Maltreatment, resilience, and sexual relationship power in a sample of justice-involved women with opioid use disorder

Justice-involved women frequently report maltreatment and intimate relationships characterized by violence and abuse throughout adulthood. The present study aimed to (a) investigate the association between victimization and sexual relationship power (SRP) among justice-involved women with opioid use disorder (OUD) and (b) explore resilience as a potential moderating factor of the association between victimization and SRP. Under the ongoing Kentucky Justice Community Opioid Innovation Network (JCOIN) cooperative, justice-involved women (N = 700) were randomly selected from eight jails in Kentucky, screened for OUD, consented to participate, and interviewed by research staff. SRP was examined using the Sexual Relationship Power Scale, a validated instrument with two distinct subscales measuring decision-making dominance (DMD) and relationship control (RC); prior maltreatment was measured using the Global Appraisal of Individual Needs General Victimization Scale, and resilience was assessed using the Brief Resilience Scale. Linear regression was used to examine the association between maltreatment and SRP, with three models constructed to account for SRP, DMD, and RC, controlled for demographic characteristics. Finally, we examined whether the association between victimization and SRP varied as a function of resilience. Significant negative associations between maltreatment and the SRP were observed, ps < .001. Resilience moderated the association between maltreatment and DMD, p = .005; however, resilience did not moderate the associations between maltreatment and SRP, p = .141, or RC, p = .735. These findings highlight the importance of increasing resilience in justice-involved women with OUD to reduce the impact of maltreatment on SRP. Prioritizing resilience may offer significant benefits for preventing and addressing maltreatment.

Results From the POINT Pragmatic Randomized Trial: An Emergency Department-Based Peer Support Specialist Intervention to Increase Opioid Use Disorder Treatment Linkage and Reduce Recurrent Overdose

BACKGROUND

People with opioid use disorder (OUD) frequently present at the emergency department (ED), a potentially critical point for intervention and treatment linkage. Peer recovery support specialist (PRSS) interventions have expanded in US-based EDs, although evidence supporting such interventions has not been firmly established.

METHODS

Researchers conducted a pragmatic trial of POINT (Project Planned Outreach, Intervention, Naloxone, and Treatment), an ED-initiated intervention for harm reduction and recovery coaching/treatment linkage in 2 Indiana EDs. Cluster randomization allocated patients to the POINT intervention (n = 157) versus a control condition (n = 86). Participants completed a structured interview, and all outcomes were assessed using administrative data from an extensive state health exchange and state systems. Target patients (n = 243) presented to the ED for a possible opioid-related reason. The primary outcome was overdose-related ED re-presentation. Key secondary outcomes included OUD medication treatment linkage, duration of medication in days, all-cause ED re-presentation, all-cause inpatient re-presentation, and Medicaid enrollment. All outcomes were assessed at 3-, 6-, and 12-months post-enrollment. Ad hoc analyses were performed to assess treatment motivation and readiness.

RESULTS

POINT and standard care participants did not differ significantly on any outcomes measured. Participants who presented to the ED for overdose had significantly lower scores (3.5 vs 4.2, P < .01) regarding readiness to begin treatment compared to those presenting for other opioid-related issues.

CONCLUSIONS

This is the first randomized trial investigating overdose outcomes for an ED peer recovery support specialist intervention. Though underpowered, results suggest no benefit of PRSS services over standard care. Given the scope of PRSS, future work in this area should assess more recovery- and harm reduction-oriented outcomes, as well as the potential benefits of integrating PRSS within multimodal ED-based interventions for OUD.

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.

Impaired driving and other risky drug use and sex behaviors: a cross-sectional examination of high-risk rural women incarcerated in jail

Background: Despite women accounting for an increasing proportion of impaired drivers and higher rates of impaired driving and road fatalities in rural areas, little is known about rural women who drive impaired and their other risky behavior.Objective: The present study assessed the association between impaired driving history, risky substance use, and other drug- and sex-related risk behaviors in a sample of high-risk rural women incarcerated in jail.Methods: Four hundred women from three rural jails provided information about their impaired driving, drug use, injection drug use practices, and sex risk behaviors. Groups were stratified on whether they self-reported impaired driving in the year prior to incarceration. Impaired drivers (n = 260, M = 31.90 years old) were compared to women who did not drive impaired (n = 131, M = 34.42 years old) using MANCOVA and logistic regression analyses.Results: Impaired drivers had significantly (p < .05) higher substance use severity scores for cannabis, sedatives, and prescription opioids. Furthermore, impaired drivers were significantly (p < .05) more likely to have been the passenger of an impaired driver (78.08% vs. 53.44%), been an injection drug user (69.62% vs. 41.98%), had a casual sex partner (47.31% vs. 25.95%), and traded sex for drugs or money (31.15% vs. 15.27%) in the year prior to incarceration.Conclusions: This study found a consistent association between past year impaired driving and a range of drug- and sex-related risk behaviors in a sample of high-risk rural women incarcerated in jail. These findings highlight an opportunity to intervene in criminal justice settings to reduce multiple health risk behaviors.

Adverse childhood experiences and mental health among incarcerated women: Self-esteem as a mediating mechanism

BACKGROUND

Adverse childhood experiences (ACEs) and mental health problems are interrelated. However, less is known about this relationship in incarcerated women and how self-esteem impacts this relationship.

OBJECTIVE

To investigate the relationship between ACEs and mental health problems (traumatic stress, depression, and anxiety) in incarcerated women with opioid use disorder (OUD) and, the possible role of self-esteem as a mediator of the relationship.

PARTICIPANTS AND SETTING

Incarcerated women (N = 500) were randomly selected from eight Kentucky jails, screened for OUD, and interviewed by research staff.

METHODS

Regression analyses and mediation models were used to examine the relationship between ACEs, mental health, and self-esteem.

RESULTS

ACEs were positively correlated with present mental health problems (traumatic stress, r = 0.407, p < .001; depression, r = 0.177, p < .001; and anxiety, r = 0.213, p < .001) and negatively correlated with current self-esteem (r = -0.241, p < .001). Linear regression analyses established that ACEs and self-esteem were significantly related to all three mental health variables of interest. Additionally, self-esteem mediated the relationship between ACEs and mental health.

CONCLUSION

This study shows that incarcerated women's experiences with ACEs are significantly related to poor mental health. Self-esteem plays a critical role in this relationship.

Identifying and Treating Incarcerated Women Experiencing Substance Use Disorders: A Review

While research on substance use disorder (SUD) treatment among justice-involved populations has grown in recent years, the majority of corrections-based SUD studies have predominantly included incarcerated men or men on community supervision. This review 1) highlights special considerations for incarcerated women that may serve as facilitating factors or barriers to SUD treatment; 2) describes selected evidence-based practices for women along the cascade of care for SUD including screening and assessment, treatment and intervention strategies, and referral to services during community re-entry; and 3) discusses conclusions and implications for SUD treatment for incarcerated women.

Transactional sex among rural, justice-involved Appalachian women who use drugs

PURPOSE

Transactional sex is associated with an array of other health risk behaviors and adverse health outcomes, including HIV. However, despite concerns regarding a potential HIV outbreak, there is limited understanding of transactional sex among rural Appalachians who engage in high-risk behaviors. Thus, the current study describes the prevalence and correlates of transactional sex among a sample of rural, justice-involved Appalachian women who use drugs.

METHODS

Participants (N = 400) were randomly selected, screened, and interviewed face-to-face at 3 rural Appalachian jails in Kentucky. Bivariate analyses were used to examine differences between those who reported trading sex for drugs, money, goods, or services in the year prior to incarceration and those who had not, and multivariable logistic regression was used to examine independent correlates of transactional sex.

FINDINGS

On average, participants were 33 years old with 11 years of education. They were predominantly White (99.0%), about half (43.7%) reported lifetime transactional sex, and 25.9% reported past year transactional sex. Past year transactional sex was positively associated with experiencing money problems, substance use problem severity, injection drug use, unprotected sex with a casual partner, and number of sexual partners in the year prior to incarceration.

CONCLUSIONS

Results suggest that transactional sex is fairly common among rural Appalachian women who use drugs and are justice-involved and may signal other HIV-related risk behaviors. Given limited service availability throughout rural Appalachia, findings emphasize a need for increased access to risk-reduction interventions, including jail-based interventions, to educate vulnerable, hard-to-reach populations on the risks associated with HIV.

Network canvas: an open-source tool for capturing social and contact network data

MOTIVATION

Social influence and contact networks are extremely important for understanding health behaviour and the spread of disease. Yet, most traditional software tools are not optimized to capture these data, making measurement of personal networks challenging. Our team developed Network Canvas to provide an end-to-end workflow with intuitive interfaces to enable researchers to design and conduct network interviews.

IMPLEMENTATION

Network Canvas consists of three applications (Architect, Interviewer and Server). All applications are written in JavaScript and run on Windows, macOS and Linux; Interviewer also runs on Android and iOS.

GENERAL FEATURES

Network Canvas substantially reduces the complexity and technical knowledge required to collect network data via three point-and-click applications. The tool has wide applicability for measuring contact and social influence networks in epidemiology.

AVAILABILITY

Network Canvas is open source and freely available [networkcanvas.com] under the GNU General Public License 3.

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.

Scales for participant Alliance with Recovery Coach (SPARC): initial development and pilot test

Recovery coaches are individuals with lived experience with recovery from substance use disorder who typically engender a greater sense of trust than found with other types of healthcare providers. However, there currently are no validated tools that measure the connection between recovery coaches and their participants. The purpose of this study was to describe the initial development of the Scales for Participant Alliance with Recovery Coach (SPARC) to measure recovery coach connection or alliance, including initial psychometric analyses. Measurement development began with five scales of the Client Evaluation of Self Treatment (treatment participation, treatment satisfaction, rapport, peer support, and social support). Adapted items were pre-tested with focus groups (n = 8) to ensure they were meaningful and accurately reflected the domains (Study 1). After modifications, the SPARC has six scales (engagement, satisfaction, rapport, motivation and encouragement, role model and community linkage). The survey was piloted with 100 individuals (Study 2) age 18 or over who had met with a recovery coach within the last six months. Most study participants were male (60%) and white (87%) with less than two years in recovery. After removing two low performing items, the items for five of the domains had acceptable internal consistency. The items for the engagement domain had a slightly lower reliability. Findings suggest that items cover relevant recovery coach roles, are internally consistent within domains, and can be easily administered to individuals engaging in recovery coaching services. Additional research is needed with a larger, more heterogenous sample to further refine items.

Perspectives of researchers with lived experience in implementation science research: Opportunities to close the research-to-practice gap in substance use systems of care

Background

The field of implementation science acknowledges the importance of diversity within research teams including members from diverse disciplines and with lived expertise in practical implementation (e.g., administrators, front-line workers, patients/clients). Gaps remain in the successful implementation of proven substance use treatment interventions.

Methods

This paper will outline the rationale for the purposeful inclusion of researchers with lived experience (RLE) related to substance use disorder (SUD) within implementation science research studies focused on improving SUD services.

Results

We posit that researchers with such experience can help address research-to-practice gaps by (1) building strong community partnerships, (2) engaging in conversations around effective interventions through knowledge translation, (3) providing community-congruent approaches to evaluation, and (4) aiding in dissemination and sustainability efforts.

Conclusions

We end by offering recommendations for researchers without lived experience as they intentionally collaborate with RLE.

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.

Rural Re-entry and Opioid Use: Identifying Health-Related Predictors of Relapse Among Formerly Incarcerated Women in Appalachia

INTRODUCTION

Despite improved knowledge of the health care needs of formerly incarcerated women, there exists a gap regarding the relationship between health, health care access, and relapse among rural women returning to the community during the opioid epidemic.

PURPOSE

With an emphasis on health care access, this study examined health-related factors associated with opioid relapse among women reentering the community in rural Appalachia.

METHODS

As part of a larger study, 400 rural women reporting a history of substance use were recruited from three Appalachian jails in Kentucky. Analyses focused on participants reporting a history of illicit opioid use prior to incarceration, who had also completed follow-up interviews at 6- and 12-months post-release from jail.

RESULTS

Fifty-five percent of participants reported relapse to opioids during the 12-month follow-up period. Compared to those who did not use opioids during this time, women who relapsed reported poorer mental and physical health, as well as encountered more barriers to needed health services. They were also more likely to report a usual source of care. Multivariate regression analyses reveal that, even when controlling for other known correlates of opioid use and relapse to any non-opioid drug during the follow-up period, the number of barriers to health service utilization was a significant predictor of opioid relapse.

IMPLICATIONS

Stakeholders should address the complex reentry needs of women who use opioids in rural Appalachia. This includes examining innovative approaches to reduce extensive barriers to quality health care utilization, such as implementing telehealth for opioid use treatment.

Adaptation of the NIDA Standard for delivery via Facebook with justice-involved women in rural Appalachia

Background:

Rising rates of intravenous drug use (IDU) in Appalachia have necessitated new approaches to providing risk-reduction interventions in a manner which will be acceptable and accessible to specific at-risk populations—particularly those with limited access to traditional evidence-based interventions. Using the ADAPT-ITT framework, the overall goal of this study is to adapt an evidence-based HIV prevention intervention—the NIDA Standard—to meet the needs of rural drug-using women post-release from jail.

Methods:

Through a series of focus groups with rural incarcerated women, theater-testing with members of the target population, and iterative refinements with topical experts, we aimed to identify potential adaptations to content and context to improve the fit, feasibility, and acceptability of the NIDA Standard for this population using social media.

Results:

Study findings confirmed the need for a preventive risk-reduction intervention targeting this population post-release. Adaptations to intervention content focused on adding, simplifying, and ensuring continuous access to content in the NIDA Standard. Adaptations to context included modifications to how the intervention will be delivered and by whom, including consideration of unique issues related to delivery using Facebook (such as privacy and confidentiality).

Conclusion:

The use of Facebook for delivery of the NIDA Standard may hold promise for increasing reach, acceptability, and feasibility of intervening with rural women with IDU released from jails, particularly when compared with traditional face-to-face sessions. With minor content adaptations to meet participant needs and preferences, plus multiple context adaptations to enhance accessibility and acceptability, the adapted NIDA Standard is intended to retain its original effectiveness while improving important implementation outcomes key to scaling-up and increasing public health impact.

Plain Language Summary

What is known about the topic? Injection drug use rates are high in rural Appalachia, and new approaches are needed to reduce the risk of HIV and HCV among injection drug using women involved in the criminal justice system in this region. While there are effective risk-reduction interventions for HIV and HCV, they are difficult to deliver in rural Appalachia and do not reach the women who need them. What does this paper add? This study describes the use of a systematic approach to improve the “fit” of an evidence-based intervention—the NIDA Standard—with the preferences and perspectives of injection drug using women involved with the justice system, aided by guidance from experts in a specific risk-reduction intervention (the NIDA Standard) and delivery of interventions using Facebook. Changes to the intervention to increase its acceptability and accessibility in this population included shifting delivery of the intervention to a closed Facebook group rather than in person; use of brief videos rather than written text to provide information; use of trusted local women to provide information through videos and Facebook posts; and inclusion of local information on community risk factors and resources. Implications for practice, research, or policy: The use of Facebook for delivery of the NIDA Standard holds promise for increasing reach, acceptability, and feasibility of risk reduction among rural injection drug using women released from jails. Next steps include testing the feasibility, acceptability, and effects of the adapted intervention in several rural Appalachian counties.

A Description of COVID-19 Lifestyle Restrictions Among a Sample of Rural Appalachian Women

Background

COVID-19 has led to swift federal and state response to control virus transmission, which has resulted in unprecedented lifestyle changes for U.S. citizens including social distancing and isolation. Understanding the impact of COVID-19 lifestyle restrictions and related behavioral risks is important, particularly among individuals who may be more vulnerable (such as rural women with a history of substance use living in Appalachia).

Purpose

The overall purpose of this study was to better understand the perceptions of lifestyle changes due to COVID-19 restrictions among this vulnerable group.

Methods

The study included a mixed methods survey with a convenience sample of rural women (n=33) recruited through a closed, private Facebook group.

Results

Study findings indicated that COVID-19 restrictions related to limited social activities and interactions with family and friends had a significant impact on women.

Implications

Findings suggest that social isolation may have a number of unintended consequences for rural women, and implications for rural health practitioners are discussed.

The role of law enforcement officers in responding to the opioid epidemic: A qualitative assessment

Background: Opioid-related overdose deaths continue to rise with the ongoing opioid epidemic. In response, changes in the role of law enforcement officers have included being trained to administer naloxone to reverse overdoses and offering navigation and referrals to substance use treatment. Methods: This secondary data analysis includes qualitative data from law enforcement officers collected as part of a mixed-methods needs assessment from one Kentucky county. Law enforcement officers (n = 151) responded to a confidential, online survey using Qualtrics and a subsample also completed a qualitative interview (n = 6). Open-ended questions in the online survey and interviews included how the opioid epidemic has affected the individual's profession, specifically their role in reversing overdoses and providing referrals to individuals who misuse opioids. Results: Law enforcement officers surveyed indicated that they have expanded their professional roles to include providing naloxone to reverse opioid overdoses and referrals. While their specific roles and duties have changed to include naloxone administration to reverse opioid overdoses and providing referrals, officers felt that this was just part of their job in responding to the needs of the community. Officers reported that they have learned how to use (99%) and carry naloxone (87%) to reverse opioid related overdoses. The majority (92%) reported providing referrals (e.g., treatment and harm reduction resources) to individuals who misuse opioids. Conclusions: The opioid epidemic has changed the roles of law enforcement officers, including providing naloxone to reverse overdoses and referrals for treatment. Future research should continue to explore how substance misuse in the community changes the roles of law enforcement officers and how to best train and support officers as their roles evolve in response to these changes.

Kentucky Women's Justice Community Opioid Innovation Network (JCOIN): A type 1 effectiveness-implementation hybrid trial to increase utilization of medications for opioid use disorder among justice-involved women

The opioid crisis has disproportionately affected women, but research on approaches to increase initiation of medications for opioid use disorder (MOUD) among women is limited. The Kentucky Justice Community Opioid Innovation Network (JCOIN) will implement a type 1 hybrid effectiveness and implementation trial to examine an innovative MOUD pretreatment model using telehealth (alone and in combination with peer navigators) for justice-involved women in transition from jail to the community. The overall goal of the project is to increase initiation and maintenance of MOUD among high-risk justice-involved women during community reentry to reduce opioid relapse and overdose. This project and other studies through the JCOIN network have the potential to significantly impact the OUD treatment field by contributing empirical evidence about the effectiveness and implementation of innovative technologies to increase initiation and maintenance of MOUD during a critical, high-risk time of community reentry among vulnerable, justice-involved individuals in both urban and nonurban communities.

Impaired driving among rural female drug-involved offenders

OBJECTIVE

Very little is known about rural female impaired drivers despite disproportionate rates of impaired driving arrests and associated traffic fatalities in rural areas. The present study examined past-year impaired driving histories and impaired driving correlates in a sample of rural female drug-involved offenders.

METHODS

Female drug-involved offenders (N = 400) from 3 rural jails completed a confidential interview focused on substance use and related risk behaviors. After removing cases with missing data (n = 23), participants self-reporting past-year impaired driving (n = 254) were compared to those who did not (n = 123) on demographic characteristics, substance use, mental health, and criminal histories. Impaired drivers also reported the substances involved in their past-year impaired driving episodes.

RESULTS

A significantly higher percentage of impaired drivers reported past-year use of 8 of the 11 substances (including alcohol) examined when compared to other drug-involved offenders. Though symptoms of major depressive and posttraumatic stress disorders were similar, significantly more impaired drivers (49.6%) reported symptoms of generalized anxiety disorder than did other drug-involved offenders (35.0%). No differences in criminal histories were found. Nearly all (94.9%) impaired drivers reported driving under the influence of drugs in the past year; less than one-fourth reported driving under the influence of alcohol. Prescription opioids were the most prevalent substance type involved in impaired driving episodes (84.6%), followed by anti-anxiety medications (40.9%). Approximately one-third of impaired drivers reported driving under the influence of methamphetamine (33.9%), marijuana (31.5%), and alcohol (30.7%) in the past year.

CONCLUSIONS

Findings indicate that rural female impaired drivers may have more extensive substance use and mental health problems than other rural female drug-involved offenders. In addition, study results suggest that a recent history of impaired driving may serve as a marker for a more extensive substance use history. Other implications include that early identification of impaired drivers in at-risk groups may be an important opportunity to prevent future traffic injuries and fatalities.

A preliminary examination of substance use risk among metropolitan and non-metropolitan girls involved in the juvenile justice system

Research is limited on geographic differences in substance use risk factors among juvenile justice-involved girls. This secondary data analysis from one state juvenile justice system, collected as part of the NIH/NIDA funded JJTRIALS cooperative agreement, assessed criminogenic needs at intake for 160 girls from metropolitan and non-metropolitan counties. Although girls from different geographic areas did not differ significantly on key variables of interest, including substance use risk and related criminality variables, findings suggest that substance use risk is related to criminal history, substance-related offenses, and relationship problems among justice-involved girls. Implications include gender-specific juvenile justice programming and research.

A mixed-methods assessment of the impact of the opioid epidemic on first responder burnout

BACKGROUND

First responders have demanding jobs and report experiencing burnout. The opioid epidemic has added to first responder workloads, which could contribute to increased burnout. This mixed-methods study examined burnout among first responders by: 1) describing burnout among first responders specifically related to workload demands associated with the opioid epidemic; 2) exploring first responder perspectives on how the opioid epidemic has affected their profession; and 3) conducting exploratory analyses to examine how burnout and perspectives on the effect of the opioid epidemic differ across first responder professions.

METHODS

First responders completed an online survey (n = 196), including a burnout questionnaire, as part of a county-wide opioid misuse resource and needs assessment. A subset completed qualitative interviews (n = 12). In both the survey and interviews, participants were asked their perspectives on how the opioid epidemic impacted their profession.

RESULTS

One-third (33%; n = 179) of survey respondents reported high burnout scores. The majority saw community opioid misuse as a significant problem (98%; n = 188) that has affected their profession (95%; n = 188). Qualitative analyses supported survey findings with participants expressing increased workloads and emotional effects related to the opioid epidemic.

CONCLUSIONS

First responders reported experiencing burnout, increased workloads, and negative emotional effects related to their role in responding to the opioid epidemic. Despite this, first responders view responding to community opioid misuse as part of their professional role for which they have received specialized training. Future research should continue to explore the impact of the opioid epidemic on first responders, including how to prevent or address burnout.

Staying Out: Reentry Protective Factors Among Rural Women Offenders

The current study examines protective factors for women who transition from county jails to rural Appalachian communities, areas with limited health and behavioral health services. The study included drug-using women recruited from three jails in rural Appalachia and were followed 12-months post-release. Analyses focused on differences between women who remained in the community and those who returned to custody, as well as a multivariate model to determine protective factors for re-entry success. At the bivariate level, staying out of jail was associated with being older, having a job, not using drugs, stable housing, receiving health treatment, and having prosocial peers. In the multivariate model, the most robust predictors of staying out of jail were drug use abstinence, health care utilization, and prosocial peers. Most research on criminogenic needs associated with re-entry success have focused on men, and most focused on re-entry to urban communities where services and resources are more accessible. These findings have important implications for criminal justice systems to implement re-entry programs for women offenders during the transition to the community.

An Examination of the Age of Substance Use Onset and Adult Severity of Use Among Offenders Entering Treatment

Early onset of substance use has demonstrated a robust relationship with later severity of use, yet this relationship has been less examined in criminal justice contexts or examined differentially by gender. The present study utilized secondary data from a sample of offenders in one small Midwestern state entering corrections-based substance abuse treatment in prison, jail, or community settings to address these gaps in the literature. Findings indicated that age of regular cigarette use did not uniquely affect severity of illicit drug use in adulthood, defined as the frequency of use or endorsement of substance use disorder criteria. In comparison, ages of onset for alcohol and illicit drug use were significantly associated with multiple severity variables examined. Gender was not found to moderate these relationships. These findings emphasize that age of use onset for alcohol and illicit drugs can be valuable in identifying offenders at risk of severe substance use in adulthood.

Drug Use and Incarceration among Rural Appalachian Women: Findings From a Jail Sample

BACKGROUND/OBJECTIVE

The purpose of this paper is to examine drug use and incarceration history among rural Appalachian women.

METHODS

This study involved random selection, screening, and interviews with rural women from local jails in Appalachia.

RESULTS

Of the women randomly selected and screened, 97% met criteria for substance use intervention. Significant factors associated with incarceration history included age, education, custody status, and mental health. A significant interaction was observed between male sex partners and drug use on incarceration history.

CONCLUSIONS

Study findings suggest that the drug/crime relationship among rural Appalachian women is associated with their high-risk home environment, partner relationships, and mental health. Specifically, in addition to drug use, factors such as family and child relationships, anxiety, victimization, and relationships with partners should also be considered in the trajectory of criminal careers among rural Appalachian women.

The Affordable Care Act and Changes in Insurance Coverage and Source of Health Care among High-risk Rural, Substance-using, Female Offenders Transitioning to the Community

PURPOSE

This study examines health care coverage and health care among rural, drug-involved female offenders under the Affordable Care Act (ACA) compared with pre-ACA and whether being insured is associated with having a usual source of care.

METHODS

This study involved random selection, screening, and face-to-face interviews with drug-using women in three rural Appalachian jails. Analyses focused on participants who had completed a three-month follow-up interview after release from jail (N=371).

RESULTS

Analyses indicated that women released after ACA implementation were more likely than those released pre-implementation to be insured. A multivariate logistic regression model showed that being insured was significantly related to having a usual health care source during community re-entry.

CONCLUSIONS

Results demonstrate the benefits of the ACA, signaling important implications for public health in rural communities and the criminal justice system, including targeting underserved groups during incarceration and providing information about and resources for health care enrollment.

Partner Relationships and Injection Sharing Practices among Rural Appalachian Women

BACKGROUND

The role of relationships in initiating and maintaining women's risk behaviors has been established. However, understanding factors that may underlie partner relationships and women's risky drug use, particularly in rural contexts, is limited. This study is the first to examine the association between injecting partners and women's risky injection practices as a function of relationship power perception.

METHODS

Female participants were recruited from three rural jails in the Appalachian region. Women were selected randomly, provided informed consent, and screened for study eligibility criteria. This cross-sectional analysis focuses on women who inject drugs during the year before entering jail (n = 199).

MAIN FINDINGS

Approximately three-quarters (76%) reported having a recent main male sexual partner with a history of injection drug use. Although having a risky partner independently increased the likelihood of women reporting shared injection practices, perceptions of relationship power significantly moderated the effect on shared needle (adjusted odds ratio, 0.02; 95% CI, 0.003-0.23; p = .001) and shared works (adjusted odds ratio, 0.17; 95% CI, 0.03-0.95; p = .04) use.

CONCLUSIONS

This interaction indicated that, for women who inject drugs with a recent injecting male partner, greater perception of relationship power was associated with a decreased likelihood of shared injection practices. Implications for clinical assessment and intervention are discussed.

Correlates of Injection Drug Use Among Rural Appalachian Women

BACKGROUND

Limited research has focused on correlates of injection drug use (IDU) among high-risk subgroups of drug users, particularly women, who may be at increased risk for transmission of infectious diseases such as HIV and Hepatitis C. The purpose of this study is to better understand the contextual and health correlates of IDU among women living in rural Appalachia by examining (1) differences between injectors and noninjectors, and (2) the unique correlates of recent IDU and past IDU.

METHODS

This study involved random selection, screening, and face-to-face interviews with 400 rural Appalachian women from jails in one state. Analyses included descriptive statistics, multinomial logistic regression, and stepwise regression to identify significant correlates of recent IDU and past IDU compared to never injecting.

RESULTS

Findings indicated that 75.3% of this randomly selected sample reported lifetime injection of drugs. Contextual factors including drug use severity (RRR = 8.66, P < .001), more male sex partners (RRR = 1.01, P < .05), and having injecting partners (RRR = 7.60, P < .001) were robust correlates of recent injection practices.

CONCLUSIONS

This study makes an important contribution to understanding factors associated with IDU among rural Appalachian women drug users, which are strongly associated with both relational and health factors. Study findings on the specific factors associated with IDU risk have important implications for tailoring and targeting interventions that should include a focus on the relationship context reducing high-risk injection practices.

Age of First Arrest, Sex, and Drug Use as Correlates of Adult Risk Behaviors Among Rural Women in Jails

Incarcerated women frequently report initiation of substance use and sexual encounters at an early age, and often engage in high-risk drug use and sexual behaviors as adults. This study examined the timing of first sex, drug use, and arrest, as well as their unique influences on specific risky behaviors in adulthood, among a high-risk population of rural women recruited from jails. Ages of initiation were all positively and significantly correlated, and each independently increased the likelihood of several risky behaviors in adulthood. Implications are discussed for screening, intervention, and treatment targeting high-risk women and girls in rural areas, particularly within criminal justice settings.

Medication Bar Coding

Practical steps for implementing a medication verification system using bar coding are provided. The authors describe the process that a two-hospital system embarked upon to implement a bedside medication verification system. Building blocks of the system are described that made the project successful and met the Patient Safety Goals of the Joint Commission on Accreditation of Healthcare Organizations. The authors identify the "pitfalls" organizations need to be prepared to handle and quantify financial and safety results achieved with this project.

Renal Allograft Tolerance in DLA-Identical and Haploidentical Dogs After Nonmyeloablative Conditioning and Transient Immunosuppression With Cyclosporine and Mycophenolate Mofetil

BACKGROUND

Canine models of bone marrow and renal transplantation have provided important preclinical data relevant to developing novel therapeutic protocols for hematopoietic and solid organ transplantation in human beings. Nonmyeloablative transplantation has been shown to induce stable mixed hematopoietic chimerism in normal dogs and correct the phenotype of canine pyruvate kinase deficiency and Glanzman's thrombasthenia. In this study, we investigated the potential for inducing renal allograft tolerance using a nonmyeloablative bone marrow transplantation strategy that induces mixed chimerism in DLA-identical dogs.

METHODS

Reciprocal renal allografts were performed in 4 DLA-identical and 4 DLA-haploidentical dogs with nonmyeloablative conditioning (200 cGy total body irradiation [TBI]) and transient immunosuppression with cyclosporine (CSP) and mycophenolate mofetil (MMF) with and without simultaneous bone marrow transplantation. Two DLA-identical control dogs received reciprocal renal allografts without TBI or immunosuppression with CSP and MMF. Serum creatinine (Cr) concentration was monitored to assess renal allograft function.

RESULTS

The renal allografts were acutely rejected in the 2 DLA-identical dogs without TBI or immunosuppression. There was long-term (>1 year) renal allograft survival as evidenced by a normal (<2.0 mg/dL) serum Cr concentration in both the DLA-identical and DLA-haploidentical dogs that underwent 200 cGy TBI and transient immunosuppression with CSP and MMF either with or without simultaneous bone marrow transplantation.

CONCLUSIONS

Nonmyeloablative conditioning (200 cGy TBI) and transient immunosuppression with CSP and MMF induce renal allograft tolerance in DLA-identical and DLA-haploidentical dogs without donor/host mixed hematopoietic chimerism. These findings suggest it may be possible to induce tolerance to solid organ transplants without the need for chronic immunosuppressive therapy or stable hematopoietic chimerism in the setting of both DLA-matched and haploidentical transplants.

Feline lameness

Feline lameness is an increasingly recognized clinical problem. Today's veterinary practitioner must be comfortable with his/her ability to diagnose the various conditions responsible for lameness in the cat and be able to discuss the significance of their findings with the client. Disease of the feline musculoskeletal system can be grouped into broad categories, including: trauma, arthritis, infectious causes, developmental disorders, neoplasia, and muscular problems. Specific diseases from each of these categories will be discussed, particularly those that differ in their presentation or clinical behavior from that same disease in the canine patient.

Tracheal resection and anastomosis for an intratracheal chondroma in a ball python

A 9-year-old female ball python was evaluated for lethargy and respiratory compromise. Radiographic and endoscopic examination revealed a 1-cm intratracheal mass occluding the tracheal lumen. A partial tracheal resection and anastomosis was performed to remove the mass. On histologic examination, the mass was determined to be an intratracheal chondroma. Eosinophilic cytoplasmic inclusions observed within the tissue were calcium deposits. Electron microscopy was used to differentiate these from viral inclusion bodies often associated with neoplasms in reptiles. Endoscopic evaluation of the trachea 5 weeks after surgery revealed complete healing and minimal stenosis at the surgery site. Indications of tumor regrowth were not evident. Clinical signs of recurrence of respiratory compromise had not been observed 9 months after surgery.