Network-Based Research on Rural Opioid Use: an Overview of Methods and Lessons Learned

Examining the social and behavioral dynamics of substance use in a longitudinal network study in rural Appalachia

BACKGROUND

Prior studies have shown that individuals and their peers often have similar substance use behaviors, but the mechanisms driving these similarities - particularly in rural settings, are not well understood. The primary objectives of this analysis are to (1) identify factors that contribute to relationship turnover and maintenance within a rural network of persons who use drugs (PWUD), (2) determine whether assimilation and/or homophily shape participants use of injection drugs, heroin, and stimulants (methamphetamine and cocaine), and (3) assess the extent that these mechanisms influence networks ties and/or behaviors and whether these effects vary across time.

METHODS

Sociometric network data were collected from a cohort of PWUD in rural Eastern Kentucky at baseline (2008-2010) and at four follow-up visits conducted approximately semiannually. Stochastic actor-oriented models (SAOMS) were used to model network structure and participant behaviors as jointly dependent variables and to identify characteristics associated with the maintenance, dissolution, and formation of network ties and changes in drug use behaviors.

RESULTS

Findings suggest (1) greater network stability over time for reciprocal and transitive relationships, (2) both homophily and assimilation played a greater role in shaping injection drug use (IDU) initiation and cessation than they did in shaping heroin and stimulant use, and (3) the importance of these mechanisms appeared consistent over time.

CONCLUSION

Given the stability of particular network structures and evidence of both homophily and assimilation with respect to drug-use behaviors, interventions that leverage social networks could be used to motivate health-promoting behaviors.

How do people who use opioids express their qualities and capacities? An assessment of attitudes, behaviors, and opportunities

People who nonmedically use drugs (PWUD) face intricate social issues that suppress self-actualization, communal integration, and overall health and wellness. "Strengths-based" approaches, an under-used pedagogy and practice in addiction medicine, underscore the significance of identifying and recognizing the inherent and acquired skills, attributes, and capacities of PWUD. A strengths-based approach engenders client affirmation and improves their capacity to reduce drug use-related harms by leveraging existing capabilities. Exploring this paradigm, we conducted and analyzed interviews with 46 PWUD who were clients at syringe services programs in New York City and rural southern Illinois, two areas with elevated rates of opioid-related morbidity and mortality, to assess respondents' perceived strengths. We located two primary thematic modalities in which strengths-based ethos is expressed: individuals (1) being and advocate and resource for harm reduction knowledge and practices and (2) engaging in acts of continuous self-actualization. These dynamics demonstrate PWUD strengths populating and manifesting in complex ways that both affirm and challenge humanist and biomedical notions of individual agency, as PWUD refract enacted, anticipated, and perceived stigmas. In conclusion, programs that blend evidence-based, systems-level interventions on drug use stigma and disenfranchisement with meso and micro-level strengths-based interventions that affirm and leverage personal identity, decision-making capacity, and endemic knowledge may help disrupt health promotion cleavages among PWUD.

Methods for Assessing Spillover in Network-Based Studies of HIV/AIDS Prevention among People Who Use Drugs

Human Immunodeficiency Virus (HIV) interventions among people who use drugs (PWUD) often have spillover, also known as interference or dissemination, which occurs when one participant's exposure affects another participant's outcome. PWUD are often members of networks defined by social, sexual, and drug-use partnerships and their receipt of interventions can affect other members in their network. For example, HIV interventions with possible spillover include educational training about HIV risk reduction, pre-exposure prophylaxis, or treatment as prevention. In turn, intervention effects frequently depend on the network structure, and intervention coverage levels and spillover can occur even if not measured in a study, possibly resulting in an underestimation of intervention effects. Recent methodological approaches were developed to assess spillover in the context of network-based studies. This tutorial provides an overview of different study designs for network-based studies and related methodological approaches for assessing spillover in each design. We also provide an overview of other important methodological issues in network studies, including causal influence in networks and missing data. Finally, we highlight applications of different designs and methods from studies of PWUD and conclude with an illustrative example from the Transmission Reduction Intervention Project (TRIP) in Athens, Greece.

Factors associated with perceived ease of access to syringes in Appalachian North Carolina

PURPOSE

To examine associations between perceived ease of syringe access, syringe sources, injection behaviors, and law enforcement (LE) interactions among people who inject drugs (PWID) in rural Appalachian North Carolina (NC).

METHODS

Using respondent-driven sampling, a diverse sample of 309 self-reported PWID were recruited from rural Appalachian NC. Data were collected via audio computer-assisted self-interview technology from February 2019 through March 2020. Respondents reported demographics, sources of syringes, LE interactions, and injection behaviors. Univariate, bivariate, and linear regression analyses were performed.

FINDINGS

Respondents most often obtained syringes from pharmacies and syringe service programs (SSPs). Twenty-one percent disagreed that it was easy to obtain sterile syringes, with 28% reporting low or no access to an SSP. PWID who reported longer physical distances to an SSP had greater difficulty accessing syringes (P<.001). PWID who reported greater ease of access to syringes reported engaging in receptive syringe sharing less often (P<.01). PWID who were stopped and searched by LE more often reported injecting drugs somebody else prepared with nonsterile supplies more often (P<.01). Participants shared used injection supplies more than twice as often than they shared used syringes.

CONCLUSIONS

These results underscore the importance of SSPs to mitigate the spread of human immunodeficiency virus and viral hepatitis in rural areas. Supporting mobile SSP services in rural areas could increase access to sterile syringes and injection supplies. SSPs should educate PWID about the importance of not sharing injection supplies. Pharmacies could increase syringe access in areas where SSPs do not operate.

The impact of syringe services program closure on the risk of rebound HIV outbreaks among people who inject drugs: a modeling study

OBJECTIVE

Despite their effectiveness in preventing the transmission of HIV among people who inject drugs (PWID), syringe services programs (SSPs) in many settings are hampered by social and political opposition. We aimed to estimate the impact of closure and temporary interruption of SSP on the HIV epidemic in a rural United States setting.

METHODS

Using an agent-based model (ABM) calibrated to observed surveillance data, we simulated HIV risk behaviors and transmission in adult populations who inject and do not inject drugs in Scott County, Indiana. We projected HIV incidence and prevalence between 2020 and 2025 for scenarios with permanent closure, delayed closure (one additional renewal for 24 months before closure), and temporary closure (lasting 12 months) of an SSP in comparison to persistent SSP operation.

RESULTS

With sustained SSP operation, we projected an incidence rate of 0.15 per 100 person-years among the overall population (95% simulation interval: 0.06-0.28). Permanently closing the SSP would cause an average of 58.4% increase in the overall incidence rate during 2021-2025, resulting in a higher prevalence of 60.8% (50.9-70.6%) (18.7% increase) among PWID by 2025. A delayed closure would increase the incidence rate by 38.9%. A temporary closure would cause 12 (35.3%) more infections during 2020-2021.

CONCLUSION

Our analysis suggests that temporary interruption and permanent closure of existing SSPs operating in rural United States may lead to 'rebound' HIV outbreaks among PWID. To reach and sustain HIV epidemic control, it will be necessary to maintain existing and implement new SSPs in combination with other prevention interventions.

A cross-sectional survey of potential factors, motivations, and barriers influencing research participation and retention among people who use drugs in the rural USA

BACKGROUND

Despite high morbidity and mortality among people who use drugs (PWUD) in rural America, most research is conducted within urban areas. Our objective was to describe influencing factors, motivations, and barriers to research participation and retention among rural PWUD.

METHODS

We recruited 255 eligible participants from community outreach and community-based, epidemiologic research cohorts from April to July 2019 to participate in a cross-sectional survey. Eligible participants reported opioid or injection drug use to get high within 30 days and resided in high-needs rural counties in Oregon, Kentucky, and Ohio. We aggregated response rankings to identify salient influences, motivations, and barriers. We estimated prevalence ratios to assess for gender, preferred drug use, and geographic differences using log-binomial models.

RESULTS

Most participants were male (55%) and preferred methamphetamine (36%) over heroin (35%). Participants reported confidentiality, amount of financial compensation, and time required as primary influential factors for research participation. Primary motivations for participation include financial compensation, free HIV/HCV testing, and contribution to research. Changed or false participant contact information and transportation are principal barriers to retention. Respondents who prefer methamphetamines over heroin reported being influenced by the purpose and use of their information (PR = 1.12; 95% CI: 1.00, 1.26). Females and Oregonians (versus Appalachians) reported knowing and wanting to help the research team as participation motivation (PR = 1.57; 95% CI: 1.09, 2.26 and PR = 2.12; 95% CI: 1.51, 2.99).

CONCLUSIONS

Beyond financial compensation, researchers should emphasize confidentiality, offer testing and linkage with care, use several contact methods, aid transportation, and accommodate demographic differences to improve research participation and retention among rural PWUD.

Hepatitis C virus infection and polysubstance use among young adult people who inject drugs in a rural county of New Mexico

AIMS

We assessed prevalence and correlates for hepatitis C virus (HCV) infection in young adult people who inject drugs (PWID) in rural New Mexico, where opioid use has been historically problematic.

METHODS

Participants were 18-29 years old with self-reported injection drug use in the past 90 days. We conducted testing for HCV antibodies (anti-HCV) and HCV ribonucleic acid (RNA) and assessed sociodemographic and risk exposures. We provided counseling and referrals to prevention services and drug treatment. We estimated prevalence ratios (PR) to assess bivariate associations with HCV infection; and adjusted PRs using modified Poisson regression methods.

RESULTS

Among 256 participants tested for anti-HCV, 156 (60.9 %) had been exposed (anti-HCV positive), and of 230 tested for both anti-HCV and HCV RNA, 103 (44.8 %) had current infection (RNA-positive). The majority (87.6 %) of participants were Hispanic. Almost all (96.1 %) had ever injected heroin; 52.4 % and 52.0 % had ever injected methamphetamine or cocaine, respectively. Polysubstance injecting (heroin and any other drug) was associated with significantly higher prevalence of HCV infection (76.0 %) compared to injecting only heroin (24.0 %) (PR: 3.17 (95 % CI:1.93, 5.23)). Years of injecting, history of non-fatal opioid-involved overdose, polysubstance injecting, and stable housing were independently associated with HCV infection.

CONCLUSIONS

HCV is highly prevalent among young adult PWID in rural NM. The high reported prevalence of polysubstance injecting and its association with HCV infection should be considered in prevention planning.

Novel Recruitment Methods for Research Among Young Adults in Rural Areas Who Use Opioids: Cookouts, Coupons, and Community-Based Staff

OBJECTIVES

Rural communities in the United States are increasingly becoming epicenters of substance use and related harms. However, best practices for recruiting rural people who use drugs (PWUD) for epidemiologic research are unknown, because such strategies were developed in cities. This study explores the feasibility of web- and community-based strategies to recruit rural, young adult PWUD into epidemiologic research.

MATERIALS AND METHODS

We recruited PWUD from rural Kentucky to participate in a web-based survey about opioid use using web-based peer referral and community-based strategies, including cookouts, flyers, street outreach, and invitations to PWUD enrolled in a concurrent substance use study. Staff members labeled recruitment materials with unique codes to enable tracking. We assessed eligibility and fraud through online eligibility screening and a fraud detection algorithm, respectively. Eligibility criteria included being aged 18-35, recently using opioids to get high, and residing in the study area.

RESULTS

Recruitment yielded 410 complete screening entries, of which 234 were eligible and 151 provided complete, nonfraudulent surveys (ie, surveys that passed a fraud-detection algorithm designed to identify duplicate, nonlocal, and/or bot-generated entries). Cookouts and subsequent web-based peer referrals accounted for the highest proportion of screening entries (37.1%, n = 152), but only 29.6% (n = 45) of entries from cookouts and subsequent web-based peer referrals resulted in eligible, nonfraudulent surveys. Recruitment and subsequent web-based peer referral from the concurrent study yielded the second most screening entries (27.8%, n = 114), 77.2% (n = 88) of which resulted in valid surveys. Other recruitment strategies combined to yield 35.1% (n = 144) of screening entries and 11.9% (n = 18) of valid surveys.

CONCLUSIONS

Web-based methods need to be complemented by context-tailored, street-outreach activities to recruit rural PWUD.

Estimation and correction of bias in network simulations based on respondent-driven sampling data

Respondent-driven sampling (RDS) is widely used for collecting data on hard-to-reach populations, including information about the structure of the networks connecting the individuals. Characterizing network features can be important for designing and evaluating health programs, particularly those that involve infectious disease transmission. While the validity of population proportions estimated from RDS-based datasets has been well studied, little is known about potential biases in inference about network structure from RDS. We developed a mathematical and statistical platform to simulate network structures with exponential random graph models, and to mimic the data generation mechanisms produced by RDS. We used this framework to characterize biases in three important network statistics – density/mean degree, homophily, and transitivity. Generalized linear models were used to predict the network statistics of the original network from the network statistics of the sample network and observable sample design features. We found that RDS may introduce significant biases in the estimation of density/mean degree and transitivity, and may exaggerate homophily when preferential recruitment occurs. Adjustments to network-generating statistics derived from the prediction models could substantially improve validity of simulated networks in terms of density, and could reduce bias in replicating mean degree, homophily, and transitivity from the original network.

Peer influence of injection drug use cessation among dyads in rural eastern Kentucky

BACKGROUND

This analysis aims to assess whether injection drug use cessation among peers predicts injection drug use cessation among individuals and explores whether this association varies by relationship type and strength.

METHODS

Data were collected through baseline and 6-month assessments for the Social Networks among Appalachian People study (2008-2011). Interviewer-administered surveys collected sociodemographic and drug use behaviors (past 6 months and lifetime). Participants also listed sex, drug use, and social support partners (past 6 months). Listed names were cross-referenced with survey participants to identify relationships between study participants. The analytic sample was further restricted to include only those relationship pairs where both individuals reported a history of injection drug use at baseline (n = 244 unique individuals and 746 dyads). We fit a generalized estimating equations logistic regression model to (1) assess the relationship between peer injection cessation and individual injection cessation and (2) determine whether the strength of this association differs by relationship-level variables (i.e., relationship role, relationship type, relationship duration, frequency of interaction, residential proximity).

RESULTS

Overall, those with a network member who ceased injection drug use were more likely to stop injecting over the following 6-month period (AOR=1.65). The magnitude of this association was greater for social support partners (AOR=2.95), family members (AOR=3.56), those with whom the participant interacted at least daily (AOR=2.17), and those who the participant knew longer (AOR=2.09). Further, among family members, the effect size was greater when relationships were further restricted to immediate family members (AOR=5.35).

CONCLUSION

Our findings suggest that in this rural community, closer, more supportive relationships, may be more influential for modeling injection cessation; however, relationship-types were not mutually exclusive so differences in effect size across strata may not be statistically significant. In this setting, social support through the recovery process (including cessation attempts with peers) may increase likelihood of injection cessation.

Rural risk environments for hepatitis c among young adults in appalachian kentucky

BACKGROUND

Rural Kentucky is an epicenter of hepatitis C(HCV), especially among young adults who inject drugs. While the Risk Environment Framework (REF) has been used widely to study and address socio-ecological determinants of infectious disease among people who inject drugs (PWID), it has been almost exclusively applied to urban environments. Applying REF to rural environments can enhance our understanding of the drivers of HCV epidemics in these hard-hit areas, and inform the creation and implementation of harm reduction interventions in this local context.

METHODS

Participants were recruited between March and August 2017 via community-based outreach methods (e.g., cookouts, flyers) and peer referral. Individuals who met eligibility criteria (aged 18-35, recently used prescription opioids and/or heroin to get high, lived in one of the 5 target counties) participated indepth, semi-structured interviews. The interview guide was informed by the REF, and covered HCV-related risk behaviors and environmental features that shaped vulnerability to engaging in these behaviors. Interviews were transcribed and analyzed using constructivist grounded-theory methods.

RESULTS

Participants (N=19) described multiple intersecting risk environment features that shaped vulnerability to HCV transmission. Economic decline generated intergenerational poverty, dwindling employment prospects, and diminished social enrichment opportunities that collectively contributed to substance misuse and risky injection practices. Geographic isolation, lack of collective knowledge about HCV transmission risks, scarce harm reduction services, familial poverty, and fear of law enforcement interacted to increase the odds of people injecting in "trap houses" (akin to shooting galleries) or secluded areas, spaces in which they rushed to inject and shared injection equipment. Pervasive stigma was a structural barrier to adopting, expanding, and using harm reduction services.

CONCLUSION

This exploratory study identified features of rural risk environments that may contribute to significant HCV burdens in Appalachian Kentucky. Findings signal the importance of expanding proven harm reduction strategies and anti-stigma interventions tailored to rural contexts.

Using Network and Spatial Data to Better Target Overdose Prevention Strategies in Rural Appalachia

This analysis uses network and spatial data to identify optimal individuals to target with overdose prevention interventions in rural Appalachia. Five hundred and three rural persons who use drugs were recruited to participate in the Social Networks among Appalachian People Study (2008-2010). Interviewer-administered surveys collected information on demographic characteristics, risk behaviors (including overdose history), network members, and residential addresses. We restricted the sample to individuals with at least one confirmed relationship to another study participant (N = 463). Using dyadic analyses (N = 1428 relationships), we identified relationship-level correlates of relationships with network members who have previously overdosed. We then examined individual- and network-level factors associated with (1) having at least one first-degree alter (i.e., network member) with a prior overdose and (2) each additional network member with a prior overdose (N = 463 study participants). Overall, 28% of the sample had previously overdosed and 57% were one-degree away from someone who previously overdosed. Relationships with those who had overdosed were characterized by closer residential proximity. Those with at least one network member who previously overdosed were more geographically central and occupied more central network positions. Further, the number of network members with an overdose history increased with decreasing distance to the town center, increasing network centrality, and prior enrollment in an alcohol detox program. Because fatal overdoses can be prevented through bystander intervention, these findings suggest that strategies that target more central individuals (both geographically and based on their network positions) and those who have previously enrolled in alcohol detox programs with overdose prevention training and naloxone may optimize intervention reach and have the potential to curb overdose fatalities in this region.

Network Research Experiences in New York and Eastern Europe: Lessons for the Southern US in Understanding HIV Transmission Dynamics

PURPOSE

This paper presents an overview of different kinds of risk and social network methods and the kinds of research questions each can address.

RECENT FINDINGS

It also reviews what network research has discovered about how network characteristics are associated with HIV and other infections, risk behaviors, preventive behaviors, and care, and discusses some ways in which network-based public health interventions have been conducted. Based on this, risk and social network research and interventions seem both feasible and valuable for addressing the many public health and social problems raised by the widespread use of opioids in the US South.