Drug treatment experiences: rural and urban comparisons

Motivations for Diverted Buprenorphine Use in a Multisite Qualitative Study

Drawing on a multisite sample of 40 persons who sell, share, or use diverted buprenorphine to manage opioid use disorder, in this study we describe why individuals seek to obtain buprenorphine outside of formal treatment contexts, and between-site variation regarding their motives and means. Findings indicate that both the provision and purchase of diverted buprenorphine support user-defined risk minimization strategies to avoid withdrawal, reduce heroin use, and satiate opioid cravings in periods of lowered tolerance. We also found that a subset of the sample used buprenorphine recreationally, and that it functioned to extend or augment illicit drug use careers. Implications of the findings are discussed in light of federal and state drug control and treatment policies.

Appalachian Women's Use of Substance Abuse Treatment: Examining the Behavioral Model for Vulnerable Populations

The Gelberg-Andersen Behavioral Model for Vulnerable Populations was applied to understand vulnerable Appalachian women's (N = 400) utilization of addiction treatment. A secondary data analyses included multiple multivariate analyses. Strongest correlates of treatment utilization included ever injecting drugs (OR = 2.77), limited availability of substance abuse treatment facilities (OR = 2.03), and invalidated violence abuse claims (OR = 2.12). This study contributes theory-driven research to the greater social work addiction literature by confirming that vulnerable domains related to substance abuse treatment utilization warrant unique considerations compared to non-vulnerable domains. Findings also highlight the importance of understanding the unique role that cultural factors play in treatment utilization among Appalachian women. Inferences relevant to clinicians and policymakers are discussed.

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

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Individual and neighborhood predictors of mortality among HIV-positive Latinos with history of injection drug use, Florida, 2000-2011

BACKGROUND

The objectives are to examine disparities in all-cause mortality risk among HIV-positive Latinos with injection drug use (IDU) history, and to identify individual- and neighborhood-level predictors.

METHODS

Florida surveillance data for persons diagnosed with HIV 2000-2008 were merged with 2007-2011 administrative data from the American Community Survey. Hazard ratios (HR) were calculated using multi-level weighted Cox regression adjusting for individual and neighborhood (ZCTA-level) factors.

RESULTS

Of 10,989 HIV-positive Latinos, 10.3% had IDU history. Latinos with IDU history were at increased mortality risk compared with Latinos without IDU history after controlling for individual and neighborhood factors (adjusted HR [aHR] 1.61, 95% confidence interval [CI] 1.43-1.80). Factors associated with mortality for those with IDU history included: being 40-59 (aHR 6.48, 95% CI 1.41-121.05) and ≥60 years (aHR 18.75, 95% CI 3.83-356.45) compared with 13-19 years of age; being diagnosed with AIDS within 3 months of HIV (aHR 2.31, 95% CI 1.87-2.86); residing in an area with ≥50% Latinos compared with <25% Latinos (aHR 1.56, 95% CI 1.19-2.04); and residing in a rural compared with an urban area at the time of diagnosis (aHR 1.73, 95% CI 1.06-2.70). Race and neighborhood poverty were not predictors among those with IDU, but were among those without.

CONCLUSION

HIV-positive Latinos with IDU history are at increased mortality risk and have unique contributing factors. Tertiary prevention strategies should target those who are older, diagnosed at later stages, and those who live in predominantly Latino and rural areas.

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

PURPOSE

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

METHODS

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

FINDINGS

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

CONCLUSIONS

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

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

OBJECTIVE

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

STUDY DESIGN

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

PRINCIPAL FINDINGS

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

CONCLUSIONS

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

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

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

A comparison of rural and urban nonmedical prescription opioid users' lifetime and recent drug use

BACKGROUND

Nonmedical prescription opioid use has emerged as a major public health concern. The growing burden of nonmedical prescription opioid use in America may have unique manifestations and consequences in rural areas, which to a large extent have yet to be explored.

OBJECTIVES

To describe rural-urban differences among drug users in recent and lifetime use and age of onset of use for alcohol, heroin, OxyContin(®), oxycodone, hydrocodone, barbiturates, benzodiazepines, cocaine, crack, methamphetamine, amphetamine, marijuana, hallucinogens, and inhalants.

METHODS

A purposive sample of 212 prescription drug users was recruited from a rural Appalachian county (n = 101) and a major metropolitan area (n = 111) in Kentucky. Consenting participants were given an interviewer-administered questionnaire examining sociodemographics, psychiatric characteristics, and self-reported drug use.

RESULTS

Rural drug users had significantly earlier ages of onset for use of oxycodone, hydrocodone, benzodiazepines, cocaine, and crack. In age-, gender-, and race-adjusted logistic regression analyses, rural drug users had significantly higher odds of lifetime and recent use of methadone, OxyContin(®), and oxycodone. Rural drug users also had significantly higher odds of lifetime cocaine and crack use. However, urban participants as expected had significantly higher odds of recent crack use.

CONCLUSIONS

The findings demonstrate that, in this sample, nonmedical prescription opioid use is dissimilar among rural and urban drug users. Additional research is needed to better understand the individual, social, and structural level factors contributing to the burden of nonmedical opioid use, particularly in rural populations, with the aim of developing tailored substance abuse treatment and prevention.

Influence of Site Differences between Urban and Rural American and Central European Opioid-Dependent Pregnant Women and Neonatal Outcome Characteristics

BACKGROUND

Multi-center trials enable the recruitment of larger study samples, although results might be influenced by site-specific factors.

METHODS

Site differences of a multi-center prospective double-blind, double-dummy randomized controlled trial (7 centers: Central Europe (Vienna)/USA (3 urban/3 rural centers)) comparing safety and efficacy of methadone and buprenorphine in pregnant opioid-dependent women and their neonates.

RESULTS

Urban US women had the highest rate of concomitant opioid (p = 0.050) and cocaine consumption (p = 0.003), the highest dropout rate (p = 0.001), and received the lowest voucher sums (p = 0.001). Viennese neonates had significantly higher Apgar scores 1 min (p = 0.001) and 5 min after birth (p < 0.001) and were more often born by cesarean section (p = 0.024). Rural US newborns had a significantly shorter neonatal abstinence syndrome treatment duration compared to Viennese and urban US sites (p = 0.006), in addition to other site-specific differences, suggesting a more severely affected group of women in the urban US sites.

CONCLUSION

This clinical trial represents a role model for pharmacological treatment in this unique sample of pregnant women and demonstrates the clinical importance of considering site-specific factors in research and clinical practice.

Rural drug users: factors associated with substance abuse treatment utilization

The purpose of this study is to use a modified version of Andersen's Behavioral Model of Health Services Use to identify the correlates of the number of substance abuse treatment episodes received by rural drug users. Data were collected from face-to-face interviews with 711 drug users in rural areas of Ohio, Arkansas, and Kentucky. Descriptive analyses examine rural drug users' substance use histories and retrospective substance abuse treatment service utilization patterns. A negative binomial regression model indicated that selected predisposing, historical health, and enabling factors were significantly associated with the utilization of substance abuse treatment among rural drug users. Despite high levels of recent and lifetime self-reported substance use among these rural drug users, treatment services were underutilized. Future studies are needed to examine the impact of the health care system and characteristics of the external environment associated with rural substance abuse treatment in order to increase utilization among drug users.

Technology and innovation in the psychosocial treatment of methamphetamine use, risk and dependence

ISSUES

The dramatic increase in methamphetamine use has led to the urgent need for high-quality, effective treatments and management strategies for methamphetamine use problems to be developed and disseminated. Although some evidence exists for the use of psychological, pharmacological and other approaches to treatment for problematic methamphetamine use, other evidence suggests that many methamphetamine users do not access these treatment options due to a range of individual and service-level barriers.

APPROACH

A review of available research literature was undertaken to identify treatment strategies for methamphetamine users, which overcome the problems associated with treatment access for this important target group and involve technological and other innovative approaches.

KEY FINDINGS

Several approaches to addressing problematic methamphetamine use have been suggested, including assertive engagement strategies, flexibility in the provision of treatment and retention strategies and use of a multi-focused intervention package, such as stepped care, perhaps including new technologies as alternatives or supplements to face-to-face-delivered treatments. No research currently exists to examine the possible benefit of these strategies for people with methamphetamine use problems.

IMPLICATIONS

The use of stepped-care intervention packages has the potential to address many of the current challenges faced by both clinicians and clients in treating methamphetamine use problems.

CONCLUSIONS

Although promising, these approaches require further attention and research effort, particularly among the specific group of methamphetamine users.

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

CONTEXT

Illicit drug use is common in rural areas, but very little research has investigated rural populations' access to drug abuse services.

PURPOSE

To describe the current state of the scientific literature on access to drug abuse services in rural areas and suggest directions for future research.

METHODS

We performed a literature review of published articles on rural drug abuse services and summarized the findings according to potential, realized, accommodating, and acceptable access. Relevant articles on rural access to medical, alcohol, and mental health care were selected to supplement the scarce literature specific to drug abuse.

FINDINGS

A limited body of work indicates that rural populations have lower availability and utilize needed drug abuse services less frequently than their urban counterparts. Even less is known about the accommodation and acceptability of drug abuse programs serving rural populations.

CONCLUSIONS

Research that investigates the existence and determinants of problems with access to drug abuse services is greatly needed to enable policy makers, drug treatment managers, and practitioners to better meet the needs of their rural clientele. As this field of inquiry advances, methodologies for constructing drug abuse service areas and measuring consumers' evaluations must be developed.

Factors that help injecting drug users to access and benefit from services: A qualitative study

BACKGROUND

International research shows that injecting drug users (IDUs) can encounter many barriers when they try to access drug treatment and other services. However, the existing literature is mostly quantitative and does not consider the kinds of factors that injectors themselves identify as enabling them to access and benefit from services. Responding to this gap in knowledge, our paper explores IDUs' own suggestions for improving service engagement and their reports of other factors enabling them to seek help.

METHODS

Semi-structured qualitative interviews were conducted with 75 current illicit drug injectors in three geographically diverse areas of West Yorkshire, England. Recruitment was through needle exchange programmes, with additional snowball sampling to ensure inclusivity of gender, ethnicity and primary drug injected. Transcribed data were analysed thematically using Framework.

RESULTS

Although participants were often satisfied with current access to services, they made three broad suggestions for improving engagement. These were: providing more services (more providers and more forms of support); better operation of existing services (including better communication systems and more flexibility around individual needs); and staffing-related improvements (particularly, less judgemental and more understanding staff attitudes). Other factors identified as important enablers of help seeking were: having supporting relationships (particularly with family members); personal circumstances/life events (especially becoming a parent); and an injector's state of mind (such as feeling motivated and positive).

CONCLUSION

A range of practical suggestions for improving IDUs' access to drug treatment and other services are identified.

Client outcomes from rural substance abuse treatment

Several national evaluations have been conducted since the late 1960s that have assessed the effectiveness of publicly-funded substance abuse treatment in the United States. These studies, however, have focused principally on urban-based treatment programs, and it is unclear whether findings from urban programs can be replicated in outcome studies of programs in rural areas. The current study, therefore, examined the treatment outcomes of clients admitted to one of several short-term inpatient or outpatient drug-free treatment agencies in rural Kentucky. Findings showed that treatment was associated with reductions in drug use and criminality during a six-month follow-up interval. Employment status also improved significantly, and health services utilization was reduced. The similarity between the current findings and findings from national outcome studies of urban-based treatment programs is discussed.

Crack across Canada: Comparing crack users and crack non-users in a Canadian multi-city cohort of illicit opioid users

AIMS

To examine possible differences between crack users and crack non-users across Canada.

DESIGN

Cohort study of illicit opioid and other drug users in five cities across Canada.

SETTING

Vancouver, Edmonton, Toronto, Montreal and Quebec City, Canada.

PARTICIPANTS

Regular illicit opioid and other street drug users not in treatment at time of assessment.

MEASUREMENTS

Participants (n = 677) were assessed at baseline (2002) by way of an interviewer-administered questionnaire, a psychiatric diagnostic instrument (Composite International Diagnostic Interview), and salivary antibody tests for infectious disease.

FINDINGS

Approximately half the sample had used crack in the past 30 days, although prevalence rates differed strongly between study sites. When examined by discriminant analysis, crack users in the study population were more likely to have: no permanent housing, have illegal and sex work income, indicate physical health problems and hepatitis C virus (HCV) antibodies, use walk-in clinics, use heroin and to have been arrested and in detention (in past year). They were less likely to report depressive symptoms, and use Dilaudid (hydromorphone) and alcohol.

CONCLUSION

These results illustrate crack users' pronounced social marginalization (as expressed by homelessness and high involvement in illegal activities) as well as extensive health problems compared to non-crack users in the Canadian context. The development of targeted interventions-addressing the dynamics of social marginalization-of this population is urgently needed.

Programmatic, counselor, and client-level comparison of rural versus urban drug court treatment

Despite a number of recent evaluations demonstrating the effectiveness of "drug court" programs for reducing both substance abuse and criminal behavior, some authors have recently called for more thorough process evaluations (inside the "black box" of treatment) of these programs. Specifically, this article describes the need for thorough process evaluation to examine differences in program implementation across rural and urban drug courts. The delivery of substance-user treatment and allied social services is examined in a sample of four adult drug courts (two urban and two rural), using a direct observation methodology, as well as traditional surveys and interviews of treatment staff and administrators. Results reveal that there are, in fact, differences in implementation, and staff and client characteristics between courts in each type of geographic region and suggest that these differences may impact the effectiveness of the court programs in meeting their goals of reduced substance use and criminal behavior.

Rural and urban similarities and differences in private substance abuse treatment centers

Although previous research has considered the unique treatment needs of rural residents, little research has investigated the potential differences in the availability of treatment services in rural and urban areas. Using three waves of longitudinal data from a nationally representative sample of privately-funded substance abuse treatment centers, this research compared rural and urban treatment centers with regard to the availability of clinical levels of care, the offering of specialty treatment tracks, the adoption of treatment innovations, and the average costs of care. Results indicate that rural and urban centers were similar in their increasing provision of inpatient psychiatric levels of care and their decreasing offering of more intensive levels of chemical dependency services between 1995 and 2001. Rural and urban centers were increasingly likely to offer specialty treatment tracks for women, adolescents, clients with HIV/AIDS, and relapsing clients over time, but rural centers were less likely to offer a treatment track tailored to substance-abusing women. The use of treatment innovations was similar at rural and urban treatment centers with the exception of lesser use of acupuncture at rural centers. Rural and urban centers did not differ in their average charges for treatment services.

Arrestees' perceived needs for substance-specific treatment: exploring urban-rural differences

An interview study among a group of arrestees in seven county jails was conducted in the state of Ohio between June 1999 and September 2001, examining the prevalence of alcohol and drug dependence within the group and assessing the need for substance-abuse treatment. Four of the county jails where interviews were conducted are in urban areas, and three are in rural areas. The present study focused on demographic variables, situation-related factors, current drug dependence diagnoses, past treatment experience, and jail location-rural or urban. It sought to assess whether these factors predicted arrestees' perceived needs for substance-specific treatment (for alcohol, marijuana, cocaine, and/or opiate addiction); and, further, whether any predictors of a perceived need for treatment would be identical for arrestees housed in rural jails and those housed in urban jails. The results show that some of the factors assessed do exert differential effects on rural and urban arrestees' perceived needs for substance-specific treatment. Future treatment policy within the criminal justice system should perhaps take into account inmates' individual characteristics and the rural or urban location of the jail initiating their processing. It may be possible, by paying attention to these variables, to enhance inmates' motivation to enter treatment programs, leading ultimately to drug-use cessation.

HIV seroprevalence across the rural/urban continuum

While the first decade of the AIDS epidemic was characterized by high prevalence rates of AIDS infection in urban areas, there is increasing recognition of the spread of HIV into rural communities in the United States. Data from the Miami CARES cohort collected on 3,555 chronic drug users from 1988 to 1994 provide a unique opportunity to assess sociodemographic characteristics, drug-using behaviors and HIV risk behaviors related to HIV seropositivity in three communities across the rural-urban continuum: Miami, Florida; Belle Glade, Florida and Immokalee, Florida. The three very different communities studied demonstrate that HIV is no respecter of ecological site. The spread of HIV between areas and within areas is specifically correlated with the risk factors including injection drug use, use of crack cocaine, exchange of sex for money, and the rates for sexually transmitted diseases. All of these factors are shown to increase the risk of HIV so that the constellation of these practices helps determine the differential rates and spread of HIV in the three different areas.

Opportunities for AIDS prevention in a rural state in criminal justice and drug treatment settings

This study examined the likelihood that drug users would receive HIV/ AIDS prevention information and supplies (e.g., condoms and bleach) in the rural state of Kentucky. Despite evidence of high HIV risk among criminal justice and substance-using populations, incarceration and substance-user treatment were only minimally associated with prior HIV prevention exposure or HIV testing. These data strongly support the use of criminal justice and treatment settings to provide AIDS prevention interventions for the high-risk drug-using populations they serve, and to target HIV prevention services in rural as well as urban areas.