A conceptual model for understanding post-release opioid-related overdose risk

Transitions of care between jail-based medications for opioid use disorder and ongoing treatment in the community: A retrospective cohort study

BACKGROUND

Offering medications for opioid use disorder (MOUD) in carceral settings significantly reduces overdose. However, it is unknown to what extent individuals in jails continue MOUD once they leave incarceration. We aimed to assess the relationship between in-jail MOUD and MOUD continuity in the month following release.

METHODS

We conducted a retrospective cohort study of linked NYC jail-based electronic health records and community Medicaid OUD treatment claims for individuals with OUD discharged from jail between 2011 and 2017. We compared receipt of MOUD within 30 days of release, among those with and without MOUD at release from jail. We tested for effect modification based on MOUD receipt prior to incarceration and assessed factors associated with treatment discontinuation.

RESULTS

Of 28,298 eligible incarcerations, 52.8 % received MOUD at release. 30 % of incarcerations with MOUD at release received community-based MOUD within 30 days, compared to 7 % of incarcerations without MOUD (Risk Ratio: 2.62 (2.44-2.82)). Most (69 %) with MOUD claims prior to incarceration who received in-jail MOUD continued treatment in the community, compared to 9 % of those without prior MOUD. Those who received methadone (vs. buprenorphine), were younger, Non-Hispanic Black and with no history of MOUD were less likely to continue MOUD following release.

CONCLUSIONS

MOUD maintenance in jail is strongly associated with MOUD continuity upon release. Still, findings highlight a gap in treatment continuity upon-reentry, especially among those who initiate MOUD in jail. In the wake of worsening overdose deaths and troubling disparities, improving MOUD continuity among this population remains an urgent priority.

Risk and protective factors for early dropout from telephone monitoring for individuals with drug convictions in community mental health centers in Japan

INTRODUCTION

Individuals involved with the criminal justice system face challenges in receiving and maintaining substance use disorder (SUD) treatment and support. Although telephone monitoring (TM) could reduce these barriers, data on TM for community-dwelling individuals involved with the criminal justice system and research on individuals who drop out of TM are scarce. We examined the factors associated with dropping out early from the Voice Bridges Project, which provides TM for individuals on probation for drug-related convictions through community mental health centers in Japan.

METHODS

Participants (n = 546) were individuals aged ≥20 years with methamphetamine-related convictions who were on probation. Univariate analyses examine the associations between one-year follow-up status and baseline variables, and multivariate Cox proportional hazards regression analyses identify the risk and protective factors associated with dropping out. Stratified analyses report results based on sex and halfway-house residency.

RESULTS

The one-year dropout rate was 43.6 % (n = 238). Multivariate analysis identified two risk factors for dropping out-halfway-house residency and suicide attempts in the past year, and two protective factors-higher education and the current use of SUD services. Sex-stratified analyses showed that halfway-house residency was a risk factor for both men and women. Attempted suicide was a risk factor for women. Conversely, higher education and current use of SUD services were protective factors for men.

CONCLUSIONS

Our results identify unique risk factors for women, such as a recent history of suicide attempts, and distinctive protective factors for men, including higher education and current use of SUD services, emphasizing the importance of sex-specific approaches. Furthermore, the study reveals that irrespective of sex, vulnerable individuals, such as halfway-house residents, are at a higher risk of dropping out from TM.

Opioid use, prescribing and fatal overdose patterns among racial/ethnic minorities in the United States: A scoping review and conceptual risk environment model

ISSUES

To date, there has been no synthesis of research addressing the scale and nuances of the opioid epidemic in racial/ethnic minority populations in the United States that considers the independent and joint impacts of dynamics such as structural disadvantage, provider bias, health literacy, cultural norms and various other risk factors.

APPROACH

Using the "risk environment" framework, we conducted a scoping review on PubMed, Embase and Google Scholar of peer-reviewed literature and governmental reports published between January 2000 and February 2024 on the nature and scale of opioid use, opioid prescribing patterns, and fatal overdoses among racial/ethnic minorities in the United States, while also examining macro, meso and individual-level risk factors.

KEY FINDINGS

Results from this review illuminate a growing, but fragmented, literature lacking standardisation in racial/ethnic classification and case reporting, specifically in regards to Indigenous and Asian subpopulations. This literature broadly illustrates racial/ethnic minorities' increasing nonmedical use of opioids, heightened burdens of fatal overdoses, specifically in relation to polydrug use and synthetic opioids, with notable elevations among Black/Latino subgroups, in addition uneven opioid prescribing patterns. Moreover, the literature implicates a variety of unique risk environments corresponding to dynamics such as residential segregation, provider bias, overpolicing, acculturative stress, patient distrust, and limited access to mental health care services and drug treatment resources, including medications for opioid use disorder.

IMPLICATIONS

There has been a lack of rigorous, targeted study on racial/ethnic minorities who use opioids, but evidence highlights burgeoning increases in usage, especially polydrug/synthetic opioid use, and disparities in prescriptions and fatal overdose risk-phenomena tied to multi-level forms of entrenched disenfranchisement.

CONCLUSION

There is a need for further research on the complex, overlapping risk environments of racial/ethnic minorities who use opioids, including deeper inclusion of Indigenous and Asian individuals, and efforts to generate greater methodological synergies in population classification and reporting guidelines.

Buprenorphine-naloxone vs. extended-release naltrexone for opioid use disorder in individuals with and without criminal legal involvement: A secondary analysis of the X:BOT randomized controlled trial

INTRODUCTION

There is uncertainty about whether criminal legal involvement (CLI) impacts the effectiveness of medications for opioid use disorder (MOUD). We aimed to determine whether CLI modifies the association between buprenorphine-naloxone (BUP-NX) vs. extended-release naltrexone (XR-NTX) and MOUD treatment outcomes.

METHODS

We conducted a secondary analysis of X:BOT, a 24-week multi-center randomized controlled trial comparing treatment outcomes between BUP-NX (n = 287) and XR-NTX (n = 283) in the general population. We used baseline Additional Severity-Index Lite responses to identify patients with recent CLI (n = 342), defined as active CLI and/or CLI in the past 30 days, and lifetime incarceration (n = 328). We explored recent CLI and lifetime incarceration as potential effect modifiers of BUP-NX vs. XR-NTX effectiveness on relapse, induction, and overdose. We conducted both intention-to-treat and per-protocol analyses for each outcome.

RESULTS

In intention-to-treat analyses, recent CLI modified the effect of BUP-NX vs. XR-NTX on odds of successful induction (p = 0.03) and hazard of overdose (p = 0.04), but it did not modify the effect on hazard of relapse (p = 0.23). All participants experienced lower odds of successful induction with XR-NTX compared to BUP-NX, but the relative likelihood of successful induction with BUP-NX was lower than XR-NTX among individuals with recent CLI (OR: 0.25, 95 % CI: 0.13-0.47, p < 0.001) compared to those without recent CLI (OR: 0.04, 95 % CI: 0.01-0.19, p < 0.001). Participants with recent CLI experienced similar hazard of overdose with XR-NTX and BUP-NX (HR: 1.12, 95 % CI: 0.42-3.01, p = 0.82), whereas those without recent CLI experienced greater hazard of overdose with XR-NTX compared to BUP-NX (HR: 12.60, 95 % CI: 1.62-98.03, p = 0.02). In per-protocol analyses, recent CLI did not modify the effect of MOUD on hazard of overdose (p = 0.10) or relapse (p = 0.41). Lifetime incarceration did not modify any outcome.

CONCLUSIONS

Compared to individuals without recent CLI, individuals with recent CLI experienced decreased relative effectiveness of BUP-NX compared to XR-NTX for induction and overdose outcomes. This highlights the importance of considering the impact of recent CLI on opioid use disorder treatment outcomes. Future research should explore the mechanisms through which recent CLI modifies MOUD effectiveness and aim to improve MOUD effectiveness for individuals with recent CLI.

Health Conditions and Treatment Utilization Among Older Male Veterans Incarcerated in Prisons

BACKGROUND

More than 50,000 older male veterans incarcerated in prisons are expected to return to their communities and utilize the Veterans Health Administration (VHA) and community healthcare systems. To support the continuity of healthcare and overall successful community reentry of older incarcerated veterans, an understanding of their health profiles and treatment utilization while in correctional care is needed.

OBJECTIVE

To assess the health status of older male veterans incarcerated in state prisons and explore demographic, military, and VHA-related factors associated with medical conditions, disabilities, behavioral conditions, and medical and behavioral treatment utilization.

DESIGN/PARTICIPANTS

Cross-sectional observational study of 880 male veterans aged 50 + incarcerated in state prisons using data from the 2016 Bureau of Justice Statistics Survey of Prison Inmates.

MAIN MEASURES

Veteran status, self-report health status, and treatment utilization since prison admission. Prevalence rates for conditions and treatment utilization were calculated. Logistic regression models were used to examine the association of characteristics with conditions and treatment utilization.

KEY RESULTS

Among the 880 older male veterans in state prisons, the majority reported having a current medical condition (79.3%) or disability (61.6%), almost half had history of a mental health condition (44.5%), and more than a quarter (29%) had a substance use disorder. Compared to White veterans, Black veterans were less likely to report a disability or mental health condition. Few demographic, military, and VA-related characteristics were associated with medical or behavioral conditions or treatment utilization.

CONCLUSION

Our results suggest that the VHA and community healthcare systems need to be prepared to address medical and disability conditions among the majority of older male veterans who will be leaving prison and returning to their communities. Integrated medical and behavioral healthcare delivery models may be especially important for these veterans as many did not receive behavioral health treatment while in prison.

Using decision tree models and comprehensive statewide data to predict opioid overdoses following prison release

PURPOSE

Identifying predictors of opioid overdose following release from prison is critical for opioid overdose prevention.

METHODS

We leveraged an individually linked, state-wide database from 2015-2020 to predict the risk of opioid overdose within 90 days of release from Massachusetts state prisons. We developed two decision tree modeling schemes: a model fit on all individuals with a single weight for those that experienced an opioid overdose and models stratified by race/ethnicity. We compared the performance of each model using several performance measures and identified factors that were most predictive of opioid overdose within racial/ethnic groups and across models.

RESULTS

We found that out of 44,246 prison releases in Massachusetts between 2015-2020, 2237 (5.1%) resulted in opioid overdose in the 90 days following release. The performance of the two predictive models varied. The single weight model had high sensitivity (79%) and low specificity (56%) for predicting opioid overdose and was more sensitive for White non-Hispanic individuals (sensitivity = 84%) than for racial/ethnic minority individuals.

CONCLUSIONS

Stratified models had better balanced performance metrics for both White non-Hispanic and racial/ethnic minority groups and identified different predictors of overdose between racial/ethnic groups. Across racial/ethnic groups and models, involuntary commitment (involuntary treatment for alcohol/substance use disorder) was an important predictor of opioid overdose.

Incarceration history and opioid use among adults living with HIV and chronic pain: a secondary analysis of a prospective cohort study

BACKGROUND

Adults living with HIV have disproportionately high chronic pain, prescription opioid use, history of substance use, and incarceration. While incarceration can have long-lasting health impacts, prior studies have not examined whether distant (>1 year prior) incarceration is associated with opioid use for chronic pain, or with opioid misuse or opioid use disorder among people living with HIV and chronic pain.

METHODS

We conducted a secondary analysis of a prospective cohort study of adults living with HIV and chronic pain. The independent variables were any distant incarceration and drug-related distant incarceration (both dichotomous). Dependent variables were current long-term opioid therapy, current opioid misuse, and current opioid use disorder. A series of multivariate logistic regression models were conducted, adjusting for covariates.

RESULTS

In a cohort of 148 participants, neither distant incarceration nor drug-related incarceration history were associated with current long-term opioid therapy. Distant incarceration was associated with current opioid misuse (AOR 3.28; 95% CI: 1.41-7.61) and current opioid use disorder (AOR 4.40; 95% CI: 1.54-12.56). Drug-related incarceration history was also associated with current opioid misuse (AOR 4.31; 95% CI: 1.53-12.17) and current opioid use disorder (AOR 7.28; 95% CI: 2.06-25.71).

CONCLUSIONS

The positive associations of distant incarceration with current opioid misuse and current opioid use disorder could indicate a persistent relationship between incarceration and substance use in people living with HIV and chronic pain. Additional research on opioid use among formerly incarcerated individuals in chronic pain treatment is needed.

Examining the relationship between social determinants of health, measures of structural racism and county-level overdose deaths from 2017-2020

INTRODUCTION

Despite being an important determinant of health outcomes, measures of structural racism are lacking in studies examining the relationship between the social determinants of health (SDOH) and overdose deaths. The aim of this study is to examine the association between per capita revenue generated from fines and forfeitures, a novel measure of structural racism, and other SDOH with county-level overdose deaths from 2017-2020.

METHODS

This longitudinal analysis of 2,846 counties from 2017-2020 used bivariate and multivariate Generalized Estimating Equations models to estimate associations between county overdose mortality rates and SDOH characteristics, including the fines and forfeitures measure.

RESULTS

In our multivariate model, higher per capita fine and forfeiture revenue (5.76; CI: 4.76, 6.78), households receiving food stamps (1.15; CI: 0.77, 1.53), residents that are veterans (1.07; CI: 0.52, 1.63), substance use treatment availability (4.69; CI: 3.03, 6.33) and lower population density (-0.002; CI: -0.004, -0.001) and percent of Black residents (-0.7`; CI: -1.01, -0.42) were significantly associated with higher overdose death rates. There was a significant additive interaction between the fines and forfeitures measure (0.10; CI: 0.03, 0.17) and the percent of Black residents.

CONCLUSIONS

Our findings suggest that structural racism, along with other SDOH, is associated with overdose deaths. Future research should focus on connecting individual-level data on fines and forfeitures to overdose deaths and other health outcomes, include measures of justice-related fines, such as court fees, and assess whether interventions aimed at increasing economic vitality in disadvantaged communities impact overdose deaths in a meaningful way.

Psychosocial factors associated with overdose subsequent to Illicit Drug use: a systematic review and narrative synthesis

BACKGROUND AND AIMS

Psychological and social status, and environmental context, may mediate the likelihood of experiencing overdose subsequent to illicit drug use. The aim of this systematic review was to identify and synthesise psychosocial factors associated with overdose among people who use drugs.

METHODS

This review was registered on Prospero (CRD42021242495). Systematic record searches were undertaken in databases of peer-reviewed literature (Medline, Embase, PsycINFO, and Cinahl) and grey literature sources (Google Scholar) for work published up to and including 14 February 2023. Reference lists of selected full-text papers were searched for additional records. Studies were eligible if they included people who use drugs with a focus on relationships between psychosocial factors and overdose subsequent to illicit drug use. Results were tabulated and narratively synthesised.

RESULTS

Twenty-six studies were included in the review, with 150,625 participants: of those 3,383-4072 (3%) experienced overdose. Twenty-one (81%) studies were conducted in North America and 23 (89%) reported polydrug use. Psychosocial factors associated with risk of overdose (n = 103) were identified and thematically organised into ten groups. These were: income; housing instability; incarceration; traumatic experiences; overdose risk perception and past experience; healthcare experiences; perception of own drug use and injecting skills; injecting setting; conditions with physical environment; and social network traits.

CONCLUSIONS

Global rates of overdose continue to increase, and many guidelines recommend psychosocial interventions for dependent drug use. The factors identified here provide useful targets for practitioners to focus on at the individual level, but many identified will require wider policy changes to affect positive change. Future research should seek to develop and trial interventions targeting factors identified, whilst advocacy for key policy reforms to reduce harm must continue.

Identifying structural risk factors for overdose following incarceration: a concept mapping study

BACKGROUND

Currently, there are more than two million people in prisons or jails, with nearly two-thirds meeting the criteria for a substance use disorder. Following these patterns, overdose is the leading cause of death following release from prison and the third leading cause of death during periods of incarceration in jails. Traditional quantitative methods analyzing the factors associated with overdose following incarceration may fail to capture structural and environmental factors present in specific communities. People with lived experiences in the criminal legal system and with substance use disorder hold unique perspectives and must be involved in the research process.

OBJECTIVE

To identify perceived factors that impact overdose following release from incarceration among people with direct criminal legal involvement and experience with substance use.

METHODS

Within a community-engaged approach to research, we used concept mapping to center the perspectives of people with personal experience with the carceral system. The following prompt guided our study: "What do you think are some of the main things that make people who have been in jail or prison more and less likely to overdose?" Individuals participated in three rounds of focus groups, which included brainstorming, sorting and rating, and community interpretation. We used the Concept Systems Inc. platform groupwisdom for our analyses and constructed cluster maps.

RESULTS

Eight individuals (ages 33 to 53) from four states participated. The brainstorming process resulted in 83 unique factors that impact overdose. The concept mapping process resulted in five clusters: (1) Community-Based Prevention, (2) Drug Use and Incarceration, (3) Resources for Treatment for Substance Use, (4) Carceral Factors, and (5) Stigma and Structural Barriers.

CONCLUSIONS

Our study provides critical insight into community-identified factors associated with overdose following incarceration. These factors should be accounted for during resource planning and decision-making.

Provision of health care services related to substance use disorder in southern U.S. jails

INTRODUCTION

The U.S. jail population has more than tripled since the 1980s, and today, one out of every three incarcerated individuals is being held in a county or city jail. Substance use disorders (SUD) are overrepresented in incarcerated populations; however, little recent research has examined the availability and quality of SUD-related health care services in jail settings. Incarcerated individuals may engage with a variety of SUD-related health care services, including: screening and withdrawal management at entry, SUD treatment or other brief health care interventions while they are being held, and overdose prevention education and reentry planning at release.

METHODS

We conducted a thematic analysis of qualitative data from 34 interviews conducted with 38 personnel from a purposive sample of jails that varied in size and rurality within a five-state study area. The goals of the analyses were to: 1) describe jail health care services for SUD and barriers to service provision, 2) compare current practices to best practice recommendations, and 3) provide context by describing factors at the jail and community level that influence service provision, such as access to resources.

RESULTS

Interviewees described wide variability in both availability and comprehensiveness of SUD-related health care services. Most adhered to federal guidance for supervising withdrawal from alcohol and benzodiazepines, but not opioids. Medication for addiction treatment was most widely available for pregnant women and rarely for other individuals. Roughly one third of the jails in our sample provided behavioral group or individual therapy with a licensed counselor and roughly one quarter offered self-help groups. Very few jails provided comprehensive re-entry planning and support. Jail staff reported specific barriers to providing each type of service, as well as limiting contextual factors. Despite observed increases in case volume, jail health care staff did not necessarily receive any additional funding or staff members. Overall, lack of investment in mental and behavioral health care contributed to recidivism and feelings of hopelessness among staff.

CONCLUSIONS

This study identified several areas where jails could improve SUD-related health care services. Many of the barriers to improvement-organizational buy-in, cost/budgeting, staffing, logistics-were not under the control of health care staff. Implementing changes will require support from local governments, jails administrators, private health care companies, and other local health care providers.

The association between attitudes and the provision of medications for opioid use disorder (MOUD) in United States jails

Background

Opioid use disorder is prevalent among individuals who are incarcerated, yet medications for opioid use disorder (MOUD) are not widely available in United States jails and prisons. Negative staff attitudes across the criminal legal system may prevent MOUD from being provided. We sought to determine if staff attitudes are associated with the provision of MOUD in prisons or jails.

Methods

227 staff members of 43 jails and partnering community-based treatment providers answered questions on the effectiveness and acceptability of methadone, buprenorphine, and naltrexone. Response patterns were summarized with principal component analysis. Mixed-effects regression was performed to determine if attitudes toward MOUD were associated with the number of individuals screened and diagnosed with an OUD, referred to treatment, provided MOUD and referred to treatment after release.

Results

Sites whose staff had negative attitudes towards methadone and positive attitudes towards naltrexone were associated with fewer people being screened (Mean ratio [MR] = 0.84, 95 % CI: [0.72, 0.97]), diagnosed (MR = 0.85, 95 % CI: [0.73, 0.99]), referred (MR = 0.76, 95 % CI: [0.65, 0.89]), provided MOUD (MR = 0.70, 95 % CI: [0.58, 0.84]), and referred after release (MR = 0.82, 95 % CI: [0.72, 0.94]). Sites with overall positive attitudes towards all MOUD were associated with more people being screened (MR = 1.16, 95 % CI: [1.01, 1.34]), diagnosed (MR = 1.37, 95 % CI: [1.18, 1.60]), and referred to treatment (MR = 1.41, 95 % CI: [1.20, 1.65]).

Conclusions

Attitudinal barriers exist in the criminal legal system and are associated with the provision of MOUD.

Police Use of Discretion in Encounters with People with Opioid Use Disorder: a Study of Illinois Police Officers

Police frequently encounter people with opioid use disorder (OUD), having a profound effect on their risk environment and health outcomes. Officers retain significant discretionary authority in their response to these encounters. To explore the factors that underlie these decisions, we surveyed a sample of Illinois police officers. We administered an online survey to Illinois police departments using a random sampling strategy, stratified by agency size and the rurality of their service areas. Our final sample was 248 police officers from 27 departments. We surveyed officers' beliefs about (1) influences and control over their decision making; (2) the approval of other actors in making referrals to treatment for addiction, and (3) the potential impacts of medication-assisted treatment (MAT). We analyzed the survey data using descriptive statistics and regression analyses. Most officers were highly influenced by the expectations of their supervisors when responding to subjects who appeared to have an OUD, and about half would take direction from addiction treatment providers. Police in urban departments perceived greater support for MAT and were more likely to believe MAT could reduce the need for future arrests. Our findings suggest ways police officers can be influenced to make discretionary decisions that improve the health outcomes of their encounters with people with OUD: (1) Supervisors should serve as champions to promote referrals to treatment for substance use disorders; (2) collaboration between law enforcement and community addiction treatment providers should be strengthened, and (3) MAT should be supported and expanded in rural areas.

Diffusion of medications for opioid use disorder treatment in jail settings: a convergent mixed methods study of jail staff perspectives

BACKGROUND

Implementation of medications for opioid use disorder (MOUD) in jails varies by facility and across states. Organizational climate, including staff attitudes toward change and exposure to education, can influence perceptions of innovations like MOUD in jails. Using a mixed methods design, we aimed to understand the association between organizational climate and jail staff perceptions of MOUD.

METHODS

Jail staff (n = 111) who operate MOUD programs in 6 Massachusetts jails completed surveys that included the Organizational Readiness for Implementing Change (ORIC) survey. Random effects logistic regression models assessed associations between organizational climate and several outcomes of perceived MOUD efficacy, acceptability, and knowledge, while controlling for covariates. Jail staff (N = 61) participated in qualitative interviews and focus groups focused on organizational climate and knowledge diffusion, which we analyzed using inductive and deductive methods.

RESULTS

The results indicate that organizational change readiness on the ORIC was associated with positive perceptions of MOUD, and educational resources facilitated MOUD implementation. Greater ORIC was associated with higher perception of methadone as highly acceptable for jail populations (Odds ratio [OR] 2.3, 95% Confidence Interval [CI] 1.2 to 4.4), and high knowledge of methadone (OR 2.3, 95% CI 1.1 to 4.9), with similar magnitude of effects for buprenorphine. High levels of training for jail staff on methadone and buprenorphine were also associated with higher knowledge of these medications (Methadone: OR 7.2, 95% CI 2.2 to 23.2; Buprenorphine: OR 3.4, 95% CI 1.2 to 9.5). Qualitative results point towards the importance of organizational climate and elucidate educational strategies to improve staff perceptions of MOUD.

CONCLUSION

Results underscore the importance of organizational climate for successful implementation of jail MOUD programs and provide support for medication-specific educational resources as a facilitator of successful MOUD implementation in jail settings. Findings highlight implementation strategies that may improve jail staff perceptions of MOUD.

Screening Incarcerated Women for Opioid Use Disorder

The overall aim of the present study is to examine the utility of the DSM OUD Checklist and the NM-ASSIST screening tools to identify symptoms consistent with OUD among incarcerated women in county jails. This study contributes to the existing literature because research on screening and assessment approaches for incarcerated women has been limited. The focus of the current study is to describe the screening procedures and study recruitment for a larger parent study focused on increasing treatment linkages. Study findings indicate a positive correlation between indicators of OUD using the two screening tools, as well as a high degree of correlation between street opioid misuse and other high-risk drug indicators (overdose and injection practices). These findings underscore the importance of outreach, screening, and intervention in real-world settings, including jails, in order to increase access to OUD treatment among this vulnerable sample of women.

"Nothing but a rope to hang yourself:" The toll of mass supervision on mental well-being

While incarceration has proven detrimental to mental well-being, it remains unknown if community supervision is better for mental well-being than incarceration. Our objective was to explore the individual- and community-level relationships between community supervision and mental well-being and to examine inequities by race. We conducted 20 in-depth interviews with individuals on community supervision (e.g., probation, parole) in North Carolina and conducted thematic analysis separately by race. For many, criminal legal involvement began at a young age, often due to substance use for White individuals or over-policing for Black participants. The themes were: (1) "It's a Thursday. Move on.": surviving over the life course in the context of the criminal legal system; (2) "Merry go round of death": the criminal legal system as a trap; (3) "I love you, but I have to love you from over here": social support as a double-edged sword while on community supervision; and (4) " [Probation] ain't nothing but a rope to hang yourself": mental health issues created and exacerbated by criminal legal involvement. Individuals' experiences on community supervision were often dehumanizing and difficult, preventing them from achieving well-being. This system must be redesigned to meet individual and community needs.

Effect of incarceration and opioid agonist treatment transitions on risk of hospitalisation with injection drug use-associated bacterial infections: A self-controlled case series in New South Wales, Australia

BACKGROUND

Transitional times in opioid use, such as release from prison and discontinuation of opioid agonist treatment (OAT), are associated with health harms due to changing drug consumption practices and limited access to health and social supports. Using a self-controlled (within-person) study design, we aimed to understand if these transitions increase risks of injection drug use-associated bacterial infections.

METHODS

We performed a self-controlled case series among a cohort of people with opioid use disorder (who had all previously accessed OAT) in New South Wales, Australia, 2001-2018. The outcome was hospitalisation with injecting-related bacterial infections. We divided participants' observed days into time windows related to incarceration and OAT receipt. We compared hospitalization rates during focal (exposure) windows and referent (control) windows (i.e., 5-52 weeks continuously not incarcerated or continuously receiving OAT). We estimated adjusted incidence rate ratios (aIRR) using conditional logistic regression, adjusted for time-varying confounders.

RESULTS

There were 7590 participants who experienced hospitalisation with injecting-related bacterial infections (35% female; median age 38 years; 78% hospitalised with skin and soft-tissue infections). Risk for injecting-related bacterial infections was elevated for two weeks following release from prison (aIRR 1.45; 95%CI 1.22-1.72). Risk was increased during two weeks before (aIRR 1.89; 95%CI 1.59-2.25) and after (aIRR 1.91; 95%CI 1.54-2.36) discontinuation of OAT, and during two weeks before (aIRR 3.63; 95%CI 3.13-4.22) and after (aIRR 2.52; 95%CI 2.09-3.04) OAT initiation.

CONCLUSION

Risk of injecting-related bacterial infections varies greatly within-individuals over time. Risk is raised immediately after prison release, and around initiation and discontinuation of OAT. Social contextual factors likely contribute to excess risks at transitions in incarceration and OAT exposure.

Opioid toxicity deaths in Black persons who experienced provincial incarceration in Ontario, Canada 2015-2020: A population-based study

OBJECTIVE

In the context of mass incarceration and the opioid toxicity crisis in North America, there is a lack of data on the burden of opioid toxicity deaths in Black persons who experience incarceration. We aimed to describe absolute and relative opioid toxicity mortality for Black persons who experienced incarceration in Ontario, Canada between 2015 and 2020.

METHODS

We linked data for all persons incarcerated in provincial correctional facilities and all persons who died from opioid toxicity in Ontario between 2015 and 2020, and accessed public data on population sizes. We described the characteristics of Black persons who were incarcerated and died from opioid toxicity, and calculated absolute mortality rates, as well as age-standardized mortality rates compared with all persons in Ontario not incarcerated during this period.

RESULTS

Between 2015 and 2020, 0.9% (n = 137) of 16,177 Black persons who experienced incarceration died from opioid toxicity in custody or post-release, for an opioid toxicity death rate of 0.207 per 100 person years. In the two weeks post-release, the opioid toxicity death rate was 1.34 per 100 person years. Standardized for age and compared with persons not incarcerated, the mortality ratio (SMR) was 17.8 (95%CI 16.4-23.1) for Black persons who experienced incarceration.

CONCLUSIONS

We identified a large, inequitable burden of opioid toxicity death for Black persons who experience incarceration in Ontario, Canada. Work is needed to support access to culturally appropriate prevention and treatment in custody and post-release for persons who are Black, and to prevent incarceration and improve determinants of health.

Recent Incarceration, Substance Use, Overdose, and Service Use Among People Who Use Drugs in Rural Communities

Importance

Drug use and incarceration have a substantial impact on rural communities, but factors associated with the incarceration of rural people who use drugs (PWUD) have not been thoroughly investigated.

Objective

To characterize associations between recent incarceration, overdose, and substance use disorder (SUD) treatment access among rural PWUD.

Design, Setting, and Participants

For this cross-sectional study, the Rural Opioid Initiative research consortium conducted a survey in geographically diverse rural counties with high rates of overdose across 10 US states (Illinois, Wisconsin, North Carolina, Oregon, Kentucky, West Virginia, Ohio, Massachusetts, New Hampshire, and Vermont) between January 25, 2018, and March 17, 2020, asking PWUD about their substance use, substance use treatment, and interactions with the criminal legal system. Participants were recruited through respondent-driven sampling in 8 rural US regions. Respondents who were willing to recruit additional respondents from their personal networks were enrolled at syringe service programs, community support organizations, and through direct community outreach; these so-called seed respondents then recruited others. Of 3044 respondents, 2935 included participants who resided in rural communities and reported past-30-day injection of any drug or use of opioids nonmedically via any route. Data were analyzed from February 8, 2022, to September 15, 2023.

Exposure

Recent incarceration was the exposure of interest, defined as a report of incarceration in jail or prison for at least 1 day in the past 6 months.

Main Outcomes and Measures

The associations between PWUD who were recently incarcerated and main outcomes of treatment use and overdose were examined using logistic regression.

Results

Of 2935 participants, 1662 (56.6%) were male, 2496 (85.0%) were White; the mean (SD) age was 36 (10) years; and in the past 30 days, 2507 (85.4%) reported opioid use and 1663 (56.7%) reported injecting drugs daily. A total of 1224 participants (41.7%) reported recent incarceration, with a median (IQR) incarceration of 15 (3-60) days in the past 6 months. Recent incarceration was associated with past-6-month overdose (adjusted odds ratio [AOR], 1.38; 95% CI, 1.12-1.70) and recent SUD treatment (AOR, 1.62; 95% CI, 1.36-1.93) but not recent medication for opioid use disorder (MOUD; AOR, 1.03; 95% CI, 0.82-1.28) or currently carrying naloxone (AOR, 1.02; 95% CI, 0.86-1.21).

Conclusions and Relevance

In this cross-sectional study of PWUD in rural areas, participants commonly experienced recent incarceration, which was not associated with MOUD, an effective and lifesaving treatment. The criminal legal system should implement effective SUD treatment in rural areas, including MOUD and provision of naloxone, to fully align with evidence-based SUD health care policies.

A Diagram of the Social-Ecological Conditions of Opioid Misuse and Overdose

The United States is experiencing a crisis of opioid misuse and overdose. To understand the underlying factors, researchers have begun looking upstream to identify social and structural determinants. However, no study has yet aggregated these into a comprehensive ecology of opioid overdose. We scoped 68 literature sources and compiled a master list of opioid misuse and overdose conditions. We grouped the conditions and used the Social Ecological Model to organize them into a diagram. We reviewed the diagram with nine subject matter experts (SMEs) who provided feedback on its content, design, and usefulness. From a literature search and SME interviews, we identified 80 unique conditions of opioid overdose and grouped them into 16 categories. In the final diagram, we incorporated 40 SME-recommended changes. In commenting on the diagram's usefulness, SMEs explained that the diagram could improve intervention planning by demonstrating the complexity of opioid overdose and highlighting structural factors. However, care is required to strike a balance between comprehensiveness and legibility. Multiple design formats may be useful, depending on the communication purpose and audience. This ecological diagram offers a visual perspective of the conditions of opioid overdose.

Characteristics of post-overdose outreach programs and municipal-level opioid overdose in Massachusetts

BACKGROUND

Post-overdose outreach programs have proliferated in response to opioid overdose. Implementing these programs is associated with reductions in overdose rates, but the role of specific program characteristics in overdose trends has not been evaluated.

METHODS

Among 58 Massachusetts municipalities with post-overdose outreach programs, we examined associations between five domains of post-overdose outreach program characteristics (outreach contact rate, naloxone distribution, coercive practices, harm reduction activities, and social service provision or referral) and rates of fatal opioid overdoses and opioid-related emergency medical system responses (i.e., ambulance activations) per calendar quarter from 2013 to 2019 using segmented regression analyses with adjustment for municipal covariates and fixed effects. For both outcomes, each domain was modeled: a) individually, b) with other characteristics, and c) with other characteristics and municipal-level fixed effects.

RESULTS

There were no significant associations (p < 0.05) between outreach contact rate, naloxone distribution, coercive practices, or harm reduction activities with municipal fatal overdose trends. Municipalities with programs providing or referring to more social services experienced 21% fewer fatal overdoses compared to programs providing or referring to more social services (Rate Ratio (RR) 0.79, 95% Confidence Interval (CI) 0.66-0.93, p = 0.01). Compared to municipalities in quarters when programs had no outreach contacts, municipalities with some, but less than the median outreach contacts, experienced 14% lower opioid-related emergency responses (RR 0.86, 95% CI 0.78-0.96, p = 0.01). Associations between naloxone distribution, coercive practices, harm reduction practices, or social services and opioid-related emergency responses were not consistently significant across modeling approaches.

CONCLUSION

Municipalities with post-overdose outreach programs providing or referring to more social services had lower fatal opioid overdose rates. Municipalities in quarters when programs outreached to overdose survivors had fewer opioid-related emergency responses, but only among programs with below the median number of outreach contacts. Social service linkage should be core to post-overdose programs. Evaluations should assess program characteristics to optimize program design.

Treatment setting among individuals with opioid use and criminal legal involvement, housing instability, or Medicaid insurance, 2015-2021

Background

Individuals with criminal legal involvement (CLI), housing instability, or Medicaid insurance may experience barriers accessing substance use treatment in certain settings. Previous research has found individuals in these groups are less likely to receive medications for opioid use disorder (MOUD), but the role treatment setting may play in low rates of MOUD is unclear.

Methods

We conducted a cross-sectional study using nationally representative survey data from 2015 to 2021. We estimated the proportion of individuals who had CLI, housing instability, or Medicaid insurance who received substance use treatment in a variety of settings. We used multivariable logistic regressions to estimate the associations between group and the receipt of MOUD across treatment settings.

Results

Individuals with CLI, housing instability, or Medicaid insurance were more likely to receive substance use treatment in hospitals, rehabilitation, and mental health facilities compared with individuals not in these groups. However, all groups accessed substance use treatment in doctors' offices at similar rates. Treatment at a doctor's office was associated with the highest likelihood of receiving MOUD (aOR 4.73 [95% CI: 2.2.15-10.43]). Across multiple treatment settings, Individuals with CLI or housing instability were less likely to receive MOUD.

Conclusions

Individuals with CLI, housing instability, or Medicaid insurance are more likely to access substance use treatment at locations associated with lower rates of MOUD use. MOUD access across treatment settings is needed to improve engagement and retention in treatment for patients experiencing structural disadvantage or who have low incomes.

Fatal drug overdose among middle-aged Black men: A life table analysis

BACKGROUND

For Black men of middle-age, the overdose mortality statistics are increasingly dire. To better understand the severity of the crisis, we estimated the cumulative risk of drug overdose deaths among non-Hispanic Black men in mid-life using a period life table approach. We report the chances of Black men aged 45 years dying of a drug overdose before age 60.

METHODS

A period life table reflects what would happen to a hypothetical cohort if it experienced the prevailing age-specific probabilities of death. In our hypothetical cohort, we followed 100,000 non-Hispanic Black men aged 45 years for 15 years. All-cause death probabilities were obtained from the National Center for Health Statistics (NCHS) 2021 life table series. Overdose mortality rates were obtained from the National Vital Statistics System through the Wide-Ranging Online Data for Epidemiologic Research of the Centers for Disease Control and Prevention (CDC WONDER) database. We also constructed a period life table for a comparison group of White men.

RESULTS

The life table shows that, for Black men who are 45 years of age in the United States, 1 in 52 (nearly 2%) is expected to die of drug overdose before reaching age 60, if current mortality rates persist. For White men, the estimate is 1 in 91 men (about 1%). The life table also shows that from age 45 to 59 years, the number of overdose deaths increased in the cohort of Black men but decreased in White men.

CONCLUSIONS

This study extends our understanding of the immense loss to Black communities from the preventable drug deaths of Black men in middle-age.

Mediation of the Effect of Incarceration on Selling Sex Among Black Sexual Minority Men and Black Transgender Women in the HPTN 061 Study

Incarceration among Black sexual minority men and Black transgender women (BSMM/BTW) is disproportionately high in the United States. Limited research has documented the disruptive effect of incarceration on sexual networks and sexual partnership exchange among BSMM/BTW. We estimate the influence of incarceration on selling sex and mediating pathways among 1169 BSMM/BTW enrolled in the HIV Prevention Trials Network (HPTN) 061 cohort to assess this relationship. Mediators investigated were social support, violence, illicit drug use, and distress due to experienced racism and homophobia. During the 6 months following baseline, 14% of the cohort was incarcerated, including 24% of BTW. After adjustment, recent incarceration was associated with 1.57 (95% CI 1.02, 2.42) times the risk of subsequently selling sex. The hypothesized mediators together explained 25% of the relationship, with an indirect effect risk ratio of 1.09 (95% CI 0.97, 1.24). Our results document an association and call for more research investigating mechanisms.

Spatiotemporal Analysis Exploring the Effect of Law Enforcement Drug Market Disruptions on Overdose, Indianapolis, Indiana, 2020-2021

Objectives. To test the hypothesis that law enforcement efforts to disrupt local drug markets by seizing opioids or stimulants are associated with increased spatiotemporal clustering of overdose events in the surrounding geographic area. Methods. We performed a retrospective (January 1, 2020 to December 31, 2021), population-based cohort study using administrative data from Marion County, Indiana. We compared frequency and characteristics of drug (i.e., opioids and stimulants) seizures with changes in fatal overdose, emergency medical services nonfatal overdose calls for service, and naloxone administration in the geographic area and time following the seizures. Results. Within 7, 14, and 21 days, opioid-related law enforcement drug seizures were significantly associated with increased spatiotemporal clustering of overdoses within radii of 100, 250, and 500 meters. For example, the observed number of fatal overdoses was two-fold higher than expected under the null distribution within 7 days and 500 meters following opioid-related seizures. To a lesser extent, stimulant-related drug seizures were associated with increased spatiotemporal clustering overdose. Conclusions. Supply-side enforcement interventions and drug policies should be further explored to determine whether they exacerbate an ongoing overdose epidemic and negatively affect the nation's life expectancy. (Am J Public Health. 2023;113(7):750-758. https://doi.org/10.2105/AJPH.2023.307291).

Police Stigma toward People with Opioid Use Disorder: A Study of Illinois Officers

BackgroundFatal opioid overdoses continue to break historical records. Stigma toward people with opioid use disorder (OUD) can negatively impact treatment access, retention, and recovery. Attitudes and beliefs of police officers can profoundly shape key discretionary decisions. Therefore, we examined police officer views indicating stigma toward those with OUD.ObjectivesWe administered an online survey to select Illinois police departments using a stratified random sampling strategy with a final sample of 248 officers from 27 police departments. We asked officers questions measuring stigmatizing attitudes toward people with OUD including distrust, blame, shame, and fear. We found officers held somewhat stigmatizing views with a mean score of 4.0 on a scale of 1 (least stigmatic) to 6 (most stigmatic).ResultsRegression results showed certain officer characteristics were associated with more stigmatizing attitudes of blaming and distrust of those with OUD, including gender, education, race, years in policing, and department size.Conclusions/ImportanceSince most officers in the sample held at least some stigmatizing views toward people with OUD, this may impede the feasibility and acceptability of criminal justice interventions meant to improve behavioral health, such as police deflection programs that link people who use drugs to treatment in lieu of arrest. Departments should offer officer training and education on substance use disorders, treatment for addiction, and the potential for a person's recovery. Training should allow officers to hear directly from, or learn about, personal experiences of people who use drugs and have been in recovery, as this type of interaction has been shown to reduce stigma.

Re-incarceration and associated social, structural and behavioural factors among people who use drugs in an urban Canadian setting

BACKGROUND

People who use drugs (PWUD) are disproportionately incarcerated, however little is known about specific substance use, social and structural factors associated with re-incarceration among PWUD. We aimed to identify the socio-structural and substance use factors associated with re-incarceration among structurally-marginalized PWUD.

METHODS

We used longitudinal data from two prospective cohorts of PWUD in Vancouver, Canada. We included adults reporting at least one incarceration event in the last six months and who completed at least one additional follow-up study visit. We performed multivariable extended Cox regression to explore factors associated with re-incarceration.

RESULTS

Among 468 eligible participants, the median age was 40 years (Q1-Q3 = 34-46 years), 346 (73.9%) were men, 177 (37.8%) identified as Indigenous, and 227 (48.5%) experienced at least one re-incarceration event. Incidence rate of re-incarceration was 157 incarceration events per 1000 person years. In multivariable analyses, homelessness (adjusted hazard ratio [AHR] = 2.17; 95% confidence interval [95% CI]: 1.79-2.61), community judicial supervision (AHR = 3.89; 95% CI: 3.21-4.71) and re-incarceration during the study period (once: AHR = 1.95, 95% CI: 1.55-2.44; two or more events: AHR = 1.53, 95% CI: 1.23-1.90) were positively associated with re-incarceration. Among substance use variables that included illicit drugs, only heavy alcohol use remained significantly associated with re-incarceration across analyses after adjustment (AHR = 1.32; 95% CI: 1.06-1.65). Engagement in addiction treatment (AHR = 0.63; 95% CI: 0.53-0.75), mental illness (AHR = 0.70; 95% CI: 0.59-0.84) and age (AHR = 0.96; 95% CI: 0.95-0.97) were negatively associated with re-incarceration.

CONCLUSION

Access to housing and substance use services, including treatment for alcohol use disorder, following incarceration may reduce re-incarceration among PWUD. The high rates of re-incarceration of PWUD in our sample underscores how structural factors-such as homelessness and criminalization of substance use-drive re-incarceration among PWUD.

Baseline characteristics of people experiencing homelessness with a recent drug overdose in the PHOENIx pilot randomised controlled trial

BACKGROUND

Drug-related deaths in Scotland are the highest in Europe. Half of all deaths in people experiencing homelessness are drug related, yet we know little about the unmet health needs of people experiencing homelessness with recent non-fatal overdose, limiting a tailored practice and policy response to a public health crisis.

METHODS

People experiencing homelessness with at least one non-fatal street drug overdose in the previous 6 months were recruited from 20 venues in Glasgow, Scotland, and randomised into PHOENIx plus usual care, or usual care. PHOENIx is a collaborative assertive outreach intervention by independent prescriber NHS Pharmacists and third sector homelessness workers, offering repeated integrated, holistic physical, mental and addictions health and social care support including prescribing. We describe comprehensive baseline characteristics of randomised participants.

RESULTS

One hundred and twenty-eight participants had a mean age of 42 years (SD 8.4); 71% male, homelessness for a median of 24 years (IQR 12-30). One hundred and eighteen (92%) lived in large, congregate city centre temporary accommodation. A quarter (25%) were not registered with a General Practitioner. Participants had overdosed a mean of 3.2 (SD 3.2) times in the preceding 6 months, using a median of 3 (IQR 2-4) non-prescription drugs concurrently: 112 (87.5%) street valium (benzodiazepine-type new psychoactive substances); 77 (60%) heroin; and 76 (59%) cocaine. Half (50%) were injecting, 50% into their groins. 90% were receiving care from Alcohol and Drug Recovery Services (ADRS), and in addition to using street drugs, 90% received opioid substitution therapy (OST), 10% diazepam for street valium use and one participant received heroin-assisted treatment. Participants had a mean of 2.2 (SD 1.3) mental health problems and 5.4 (SD 2.5) physical health problems; 50% received treatment for physical or mental health problems. Ninety-one per cent had at least one mental health problem; 66% had no specialist mental health support. Participants were frail (70%) or pre-frail (28%), with maximal levels of psychological distress, 44% received one or no daily meal, and 58% had previously attempted suicide.

CONCLUSIONS

People at high risk of drug-related death continue to overdose repeatedly despite receiving OST. High levels of frailty, multimorbidity, unsuitable accommodation and unmet mental and physical health care needs require a reorientation of services informed by evidence of effectiveness and cost-effectiveness. Trial registration UK Clinical Trials Registry identifier: ISRCTN 10585019.

"Just fighting for my life to stay alive": a qualitative investigation of barriers and facilitators to community re-entry among people with opioid use disorder and incarceration histories

BACKGROUND

During the period of community re-entry immediately following release from jail or prison, individuals with opioid use disorder (OUD) face structural barriers to successful re-entry and high risk of overdose. Few published studies investigate experiences in the immediate period (i.e., first 24 h) of re-entry among people with OUD.

AIM

To understand the barriers and facilitators to treatment and reintegration of people with OUD during the initial transition from carceral settings back into the community.

METHODS

From January-December 2017, we conducted 42 semi-structured qualitative interviews with patients with a history of incarceration who were receiving methadone at a not-for-profit, low-barrier opioid treatment program. Interviews probed participants' community re-entry experiences immediately following incarceration. Interviews were transcribed and analyzed using a Thematic Analysis approach.

RESULTS

The main themes described the experiences during the 24 h following release, reacclimating and navigating re-entry barriers, and re-entry preparedness and planning. Participants noted the initial 24 h to be a period of risk for returning to substance use or an opportunity to engage with OUD treatment as well as a tenuous period where many lacked basic resources such as shelter or money. When discussing the subsequent re-entry period, participants noted social challenges and persistent barriers to stable housing and employment. Participants overall described feeling unprepared for release and suggested improvements including formal transition programs, improved education, and support to combat the risk of overdose and return to substance use after incarceration.

CONCLUSIONS

In this study that qualitatively examines the experiences of people with incarceration histories and OUD enrolled in methadone treatment, we found that participants faced many barriers to community re-entry, particularly surrounding basic resources and treatment engagement. Participants reported feeling unprepared for release but made concrete suggestions for interventions that might improve the barriers they encountered. Future work should examine the incorporation of these perspectives of people with lived experience into the development of transition programs or re-entry classes.

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

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

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.

Medications for opioid use disorder during incarceration and post-release outcomes

BACKGROUND

Continuation or initiation of MOUDs during incarceration could improve post-release outcomes by preventing return to opioid use and reducing risk of overdose. People with OUD involved in the criminal legal system are a vulnerable population, yet little research has comprehensively examined post-release outcomes associated with receiving MOUDs in jail and prison settings.

METHODS

The authors conducted a review of published peer-reviewed literature on post-release outcomes associated with the use of MOUDs in correctional settings to determine implications for further research and policy.

RESULTS

Results showed compelling evidence supporting the use of MOUDs for currently incarcerated populations, with almost all studies showing that MOUDs provided during incarceration increased community-based treatment engagement post-release. There is also evidence that initiating or continuing MOUDs during incarceration is associated with decreased opioid use and overdoses post-release, without increasing criminal involvement.

CONCLUSIONS

Findings indicate that forcing tapering and withdrawal during incarceration can have dire consequences upon release into the community. Initiating or continuing MOUDs during incarceration reduces the risk for opioid use and overdose upon release by maintaining opioid tolerance and increasing community treatment engagement.

Multidimensional assessment of access to medications for opioid use disorder across urban and rural communities: A scoping review

BACKGROUND

The majority of patients with opioid use disorder do not receive medications for opioid use disorder (MOUD), especially in rural areas. The patient-centered access to healthcare framework posits access as a multidimensional phenomenon impacted by five healthcare system and five patient ability dimensions. Interventions to improve local MOUD treatment outcomes require an understanding of how these dimensions differ across urban and rural communities. This scoping review sought to systematically appraise the literature on MOUD access across urban and rural communities (i.e., rurality) in the US using the patient-centered access framework.

METHODS

We performed a scoping review of 1) electronic databases, 2) grey literature, and 3) correspondence with content experts (March 2021). We included articles specifying the study sample by rurality and examining at least one dimension of access to MOUD. The analysis and qualitative synthesis of study results examined study characteristics and categorized key findings by access dimensions.

RESULTS

The search produced 3963 unique articles, of which 147 met inclusion criteria. Among included studies, 96% (142/147) examined healthcare system dimensions of access while less than 20% (25/147) examined any of the five dimensions of patient ability. Additionally, 49% (72/147) of studies compared access dimensions by rurality. Across studies, increasing rurality was associated with fewer available MOUD services, but little was known about geographic variation in other critical dimensions of access.

CONCLUSIONS

The vast majority of studies examined healthcare system dimensions of MOUD access and few studies made comparisons by rurality or prioritized the patient's perspective, limiting our understanding of how access differs by rurality in the US. As COVID-19 spurs novel changes in MOUD delivery, this inadequate multidimensional understanding of MOUD access may impede the tailoring of interventions to local needs. There is an urgent need for mixed-methods and community-engaged research prioritizing the patient's perspective of MOUD access by rurality.

REGISTRATION

Open Science Framework (https://osf.io/wk6b9/).

Trust and service engagement among people who inject drugs after release from prison

BACKGROUND

Compounding histories of injecting drug use and incarceration can marginalise people engaging with services, making it difficult for them to address their health and social welfare needs, particularly when they navigate community re-entry service supports. Drawing on Hall and colleagues' five components of trust, this paper seeks to understand how trust in service providers fosters (or inhibits) effective service engagement from the perspective of people who inject drugs during the prison post-release period.

METHODS

Between September 2018 and May 2020, qualitative in-depth interviews were completed with 48 adults (33 men, 15 women) recruited from SuperMIX (a longitudinal cohort study of people with a history of injection drug use in Victoria, Australia). Data relating to service engagement were coded against the five components of trust: competence, fidelity, honesty, global trust, and confidence.

RESULTS

Reflections of post-release service engagement frequently focused on interactions with community corrections (parole) officers. Depictions of trust were consistently portrayed within the context of negative experiences and deficits, whereby trusting provider relationships and interactions were rarely described. Most participants recounted a stark absence of fidelity (that is, "pursuing a [client's] best interests"), with some participants detailing circumstances in which their vulnerability was purposefully, almost strategically, exploited. These encounters nearly always had the consequence of impeding the participant's positive progression in the post-release integration period.

CONCLUSION

There is an urgent need to prioritise the client in health and social service delivery in the post-release transition-to-community period and recognise the importance of trust in delivering effective services to people whose life histories make them highly vulnerable to marginalisation.

Incarceration history, antiretroviral therapy, and stigma: A cross-sectional study of people with HIV who inject drugs in St. Petersburg, Russia

BACKGROUND

The HIV epidemic is intertwined with substance use and incarceration in Russia. The relationships between incarceration history, HIV treatment history, and stigma experiences among people with HIV (PWH) who inject drugs in Russia have not been well described.

METHODS

We conducted a cross-sectional study of a cohort of PWH with opioid use disorder who inject drugs (n=201) recruited at a narcology (substance use treatment) hospital in St. Petersburg, Russia from September 2018 to December 2020. The primary analysis evaluated the association between self-reported prior incarceration and prior antiretroviral therapy (ART) initiation using multivariable logistic regression to adjust for demographic, social, and clinical covariates. We used multivariable linear regression models to analyze associations between prior incarceration and two secondary outcomes: HIV stigma score (11-item abbreviated Berger scale) and substance use stigma score (21-item combination of Substance Abuse Self-Stigma Scale and Stigma-related Rejection Scale).

RESULTS

Mean age was 37 (SD 5) years; 58.7% were male. Participants had been living with HIV for a mean of 13 (SD 6) years. Over two thirds (69.2%) of participants reported prior incarceration. One third (35.3%) of participants reported prior ART initiation. Prior incarceration was not significantly associated with prior ART initiation (AOR 1.76; 95% CI: 0.81, 3.83). Prior incarceration was associated with a lower HIV stigma score (adjusted mean difference in z-score: -0.50; 95%CI: -0.81, -0.19) but was not significantly associated with substance use stigma score (adjusted mean difference in z-score: -0.10; 95%CI: -0.42, 0.21).

CONCLUSION

Prior incarceration was common, and rates of prior ART initiation were low even though most participants had been living with HIV for at least a decade. We did not find an association between prior incarceration and prior ART initiation, which suggests a need to explore whether opportunities to initiate ART during or after incarceration are missed.

CLINICAL TRIAL NUMBER

NCT03290391.

"And Then COVID Hits": A Qualitative Study of How Jails Adapted Services to Treat Opioid Use Disorder During COVID-19

Background: Jails in Massachusetts are among the first nationwide to provide correctional populations with medications to treat opioid use disorder (MOUD). The COVID-19 pandemic caused jails to pivot and adapt MOUD programming. We aimed to identify adaptations and barriers to MOUD access that COVID-19 exacerbated or created, and document new elements that staff wish to sustain as COVID-19 recedes. Methods: We conducted semi-structured in-depth interviews and focus groups in 2020-2021 with 29 jail staff who implement MOUD programming in two Massachusetts jails. We conducted qualitative data analysis in Atlas.ti 8 using an inductive approach. Results: Participants shared that access to MOUD among correctional populations is understood by jail staff to be an essential health service. Thus, to facilitate continued access to MOUD, both during incarceration and also at community reentry, jail staff quickly implemented changes in MOUD regulations and dosing protocols and established telehealth capacity. Despite these program adaptations, participants identified how COVID-19 increased health and social needs among correctional populations, reduced availability of community-based healthcare and recovery-supportive services, and introduced new factors that could undermine recovery. Innovations that participants wished to sustain as COVID-19 receded included telehealth capacity, smaller-sized therapeutic groups, and application of a public health approach to treat opioid use disorder among correctional populations. Conclusions: During disruptive events, jails can adapt MOUD programming to ensure access for people living in jail and upon release. Findings identify factors for understanding the outcomes of jail-based MOUD programming during COVID-19 and highlight opportunities to improve service delivery after COVID-19.

[Prevention of Drug-related Mortality after Release from Prison]

The transition process of release from prisons into the community is associated with high risks for users of opioids. Especially in the first 10-14 days in freedom, the risk of drug-related overdoses is extremely high, in the worst case with lethal outcome. There are two main medical strategies for the target group: on the one hand, medication-assisted treatment before, during and after incarceration, and on the other hand, edcuation about and acccess to naloxone as an antidote in case of opioid-related overdose. This article gives an overview of current numbers of drug-related deaths after release from prison in Germany and of scientific knowledge regarding the efficacy of medication-assisted treatment and naloxone provision for opioid users at the interface of custody and freedom. Finally, necessary interventions to avoid drug-related overdose with lethal consequences are described. For this purpose, a selective literature review was carried out and 16 crime agencies in Germany were contacted.

Barriers and facilitators to opioid agonist treatment (OAT) engagement among individuals released from federal incarceration into the community in Ontario, Canada

Introduction

Correctional populations with opioid use disorder experience increased health risks during community transition periods. Opioid Agonist Treatment (OAT) can reduce these risks, but retention is a key challenge. This study addresses a knowledge gap by describing facilitators and barriers to OAT engagement among federal correctional populations released into the community in Ontario, Canada.

Methods

This article describes results from a longitudinal mixed-methods study examining OAT transition experiences among thirty-five individuals released from federal incarceration in Ontario, Canada. Assessments were completed within one year of participants’ release. Data were thematically analyzed.

Results

The majority (77%) of participants remained engaged in OAT, however, 69% had their release suspended and 49% returned to custody. Key facilitators for OAT engagement included flexibility, positive staff rapport, and structure. Fragmented OAT transitions, financial OAT coverage, balancing reintegration requirements, logistical challenges, and inaccessibility of ‘take-home’ OAT medications were common barriers.

Conclusions

Post-incarceration transition periods are critical for OAT retention, yet individuals in Ontario experience barriers to OAT engagement that contribute to treatment disruptions and related risks such as relapse and/or re-incarceration. Additional measures to support community OAT transitions are required, including improved discharge planning, amendments to OAT and financial coverage policies, and an expansion of OAT options.

Medication for opioid use disorder treatment continuity post-release from jail: A qualitative study with community-based treatment providers

BACKGROUND

People released from jail are at elevated opioid overdose risk. Medications for opioid use disorder (MOUD) are effective in reducing overdoses. MOUD treatment was recently mandated in seven Massachusetts jails, but little is known about barriers and facilitators to treatment continuity post-release. We aimed to assess MOUD provider perspectives on treatment continuity among people released from jail.

METHODS

We conducted qualitative interviews with 36 medical, supervisory, and administrative staff at MOUD programs that serve jail-referred patients. We used the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation science framework to guide development of instruments, codes, and analyses. We employed deductive and inductive coding, and a grounded theory analytical approach to identify salient themes.

RESULTS

Inner context findings highlighted necessary adjustments among jail staff to approve MOUD treatment, especially with agonist medications that were previously considered contraband. Participants perceived that some staff within jails favored abstinence-based recovery, viewing agonists as a crutch. Bridging results highlighted the importance of inter-agency communication and coordination to ensure information transfer for seamless treatment continuity in the community post-release. Pre-release planning, release on pre-scheduled dates, medication provision to cover gaps between jail release and intake at community MOUD sites, and exchange of treatment information across agencies were viewed as paramount to success. Unexpected early releases and releases from court were viewed as barriers to treatment coordination. Outer context domains were largely tied to social determinants of health. Substantial barriers to treatment continuity included shelter, food security, employment, transportation, and insurance reactivation.

CONCLUSION

Through qualitative interviews with community-based MOUD staff, we identified salient barriers and facilitators to treatment continuity post-release from jails. Findings point to needed investments in care coordination, staffing, and funding to strengthen jail-to-community-based MOUD treatment, removing barriers to continuity, and decreasing opioid overdose deaths during this high-risk transition.

Patient-centered quality measurement for opioid use disorder: Development of a taxonomy to address gaps in research and practice

Background: Evidence-based treatment is provided infrequently and inconsistently to patients with opioid use disorder (OUD). Treatment guidelines call for high-quality, patient-centered care that meets individual preferences and needs, but it is unclear whether current quality measures address individualized aspects of care and whether measures of patient-centered OUD care are supported by evidence. Methods: We conducted an environmental scan of OUD care quality to (1) evaluate patient-centeredness in current OUD quality measures endorsed by national agencies and in national OUD treatment guidelines; and (2) review literature evidence for patient-centered care in OUD diagnosis and management, including gaps in current guidelines, performance data, and quality measures. We then synthesized these findings to develop a new quality measurement taxonomy that incorporates patient-centered aspects of care and identifies priority areas for future research and quality measure development. Results: Across 31 endorsed OUD quality measures, only two measures of patient experience incorporated patient preferences and needs, while national guidelines emphasized providing patient-centered care. Among 689 articles reviewed, evidence varied for practices of patient-centered care. Many practices were supported by guidelines and substantial evidence, while others lacked evidence despite guideline support. Our synthesis of findings resulted in EQuIITable Care, a taxonomy comprised of six classifications: (1) patient Experience and engagement, (2) Quality of life; (3) Identification of patient risks; (4) Interventions to mitigate patient risks; (5) Treatment; and (6) Care coordination and navigation. Conclusions: Current quality measurement for OUD lacks patient-centeredness. EQuIITable Care for OUD provides a roadmap to develop measures of patient-centered care for OUD.

Concurrent use of opioids and stimulants and risk of fatal overdose: A cohort study

Background

Stimulant use has been rising among people with opioid use disorder in recent years in North America, alongside a parallel rise in illicit drug toxicity (overdose) deaths. This study aimed to examine the association between stimulant use and overdose mortality.

Methods

Data from a universal health insurance client roster were used to identify a 20% random general population sample (aged ≥12) in British Columbia, Canada between January 1 2015 and December 31 2018 (N = 1,089,682). Provincial health records were used to identify people who used opioids and/or stimulants. Fatal overdose observed during follow-up (January 12,015- December 312,018) was retrieved from Vital Statistics Death Registry and BC Coroners Service Data. Potential confounders including age, sex, health region, comorbidities and prescribed medications were retrieved from the provincial client roster and health records.

Results

We identified 7460 people who used stimulants and or opioids. During follow-up there were 272 fatal overdose events. People who used both opioids and stimulants had more than twice the hazard of fatal overdose (HR: 2.02, 95% CI: 1.47-2.78, p < 0.001) compared to people who used opioids only. The hazard of death increased over time among people who used both opioids and stimulants.

Conclusions

There is an urgent need to prioritize the service needs of people who use stimulants to reduce overdose mortality in British Columbia. Findings have relevance more broadly in other North American settings, where similar trends in opioid and stimulant polysubstance use have been observed.

Residential treatment and medication treatment for opioid use disorder: The role of state Medicaid innovations in advancing the field

BACKGROUND

Mortality due to opioid use continues to increase; effective strategies to improve access to treatment for opioid use disorder (OUD) are needed. While OUD medications exist, they are used infrequently and often not available in residential addiction treatment settings. CMS provides expanded opportunities for Medicaid reimbursement of treatment in residential facilities and requires states that request Medicaid SUD Waivers to provide a full continuum of care including medication treatment. The objective of this study was to assess how states facilitate access to OUD medications in residential settings and whether Medicaid requirements play a role.

METHODS

Using a legal mapping framework, across the 50 states and DC, we abstracted data from state regulations in 2019 - 2020 and Medicaid Section 1115(a) demonstration applications. We examined the temporal relationship between state regulations regarding medication-assisted treatment for OUD in residential settings and Section 1115(a) demonstrations.

RESULTS

We identified variation in regulations regarding medication treatment for OUD in residential settings and possible spillover effects of the CMS requirements for Medicaid SUD Waivers. In 18 states with relevant regulations, regulatory approaches include identifying opioid medication treatment as a right, requiring access to OUD medication treatment, and establishing other requirements. 25 of 30 states with approved Section 1115(a) demonstrations included explicit requirements for OUD medication treatment access. Four states updated OUD medication treatment regulations for residential treatment settings within a year of applying for a Section 1115(a) demonstration.

CONCLUSIONS

State regulations and Medicaid program requirements are policy levers to facilitate OUD medication treatment access.

Infectious disease surveillance in U.S. jails: Findings from a national survey

While infectious diseases (ID) are a well-documented public health issue in carceral settings, research on ID screening and treatment in jails is lacking. A survey was sent to 1,126 jails in the United States to identify the prevalence of health screenings at intake and characteristics of care for ID; 371 surveys were completed correctly and analyzed. Despite conflicting Centers for Disease Control (CDC) guidance, only seven percent of surveyed jails test individuals for HIV at admission. In 46% of jails, non-healthcare personnel perform ID screenings. Jails in less urban areas were more likely to report healthcare screenings performed by correctional officers. Survey findings indicate that HIV, HCV and TB testing during jail admissions and access to PrEP are severely lacking in less urban jails in particular. Recommendations are provided to improve ID surveillance and address the burden of ID in correctional facilities.

Impacts of COVID-19 at the intersection of substance use disorder treatment and criminal justice systems: findings from three states

BACKGROUND

Individuals with substance use disorders (SUD), particularly opioid use disorder (OUD), who are criminal justice-involved are a particularly vulnerable population that has been adversely affected by COVID-19 due to impacts of the pandemic on both the criminal justice and treatment systems. The manuscript presents qualitative data and findings exploring issues related to SUD/OUD treatment among individuals involved in the justice system and the impacts of COVID-19 on these service systems. Qualitative data were collected separately by teams from three different research hubs/sites in Illinois, Indiana, and Kentucky; at each hub, data were collected from justice system personnel (n = 17) and community-level SUD/OUD providers (n = 21). Codes from two hubs were reviewed and merged to develop the cross-hub coding list. The combined codes were used deductively to analyze the third hub's data, and higher-level themes were then developed across all the hubs' data.

RESULTS

Themes reflected the justice and treatment systems' responses to COVID-19, the intersection of systems and COVID-19's impact on providing OUD treatment for such individuals, and the use of telehealth and telejustice.

CONCLUSIONS

Results highlight that despite rapid adaptations made by systems during the pandemic, additional work is needed to better support individuals with OUD who are involved in the justice system. Such work can inform longer-term public health crisis planning to improve community OUD treatment access and linkage for those who are criminal justice-involved.

Preventing Interruptions in Health Care After Release From Jail

The burden of illness, especially mental health and substance abuse, among the incarcerated population is a major factor for recidivism. County jails throughout the United States provide health care disconnected to care given before and after incarceration. Although the mental health issues of incarcerated individuals are well managed during incarceration, they have inadequate medical coverage and medications upon release. In partnership with the Philadelphia Department of Prisons, we launched a new initiative to enroll women into Medicaid before release and set up their first doctor's appointments to ensure continuous access to treatment. This article presents a methodology for connection between health care provided while inside a jail and health care given in the community for people returning to communities after incarceration. We describe a process for establishing and reestablishing health insurance while incarcerated and making first appointments in preparation for discharge from a large urban jail.

Gaps in naloxone ownership among people who inject drugs during the fentanyl wave of the opioid overdose epidemic in New York City, 2018

Background: Community distribution of naloxone, a medication that reverses opioid overdose, is an effective public health strategy to prevent overdose deaths. However, data are limited on who has naloxone during the current fentanyl wave of the opioid overdose epidemic in the United States. We aim to determine correlates of naloxone ownership among a community sample of people who inject drugs (PWID) from New York City (NYC). Methods: Data were drawn from the National HIV Behavioral Surveillance Study among PWID. Participants were recruited via respondent-driven sampling. Eligible participants completed an interviewer-administered survey. Log-linked Poisson regression was used to determine adjusted prevalence ratios (aPR) and 95% confidence intervals (CIs) current naloxone ownership. Results: Of 503 PWID, 60% currently owned naloxone. In the past 12 months, 74% witnessed an opioid overdose and 25% experienced one. Those who experienced current homelessness were less likely to own naloxone (aPR: 0.79; 95% CI: 0.68, 0.91), as were those who had been recently incarcerated (aPR: 0.83; 95% CI: 0.71, 0.97). Respondents who reported recent known or possible fentanyl use were more likely to own naloxone (aPR: 1.23; 95% CI: 1.07, 1.43) as were those who experienced an opioid overdose in the past 12 months (aPR: 1.33; 95% CI: 1.15, 1.53). Conclusions: The prevalence of naloxone ownership among PWID in NYC was high, potentially due to widespread community naloxone distribution programs; however, gaps in naloxone ownership existed. Interventions that further ease access to naloxone, such as reclassifying naloxone as an over-the-counter medication and making it available "off the shelf," should be considered. More research is needed to identify barriers to access, uptake, and sustained possession within this group to maximize the impact of naloxone distribution during the ongoing fentanyl wave of the opioid overdose epidemic.