considering each child from a multidimensional perspective. Additional research is needed to represent the profile of these children more completely and to identify successful supports that will improve their speech and language outcomes, educational achievement, and their overall quality of life.

Perceptions of Speech-Language Pathologists' Service Provision in the Opioid Epidemic: A Focus Group Study

PURPOSE

This research intended to identify current practices being implemented with children who have a history or suspected history of opioid exposure, as well as challenges faced by speech-language pathologists in the schools.

METHOD

Focus group data from three groups totaling 20 speech-language pathologists (SLPs) working in schools in West Virginia, also used in a previous study, were analyzed using qualitative thematic analysis to better understand SLP service provision to children with a history or suspected history of opioid exposure.

RESULTS

Results revealed two primary themes, reported as (a) service delivery in action (current practice trends and challenges) and (b) affective/cognitive manifestations (uncertainty about their role and various emotions expressed) of the SLPs who participated in the focus groups.

CONCLUSIONS

This study revealed important clinical implications derived from the reports of participants. Particularly, the importance of communication and advocacy in the care of these children and the need to rethink what our scope of practice means when working with this vulnerable population are discussed.

Individual, interpersonal, and neighborhood measures associated with opioid use stigma: Evidence from a nationally representative survey

Despite growing awareness of opioid use disorder (OUD), fatal overdoses and downstream health conditions (e. g., hepatitis C and HIV) continue to rise in some populations. Various interrelated structural forces, together with social and economic determinants, contribute to this ongoing crisis; among these, access to medications for opioid use disorder (MOUD) and stigma towards people with OUD remain understudied. We combined data on methadone, buprenorphine, and naltrexone providers from SAMHSA’s 2019 directory, additional naltrexone providers from Vivitrol’s location finder service, with a nationally representative survey called “The AmeriSpeak survey on stigma toward people with OUD.” Integrating the social-ecological framework, we focus on individual characteristics, personal and family members’ experience with OUD, and spatial access to MOUD at the community level. We use nationally representative survey data from 3008 respondents who completed their survey in 2020. Recognizing that stigma is a multifaceted construct, we also examine how the process varies for different types of stigma, specifically perceived dangerousness and untrustworthiness, as well as social distancing measures under different scenarios. We found a significant association between stigma and spatial access to MOUD — more resources are related to weaker stigma. Respondents had a stronger stigma towards people experiencing current OUD (versus past OUD), and they were more concerned about OUD if the person would marry into their family (versus being their coworkers). Additionally, respondents’ age, sex, education, and personal experience with OUD were also associated with their stigma, and the association can vary depending on the specific type of stigma. Overall, stigma towards people with OUD was associated with both personal experiences and environmental measures.

Suicide Among Women and the Role of Women's Health Care Providers

Importance

Suicide is a leading cause of death in the United States, with increasing rates among women. Women are more likely to experience suicidal ideation and engage in suicide behavior than men, and risk is elevated at key points where they may engage in care with a women's health care provider.

Objective

This review describes the prevalence of and risk factors for suicide among women and highlights the role of obstetrician-gynecologists in suicide prevention.

Evidence Acquisition

A PubMed, MEDLINE, and PsycINFO search was completed for English-language publications about suicide among women, including subtopics (eg, perinatal suicide, suicide during perimenopause).

Results

There are overlapping risk factors that contribute to suicide among women, including intimate partner violence and substance use. Specific groups of women may present with unique risk factors, such as women veterans, women in rural areas, and women with preexisting mental health diagnoses, particularly serious mental illnesses. Some women at risk for suicide are not seen in clinical settings, and thus community interventions may be beneficial. There are roles for obstetrician-gynecologists within and outside of the clinic to prevent suicide.

Conclusions and Relevance

Obstetrician-gynecologists can save lives by being aware of the prevalence of suicide ideation and behavior among women, understanding risk factors for suicide over the lifespan, regularly screening for these factors, asking directly about suicide ideation and intent, and being aware of clinical and community resources. Outside of the clinic, they can advocate for increased health care access and community-based interventions. These efforts can contribute to the reduction of preventable death and maternal mortality.

Development of opioid rapid response system: Protocol for a randomized controlled trial

BACKGROUND

Opioid overdoses require a rapid response, but emergency responders are limited in how quickly they can arrive at the scene for administering naloxone. If laypersons are trained to administer naloxone and are notified of overdoses, more lives can be saved.

OBJECTIVE

This study aimed to examine the feasibility of the Opioid Rapid Response System (ORRS) that recruits, trains, and links citizen responders to overdose events in their community in real-time to administer naloxone. Aim of this paper is to present the protocols for recruiting participants through multiple communication channels; developing and evaluating the online training which has both interactive and asynchronous modules; randomly assigning laypersons to either online naloxone training or waitlist control group; measuring participants' knowledge, skills, and attitudes before and after the training; and distributing intranasal naloxone kits to participants for use in events of overdose in their community.

METHODS

Sampling: Utilizing a combination of purposive sampling methods, laypersons from across five Indiana counties who did not self-identify as current first responders were invited to participate.

DESIGN

In this two-arm randomized waitlist-controlled study (N = 220), individuals were assigned into either online training or waitlist control that received the training two weeks later.

ANALYSIS

A linear mixed model will be used for determining the changes in targeted outcomes in the training group and accommodate for fixed and random effects.

IMPLICATIONS

While ORRS can become a community-engaged, cost-effective model for technology-based emergency response for opioid overdoses, study protocols can be useful for other emergency response programs that involve laypersons.

CLINICALTRIALS

gov Registration Number: NCT04589676.

Medications for Opioid Use Disorder in the Criminal/Legal System: Knowledge, Beliefs, and Attitudes Among Rural Community-Based Stakeholders

The aim of this study was to describe rural community stakeholders’ attitudes and perceptions of providing medication for opioid use disorder (MOUD) to individuals in the criminal/legal system. Data were utilized from a technical assistance initiative aimed at strengthening community-based OUD treatment within criminal/legal systems. A mixed-methods approach was applied. Survey responses were used to compare stakeholders’ who had and had not attended an MOUD training, and semistructured interviews were conducted with a convenience sample of rural criminal/legal and treatment stakeholders. MOUD training was associated with endorsing the effectiveness of methadone, oral naltrexone, and injectable naltrexone. Three primary themes emerged from the stakeholder interviews: 1) acceptance of MOUD uptake; 2) stigma of MOUD and diversion concerns; and 3) gaps in MOUD treatment. Most interviewees noted that there is a scarcity of treatment options in their community, and among the existing services, there are considerable barriers to care.

Impact of in utero opioid exposure on newborn outcomes: beyond neonatal opioid withdrawal syndrome

BACKGROUND AND OBJECTIVES

Research on in utero opioid exposure impacts has focused on Neonatal Opioid Withdrawal Syndrome (NOWS). However, possible impacts on fetal growth and newborn wellbeing have emerged, with inconsistencies likely driven by methodological issues. Our goal was to compare birth outcomes between newborns with prenatal opioid exposure and a matched control group.

METHODS

Participants were identified via manual review of electronic medical records of all deliveries over five years within a regional health system (6 delivery hospitals across 2 states). From over 18,000 births, 300 with prenatal opioid exposure and 300 control newborns matched on exposure, medical, and background factors were included. Additional factors were statistically controlled. Outcomes included pregnancy/delivery complications, newborn size, and newborn health complications.

RESULTS

Compared to biochemically verified controls, exposed newborns had higher rates of fetal growth restriction, weighed less, had decreased length and head circumference, and had higher rates of respiratory distress, sepsis, and jaundice. No significant differences in gestational length, Apgar scores, or neonatal hypoglycemia were found. Adjusted regression analyses revealed that compared to controls, those exposed had an average 150 g decrease in birth weight, a two-fold increased risk for IUGR (OR = 2.09), a nearly three-fold (OR = 2.80) increased risk for jaundice, a more than seven-fold (OR = 7.40) increased risk for respiratory distress, and a thirty-fold (OR = 30.47) increased risk for sepsis.

CONCLUSIONS

Results suggest significant pregnancy and newborn outcomes beyond NOWS following pregnancy opioid use, informing clinical screening and treatment decisions to enhance health and wellbeing in pregnancy, during the neonatal period, and beyond.

Attitudes, self-efficacy, and practices related to opioid risk assessment and mitigation: A comparison of health care professionals in rural communities

Background: Health care professionals (HCPs) play an important role in opioid misuse and opioid use disorder (OUD) screening/identification, mitigation, and referral to treatment. This study compared attitudes, self-efficacy, and practices related to opioid risk assessment and mitigation among pregnancy and non-pregnancy HCPs in rural communities. Methods: We conducted a secondary analysis of cross-sectional, self-report survey data of HCPs in two rural counties in southern Utah. Pregnancy HCPs were identified by a question asking whether they provide care to pregnant patients. HCPs' attitudes toward their patients with opioid misuse/OUD were measured using the Survey of Attitudes and Perceptions questionnaire. Self-efficacy and practices related to opioid risk assessment and mitigation were captured with questions asking about assessment and screening of opioid use, advisement to change opioid use behavior, and referral to treatment for OUD. We used linear regression analyses to estimate associations between HCPs' attitudes toward patients with opioid misuse/OUD and their self-efficacy and use of opioid risk assessment and mitigation practices. Results: This sample included a total of 132 HCPs, including 82 pregnancy HCPs and 50 non-pregnancy HCPs. Attitudes domains were similar among pregnancy and non-pregnancy HCPs. Among pregnancy HCPs, role adequacy (β = .48, 95% CI = .16-.80), role legitimacy (β = .72, 95% CI = .21-1.22), motivation (β = .68, 95% CI = .14-1.21), and positive task-specific self-esteem (β = 1.52, 95% CI = .70-2.35) were positively associated with more frequent use of opioid risk assessment and mitigation practices, while attitudes were not associated with these practices among non-pregnancy HCPs. Conclusions: Training initiatives that lead to improved HCP attitudes could improve opioid care management among rural pregnancy HCPs. More research is needed to determine approaches to increase the use of opioid risk assessment and mitigation practices among rural non-pregnancy HCPs.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Hemorrhagic stroke outcomes of KApSR patients with co-morbid diabetes and Alzheimer's disease

Background

Vascular risk factors, such as diabetes mellitus (DM), are associated with poorer outcomes following many neurodegenerative diseases, including hemorrhagic stroke and Alzheimer's disease (AD). Combined AD and DM co-morbidities are associated with an increased risk of hemorrhagic stroke and increased Medicare costs. Therefore, we hypothesized that patients with DM in combination with AD, termed DM/AD, would have increased hemorrhagic stroke severity.

Methods

Kentucky Appalachian Stroke Registry (KApSR) is a database of demographic and clinical data from patients that live in Appalachia, a distinct region with increased health disparities and stroke severity. Inpatients with a primary indication of hemorrhagic stroke were selected from KApSR for retrospective analysis and were separated into four groups: DM only, AD only, neither, or both.

Results

Hemorrhagic stroke patients (2,071 total) presented with either intracerebral hemorrhage (ICH), n=1,448, or subarachnoid hemorrhage (SAH), n=623. When examining all four groups, subjects with AD were significantly older (AD+, 80.9±6.6 yrs) (DM+/AD+, 77.4±10.0 yrs) than non AD subjects (DM-/AD-, 61.3±16.5 yrs) and (DM+, 66.0±12.5 yrs). A higher percentage of females were among the AD+ group and a higher percentage of males among the DM+/AD+ group. Interestingly, after adjusting for multiple comparison, DM+/AD+ subjects were ten times as likely to suffer a moderate to severe stroke based on a National Institute of Health Stroke (NIHSS) upon admission [odds ratio (95% CI)] compared to DM-/AD- [0.1 (0.02-0.55)], DM+ [0.11 (0.02-0.59)], and AD+ [0.09(0.01-0.63)]. The odds of DM+/AD+ subjects having an unfavorable discharge destination (death, hospice, long-term care) was significant (P<0.05) from DM-/AD- [0.26 (0.07-0.96)] when adjusting for sex, age, and comorbidities.

Conclusions

In our retrospective analysis utilizing KApSR, regardless of adjusting for age, sex, and comorbidities, DM+/AD+ patients were significantly more likely to have had a moderate or severe stroke leading to an unfavorable outcome following hemorrhagic stroke.

Syringe services programs in the Bluegrass: Evidence of population health benefits using Kentucky Medicaid data

PURPOSE

To evaluate whether Kentucky counties that established a new syringe services program realized a significant decline in the incidence rate of a set of infectious disease diagnoses commonly transmitted via injection drug use.

METHODS

Longitudinal count models of within-county rates of newly diagnosed infections among populations at risk were estimated using Medicaid claims/encounters data. Generalized estimating equation models were used to report incident rate ratios of 6 diagnoses: (1) HIV; (2) hepatitis C; (3) hepatitis B; (4) osteomyelitis; (5) endocarditis; and (6) skin/soft tissue infection. To investigate whether a delay in effect was present, separate models were fit to estimate the effects of establishing a syringe services program: at its opening date, and again at 1, 3, and 6 months postopening date.

FINDINGS

Taken together, the aggregated within-county incidence rate of these 6 diagnoses was significantly lower following the implementation of a syringe services program (P < .05). Our models estimated that counties which opted to open a syringe services program realized an approximate month-over-month decline in new diagnoses of 0.5% among the population at risk.

CONCLUSIONS

These results lend further support to previous conclusions made in the public health literature regarding the efficacy of syringe services programs. Specifically, declines in incidence rates were observable beginning at 1 month post syringe services program opening. These results are particularly notable due to the typical setting in which these syringe services programs operated-rural communities of fewer than 40,000 residents.

Barriers to Integrated Medication-Assisted Treatment for Rural Patients With Co-occurring Disorders: The Gap in Managing Addiction

OBJECTIVE

Guidelines for treatment of opioid use disorder stipulate for mental health assessment and the option for treatment alongside medication for opioid use disorder (MOUD). Yet efforts to expand MOUD treatment capacity have focused on expanding the workforce of buprenorphine providers. This article aims to describe the processes facilitating and impeding integrated care for rural patients with co-occurring opioid use disorder and mental health conditions.

METHODS

Qualitative interviews were conducted with primary care and specialty providers (N=26) involved in integrated care through the state's hub-and-spoke system and with system-level stakeholders (N=16) responsible for expanding access to MOUD in rural California.

RESULTS

Rural primary care providers struggled to offer adequate mental health resources to patients with co-occurring conditions because of personnel shortages and inadequate availability of telehealth. Efforts to intensify care through referral to county mental health systems and private community providers were thwarted by access barriers. The bifurcated nature of treatment systems resulted in inadequate training in integrated care and the deprioritization of mental health in patient evaluations.

CONCLUSIONS

Significant system-level barriers undermine the implementation of integrated MOUD in rural areas, potentially increasing the suffering of residents with co-occurring conditions and intensifying burnout among providers.

Neonatal Abstinence Syndrome in Rural Appalachia

As the United States faces the repercussions of the current opioid epidemic, it is important for social workers to be able to identify risks for poor birth outcomes in infants with neonatal abstinence syndrome (NAS). Although some studies have identified single risk factors, no studies have tested associations between total amount of risk (that is, cumulative risk) and birth outcomes in infants with NAS. Authors examined 318 mothers who used opioids during pregnancy and their infants' birthweight, length, head circumference, and Apgar scores (which measure overall infant health after birth). All infants were admitted to a neonatal intensive care unit in Appalachia and were diagnosed with NAS. Authors found that high cumulative risk during pregnancy was associated with lower birthweight and Apgar scores one and five minutes after birth as well as shorter length and smaller head circumference at birth. Social workers are encouraged to assess for the quantity of prenatal adversity experienced by the mothers they serve and to consider multicomponent, comprehensive community-based interventions to reduce cumulative risk.

Contraceptive Needs Among Women Recently Incarcerated at a Rural Appalachian Jail

Background: Incarceration is associated with negative sexual and reproductive health outcomes. We examined contraceptive needs among women incarcerated at a rural Appalachian jail with emphasis on pregnancy history, recent contraceptive use, and current and near-future contraceptive needs. Materials and Methods: A survey was administered to newly incarcerated women at a jail in Southwest Virginia. It included questions about (1) prior pregnancies; (2) pregnancy intentions, contraceptive use, and sexual activity in the 3 months before jail; (3) unprotected sex in the 5 days before jail; (4) interest in contraceptive education and access during incarceration; and (5) post-release sexual activity, pregnancy, and contraceptive plans. Results: One hundred ninety-three women completed surveys. Analyses focused on the 95 at risk for pregnancy. Fifty-eight percent of prior pregnancies on which women provided intention information were unintended, with 74% of respondents reporting at least 1 such pregnancy. Ninety-four percent of women reported vaginal intercourse during the 3 months before jail. Only 46% of those who did not want to get pregnant reported consistent contraceptive use. Condoms and withdrawal were the most common methods used. Forty percent of women were eligible for emergency contraception (EC). Most (78%) participants anticipated sex with a man within 6 months of release, and most (63%) did not want to become pregnant within a year of release. Almost half (47%) expressed interest in receiving birth control while in jail. Conclusions: Results support the need to offer women EC on incarceration, family planning education during confinement, and effective birth control before release.

Rural Emergency Medical Service Providers Perceptions on the Causes of and Solutions to the Opioid Crisis: A Qualitative Assessment

Introduction:

The continuing opioid crisis poses unique challenges to remote and often under-resourced rural communities. Emergency medical service (EMS) providers serve a critical role in responding to opioid overdose for individuals living in rural or remote areas who experience opioid overdoses. They are often first at the scene of an overdose and are sometimes the only health care provider in contact with an overdose patient who either did not survive or refused additional care. As such, EMS providers have valuable perspectives to share on the causes and consequences of the opioid crisis in rural communities.

Methods:

EMS providers attending a statewide EMS conference serving those from greater Minnesota and surrounding states were invited to take a 2-question survey asking them to reflect upon what they believed to be the causes of the opioid crisis and what they saw as the solutions to the opioid crisis. Results were coded and categorized using a Consensual Qualitative Research approach.

Results:

EMS providers’ perceptions on causes of the opioid crisis were categorized into 5 main domains: overprescribing, ease of access, socioeconomic vulnerability, mental health concerns, and lack of resources and education. Responses focused on solutions to address the opioid crisis were categorized into 5 main domains: need for increased education, enhanced opioid oversight, increased access to treatment programs, alternative therapies for pain management, and addressing socioeconomic vulnerabilities.

Conclusion:

Along with the recognition that the opioid crisis was at least partially caused by overprescribing, rural EMS providers who participated in this study recognized the critical role of social determinants of health in perpetuating opioid-related harm. Participants in this study reported that education and increased access to treatment facilities and appropriate pain management, along with recognition of the role of social determinants of health in opioid dependency, were necessary steps to address the opioid crisis.

Characterization of neonatal opioid withdrawal syndrome in Arizona from 2010-2017

In this paper, we describe a population of mothers who are opioid dependent at the time of giving birth and neonates exposed to opioids in utero who experience withdrawal following birth. While there have been studies of national trends in this population, there remains a gap in studies of regional trends. Using data from the Arizona Department of Health Services Hospital Discharge Database, this study aimed to characterize the population of neonates with neonatal opioid withdrawal syndrome (NOWS) and mothers who were opioid dependent at the time of giving birth, in Arizona. We analyzed approximately 1.2 million electronic medical records from the Arizona Department of Health Services Hospital Discharge Database to identify patterns and disparities across socioeconomic, ethnic, racial, and/or geographic groupings. In addition, we identified comorbid conditions that are differentially associated with NOWS in neonates or opioid dependence in mothers. Our analysis was designed to assess whether indicators such as race/ethnicity, insurance payer, marital status, and comorbidities are related to the use of opioids while pregnant. Our findings suggest that women and neonates who are non-Hispanic White and economically disadvantaged, tend be part of our populations of interest more frequently than expected. Additionally, women who are opioid dependent at the time of giving birth are unmarried more often than expected, and we suggest that marital status could be a proxy for support. Finally, we identified comorbidities associated with neonates who have NOWS and mothers who are opioid dependent not previously reported.

Reproductive-Age Women's Experience of Accessing Treatment for Opioid Use Disorder: "We Don't Do That Here"

PURPOSE

For reproductive-age women, medications for opioid use disorder (OUD) decrease risk of overdose death and improve outcomes but are underutilized. Our objective was to provide a qualitative description of reproductive-age women's experiences of seeking an appointment for medications for OUD.

METHODS

Trained female callers placed telephone calls to a representative sample of publicly listed opioid treatment clinics and buprenorphine providers in Florida, Kentucky, Massachusetts, Michigan, Missouri, North Carolina, Tennessee, Virginia, Washington, and West Virginia to obtain appointments to receive medication for OUD. Callers were randomly assigned to be pregnant or non-pregnant and have private or Medicaid-based insurance to assess differences in the experiences of access by these characteristics. The callers placed 28,651 uniquely randomized calls, 10,117 to buprenorphine-waivered prescribers and 754 to opioid treatment programs. Open-ended, qualitative data were obtained from the callers about the access experiences and were analyzed using a qualitative, iterative inductive-deductive approach. From all 28,651 total calls, there were 17,970 unique free-text comments to the question "Please give an objective play-by-play of the description of what happened in this conversation."

FINDINGS

Analysis demonstrated a common path to obtaining an appointment. Callers frequently experienced long hold times, multiple transfers, and difficult interactions. Clinic receptionists were often mentioned as facilitating or obstructing access. Pregnant callers and those with Medicaid noted more barriers. Obtaining an appointment was commonly difficult even for these persistent, trained callers.

CONCLUSIONS

Interventions are needed to improve the experiences of reproductive-age women as they enter care for OUD, especially for pregnant women and those with Medicaid coverage.

Disparities in neonatal abstinence syndrome and health insurance status: A statewide study using non-claims real-time surveillance data

BACKGROUND

Most studies examining the relationship between neonatal abstinence syndrome (NAS) and health insurance status in the United States (USA) have used administrative insurance claims data, which is subject to myriad limitations. We examined the association between NAS and health insurance status in a large geographically defined rural population in the United States, using non-claims data.

METHODS

We utilized data from a population-based cohort of all newborns born in 2017-2019 in the rural state of West Virginia (WV) and restricted analyses to WV residents' births (n = 46 213). NAS was defined as neonatal withdrawal from many substances, including opiates and not limited to those cases that require pharmacological treatment.

RESULTS

Medicaid covered more than half (52.6%) of all infants' births in the state of WV. The incidence of NAS was 85.8 and 12.7 per 1000 livebirths in the Medicaid and privately insured groups, respectively. Among all infants diagnosed with NAS, 86.1% were enrolled in the state's Medicaid programme. The risk of NAS in the Medicaid-insured newborns was higher than privately insured newborns in the unadjusted analysis (risk ratio (RR) 6.76, 95% confidence interval (CI) 5.95, 7.68) and the adjusted analysis RR 3.00, 95% CI 2.01, 4.49); adjusted risk difference 20.3 (95% CI 17.5, 23.1 cases per 1000 livebirths).

CONCLUSIONS

NAS is an important indicator of the immediate effect of the opioid crisis. This study shows the disparity in NAS by health insurance status for a large rural population in the United States, and its burden on the state's Medicaid programme. Providing timely and accurate estimates of NAS is important for public health policies and decision making.

Contextual risk and psychosocial profiles of opioid-using mothers: A mixed-methods study

INTRODUCTION

There is an increase in cases of mothers using opioids during pregnancy in the United States but research investigating mothers' psychosocial environments along with individual variability among this high-risk group of women is scarce.

METHODS

This mixed-methods study aims to examine the complex interplay of contextual risks and experiences of opioid-using mothers. A sample of 50 opioid-using biological mothers of infants diagnosed with neonatal opioid withdrawal syndrome (NOWS) were studied using a set of standardized and open-ended questions, along with medical records extraction.

RESULTS

A high-risk subgroup of 36 mothers was identified using cluster analysis, characterized by a distinct profile of psychosocial risk. Thematic content analysis revealed four themes: (1) barriers to communication and mistrust of health professionals, (2) limitations of access to health care and the amplification of disadvantages related to COVID-19, (3) lifelong consequences of adverse childhood experiences (ACEs), and (4) intimate partner violence and its influence on drug use.

CONCLUSION

Our findings highlight important information toward health services provision for opioid-using women of childbearing age. Efforts to reduce opioid usage in mothers need to consider psychosocial and contextual risks.

Buprenorphine dispensing in an epicenter of the U.S. opioid epidemic: A case study of the rural risk environment in Appalachian Kentucky

BACKGROUND

Buprenorphine is a cornerstone to curbing opioid epidemics, but emerging data suggest that rural pharmacists in the US sometimes refuse to dispense this medication. We conducted a case study to explore buprenorphine dispensing practices in 12 rural Appalachian Kentucky counties, and analyze whether and how they were shaped by features of the rural risk environment.

METHODS

In this case study, we conducted one-on-one semi-structured interviews with 14 pharmacists operating 15 pharmacies in these counties to explore buprenorphine dispensing practices and perceived influences on these practices. Thematic analyses of the resulting transcripts revealed three features of the rural risk environment that shaped dispensing. To explore these three risk environment features, we analyzed policy documents (e.g., Attorney General lawsuits) and administrative databases (e.g., incarceration data). Textual documents were analyzed using thematic analyses and administrative data were analyzed using descriptive statistics; memoes explored relationships among risk environment features and dispensing practices.

RESULTS

Twelve of the 15 pharmacies limited dispensing, by refusing to serve new patients; limiting dispensing to known patients or prescribers; or refusing to dispense buprenorphine altogether. Concerns about exceeding a "Drug Enforcement Administration (DEA) cap" on opioid dispensing stifled dispensing. A legacy of aggressive and fraudulent marketing of opioid analgesics (OAs) by pharmaceutical companies and physician OA overprescribing undermined pharmacist trust in buprenorphine and in its prescribers. The escalating local war on drugs may have undermined dispensing by reinforcing stigma against people who use drugs.

CONCLUSIONS

Initiatives to increase buprenorphine prescribing must be accompanied by policy changes to increase dispensing. Specifically, buprenorphine should be removed from opioid monitoring systems; efforts to de-escalate the war on drugs should be extended to encompass rural areas; initiatives to dismantle aggressive OA marketing should be strengthened; and efforts to re-build pharmacist trust in physicians are needed.

Rural risk environments, opioid-related overdose, and infectious diseases: A multidimensional, spatial perspective

BACKGROUND

Much remains unknown in rural risk environments, despite a growing crisis in these areas. We adapt a risk environment framework to characterize rural southern Illinois and describe the relations of risk environments, opioid-related overdose, HIV, Hepatitis C, and sexually transmitted infection rates between 2015 and 2017.

METHODS

Over two dozen risk environment variables are summarized across zip-code (n = 128) or county levels (n = 16) based on availability and theoretical relevance. We calculate data attribute associations and characterize spatial and temporal dimensions of longitudinal health outcomes and the rural risk environment. We then use a "regional typology analysis" to generate data-driven risk regions and compare health outcomes.

RESULTS

Pervasive risk hotspots were identified in more populated locales with higher rates of overdose and HCV incidence, whereas emerging risk areas were isolated to more rural locales that had experienced an increase in analgesic opiate overdoses and generally lacked harm-reduction resources. At-risk areas were characterized with underlying socioeconomic vulnerability but in differing ways, reflecting a nuanced and shifting structural risk landscape.

CONCLUSIONS

Rural risk environment vulnerabilities and associated opioid-related health outcomes are multifaceted and spatially heterogeneous. More research is needed to better understand how refining geographies to more precisely define risk can support intervention efforts and further enrich investigations of the opioid epidemic.

Addressing opioid use disorder among rural pregnant and postpartum women: a study protocol

BACKGROUND

Opioid use disorder (OUD) among women delivering at a hospital has increased 400% from 1999-2014 in the United States. From the years 2007 to 2016, opioid-related mortality during pregnancy increased over 200%, and drug-overdose deaths made up nearly 10% of all pregnancy-associated mortality in 2016 in the US. Disproportionately higher rates of neonatal opioid withdrawal syndrome (NOWS) have been reported in rural areas of the country, suggesting that perinatal OUD is a pressing issue among these communities. There is an urgent need for comprehensive, evidence-based treatment services for pregnant women experiencing OUD. The purpose of this article is to describe a study protocol aimed at developing and evaluating a perinatal OUD curriculum, enhancing evidence-based perinatal OUD treatment in a rural setting, and evaluating the implementation of such collaborative care for perinatal OUD.

METHODS

This two-year study employed a one group, repeated measures, hybrid type-1 effectiveness-implementation design. This study delivered interventions at 2 levels, both targeting improvement of care for pregnant women with OUD. The first area of focus was at the community healthcare provider-level, which aimed to evaluate the acceptability and feasibility of perinatal OUD education across time and to improve provider education by increasing knowledge specific to: MOUD provision; screening, brief intervention, and referral to treatment (SBIRT) utilization; and NOWS treatment. The second area of intervention focus was at the patient-level, which assessed the preliminary effect of perinatal OUD provider education in promoting illicit opioid abstinence and treatment engagement among pregnant women with OUD. We adopted constructs from the Consolidated Framework for Implementation Research (CFIR) to assess contextual factors that may influence implementation, and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model to comprehensively evaluate implementation outcomes.

DISCUSSION

This article presents the protocol of an implementation study that is employing the CFIR and RE-AIM frameworks to implement and evaluate a perinatal OUD education and service coordination program in two rural counties. This protocol could serve as a model for clinicians and researchers seeking to implement improvements in perinatal care for women with OUD in other rural communities. Trial registration NCT04448015 clinicaltrials.gov.

"He Would Take My Shoes and All the Baby's Warm Winter Gear so We Couldn't Leave": Barriers to Safety and Recovery Experienced by a Sample of Vermont Women With Partner Violence and Opioid Use Disorder Experiences

PURPOSE

This qualitative study explored themes about barriers to substance use treatment for women who experience intimate partner violence (IPV) and opioid use in rural Vermont. The goal was to collect descriptive information to aid in the development of intervention ideas to facilitate better treatment access for women in this situation.

METHODS

One-on-one telephone interviews with 33 rural Vermont women who experienced both IPV and opioid use took place between February and August 2019.

FINDINGS

There were 5 main themes that emerged as barriers to accessing needed services: (1) geographic isolation and transportation difficulties, (2) inaccessibility of existing services, (3) lack of integrated substance use treatment and domestic violence services, (4) social isolation, and (5) amplification of stigma in small rural communities.

CONCLUSIONS

Improved access to care and increased collaboration between IPV and substance use service providers are required to better serve rural communities in which IPV and opioid use disorder are concurrent problems.

Contraceptive use in Appalachian women who use drugs and were recruited from rural jails

This study describes a secondary data analysis of contraceptive use across the lifetime and within the six months prior to incarceration in a sample of 400 currently incarcerated women recruited from rural, Appalachian jails, who were using drugs prior to incarceration. Phase 1 (baseline) data from an NIH funded study were used to examine rates of contraceptive use, reasons for nonuse of condoms, and correlates of condom use. Results indicate that the majority (96.5%) of respondents reported lifetime use of contraceptives, and most (70.5%) had a history of using multiple methods, with male condoms, oral contraceptive pills, and contraceptive injections being the most commonly used methods. Almost 69% of respondents reported nonuse of contraceptives within the last six months, despite high rates of involvement in risky, intimate male partnerships prior to incarceration. Contraceptive use was found to be historically acceptable in this sample, in stark contrast to rates of use within the last six months prior to incarceration, suggesting that reproductive justice-informed, social work interventions to help improve current contraceptive use are warranted as a harm-reduction approach.

Clinical and basic research investigations into the long-term effects of prenatal opioid exposure on brain development

Coincident with the opioid epidemic in the United States has been a dramatic increase in the number of children born with neonatal abstinence syndrome (NAS), a form of withdrawal resulting from opioid exposure during pregnancy. Many research efforts on NAS have focused on short-term care, including acute symptom treatment and weaning of the infants off their drug dependency prior to authorizing their release. However, investigations into the long-term effects of prenatal opioid exposure (POE) on brain development, from the cellular to the behavioral level, have not been as frequent. Given the importance of the perinatal period for human brain development, opioid-induced disturbances in the formation and function of nascent synaptic networks and glia have the potential to impact brain connectivity and cognition long after the drug supply is cutoff shortly after birth. In this review, we will summarize the current state of NAS research, bringing together findings from human studies and preclinical animal models to highlight what is known about how POE can induce significant, prolonged deficits in brain structure and function. With rates of NAS continuing to rise, particularly in regions that already face substantial socioeconomic challenges, we speculate as to the most promising avenues for future research to alleviate this growing multigenerational threat.

Opioid use disorder among pregnant women in the 2000-2014 North Carolina state inpatient database

Background: The opioid epidemic's impact reached an increasing portion of the United States population, including pregnant women.Objectives: We sought to determine the prevalence and factors associated with opioid use disorders during pregnancy in North Carolina.Study Design: Using North Carolina's State Inpatient Sample, a retrospective study was conducted to identify pregnancy-related discharges between 2000 and 2014. Hospital discharge records associated with ICD-9-CM diagnoses codes for the use of opioids for all eligible pregnancy-related discharges were extracted. Logistic regression models were used to estimate unadjusted and adjusted bivariate and multivariate relationships.Results: Of 1,937,455 pregnancy-related hospitalization in North Carolina, 6,084 were associated with opioid use, a prevalence of 3.14 cases per 1,000 discharge. Maternal opioid use was associated with an increased odds of early onset delivery, threatened preterm labor, premature rupture of membranes, postpartum depression, stillbirth and poor fetal growth. Women who used opioids during pregnancy had prolonged hospital stays (>5 days) and were 2 times as likely to have more than 4 procedures performed during hospitalization. Compared to other racial groups, non-Hispanic whites had a notably higher prevalence of opioid use disorders (5.8/1,000 pregnancy-related discharges) (P < 0.05 for all).Conclusions: Very few health issues have garnered the attention of such diverse sectors of our society as the opioid epidemic. As the first state-level analysis of opioid use disorders among delivery hospitalizations, these findings suggest the need for a system-wide public health response such as improved funding for Medicaid and child welfare systems to improve the health of the opioid-exposed mother-infant dyad.

Are Children's Hospitals Unique in the Community Benefits They Provide? Exploring Decisions to Prioritize Community Health Needs Among U.S. Children's and General Hospitals

The Affordable Care Act expanded community benefit requirements for nonprofit hospitals, which now must demonstrate that they take into account the needs of their surrounding community in deciding where to make community benefit investments. No study to date has assessed the Community Health Needs Assessments (CHNAs) of a large sample of nonprofit hospitals to understand how hospitals determine the priority health needs that they include for their community or how prioritized health needs differ between general and children's hospitals. We analyzed the CHNAs of a 20% random sample of general hospitals in the United States as well as all children's hospitals. After identifying the five most common needs across all hospitals-mental health, substance misuse, social needs, chronic illness, and access to care-we used descriptive statistics and multivariate logistic regression to determine which hospitals were most likely to prioritize each of these five needs in their CHNA and the organizational, county, and regional factors associated with prioritizing a need. We found that children's hospitals were more likely than general hospitals to prioritize each of these five needs in their CHNA and that related county-level health indicators were significantly associated with hospitals prioritizing social needs and substance misuse as top needs in their CHNAs. County-level demographic variation, such as the percentage of white residents, and regional location were significantly related to whether hospitals prioritized a need in their CHNA. Our results suggest that children's hospitals are more likely to include a similar list of health issues on their CHNAs and that factors beyond county-level health indicators (e.g., organizational mission, regional health indicators, etc.) are operative in hospital decisions to include needs on their CHNAs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Family Planning Practices in Appalachia: Focus Group Perspectives on Service Needs in the Context of Regional Substance Abuse

Reproductive health disparities in the Appalachian region may be driven by barriers to healthcare access. However, the barriers specific to accessing family planning services in Appalachia have not yet been identified from the perspectives of Appalachian community members. Moreover, it is unclear how community members might perceive elevated levels of opioid use in the region to impact family planning practices. To fill this gap in knowledge, the current qualitative study explored community perspectives about family planning in Appalachia in the context of the opioid epidemic for the purpose of developing a survey instrument based on these responses. We conducted three video call focus group interviews with community stakeholders, those who live, work and are invested in Appalachia (N = 16), and analyzed the responses using Levesque, Harris, and Russell's (2013) five pillars of healthcare access as a framework to categorize family planning practices and perceptions of service needs in the context of regional substance abuse: (1) approachability, (2) acceptability, (3) availability and accommodation, (4) affordability, and (5) appropriateness. Subthemes within each of these five categories were also identified. Our findings highlight stakeholder concerns around a lack of knowledge about and access to family planning services in Appalachia. Community members also expressed concern around the lack of availability of substance use treatment services, which may negatively impact family planning use and access in the region.

Family Planning Practices in Appalachia: Focus Group Perspectives on Service Needs in the Context of Regional Substance Abuse

Reproductive health disparities in the Appalachian region may be driven by barriers to healthcare access. However, the barriers specific to accessing family planning services in Appalachia have not yet been identified from the perspectives of Appalachian community members. Moreover, it is unclear how community members might perceive elevated levels of opioid use in the region to impact family planning practices. To fill this gap in knowledge, the current qualitative study explored community perspectives about family planning in Appalachia in the context of the opioid epidemic for the purpose of developing a survey instrument based on these responses. We conducted three video call focus group interviews with community stakeholders, those who live, work and are invested in Appalachia (N = 16), and analyzed the responses using Levesque, Harris, and Russell’s (2013) five pillars of healthcare access as a framework to categorize family planning practices and perceptions of service needs in the context of regional substance abuse: (1) approachability, (2) acceptability, (3) availability and accommodation, (4) affordability, and (5) appropriateness. Subthemes within each of these five categories were also identified. Our findings highlight stakeholder concerns around a lack of knowledge about and access to family planning services in Appalachia. Community members also expressed concern around the lack of availability of substance use treatment services, which may negatively impact family planning use and access in the region.

Prevalence of Parent Reported Health Conditions Among 0- to 17-Year-Olds in Rural United States: National Survey of Children's Health, 2016-2017

PURPOSE

This study's purpose was to determine the prevalence of physical, mental, and developmental health conditions among US children and assess the association with urban versus rural residence.

METHODS

Bivariate/multivariable analyses were conducted with cross-sectional data for children aged 0-17 years (N = 71,811) from the 2016-2017 National Survey of Children's Health. Prevalence estimates of excellent/very good health were derived from parents' qualitative judgments. Parent-reported health conditions were aggregated by condition type (physical, mental, developmental). Prevalence was determined for condition type and severity. Adjusted risk ratios assessed the effect of residence on having physical, mental, or developmental conditions.

RESULTS

Among rural children in the general population, we found lower crude rates of excellent/very good overall health and higher rates of ≥1 physical condition(s) and ≥1 mental condition(s), as well as these 2 conditions in combination with ≥1 developmental condition(s). Rural children in the general population were also more likely to have physical and mental conditions that parents rated as moderate/severe in unadjusted analyses. To a lesser extent, these differences held true for the children with special health care needs. Risk ratios for rural residence were largely nonsignificant in adjusted analyses.

CONCLUSIONS

While rural children had lower crude rates of parent-reported excellent/very good health and higher crude rates of parent-reported or doctor-diagnosed physical and mental health conditions compared to urban children, the same pattern of urban-rural differentials was not evident in the adjusted analyses. Compositional and contextual differences in the urban/rural populations suggest that social determinants of health may have accounted for rate disparities in child health conditions.

Latent Profiles of Health and Reproductive Risk and Protective Factors among Women in Appalachia

Women who use opiates and are involved in the criminal justice system in Appalachia may be prone to adverse health outcomes. In this study, we performed a latent class analysis of risk and protective factors on 400 drug-using women recruited from rural, Appalachian jails. A two-profile solution best fit the data. Both profiles evinced low levels of condom use, reproductive and physical health screens, and STD history. However, the primary substantive difference between the profiles was partner risk behavior: the higher risk class had main male partners with histories of injection drug use and incarceration. Results suggest that interventions need to be tailored to unique profiles of risk and protective factors, which should include taking partner risk into consideration.

A systematic review of rural-specific barriers to medication treatment for opioid use disorder in the United States

BACKGROUND

Opioid-related deaths have risen dramatically in rural communities. Prior studies highlight few medication treatment providers for opioid use disorder in rural communities, though literature has yet to examine rural-specific treatment barriers.

OBJECTIVES

We conducted a systematic review to highlight the state of knowledge around rural medication treatment for opioid use disorder, identify consumer- and provider-focused treatment barriers, and discuss rural-specific implications.

METHODS

We systematically reviewed the literature using PsycINFO, Web of Science, and PubMed databases (January 2018). Articles meeting inclusion criteria involved rural samples or urban/rural comparisons targeting outpatient medication treatment for opioid use disorder, and were conducted in the U.S. to minimize healthcare differences. Our analysis categorized consumer- and/or provider-focused barriers, and coded barriers as related to treatment availability, accessibility, and/or acceptability.

RESULTS

Eighteen articles met inclusion, 15 which addressed consumer-focused barriers, while seven articles reported provider-focused barriers. Availability barriers were most commonly reported across consumer (n = 10) and provider (n = 5) studies, and included the lack of clinics/providers, backup, and resources. Acceptability barriers, described in three consumer and five provider studies, identified negative provider attitudes about addiction treatment, and providers' perceptions of treatment as unsatisfactory for rural patients. Finally, accessibility barriers related to travel and cost were detailed in four consumer-focused studies whereas two provider-focused studies identified time constraints.

CONCLUSIONS

Our findings consistently identified a lack of medication providers and rural-specific implementation challenges. This review highlights a lack of rural-focused studies involving consumer participants, treatment outcomes, or barriers impacting underserved populations. There is a need for innovative treatment delivery for opioid use disorder in rural communities and interventions targeting provider attitudes.

Research and policy priorities for addressing prenatal exposure to opioids in Alaska

The current opioid crisis in Alaska and the USA will negatively affect the health and wellbeing of future generations. The increasing number of infants born with neonatal opioid withdrawal syndrome (NOWS) has had a profound impact on families, health care providers and the child welfare system. This manuscript summarises the main themes of a Symposium held in Anchorage, Alaska with health care providers, researchers, elders and public health officials that focused on identifying emerging challenges, trends and potential solutions to address the increasing number of infants and children affected by maternal opioid use. Five areas of importance for research and policy development that would direct improvement in the care of infants with NOWS in Alaska are outlined with the goal of supporting a research agenda on opioid misuse and child health across the circumpolar north. Abbreviations: NOWS - neonatal opioid withdrawal syndrome; NAS - neonatal abstinence syndrome; MAT - medication-assisted treatment; NICU - neonatal intensive care unit; OATs - opioid agonist treatments; OCS - office of children's services; ANTHC - Alaska Native Tribal Health Consortium; OUD - opioid use disorder; SBIRT - screening, brief intervention and referral to treatment; ISPCTN - IDeA States Pediatric Clinical Trials Network; NIH - National Institutes of Health; ANMC - Alaska Native Medical Center; DHSS - Department of Health and Social Services; AAPP - All Alaska Pediatric Partnership.

Evaluating non-medical prescription opioid demand using commodity purchase tasks: test-retest reliability and incremental validity

RATIONALE

Non-medical prescription opioid use and opioid use disorder (OUD) present a significant public health concern. Identifying behavioral mechanisms underlying OUD will assist in developing improved prevention and intervention approaches. Behavioral economic demand has been extensively evaluated as a measure of reinforcer valuation for alcohol and cigarettes, whereas prescription opioids have received comparatively little attention.

OBJECTIVES

Utilize a purchase task procedure to measure the incremental validity and test-retest reliability of opioid demand.

METHODS

Individuals reporting past year non-medical prescription opioid use were recruited using the crowdsourcing platform Amazon Mechanical Turk (mTurk). Participants completed an opioid purchase task as well as measures of cannabis demand, delay discounting, and self-reported pain. A 1-month follow-up was used to evaluate test-retest reliability.

RESULTS

More intense and inelastic opioid demand was associated with OUD and more intense cannabis demand was associated with cannabis use disorder. Multivariable models indicated that higher opioid intensity and steeper opioid delay discounting rates each significantly and uniquely predicted OUD. Increased opioid demand intensity, but not elasticity, was associated with higher self-reported pain, and no relationship was observed with perceived pain relief from opioids. Opioid demand showed acceptable-to-good test-retest reliability (e.g., intensity rxx = .75; elasticity rxx = .63). Temporal reliability was lower for cannabis demand (e.g., intensity rxx = .53; elasticity rxx = .58) and discounting rates (rxx = .42-.61).

CONCLUSIONS

Opioid demand was incrementally valid and test-retest reliable as measured by purchase tasks. These findings support behavioral economic demand as a clinically useful measure of drug valuation that is sensitive to individual difference variables.