Impact of incarceration on rates of methadone use in a community recruited cohort of injection drug users

Structural and social changes due to the COVID-19 pandemic and their impact on engagement in substance use disorder treatment services: a qualitative study among people with a recent history of injection drug use in Baltimore, Maryland

BACKGROUND

Substance use disorder treatment and recovery support services are critical for achieving and maintaining recovery. There are limited data on how structural and social changes due to the COVID-19 pandemic impacted individual-level experiences with substance use disorder treatment-related services among community-based samples of people who inject drugs.

METHODS

People with a recent history of injection drug use who were enrolled in the community-based AIDS Linked to the IntraVenous Experience study in Baltimore, Maryland participated in a one-time, semi-structured interview between July 2021 and February 2022 about their experiences living through the COVID-19 pandemic (n = 28). An iterative inductive coding process was used to identify themes describing how structural and social changes due to the COVID-19 pandemic affected participants' experiences with substance use disorder treatment-related services.

RESULTS

The median age of participants was 54 years (range = 24-73); 10 (36%) participants were female, 16 (57%) were non-Hispanic Black, and 8 (29%) were living with HIV. We identified several structural and social changes due the pandemic that acted as barriers and facilitators to individual-level engagement in treatment with medications for opioid use disorder (MOUD) and recovery support services (e.g., support group meetings). New take-home methadone flexibility policies temporarily facilitated engagement in MOUD treatment, but other pre-existing rigid policies and practices (e.g., zero-tolerance) were counteracting barriers. Changes in the illicit drug market were both a facilitator and barrier to MOUD treatment. Decreased availability and pandemic-related adaptations to in-person services were a barrier to recovery support services. While telehealth expansion facilitated engagement in recovery support group meetings for some participants, other participants faced digital and technological barriers. These changes in service provision also led to diminished perceived quality of both virtual and in-person recovery support group meetings. However, a facilitator of recovery support was increased accessibility of individual service providers (e.g., counselors and Sponsors).

CONCLUSIONS

Structural and social changes across several socioecological levels created new barriers and facilitators of individual-level engagement in substance use disorder treatment-related services. Multilevel interventions are needed to improve access to and engagement in high-quality substance use disorder treatment and recovery support services among people who inject drugs.

Prevalence and Correlates of Incarceration Among Trans Men, Nonbinary People, and Two-Spirit People in Canada

In the United States, sexual and gender minority populations are known to experience both higher rates of incarceration and more harmful experiences while incarcerated. However, little is known about incarceration rates or experiences among these populations in Canada or among trans men, nonbinary people, and Indigenous Two-Spirit people. This community-based research study analyzed anonymous self-completed survey data from gay, bisexual, trans, and queer men, and nonbinary and Two-Spirit people to determine the prevalence and correlates of lifetime incarceration among trans men, nonbinary, and Two-Spirit participants. Overall, 5.7% of trans participants, 10.6% of nonbinary participants, and 19.7% of Two-Spirit participants reported being incarcerated in their lifetime, all higher than the prevalence among cisgender non-Two-Spirit participants (3.7%). Multivariable logistic regression models revealed both similar and different correlates of incarceration for trans, nonbinary, and Two-Spirit participants, including older age, less education, experiences of forced sex as a minor, hepatitis C virus (HCV) and HIV diagnoses, substance use, and being less out about one's sexuality. Our findings highlight the disproportionate and inequitable incarceration of trans men, nonbinary, and Two-Spirit people and underscore the need for access to gender diverse, culturally competent HCV and HIV screening, prevention, treatment, and harm reduction in correctional facilities.

HIV and Incarceration: Implications for HIV-Positive People Who Use Illicit Drugs During a Seek, Test, Treat, and Retain Initiative in Canada

People who use illicit drugs (PWUD) face increased exposure to the criminal justice system and disproportionate burdens of HIV infection. This article investigated the effects of incarceration on HIV cascade of care-related measures in a setting with a community-wide seek, test, treat, and retain (STTR) initiative. Using a multivariable logistic regression analysis of 935 HIV-positive PWUD between 2005 and 2017, this article showed a negative relationship between periods of incarceration and two measures of engagement in clinical care for HIV among PWUD: recent dispensation of antiretroviral therapy and suppression of HIV viral load. These findings suggest the benefits of STTR-based efforts are limited by exposure to the criminal justice system and highlight the need for additional supports for PWUD with HIV exposed to the criminal justice system.

Characteristics and risk of incarceration among "hard-to-reach" people who use drugs: A five-year prospective cohort study combining self-reports and registry data

BACKGROUND

Incarcerations are associated with an increased risk of morbidity and mortality among people who use drugs (PWUD). In a sample of 884 PWUD, we examine and estimate the risk of incarcerations (i.e., number, duration, and most serious offense).

METHODS

In this prospective cohort study, PWUD were recruited from street- and low-threshold services in seven Norwegian cities in 2013 (Sept-Nov), and followed through the Correctional Service Registry until 20.12.2018. The risk of incarceration during follow-up was examined with multivariable logistic (no incarceration vs. at least one) and multinomial regression models ("no incarcerations", vs. "1″, "≥2″), while accounting for gender, age, homelessness/shelter use, opioid substitution treatment, illegal income sources, injecting behaviours, previous incarcerations, and recruitment city.

RESULTS

During follow-up, there were in total 662 incarceration episodes, and 44.7% of the participants were incarcerated at least once. Overall, 37.5% of those incarcerated had at least one episode due to a drug offense. The average incarceration duration was 65.2 days with 3.5% of the episodes lasting ≥one year. Gender (male), homelessness/shelter use, illegal income sources, injecting stimulants, and previous incarcerations increased the odds of incarceration, while older age decreased the odds. Gender (male), younger age, self-reported theft or theft and dealing, injecting stimulants or heroin and stimulants and previous incarcerations increased the risk of multiple incarcerations.

CONCLUSION

In a five-year prospective study of PWUD, incarcerations were common, and short-term sentences and recidivism were the norm. This is of concern as incarcerations add to an already elevated morbidity and mortality risk in this population.

HIV Risk-Related Behaviors and Willingness to Use Pre-Exposure Prophylaxis Among Black Americans with an Arrest History

OBJECTIVE

Black individuals in the USA are arrested and incarcerated at a significantly higher rate than White individuals, and incarceration is associated with increased HIV vulnerability. Pre-exposure prophylaxis (PrEP) reduces the risk for HIV transmission, but little is known about the relationship between HIV risk behavior and willingness to use PrEP among Black individuals with an arrest history.

METHOD

A total of 868 individuals completed a nationally representative survey and provided baseline data on sexual risk. Participants were grouped as those with a history of arrest (N = 226) and those with no history of arrest (N=619) based on self-reported arrest history. Our study examined HIV risk behaviors associated with willingness to use PrEP between those with arrest history and those without arrest history.

RESULTS

Participants with an arrest history were more likely to have a lifetime history of anal sex (p<0.0001) and sexually transmitted diseases (p=0.0007). A history of multiple sexual partners in the past 3 months was associated with PrEP willingness in individuals with an arrest history [aPR 2.61 (1.77, 3.85), p<0.0001], adjusting for other covariates in the model.

CONCLUSIONS

Differences in risk behavior and willingness to use PrEP exist by arrest history. Understanding these risk behaviors are necessary to increase access to PrEP. PrEP uptake and adherence interventions, when recommended and made available for individuals at substantive risk of HIV infection at the time of arrest and during incarceration, are essential to reducing the spread of HIV in correctional facilities and in communities to which they return.

Recent incarceration and risk of first-time injection initiation assistance: A prospective cohort study of persons who inject drugs

BACKGROUND

Given the prevalence and harms of incarceration among persons who inject drugs (PWID) and their role in injection drug use initiation, we aimed to investigate whether recent incarceration influences the likelihood PWID assist others in their first-ever injection.

METHODS

Prospective cohort study of PWID in Vancouver, Canada who had their PReventing Injecting by Modifying Existing Responses (PRIMER) baseline visit between December 2014 and May 2017, reported never providing injection initiation assistance previously, and had ≥1 follow-up visit. The primary outcome, provision of injection initiation assistance, was defined via self-report as helping anybody inject for the first time in the past six months. The primary exposure was recent incarceration, i.e., self-report of being jailed, imprisoned or detained in the past six months. Participants were assessed biannually until November 2017, drop-out, or their first report of the primary outcome.

RESULTS

1,199 PWID (62.1% male; mean (SD) age, 44.4 (12.3) years) were included in our study. Across 4,171 follow-up visits, 67 participants (5.6%) reported providing injection initiation assistance. The proportion of participants reporting recent incarceration varied between 2.4% to 5.1% per follow-up visit. Based on a multivariable discrete-time proportional hazards regression analysis, recent incarceration was associated with an increased risk of providing injection initiation assistance during the same six-month period (adjusted hazard ratio, 2.64; 95% CI, 1.19 to 5.86).

CONCLUSIONS

The observed association between recent incarceration and risk of providing injection initiation assistance suggests that incarceration could be contributing to the expansion of injection drug use practices within vulnerable populations over time.

Drug Use Disorders and Violence: Associations With Individual Drug Categories

We conducted a systematic review that examined the link between individual drug categories and violent outcomes. We searched for primary case-control and cohort investigations that reported risk of violence against others among individuals diagnosed with drug use disorders using validated clinical criteria, following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We identified 18 studies published during 1990–2019, reporting data from 591,411 individuals with drug use disorders. We reported odds ratios of the violence risk in different categories of drug use disorders compared with those without. We found odds ratios ranging from 0.8 to 25.0 for most individual drug categories, with generally higher odds ratios among individuals with polydrug use disorders. In addition, we explored sources of between-study heterogeneity by subgroup and meta-regression analyses. Cohort investigations reported a lower risk of violence than case-control reports (odds ratio =  2.7 (95% confidence interval (CI): 2.1, 3.5) vs. 6.6 (95% CI: 5.1, 8.6)), and associations were stronger when the outcome was any violence rather than intimate partner violence (odds ratio = 5.7 (95% CI: 3.8, 8.6) vs. 1.7 (95% CI: 1.4, 2.1)), which was consistent with results from the meta-regression. Overall, these findings highlight the potential impact of preventing and treating drug use disorders on reducing violence risk and associated morbidities.

Characteristics Associated with Nonmedical Methadone Use among People Who Inject Drugs in California

Background: Illicit, nonmedical use of opioid agonist medications such as methadone is an ongoing concern. Yet, few studies have examined nonmedical use of methadone by people who inject drugs (PWID). Objectives: This study describes the prevalence of nonmedical methadone use in a community sample of PWID and examines factors associated with recent use of nonmedical methadone. Methods: A cross-sectional sample of PWID (N = 777) was recruited using targeted sampling and interviewed in California (2011-2013). Descriptive, bivariate, and multivariate logistic regression analyses were used to determine characteristics associated with nonmedical methadone use in the last 30 days. To determine if nonmedical methadone use was associated with overdose in the last 6 months, a separate multivariate analysis was conducted. Results: Among PWID sampled, 21% reported nonmedical methadone use in the last 30 days. In multivariate logistic regression analysis, nonmedical methadone use was associated with recent methadone maintenance treatment (adjusted odds ratio [AOR] = 2.86; 95% confidence interval [CI] = 1.90, 4.30), recent nonmedical buprenorphine use (AOR = 3.12; 95% CI = 1.31, 7.47), higher injection frequency (referent <30 injections; 30-89 injections AOR = 1.89; 95% CI = 1.19, 3.02; 90-plus injections AOR = 2.43; 95% CI = 1.53, 3.87), schizophrenia diagnosis (AOR = 2.36; 95% CI = 1.36, 4.10), recent non-injection opioid prescription use (AOR = 2.97; 95% CI = 1.99, 4.43), and recent injection opioid prescription misuse (AOR = 2.13; 95% CI = 1.27, 3.59). Nonmedical methadone use was found not to be associated with nonfatal overdose (AOR = 0.77; 95% CI = 0.38, 1.56). Conclusion: Nonmedical methadone use identifies a vulnerable subpopulation among PWID, is not associated with elevated nonfatal overdose risk, and evidences a need to expand methadone treatment availability.

Incarceration history and risk of HIV and hepatitis C virus acquisition among people who inject drugs: a systematic review and meta-analysis

BACKGROUND

People who inject drugs (PWID) experience a high prevalence of incarceration and might be at high risk of HIV and hepatitis C virus (HCV) infection during or after incarceration. We aimed to assess whether incarceration history elevates HIV or HCV acquisition risk among PWID.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, and PsycINFO databases for studies in any language published from Jan 1, 2000 until June 13, 2017 assessing HIV or HCV incidence among PWID. We included studies that measured HIV or HCV incidence among community-recruited PWID. We included only studies reporting original results and excluded studies that evaluated incident infections by self-report. We contacted authors of cohort studies that met the inclusion or exclusion criteria, but that did not report on the outcomes of interest, to request data. We extracted and pooled data from the included studies using random-effects meta-analyses to quantify the associations between recent (past 3, 6, or 12 months or since last follow-up) or past incarceration and HIV or HCV acquisition (primary infection or reinfection) risk among PWID. We assessed the risk of bias of included studies using the Newcastle-Ottawa Scale. Between-study heterogeneity was evaluated using the I2 statistic and the P-value for heterogeneity.

FINDINGS

We included published results from 20 studies and unpublished results from 21 studies. These studies originated from Australasia, western and eastern Europe, North and Latin America, and east and southeast Asia. Recent incarceration was associated with an 81% (relative risk [RR] 1·81, 95% CI 1·40-2·34) increase in HIV acquisition risk, with moderate heterogeneity between studies (I2=63·5%; p=0·001), and a 62% (RR 1·62, 95% CI 1·28-2·05) increase in HCV acquisition risk, also with moderate heterogeneity between studies (I2=57·3%; p=0·002). Past incarceration was associated with a 25% increase in HIV (RR 1·25, 95% CI 0·94-1·65) and a 21% increase in HCV (1·21, 1·02-1·43) acquisition risk.

INTERPRETATION

Incarceration is associated with substantial short-term increases in HIV and HCV acquisition risk among PWID and could be a significant driver of HCV and HIV transmission among PWID. These findings support the need for developing novel interventions to minimise the risk of HCV and HIV acquisition, including addressing structural risks associated with drug laws and excessive incarceration of PWID.

FUNDING

Engineering and Physical Sciences Research Council, National Institute for Health Research, National Institutes of Health.

Recent incarceration and buprenorphine maintenance treatment outcomes among human immunodeficiency virus-positive patients

BACKGROUND

Opioid use disorder is a common cause of morbidity and mortality among people living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). Buprenorphine maintenance treatment (BMT) is an effective means of therapy, but patients with recent criminal justice involvement may need more support during BMT than other patients. The authors hypothesized that recently incarcerated BMT patients who initiated treatment in primary care would have poorer treatment outcomes than those who were not recently incarcerated.

METHODS

Investigators analyzed data from a multisite cohort study of BMT integrated into HIV care. Patients were stratified by self-reported incarceration in the 30 days before initiation of BMT. The outcomes of interest were 6- and 12-month treatment retention and self-reported opioid use. Investigators used multivariable logistic regression and hierarchical linear model, respectively, to evaluate the association between recent incarceration and these outcomes while adjusting for potential confounding variables.

RESULTS

Among 305 BMT patients living with HIV/AIDS, 39 (13%) reported recent incarceration. Patients with recent incarceration (vs. without) were more likely to be homeless, unemployed, and previously diagnosed with mental illness. Recent incarceration was not significantly associated with differences in 6-month (odds ratio [OR] = 0.95; 95% confidence interval [CI] = 0.46-1.98) and 12-month (OR = 0.57; 95% CI = 0.27-1.18) treatment retention or in self-reported opioid use (OR = 0.99; 95% CI = 0.51-1.92) after adjustment for potential confounding variables.

CONCLUSIONS

Those with incarceration in the 30 days prior to BMT initiation were more likely to be homeless, unemployed, and previously diagnosed with mental illness than those without recent incarceration. However, no significant difference in self-reported opioid use or 6-month or 12-month retention in treatment was detected between those with and without recent incarceration. Future studies should confirm these findings with larger sample sizes. Encouraging formerly incarcerated individuals with opioid use disorder to initiate evidence-based treatments, including BMT, should be part of efforts to confront the opioid addiction epidemic in the United States.

Income generation and attitudes towards addiction treatment among people who use illicit drugs in a Canadian setting

INTRODUCTION

Socioeconomically marginalized people who use illicit drugs (PWUD) often engage in alternative income generating activities to meet their basic needs. These activities commonly carry a number of health and social risks, which may prompt some PWUD to consider addiction treatment to reduce their drug use or drug-related expenses. We sought to determine whether engaging in certain forms of income generation was independently associated with self-reported need for addiction treatment among a cohort of PWUD in Vancouver, Canada.

METHODS

Data from two prospective cohorts of PWUD in Vancouver were used in generalized estimating equations to identify factors associated with self-reported need for addiction treatment, with a focus on income generating activities.

RESULTS

Between June 2013 and May 2014, 1285 respondents participated in the study of whom 483 (34.1%) were female and 396 (30.8%) indicated that they needed addiction treatment. In final multivariate analyses, key factors significantly and positively associated with self-reported need for addiction treatment included engaging in illegal income generating activities (adjusted odds ratio [AOR]=1.96, 95% confidence interval [CI}: 1.11-3.46); sex work (AOR=1.61, 95% CI: 1.05-2.47), homelessness (AOR=1.65, 95% CI: 1.22-2.25); and recent engagement in counselling (AOR=1.85, 95% CI: 1.40-2.44).

DISCUSSION

Our results suggest that key markers of socioeconomic marginalization are strongly linked with a stated need for addiction treatment. These findings underscore the need to provide appropriate and accessible addiction treatment access to marginalized PWUD and to consider alternative approaches to reduce socioeconomic disadvantage.