A Harm Reduction Approach to Treating Opioid Use Disorder in an Independent Primary Care Practice: a Qualitative Study

"It's Like A Partnership": Exploring the Primary Care Experiences and Patient-Defined Goals of People Who Use Drugs

BACKGROUND

Primary care is an important yet underutilized resource in addressing the overdose crisis. Previous studies have identified important aspects of primary care for people who use drugs (PWUD) and have found patient involvement in healthcare decisions and goal-setting to be especially critical. However, there has been limited research describing the primary care goals of PWUD. In harm reduction settings, where it is imperative that PWUD set their own goals, this research gap becomes especially relevant.

OBJECTIVE

To explore how PWUD navigate primary care with a focus on understanding their primary care goals.

DESIGN

A qualitative study using semi-structured interviews.

PARTICIPANTS

PWUD currently engaged in primary care at the Respectful and Equitable Access to Comprehensive Healthcare (REACH) Program, a harm reduction-based primary care program in New York City.

APPROACH

Between June 2022 and August 2022, we conducted 17 semi-structured interviews. Informed by phenomenology, transcripts were coded using both inductive and deductive codes and themes were developed using thematic analysis approaches.

KEY RESULTS

Phenomenological analysis identified four core components that, together, created an experience that participants described as "a partnership" between patient and provider: (1) patient-provider collaboration around patient-defined healthcare goals; (2) support provided by harm reduction-based approaches to primary care anchored in incrementalism and flexibility; (3) care teams' ability to address healthcare system fragmentation; and (4) the creation of social connections through primary care. This holistic partnership fostered positive primary care experiences and supported participants' self-defined care goals, thereby facilitating meaningful care outcomes.

CONCLUSIONS

To best meet the primary care goals of PWUD, these findings underscore the importance of primary care providers and programs facilitating such partnerships through organizational-level support anchored in harm reduction. Future research should explore how these experiences in primary care affect patient health outcomes, ultimately shaping best practices in the provision of high-quality primary care for PWUD.

Understanding healthcare engagement for people who inject drugs

People who inject drugs (PWID) are at an increased risk of multimorbid mental health and chronic diseases, which are frequently underdiagnosed and under-treated due to systemic barriers and ongoing substance use. Healthcare engagement is essential to address these conditions and prevent excess morbidity and mortality. The goal of this study was to understand how PWID engage in care for their chronic health conditions and substance use treatment given the known historic and pervasive barriers. We conducted 24 semistructured qualitative interviews informed by the Behavioral Model for Vulnerable Populations between July-September 2019. Participants were sampled across a range of comorbidities, including co-occurring mental health disorders. Thematic analysis was conducted to explore experiences of healthcare engagement for multimorbid chronic diseases, mental health, and treatment for substance use disorder. Mean age for participants was 58 years; 63% reported male sex and 83% reported Black race. Interviews yielded themes regarding healthcare access and wraparound services, positive patient-provider relationships, service integration for substance use treatment and mental health, healthcare needs alignment, medication of opioid use disorder stigma, and acceptance of healthcare. Taken together, participants described how these themes enabled healthcare engagement. Engagement in care is crucial to support health and recovery. Clinical implications include the importance of strengthening patient-provider relationships, encouraging integration of medical and mental health services, and counseling on substance use treatment options in a non- stigmatizing manner. Additionally, policy to reimburse wrap-around support for substance use recovery can improve care engagement and outcomes related to chronic diseases, mental health, and substance use among PWID. No Patient or Public Contribution: While we acknowledge and thank ALIVE participants for their time for data collection and sharing their perspectives, no ALIVE participants, other people who use drugs, and service users were involved in data collection, analysis or interpretation of data, or in preparation of the manuscript.

Clinical stakeholders' perceptions of patient engagement in outpatient medication treatment for opioid use disorder: A qualitative study

INTRODUCTION

Medications for opioid use disorder (MOUD) reduce risk of opioid overdose and promote recovery from opioid use disorder, but poor retention in MOUD limits these positive effects. This study explored patient engagement in MOUD from the perspective of clinical stakeholders within an outpatient addiction medicine program to identify program factors influencing patient engagement with treatment.

METHODS

We conducted a qualitative case study of a multi-clinic outpatient addiction medicine program embedded within an integrated health system that serves a geographically diverse area of Pennsylvania. Collectively, the program's clinics provide MOUD (primarily buprenorphine) to ~2000 patients annually. From January to March 2021, we conducted semi-structured telephone/video interviews with three stakeholder groups involved in delivering MOUD: administrators (n = 4), providers (n = 7), and addiction care coordinators (n = 5). Data analysis utilized the framework method.

RESULTS

We identified five themes related to patient engagement. First, participants described health system integration as enhancing quality and offering opportunities for addressing patients' comprehensive health care needs. However, lack of knowledge about addiction and stigma among health system providers was felt to limit patient benefits from this integration, including access to MOUD. Second, participants viewed patient engagement as central to the program's policies, practices, and clinical environment. Adoption of a harm reduction approach and maintenance of a non-stigmatizing clinic environment were described as essential facilitators of engagement. Third, while clinics followed uniform operations, physician leads expressed differing philosophical approaches to treatment, which participants associated with variations in clinical practice and patient engagement. Fourth, participants identified key services that bolstered engagement in MOUD, including psychosocial services, psychiatric care, and telemedicine. Finally, staff well-being emerged as a key consideration for patient engagement.

CONCLUSIONS

Understanding perceptions of those who administer and deliver care is critical for identifying barriers and facilitators to patient engagement in MOUD. Findings suggest potential opportunities for addiction treatment programs to improve patient engagement and ultimately MOUD retention, including integration with other healthcare services to meet comprehensive healthcare needs; adoption of a harm reduction approach; creation of non-stigmatizing clinical environments; investment in psychosocial services, psychiatric care, and telemedicine; and prioritization of staff wellness.

Differences in buprenorphine prescribing readiness among primary care professionals with and without X-waiver training in the US

BACKGROUND

Medications for opioid use disorder (OUD) are effective at preventing overdose and infectious disease but are vastly under-prescribed in the US. For decades, prescribers faced additional training and regulation to prescribe buprenorphine which stigmatized the medication and lessened support for a harm reduction approach to treating opioid use disorder. The Drug Enforcement Administration removed the X-waiver requirement for prescribing buprenorphine in late 2022, which removed stigma and lessened important barriers to prescribing but also left training at the discretion of individual organizations. Our study aimed to assess differences in knowledge, confidence, and stigma regarding buprenorphine between those who went through the X-waiver training and those who did not, among practicing primary care providers (PCPs).

METHODS

We assessed buprenorphine prescribing readiness among primary care aligned outpatient providers in Ohio, USA. Using survey data, we conducted bivariate and regression analyses predicting primary prescribing outcomes. Primary outcomes measured knowledge of and confidence in buprenorphine, as well as perceived adequacy of one's training. Secondary outcomes were attitudes toward patients with OUD, including bias toward OUD patients, stress when working with them, and empathy toward them. Participants (n = 403) included physicians, nurse practitioners, and physician assistants practicing in primary care aligned disciplines.

RESULTS

Survey data showed that PCPs who received X-waiver training were more likely to understand and have confidence in the mechanism of buprenorphine, and consider their training on treating OUD to be adequate. PCPs with an X-waiver showed more empathy, less negative bias, and experienced less stress when working with patients with OUD.

CONCLUSION

Removing restrictive policies for prescribing buprenorphine is an important step to expanding access and reducing the stigma associated with opioid use disorder treatment. Yet, our findings suggest that the training received alongside regulation may be important for improving prescribing confidence and reducing stigma. Strategies to increase buprenorphine prescribing are unlikely to be effective without also expanding access to prescribing support for primary care providers across the career course.

The association of medical providers' attitudes about naloxone and people with opioid use disorder and their self-reported "low-barrier" treatment practices

Opioid-involved overdose deaths continue to climb, in part because of suboptimal access to and retention on medications for opioid use disorder (MOUD), including buprenorphine. Low barrier buprenorphine treatment aims to reduce or eliminate the threshold for getting and staying on medication by providing immediate and long-term access to buprenorphine without strict rules or requirements. This study examines associations between medical providers' beliefs about treating people with opioid use disorder (OUD) and naloxone access with their self-reported low-barrier buprenorphine prescribing practices. We surveyed and analyzed responses from providers (N = 86) who completed X-waiver courses in Missouri between March 2017 and September 2019, of which 55% (n = 47) both completed the full survey and endorsed prescribing buprenorphine since the training. The survey included questions about buprenorphine prescribing behaviors as well as the Naloxone-Related Risk Compensation Beliefs (NaRCC-B) scale and the Attitudes toward Patients with OUD scale. Analyses consisted of a series of linear and logistic regressions with the NaRCC-B and OUD Attitudes scales predicting various domains of low-barrier prescribing behaviors. Findings indicate medical providers' beliefs about treating people with OUD are associated with their practice of addiction medicine, with individuals with more favorable views being more likely to endorse low-barrier buprenorphine prescribing practices including offering telemedicine and at-home inductions, prescribing higher doses of buprenorphine, treating larger caseloads, and discussing overdose risk and protective factors with their patients. Providers' beliefs about naloxone being enabling were less related to their buprenorphine practices but strongly related to their likelihood of providing naloxone. Future research may examine which strategies effectively change prescriber attitudes and their adoption of lower-barrier prescribing practices.

Opioid Risk Mitigation Practices of Interprofessional Oncology Personnel: Results From a Cross-Sectional Survey

BACKGROUND

This study explored the risk mitigation practices of multidisciplinary oncology health-care personnel for the nonmedical use of opioids in people with cancer.

METHODS

An anonymous, cross-sectional descriptive survey was administered via email to eligible providers over 4 weeks at The Ohio State University's Arthur G. James Cancer Hospital. The survey asked about experiences and knowledge related to opioid use disorders.

RESULTS

The final sample of 773 participants included 42 physicians, 213 advanced practice providers (APPs consisted of advanced practice nurses, physician assistants, and pharmacists), and 518 registered nurses. Approximately 40% of participants responded feeling "not confident" in addressing medication diversion. The most frequent risk reduction measure was "Checking the prescription drug monitoring program" when prescribing controlled medications, reported by physicians (n = 29, 78.4%) and APPs (n = 164, 88.6%).

CONCLUSION

People with cancer are not exempt from the opioid epidemic and may be at risk for nonmedical opioid use (NMOU) and substance use disorders. Implementing risk reduction strategies with every patient, with a harm reduction versus abstinence focus, minimizes harmful consequences and improves. This study highlights risk mitigation approaches for NMOU, representing an opportunity to improve awareness among oncology health-care providers. Multidisciplinary oncology teams are ideally positioned to navigate patients through complex oncology and health-care journeys.

The Impact of Later Life Events on Cessation Motivation of Older Adults with Substance Use Disorder in Hong Kong

Life-course researchers have found that age-graded life events, such as marriage and employment, may provoke a turning point in the trajectories of substance use and motivate young adults with substance use disorder (SUD) to seek addiction treatment and cease illegal drug use. However, few studies have focused on the impact of the life events experienced by older adults with SUD in their later life on these trajectories. Even less is known about this phenomenon in non-Western contexts. Thus, we conducted interviews with 34 older individuals with SUD in Hong Kong and explored how later life events affected their motivation to cease illegal drug use. Our findings highlight the influence of age on how life events are experienced and the need for age-specific academic studies of substance use trajectories. The results also have implications for policymakers, as the criminalization and stigmatization of drug use may have a negative impact on the trajectories of substance use among older populations.

Opioid use disorder treatment and the role of New Jersey Medicaid policy changes: perspectives of office-based buprenorphine providers

Background: In the US, seventy percent of drug-related deaths are attributed to opioids. In response to the ongoing opioid crisis, New Jersey's (NJ) Medicaid program implemented the MATrx model to increase treatment access for Medicaid participants with opioid use disorder (OUD). The model's goals include increasing the number of office-based treatment providers, enhancing Medicaid reimbursement for certain treatment services, and elimination of prior authorizations for OUD medications.Objectives: To explore office-based addiction treatment providers' experiences delivering care in the context of statewide policy changes and their perspectives on treatment access changes and remaining barriers.Methods: This qualitative study used purposive sampling to recruit office-based New Jersey medications for opioid use disorder (MOUD) providers . Twenty-two providers (11 females, 11 males) discussed treatment experiences since the policy changes in 2019, including evaluations of the current state of OUD care in New Jersey and perceived outcomes of the MATrx model policy changes.Results: Providers reported the MOUD climate in NJ improved as Medicaid implemented policies intended to reduce barriers to care and increase treatment access. Elimination of prior authorizations was noted as important, as it reduced provider burden and allowed greater focus on care delivery. However, barriers remained, including stigma, pharmacy supply issues, and difficulty obtaining injectable or non-generic medication formulations.Conclusion: NJ policies may have improved access to care for Medicaid beneficiaries by reducing barriers to care and supporting providers in prescribing MOUD. Yet, stigma and lack of psychosocial supports still need to be addressed to further improve access and care quality.

Evidence on Buprenorphine Dose Limits: A Review

OBJECTIVES

As overdose deaths from fentanyl continue to increase, optimizing use of medications for opioid use disorder has become increasingly important. Buprenorphine is a highly effective medication for reducing the risk of overdose death, but only if a patient remains in treatment. Shared decision making between prescribers and patients is important to establish a dose that meets each patient's treatment needs. However, patients frequently face a dose limit of 16 or 24 mg/d based on dosing guidelines on the Food and Drug Administration's package label.

METHODS

This review discusses patient-centered goals and clinical criteria for determining dose adequacy, reviews the history of buprenorphine dose regulation in the United States, examines pharmacological and clinical research results with buprenorphine doses up to 32 mg/d, and evaluates whether diversion concerns justify maintaining a low buprenorphine dose limit.

RESULTS

Pharmacological and clinical research results consistently demonstrate buprenorphine's dose-dependent benefits up to at least 32 mg/d, including reductions in withdrawal symptoms, craving, opioid reward, and illicit use while improving retention in care. Diverted buprenorphine is most often used to treat withdrawal symptoms and reduce illicit opioid use when legal access to it is limited.

CONCLUSIONS

In light of established research and profound harms from fentanyl, the Food and Drug Administration's current recommendations on target dose and dose limit are outdated and causing harm. An update to the buprenorphine package label with recommended dosing up to 32 mg/d and elimination of the 16 mg/d target dose would improve treatment effectiveness and save lives.

Opioid use and HIV treatment services experiences among male criminal justice-involved persons in South Africa: a qualitative study

BACKGROUND

Opioid use disorder (OUD) is overrepresented among people with criminal justice involvement; HIV is a common comorbidity in this population. This study aimed to examine how formerly incarcerated men living with HIV and OUD in South Africa experienced HIV and OUD services in correctional facilities and the community.

METHODS

Three focus group discussions were conducted with 16 formerly incarcerated men living with HIV and OUD in Gauteng, South Africa. Discussions explored available healthcare services in correctional facilities and the community and procedural and practice differences in health care between the two types of settings. Data were analyzed thematically, using a comparative lens to explore the relationships between themes.

RESULTS

Participants described an absence of medical services for OUD in correctional facilities and the harms caused by opioid withdrawal without medical support during incarceration. They reported that there were limited OUD services in the community and that what was available was not connected with public HIV clinics. Participants perceived correctional and community HIV care systems as readily accessible but suggested that a formal system did not exist to ensure care continuity post-release.

CONCLUSIONS

OUD was perceived to be medically unaddressed in correctional facilities and marginally attended to in the community. In contrast, HIV treatment was widely available within the two settings. The current model of OUD care in South Africa leaves many of the needs of re-entrants unmet. Integrating harm reduction into all primary care medical services may address some of these needs. Successful HIV care models provide examples of approaches that can be applied to developing and expanding OUD services in South Africa.

Characteristics of Stress Sensitivity in Heroin Use Disorder Patients during Their Opioid Agonist Treatment

In the present study, performed on a sample of Heroin Use Disorder (HUD) patients undergoing Opioid Agonist Treatment (OAT), we attempted to explore the relationships between stress sensitivity and heroin addiction-related clinical aspects. HUD patients' stress sensitivity was evaluated with the Heroin/PTSD-Spectrum questionnaire (H/PSTD-S). The Drug Addiction History Questionnaire (DAH-Q), the Symptomatological Check List-90 (SCL-90), and The Behavioural Covariate of Heroin Craving inventory (CRAV-HERO) were all used, as were the Deltito Subjective Wellness Scale (D-SWS), a self-report scale evaluating subjective well-being; the Cocaine Problem Severity Index (CPSI), a questionnaire determining the extent of a cocaine problem; and the Marijuana Craving Questionnaire (MC-Q), an instrument assessing craving for cannabinoids. We checked correlations between stress sensitivity and the extent of HUD clinical features and compared patients with and without problematic stress sensitivity. H/PTSD-S was positively correlated with patients' income, altered mental status, legal problems, the lifetime different treatments index, the current treatment load index, and all SCL-90 indexes and factors. Regarding subjective well-being, stress sensitivity negatively correlated with the contrast best week (last five years) index. Patients with high-stress sensitivity were females with a low income. They exhibited a more severe mental status at treatment entry, greater difficulty in working adaptation, and legal problems during treatment. Additionally, these patients showed a higher level of psychopathology, more impairment in well-being, and more risky behaviours during treatment. Stress sensitivity, as H/PTSD-S, must be considered an outcome of HUD. HUD's addiction history and clinical features are significant risk factors for H/PTSD-S. Therefore, social and behavioural impairment in HUD patients could be considered the clinical expression of the H/PTSD spectrum. In summary, the long-term outcome of HUD is not represented by drug-taking behaviours. Rather, the inability to cope with the contingent environmental conditions is the key feature of such a disorder. H/PTSD-S, therefore, should be seen as a syndrome caused by an acquired inability (increased salience) concerning regular (daily) life events.

Feasibility and Short-Term Effects of Low-Threshold Opioid Substitution Treatment during the COVID-19 Pandemic in Hamburg, Germany

INTRODUCTION

After rapidly opening up a low-threshold clinic to support heavily opioid-dependent persons at the beginning of the COVID-19 pandemic in April 2020 in Hamburg (Germany), this non-interventional study evaluated the feasibility and short-term effects of opioid substitution treatment (OST). The low-threshold concept was customized for the pandemic situation and is the first of its kind in Germany.

METHODS

Patients who had already begun treatment were questioned in two assessments, at T1 shortly after beginning treatment and at T2 6 months later. The primary outcome criterion was their quality of life using the OSTQOL. Secondary criteria included retention rate, their mental and physical health (measured by the BSI-18 and the OTI Health Scale), social situation, drug use, COVID-19 status, and satisfaction with treatment.

RESULTS

Out of 84 patients included in the study, 51 participated in both assessments, resulting in a 6-month retention rate of 60.7%. 27.5% were females, and 72.5% were males. The feasibility question of the low-threshold OST clinic can clearly be answered positively. During the course of the study over 6 months, the situation mainly remained stable regarding quality of life, physical and mental health, and days of drug consumption. Patients significantly reduced the time they spent on the drug scene from 8.5 (SD = 7.56) to 6.1 (SD = 6.71) hours a day between the beginning of OST and T2 (p = 0.020). While 56.9% answered to be homeless at the beginning of OST, only 33.3% answered not to have found an accommodation by T2 (p = 0.012). The number of patients having contact to social workers increased from 51.0% to 74.5% (p = 0.004). Almost 2 fifths of the patients took part in PCR testing for COVID-19 (that only being done if they had symptoms), and none of the tests were positive.

DISCUSSION/CONCLUSIONS

Overall, the low-threshold OST clinic has been successfully implemented in order to help a vulnerable group of people navigate through a global pandemic and support the public health sector. Further conclusions on effects are limited by the short study period and the small number of patients, which calls for further research studies in a larger setting.

Barriers to Buprenorphine Prescribing for Opioid Use Disorder in Hospice and Palliative Care

CONTEXT

Hospice and palliative care (HPC) clinicians increasingly care for patients with concurrent painful serious illness and opioid use disorder (OUD) or opioid misuse; however, only a minority of HPC clinicians have an X-waiver license or actively use it to prescribe buprenorphine as medication treatment for OUD.

OBJECTIVES

To understand barriers for HPC clinicians to obtaining an X-waiver and prescribing buprenorphine as medication treatment for OUD.

METHODS

We performed content analysis on 100 survey responses from members of the national Buprenorphine Peer Support Network, a group of HPC clinicians interested in buprenorphine, on X-waiver status, barriers to obtaining an X-waiver, and barriers to active prescribing.

RESULTS

Of 100 HPC clinicians surveyed, only 26 of 57 HPC clinicians with X-waivers had ever prescribed. Prominent barriers included discomfort managing concurrent pain, buprenorphine, and OUD; concerns about impacts on practice; unsupportive practice culture; insufficient practice support; patient facing challenges; and cumbersome regulatory policies.

CONCLUSION

Despite HPC clinicians' interest in buprenorphine prescribing for OUD, several steps are needed to facilitate the practice, including clinician education tailored to pain and to clinical challenges faced by HPC clinicians, mentorship on buprenorphine use, and cultural and practice changes to dismantle systemic stigma towards addiction. We propose evidence-based steps derived from our survey findings that individual clinicians, HPC leaders, and national HPC organizations can take to improve care for patients with painful serious illness and OUD.

Implementation of buprenorphine services in NYC syringe services programs: a qualitative process evaluation

BACKGROUND

Syringe services programs (SSPs) hold promise for providing buprenorphine treatment access to people with opioid use disorder (OUD) who are reluctant to seek care elsewhere. In 2017, the New York City Department of Health and Mental Hygiene (DOHMH) provided funding and technical assistance to nine SSPs to develop "low-threshold" buprenorphine services as part of a multipronged initiative to lower opioid-related overdose rates. The aim of this study was to identify barriers to and facilitators of implementing SSP-based buprenorphine services.

METHODS

We conducted 26 semi-structured qualitative interviews from April 2019 to November 2019 at eight SSPs in NYC that received funding and technical assistance from DOHMH. Interviews were conducted with three categories of staff: leadership (i.e., buprenorphine program management or leadership, eight interviews), staff (i.e., buprenorphine coordinators or other staff, eleven interviews), and buprenorphine providers (six interviews). We identified themes related to barriers and facilitators to program implementation using thematic analysis. We make recommendations for implementation based on our findings.

RESULTS

Programs differed in their stage of development, location of services provided, and provider type, availability, and practices. Barriers to providing buprenorphine services at SSPs included gaps in staff knowledge and comfort communicating with participants about buprenorphine, difficulty hiring buprenorphine providers, managing tension between harm reduction and traditional OUD treatment philosophies, and financial constraints. Challenges also arose from serving a population with unmet psychosocial needs. Implementation facilitators included technical assistance from DOHMH, designated buprenorphine coordinators, offering other supportive services to participants, and telehealth to bridge gaps in provider availability. Key recommendations include: (1) health departments should provide support for SSPs in training staff, building health service infrastructure and developing policies and procedures, (2) SSPs should designate a buprenorphine coordinator and ensure regular training on buprenorphine for frontline staff, and (3) buprenorphine providers should be selected or supported to use a harm reduction approach to buprenorphine treatment.

CONCLUSIONS

Despite encountering challenges, SSPs implemented buprenorphine services outside of conventional OUD treatment settings. Our findings have implications for health departments, SSPs, and other community organizations implementing buprenorphine services. Expansion of low-threshold buprenorphine services is a promising strategy to address the opioid overdose epidemic.

The Experience of Implementing a Low-Threshold Buprenorphine Treatment Program in a Non-Urban Medical Practice

BACKGROUND

To respond to the U.S. opioid crisis, new models of healthcare delivery for opioid use disorder treatment are essential. We used a qualitative approach to describe the implementation of a low-threshold buprenorphine treatment program in an independent, community-based medical practice in Ithaca, NY.

METHODS

We conducted 17 semi-structured interviews with program staff, leadership, and external stakeholders. Then we analyzed these data using content analysis. We used purposeful sampling aiming for variation in job title for program staff, and in organizational affiliation for external stakeholders.

RESULTS

We found that opening an independent medical practice allowed for low-threshold buprenorphine treatment with less regulatory oversight, but state-certification was ultimately required to ensure financial sustainability. Relying on health insurance reimbursement alone led to funding shortfalls and additional funding sources were also required. The practice's ability to build relationships with licensed substance use treatment programs, community organizations, the legal system, and government agencies in the region differed depending on how much these entities supported a harm reduction philosophy compared to abstinence-based treatment. Finally, expanding the practice to a second location in a different region, co-located with a syringe service program, required adapting to a new cultural and political environment.

CONCLUSION

The results from this study provide insight about the challenges that independent medical practices might face in delivering low-threshold buprenorphine treatment. They support policy efforts to address the financial burdens associated with providing low-threshold buprenorphine therapy and inform the external relationships that other providers would need to consider when delivering novel treatment models.

Characterizing opioid-involved overdose risk in local communities: An opioid overdose vulnerability assessment across Indiana, 2017

The objective of this initiative was to conduct a comprehensive opioid overdose vulnerability assessment in Indiana and evaluate spatial accessibility to opioid use disorder treatment, harm reduction services, and opioid response programs. We compiled 2017 county-level (n = 92) data on opioid-related and socioeconomic indicators from publicly available state and federal sources. First, we assessed the spatial distribution of opioid-related indicators in a geographic information system (GIS). Next, we used a novel regression-weighted ranking approach with mean standardized covariates and an opioid-involved overdose mortality outcome to calculate county-level vulnerability scores. Finally, we examined accessibility to opioid use disorder treatment services and opioid response programs at the census tract-level (n = 1511) using two-step floating catchment area analysis. Opioid-related emergency department visit rate, opioid-related arrest rate, chronic hepatitis C virus infection rate, opioid prescription rate, unemployment rate, and percent of female-led households were independently and positively associated with opioid-involved overdose mortality (p < 0.05). We identified high-risk counties across the rural-urban continuum and primarily in east central Indiana. We found that only one of the 19 most vulnerable counties was in the top quintile for treatment services and had naloxone provider accessibility in all of its census tracts. Findings from our vulnerability assessment provide local-level context and evidence to support and inform future public health policies and targeted interventions in Indiana in areas with high opioid overdose vulnerability and low service accessibility. Our approach can be replicated in other state and local public health jurisdictions to assess opioid-involved public health vulnerabilities.