A scoping review of opioid misuse in the rural United States

"I'm tired of seeing my friends die": Barriers and facilitators to participating in clinical trials among rural people who use drugs in the United States

PURPOSE

Participation in clinical trials among people who use drugs (PWUD) in rural areas remains disproportionately low compared to those in urban communities. Our objective was to describe the barriers and facilitators to clinical trial participation among this understudied and underserved population.

METHODS

We conducted semi-structured in-depth interviews among rural PWUD in Kentucky, Ohio, and Oregon. Using the Ickovics and Meisler framework, we classified factors associated with participation in clinical trials among rural PWUD into five categories: the individual, trial and intervention characteristics, participant-trial staff relationship, clinical trial setting, and features of the disease. We used inductive qualitative analysis methods to identify salient themes.

FINDINGS

Thirty-five rural participants (median age: 39, 51% men) completed in-depth interviews. Facilitators for rural clinical trial participation were mainly situated within the individual, trial and intervention characteristics, and clinical trial setting. Individual characteristics, such as altruistic motivations to help their communities and peers, as well as trial and intervention characteristics like visit reminders and resource assistance, were the most frequently noted facilitators of clinical trial participation. In contrast, participation barriers were mainly related to participant-trial staff relationships and disease features. Judgmental and untrustworthy trial staff, along with involvement in the criminal legal system, were obstacles to clinical trial participation.

CONCLUSIONS

Individual, intrapersonal, and logistical factors described by rural PWUD must be addressed to enhance the participation and retention of this population in clinical trials. Successful clinical trial participation may contribute to equitable access to essential health services by PWUD in rural communities.

Statewide implementation for medications for opioid use disorder (MOUD) in urban and rural emergency departments

BACKGROUND

Medications for opioid use disorder (MOUD) programs in Emergency Departments (EDs) are feasible and effective, but uptake lags despite rising overdose deaths. NM Bridge partners with hospitals across highly rural New Mexico to guide implementation for ED-based MOUD using a Dissemination & Implementation (D&I) approach. This manuscript describes NM Bridge's outcomes in its first three years (2020-2023).

METHODS

NM Bridge offers partner hospitals a D&I intervention called implementation facilitation (IF) to guide their implementation of ED-based MOUD. The IF intervention has three mechanisms: (1) trainings, (2) a guiding blueprint (implementation plan), and (3) biweekly meetings. Each hospital receives tailored trainings, builds a team of champions who lead the work in the blueprint and are supported in biweekly meetings by the NM Bridge team. Successful implementation is defined as hospitals completing trainings, prescribing buprenorphine from the ED, and providing a warm hand-off to outpatient treatment. Primary outcomes include buprenorphine prescriptions written, clinicians trained, and peer support workers (PSW) hired.

RESULTS

From 10/2020 to 12/2023, NM Bridge recruited 34 hospitals, engaged 12, with six fully participating. In engaged hospitals (8 rural, 4 urban), 100% recognized MOUD as a vital practice, but all reported barriers of locums staffing, <25% x-waivered clinicians, and stigma. The six participating hospitals (4 rural, 2 urban) achieved 100% of IF mechanisms, variable blueprint (implementation plan) achievement, and 100% successfully implemented MOUD. This resulted in a 52.3% increase in buprenorphine prescriptions [728 patients (592 rural, 136 urban)], 144 clinicians trained, and 50% of EDs hiring a PSW.

CONCLUSIONS

Implementation facilitation of ED-based MOUD programs was successful across six diverse hospitals, in a highly rural state.

Rural-urban divide in risk perception of LSD: Implications for psychedelic-assisted therapy

BACKGROUND

Recent legislative initiatives in the United States have focused on the medical and legal status of psychedelics, prompting interest in understanding public perceptions of their risks. This study investigates rural-urban differences in the perception of LSD and cannabis risks using national survey data.

METHODS

Data from the National Survey of Drug Use and Health (NSDUH) between 2015 and 2021 were analyzed. Logistic regression models were used to compare risk perceptions of LSD and cannabis between rural and urban respondents, adjusting for relevant factors.

RESULTS

Rural residents were 1.2 to 1.4 times more likely to perceive using LSD once or twice as of great risk compared to urban residents during the survey period. However, the perception of monthly cannabis use as having great risk was slightly higher among rural residents only until 2019, with no significant differences observed in 2020 and 2021.

CONCLUSION

The study highlights a significant rural-urban divide in the perception of LSD risk, which could impact policymaking on psychedelic therapies. Understanding these differences is crucial for developing effective and equitable policies regarding psychedelic substances and treatments.

Family Check-Up Online effects on parenting and parent wellbeing in families of toddler to preschool-age children

Online parenting interventions hold promise for increasing access to behavioral support for families with low income and who reside in rural areas. The current study evaluates the efficacy of a mobile app-based parenting support program, the Family Check-Up Online (FCU-O) with telehealth coaching support, for parents of children 1.5-5 years old at risk of experiencing parenting challenges. We tested effects of the FCU-O on parent wellbeing (parenting self-efficacy and symptoms of depression and anxiety) and parent-reported parenting skills (support for positive behavior, limit-setting, and proactive parenting) at the 3-month follow-up in a randomized controlled trial (FCU-O versus control). We also tested relationships between parents' baseline characteristics and their engagement with the app and telehealth coaching. Eligibility criteria included endorsing depressive symptoms or current or past substance misuse. Participants (N = 356) were predominantly White (72%) and low-income, with 43% of families residing in a rural area. Approximately one third of participants reported clinically significant symptoms of anxiety or depression and one third endorsed a lifetime history of opioid misuse. Intent to treat analyses tested effects of the FCU-O on parent wellbeing and parenting skills. The FCU-O was associated with improvements to parents' support for positive behavior, limit-setting, and proactive parenting skills, as well as parenting self-efficacy and depressive symptoms. Parents' initial symptoms of depression and anxiety significantly predicted greater telehealth coach engagement; low levels of initial self-reported skills positive behavior support and limit-setting significantly predicted greater app engagement. Results provide support for the FCU-O as a preventive parenting intervention for parents experiencing mental health challenges, with implications for reducing barriers to accessing parenting support for underserved families.

Designing and Evaluating Opioid Misuse Prevention Training for Rural Communities and Health Care Providers

Through Substance Abuse and Mental Health Services Administration funding, Michigan State University (MSU) Extension partnered with MSU's Family Medicine and Health Department of Northwest Michigan to implement trainings for community members and health care providers to increase awareness and improve prevention efforts addressing opioid use disorder (OUD) in rural areas. We formed the Michigan Substance Use Prevention, Education and Recovery (MiSUPER) project to design and evaluate opioid misuse prevention trainings. A socio-ecological prevention model was an underlying conceptual framework for this project and drove strategies used in trainings, products created, and measurement. The purpose of this study is to determine the effectiveness of one-time online educational training events for rural community members and health care providers on community OUD issues, treatment options, and supports for those in recovery. Between 2020 and 2022, rural participants completed pre- and posttraining, and 30-day follow-up evaluation surveys. We report the demographic characteristics of community (n = 451) and provider (n = 59) participants, self-reported knowledge gained, and overall perceptions of the trainings. Findings show community members' knowledge increased from pre- to posttraining (p < .001) and was maintained at 3 months, while providers' knowledge was unchanged over time. Posttraining, community participants felt more comfortable speaking about addiction with family and friends (p < .001), and providers had better knowledge of local resources for patients who could not afford opioid misuse treatments (p < .05). All participants reported gaining knowledge of community resources for opioid misuse prevention, treatment, and recovery (p < .01). Opioid misuse prevention trainings may be most effective when adapted to leverage local resources.

Comparison of Use Rates of Telehealth Services for Substance Use Disorder During and Following COVID-19 Safety Distancing Recommendations: Two Cross-Sectional Surveys

Background

The COVID-19 social distancing guidelines resulted in a dramatic transition to telephone and video technologies to deliver substance use disorder (SUD) treatment. Before COVID-19, the question was "Will telehealth ever take hold for SUD services?" Now that social distancing guidelines have been lifted, the question is "Will telehealth remain a commonly used care modality?"

Objective

The principal purpose of this investigation was to examine the extent to which telehealth use in SUD service settings persisted following the lifting of COVID-19 safety distancing recommendations. Additionally, the study aimed to explore practitioners' perceptions of telehealth convenience and value after its regular implementation during the pandemic. Specifically, the goal of this study was to compare telehealth activity between time intervals: May-August 2020 (during peak COVID-19 safety distancing recommendations) and October-December 2022 (following discontinuation of distancing recommendations). Specifically, we compared (1) telehealth technologies and services, (2) perceived usefulness of telehealth, (3) ease of use of telephone- and video-based telehealth services, and (4) organizational readiness to use telehealth.

Methods

An online cross-sectional survey consisting of 108 items was conducted to measure the use of telehealth technologies for delivering a specific set of SUD services in the United States and to explore the perceived readiness for use and satisfaction with telephonic and video services. The survey took approximately 25-35 minutes to complete and used the same 3 sets of questions and 2 theory-driven scales as in a previous cross-sectional survey conducted in 2020. Six of 10 Regional Addiction Technology Transfer Centers funded by the Substance Abuse and Mental Health Services Administration distributed the survey in their respective regions, collectively spanning 37 states. Responses of administrators and clinicians (hereafter referred to as staff) from this 2022 survey were compared to those obtained in the 2020 survey. Responses in 2020 and 2022 were anonymous and comprised two separate samples; therefore, an accurate longitudinal model could not be analyzed.

Results

A total of 375 staff responded to the 2022 survey (vs 457 in 2020). Baseline organizational characteristics of the 2022 sample were similar to those of the 2020 sample. Phone and video telehealth utilization rates remained greater than 50% in 2022 for screening and assessment, case management, peer recovery support services, and regular outpatient services. The perceived usefulness of phone-based telehealth was higher in 2022 than in 2020 (mean difference [MD] -0.23; P=.002), but not for video-based telehealth (MD -0.12; P=.13). Ease of use of video-based telehealth was perceived as higher in 2022 than in 2020 (MD-0.35; P<.001), but no difference was found for phone-based telehealth (MD -0.12; P=.11). From the staff's perspective, patients had greater readiness for using telehealth via phone than video, but the staff perceived their personal and organizational readiness for using telehealth as greater for video-based than for phone-based telehealth.

Conclusions

Despite lower telephone and video use in 2022 for telehealth services than in 2020, both modalities continue to be perceived positively. Future research may further determine the relative cost and clinical effectiveness of video-based services and thereby help to address some sources of the noted challenges to implementation by SUD organizations.

Examining the association of rurality with opioid-related morbidity and mortality in Georgia: A geospatial analysis

INTRODUCTION

The US opioid epidemic continues to escalate, with overdose deaths being the most-used metric to quantify its burden. There is significant geographic variation in opioid-related outcomes. Rural areas experience unique challenges, yet many studies oversimplify rurality characterizations. Contextual factors, such as area deprivation, are also important to consider when understanding a community's need for treatment services and prevention programming. This study aims to provide a geospatial snapshot of the opioid epidemic in Georgia using several metrics of opioid-related morbidity and mortality and explore differences by rurality across counties.

METHODS

This was a spatial ecologic study. Negative binominal regression was used to model the relationship of county rurality with four opioid-related outcomes - overdose mortality, emergency department visits, inpatient hospitalizations, and overdose reversals - adjusting for county-level sex, racial/ethnic, and age distributions. Area Deprivation Index was also included.

RESULTS

There was significant geographic variation across the state for all four opioid-related outcomes. Counts remained highest among the metro areas. For rates, counties in the top quartile of rates varied by outcome and were often rural areas. In the final models, rurality designation was largely unrelated to opioid outcomes, with the exception of medium metro areas (inversely related to hospitalizations and overdose reversals) and non-core areas (inversely related to hospitalizations), as compared to large central metro areas. Higher deprivation was significantly related to increased ED visits and hospitalizations, but not overdose mortality and reversals.

CONCLUSIONS

When quantifying the burden of the opioid epidemic in a community, it is essential to consider multiple outcomes of morbidity and mortality. Understanding what outcomes are problematic for specific communities, in combination with their demographic and socioeconomic context, can provide insight into gaps in the treatment continuum and potential areas for intervention. Additionally, compared to demographic and socioeconomic factors, rurality may no longer be a salient predictor of the severity of the opioid epidemic in an area.

'I'm on the coast and I'm on methadone': A qualitative study examining access to opioid agonist treatment in rural and coastal British Columbia

INTRODUCTION

Despite rural regions being disproportionately impacted by the toxic drug supply, little is known about the contextual factors influencing access to opioid agonist treatment (OAT) specific to rural residents. The present study examines these factors in a rural and coastal setting in British Columbia, Canada.

METHODS

The qualitative methods were used to examine the barriers and facilitators to OAT access. Between July and October 2021, semi-structured interviews were conducted with people who use drugs who reside in a rural and coastal community. Thematic analysis was used to identify emergent themes and subthemes. Results were corroborated by the research team and a local community advisory board.

RESULTS

Twenty-seven (n = 27) participants described both limiting and facilitating factors that influenced OAT accessibility. Access was less challenging when participants' OAT dispensing pharmacy was in close proximity, had extended hours of operation, or when pharmacies provided delivery services. Barriers to OAT access identified by participants included the high cost of transportation, residing or working in remote communities and few local OAT prescribers. A variety of treatment motivations and goals that impacted OAT satisfaction are also highlighted.

CONCLUSION

This study demonstrates that patient satisfaction with OAT service access in a rural and coastal setting is multi-factorial and geographic proximity alone does not fully explain OAT accessibility issues in these settings. Accessibility to OAT may be improved through delivery services, expanded OAT prescribing authorisation beyond physician-only regulations, health authorities covering transportation costs and continual assurance that prescribing practices meet individuals' goals.

INTRODUCTION

Bien que les régions rurales soient touchées de manière disproportionnée par l'approvisionnement en drogues toxiques, on sait peu de choses sur les facteurs contextuels qui influencent l'accès au traitement par agoniste opioïde (TAO) spécifique aux résidents ruraux. La présente étude examine ces facteurs dans un contexte rural et côtier en Colombie-Britannique, au Canada.

MTHODES

Des méthodes qualitatives ont été utilisées pour examiner les obstacles et les facilitateurs de l'accès aux TAO. Entre juillet et octobre 2021, des entretiens semi-structurés ont été menés avec des personnes qui consomment des drogues résidant dans une communauté rurale et côtière. L'analyse thématique a été utilisée pour identifier les thèmes et sous-thèmes émergents. Les résultats ont été corroborés par l'équipe de recherche et un comité consultatif communautaire local.

RSULTATS

Vingt-sept (n = 27) participants ont décrit les facteurs limitants et facilitants qui ont influé sur l'accessibilité au TAO. L'accès était moins difficile lorsque la pharmacie du TAO des participants était proche, avait des heures d'ouverture prolongées ou lorsque les pharmacies offraient des services de livraison. Parmi les obstacles à l'accès au TAO mentionnés par les participants, il y avait le coût élevé du transport, le fait de résider ou de travailler dans des collectivités éloignées et la rareté des prescripteurs locaux du TAO. Les participants ont également fait état de divers objectifs et motivations liés au traitement qui ont eu une incidence sur la satisfaction à l'égard du TAO.

CONCLUSION

Cette étude démontre que la satisfaction des patients à l'égard de l'accès aux services du TAO en milieu rural et côtier est multifactorielle et que la proximité géographique n'explique pas à elle seule les problèmes d'accessibilité au TAO dans ces milieux. Cette accessibilité peut être améliorée par des services de livraison, l'élargissement de l'autorisation de prescrire un TAO au-delà des règlements réservés aux médecins, la prise en charge des coûts de transport par les autorités sanitaires et l'assurance continue que les pratiques de prescription répondent aux objectifs des individus.

Overdose responses among rural people who use drugs: A multi-regional qualitative study

BACKGROUND

Efforts to distribute naloxone have equipped more people with the ability to reverse opioid overdoses but people who use drugs are often reluctant to call 911 due to concerns for legal repercussions. Rural communities face unique challenges in reducing overdose deaths compared to urban communities, including limited access to harm reduction services as well as greater concerns about stigma and privacy.

METHODS

The Rural Opioid Initiative was funded in 2017 to better understand the health-related harms associated with the opioid crisis in rural US communities and consists of eight studies spanning ten states and 65 counties. Each study conducted semi-structured qualitative interviews with people who use drugs to understand contextual factors influencing drug use and health behaviors. We analyzed qualitative data from seven studies with data available at the time of analysis to understand peer response to overdose.

RESULTS

Of the 304 participants interviewed, 55% were men, 70% were white, 80% reported current injection drug use, and 60% reported methamphetamine use. Similar to what has been found in studies focused on urban settings, people who use drugs in rural communities use a range of strategies to reverse overdoses, including non-evidence-based approaches. Several reported that multiple doses of naloxone are needed to reverse overdose. Three themes emerged around the willingness to call 911, including (1) hesitancy to call 911 for fear of legal consequences, (2) negative perceptions or experiences with law enforcement officers, and (3) efforts to obtain medical intervention while avoiding identification/law enforcement involvement.

CONCLUSION

People who use drugs employ multiple strategies to attempt overdose reversal, including non-evidence-based approaches. Greater education about the most effective and least harmful strategies is needed. Reluctance to call 911 is rooted in concerns about potential legal consequences as well as perceptions about law enforcement officers, which may be heightened in rural communities where people who use drugs are more easily identified by law enforcement. People who use drugs will go to great strides to connect their peers to needed medical services, suggesting that comprehensive interventions to reduce interactions with law enforcement officers and eliminate legal consequences for reporting overdoses are critical.

The relationship between felt stigma and non-fatal overdose among rural people who use drugs

BACKGROUND

Drug overdose deaths in the United States exceeded 100,000 in 2021 and 2022. Substance use stigma is a major barrier to treatment and harm reduction utilization and is a priority target in ending the overdose epidemic. However, little is known about the relationship between stigma and overdose, especially in rural areas. We aimed to characterize the association between felt stigma and non-fatal overdose in a multi-state sample of rural-dwelling people who use drugs.

METHODS

Between January 2018 and March 2020, 2,608 people reporting past 30-day opioid use were recruited via modified chain-referral sampling in rural areas across 10 states. Participants completed a computer-assisted survey of substance use and substance-related attitudes, behaviors, and experiences. We used multivariable logistic regression with generalized estimating equations to test the association between felt stigma and recent non-fatal overdose.

RESULTS

6.6% of participants (n = 173) reported an overdose in the past 30 days. Recent non-fatal overdose was significantly associated with felt stigma after adjusting for demographic and substance use-related covariates (aOR: 1.47, 95% CI: 1.20-1.81). The association remained significant in sensitivity analyses on component fear of enacted stigma items (aOR: 1.48, 95% CI: 1.20-1.83) and an internalized stigma item (aOR: 1.51, 95% CI: 1.07-2.14).

CONCLUSIONS

Felt stigma related to substance use is associated with higher risk of non-fatal overdose in rural-dwelling people who use drugs. Stigma reduction interventions and tailored services for those experiencing high stigma are underutilized approaches that may mitigate overdose risk.

Addressing the Spectrum of Opioid Misuse Prevention, Treatment, and Recovery in Rural Washington State Communities: Provider Identified Barriers and Needs

The opioid overdose epidemic has significantly impacted rural communities. Rural settings present unique challenges to addressing opioid misuse. The purpose of the current study was to understand the similarities and differences between rural and urban-based providers serving rural communities. Washington state-based opioid-related service providers who serve rural communities (N = 75) completed an online survey between July and September 2020. Chi-square tests of association were used to examine significant differences in proportions between rural providers and rural-serving urban providers across opioid prevention, treatment, and recovery training topics. Rural providers reported receiving significantly less opioid treatment and recovery training on the criminal legal system, workplace-based education on treatment and recovery, and co-occurring disorder treatment; and significantly higher prior opioid prevention training on the prevention programs for youth and accessing prevention funding. Differences between rural and rural-serving urban providers demonstrate ways in which rural-urban partnerships can be strengthened to enhance public health.

Prescription Opioid Use before and after Diagnosis of Cancer Among Older Cancer Survivors With Non-Cancer Chronic Pain Conditions (NCPCs): An Application of Group-Based Trajectory Modeling (GBTM)

BACKGROUND

Prescription opioids are essential in managing pain among adults with chronic pain conditions. However, persistent use over time can lead to negative health consequences. Identifying individuals with persistent use over time and their characteristics can inform clinical decision-making and aid in reducing the risk of abuse and overdose deaths.

OBJECTIVE

This study aims to examine trajectories of prescription opioid use over time and factors associated with these trajectories among older cancer survivors with any non-cancer pain conditions (NCPC).

METHODS

We conducted a retrospective cohort study design with longitudinal data of older (age at cancer diagnosis ≥67 years) cancer (incident breast, colorectal, and prostate cancers, or non-Hodgkin lymphoma) survivors with any NCPC. Data were derived from the 2007-2015 linked Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset (N = 35,071). Group-Based Trajectory Modeling (GBTM) was used to identify homogeneous subgroups (distinct trajectories) of individuals based on every 90-day prescription opioid use during pre-cancer diagnosis (t1-t4), acute cancer treatment (t5-t8), and post-cancer treatment (t9-t12) periods. Biological factors, social determinants of health (SDoH), physical and mental health, medication use, health care use, and external factors associated with a trajectory membership were analyzed with multivariable multinomial logistic regressions.

RESULTS

Four distinct trajectories of opioid use were identified: (1) increase-decrease use (6.1%); (2) short-term use after cancer diagnosis (40.6%); (3) low-use (41.0%); and (4) persistent use (12.3%). In the fully-adjusted multinomial logistic regression, the SDoH such as Non-Hispanic Black [adjusted odds ratios (AOR) = 1.69; 95%CI = 1.48, 1.93)] and rural residence (AOR = 1.49; 95%CI = 1.15, 1.94)], comorbid anxiety (AOR = 1.33; 95%CI = 1.18, 1.51), and medication use (NSAIDs - AOR = 1.20; 95%CI = 1.10, 1.30) were associated with membership in the persistent use group. Persistent use was less likely among those with higher fragmented care index (AOR = 0.95, 95%CI = 0.93, 0.97) and those living in counties with higher Medicare advantage penetration (AOR = 0.96; 95%CI = 0.95, 0.97).

CONCLUSIONS

One in eight older adults had persistent opioid use over time. The profile characteristics of this group were different from the other trajectory groups. Policies and programs to reduce chronic opioid use need to consider the intra- and inter-individual variability to reduce opioid-related morbidity and mortality.

Self-reported Impacts of the COVID-19 Pandemic and Economic Inflation on the Well-being of Low-income U.S. Veterans

The health and well-being of low-income populations may be disproportionately impacted by major public health and economic events. This study examined written self-reported impacts of the Coronavirus Disease-2019 (COVID-19) pandemic and the economic inflationary period on health from a national sample of 854 low-income U.S. veterans. Responses were analyzed using rapid assessment procedures. In response to the COVID-19 pandemic, 59% of participants reported the pandemic had "no effect" on their health, 7% reported increased social isolation, and small proportions of participants reported negative effects on physical and mental health. In response to economic inflation, 43% of participants reported inflation had "no effect" on their health, 11% reported concerns about personal finances, and only small proportions reported other negative psychosocial impacts. Collectively, these findings suggest many low-income veterans are resilient during major events. Further research is needed on long-term health effects of inflation on this population.

Community Health Partners in Unexpected Places

Overcoming barriers to accessing health services is especially difficult in minority groups and rural populations. Nontraditional sites for delivering health care in the United States offer opportunities to reduce health disparities. Actually realizing these reductions, however, requires health systems to partner with trusted, convenient community services where people who experience health disparities spend substantial time - and, in turn, for those trusted service sites to seek partnerships with health systems. Libraries, places of worship, laundromats, barber shops, fire departments, dollar stores, shopping malls, and other local sites offer the chance to serve people who most need supportive health services in places they already trust enough to meet their other basic needs. Examples of such community health partnerships are cropping up around the United States, with some showing great success, although typically on a small scale. So, how will these small-scale successes proliferate? The answer lies in the "nuts and bolts" of implementation logistics. First, successful community health partnerships must be cultivated so that health systems and community venues co-design programs with direct input from community members. Second, entities seeking partnerships must explore multiple ways to procure funding. Third, coordinated efforts must be made to create awareness among the population a program seeks to serve. Fourth, day-to-day operations may need to be conducted in novel ways, especially considering physical, technological, and other implementation challenges that most nontraditional sites would face. As such successes proliferate and garner publicity, community health partnerships will be formed in greater numbers of unexpected places, with an ever-growing potential to reduce health disparities.

Patient Experience and Satisfaction with Opioid-Related Screening and Intervention in North Dakota Community Pharmacies

Background: Screening for patient-level opioid-related risk in the community pharmacy setting has increased patient education about opioids and naloxone distribution, helping to mitigate the impact of the opioid epidemic. However, patient experience and satisfaction with opioid screening and education is unknown. Fear of patient dissatisfaction may limit pharmacists' willingness to implement screening activities. Objective: To report patient experience and satisfaction of a convenience sample of patients undergoing screening and intervention for opioid-related risk as a part of the ONE Program (formerly ONE Rx). Methods: Patients who received ONE Program screening and intervention from their community pharmacist were recruited to participate in a 9 item survey regarding their experience and satisfaction. Results were analyzed by urban and rural location of participants. Results: Urban (n = 42) and rural (n = 32) patients who completed the survey reported positive experiences namely feeling comfortable with the ONE process (86.5%), the process taking an appropriate amount of time (93.2%) and feeling safer as a result of their pharmacist's attention to their opioid-related medication risk (86.3%). Urban patients were significantly more likely than rural patients to report positive attitude and behavior changes as a result of the ONE process. Conclusion: High levels of patient satisfaction and positive experience with the ONE Program screening and intervention process for patient-level opioid-related risks may encourage community pharmacists to more broadly implement such activities.

The effects of race and class on community-level stigmatization of opioid use and policy preferences

BACKGROUND

With opioid use and overdose rates continuing to plague minority communities in the U.S., we explored whether a geographic community's racial composition and social class affect how opioid use in the community is stigmatized and what policy preferences arise in response.

METHODS

We use case vignettes in a randomized, between-subjects study (N = 1478) with a nation-wide survey. The vignettes describe a community where opioids are harmfully used, varying whether the community was (1) wealthy or poor, (2) predominantly Black or White and (3) facing prevalent use of painkillers or heroin. We tested how these variables affect public stigmatization of opioid use (measured with ratings of responsibility, dangerousness, sympathy, concern, anger, and disappointment) preferred levels of social distance from communities with opioid use (measured with responses to questions about living, working, and interacting in the community), and policy preferences for responding to opioid use (measured with levels of support for providing a safe-consumption site in the community, treating drug use in the community punitively, treating drug use in the community as an illness, and funding drug treatment in the community through income redistribution).

RESULTS

Compared to wealthy communities with opioid use, poor communities with opioid use were less stigmatized in terms of responsibility, sympathy, concern, anger, and disappointment; they were also met with less support for punitiveness, more support for treating drug use as an illness, and preferences for greater social distance. Compared to White communities with opioid use, Black communities with opioid use were less stigmatized in terms of responsibility, and they were met with stronger preferences to not live and work there and with reduced support for using income redistribution to provide drug treatment for people in the community. Poor-Black communities with opioid use were also perceived to be more dangerous than both poor-White and wealthy-Black communities with opioid use.

CONCLUSION

These results point to class- and race-based territorial stigma affecting how communities with opioid use are judged and whether policies for providing communities with treatment are supported.

Culturally Responsive Opioid and Other Drug Prevention for American Indian/Alaska Native People: a Comparison of Reservation- and Urban-Based Approaches

There are few substance use treatment and prevention programs for AI/AN people that integrate culturally based practices with evidence-based treatment and prevention. The National Institutes of Health's (NIH's) Helping to End Addiction Long-term (HEAL) Prevention Cooperative supports two projects focused on AI/AN populations. One focuses on youth ages 15 to 20 years living within the Cherokee Nation reservation, a multicultural rural area in northeastern Oklahoma, and the second focuses on emerging adults ages 18 to 25 years living in diverse urban areas. We provide a brief overview of the two prevention trials and a case comparison across approaches using the framework of promising practices for intervention science with Indigenous communities (Whitesell et al., 2020) related to (1) integration of Indigenous and academic perspectives to respond to community needs, (2) community partnership and engagement, (3) alignment with Indigenous cultural values and practices, (4) capacity building and empowerment, (5) implementation within complex cultural contexts, and (6) tribal oversight. Overall, these two projects highlight the importance of long-standing relationships with community partners, engaging the community at all levels to ensure that programming is culturally and developmentally appropriate, and having tribal and elder oversight. These practices are key to establishing trust and building confidence in research in these communities and ensuring that research can benefit AI/AN people. These studies showcase how strong partnerships can advance health and support the conduct of rigorous science to help pinpoint optimal health solutions by identifying efficacious, culturally grounded intervention strategies. Although the sovereign status of tribes demands this type of partnership, this research serves as a model for all community research that has a goal of improving health.

Implementation of substance use screening in rural federally-qualified health center clinics identified high rates of unhealthy alcohol and cannabis use among adult primary care patients

BACKGROUND

Screening for substance use in rural primary care clinics faces unique challenges due to limited resources, high patient volumes, and multiple demands on providers. To explore the potential for electronic health record (EHR)-integrated screening in this context, we conducted an implementation feasibility study with a rural federally-qualified health center (FQHC) in Maine. This was an ancillary study to a NIDA Clinical Trials Network study of screening in urban primary care clinics (CTN-0062).

METHODS

Researchers worked with stakeholders from three FQHC clinics to define and implement their optimal screening approach. Clinics used the Tobacco, Alcohol, Prescription Medication, and Other Substance (TAPS) Tool, completed on tablet computers in the waiting room, and results were immediately recorded in the EHR. Adult patients presenting for annual preventive care visits, but not those with other visit types, were eligible for screening. Data were analyzed for the first 12 months following implementation at each clinic to assess screening rates and prevalence of reported unhealthy substance use, and documentation of counseling using an EHR-integrated clinical decision support tool, for patients screening positive for moderate-high risk alcohol or drug use.

RESULTS

Screening was completed by 3749 patients, representing 93.4% of those with screening-eligible annual preventive care visits, and 18.5% of adult patients presenting for any type of primary care visit. Screening was self-administered in 92.9% of cases. The prevalence of moderate-high risk substance use detected on screening was 14.6% for tobacco, 30.4% for alcohol, 10.8% for cannabis, 0.3% for illicit drugs, and 0.6% for non-medical use of prescription drugs. Brief substance use counseling was documented for 17.4% of patients with any moderate-high risk alcohol or drug use.

CONCLUSIONS

Self-administered EHR-integrated screening was feasible to implement, and detected substantial alcohol, cannabis, and tobacco use in rural FQHC clinics. Counseling was documented for a minority of patients with moderate-high risk use, possibly indicating a need for better support of primary care providers in addressing substance use. There is potential to broaden the reach of screening by offering it at routine medical visits rather than restricting to annual preventive care visits, within these and other rural primary care clinics.

Factors associated with hospitalizations for co-occurring HIV and opioid-related diagnoses: Evidence from the national inpatient sample, 2009-2017

There has been evidence of rising HIV incidence attributable to opioid misuse within some areas of the U.S. The purpose of our study was to explore national trends in co-occurring HIV and opioid-related hospitalizations and to identify their risk factors. We used the 2009-2017 National Inpatient Sample to indicate hospitalizations with co-occurring HIV and opioid misuse diagnoses. We estimated the frequency of such hospitalizations per year. We fitted a linear regression to the annual HIV-opioid co-occurrences with year as a predictor. The resulting regression did not reveal any significant temporal changes. We used multivariable logistic regression to determine the adjusted odds (AOR) of hospitalization for co-occurring HIV and opioid-related diagnoses. The odds of hospitalization were lower for rural residents (AOR = 0.28; CI = 0.24-0.32) than urban. Females (AOR = 0.95, CI = 0.89-0.99) had lower odds of hospitalization than males. Patients identifying as White (AOR = 1.23, CI = 1.00-1.50) and Black (AOR = 1.27, CI = 1.02-1.57) had higher odds of hospitalization than other races. When compared to co-occuring hospitalizations in the Midwest, the odds were higher in the Northeast. (AOR = 2.56, CI = 2.07-3.17) Future research should explore the extent to which similar findings occur in the context of mortality and targeted interventions should intesify for subpopulations at highest risk of co-occuring HIV and opioid misuse diagnoses.

The Opioid Epidemic: A Review of the Contributing Factors, Negative Consequences, and Best Practices

The opioid epidemic is a significant public health crisis that has caused extensive harm and devastation in the United States. This literature review aimed to identify the contributing factors and negative consequences of the epidemic, as well as best practices for healthcare providers in managing the epidemic. Overprescribing opiates and opioids, lack of education and opportunity, and being unmarried or divorced were some of the identified contributing factors to dependence on opioids. The epidemic's negative consequences are substantial, leading to increased access to opioids for vulnerable populations, which consequently cause accidental death among men and the degradation of rural community health services. As part of the literature review, we also analyzed the best practices for healthcare providers, including implementing prescription drug monitoring programs (PDMPs). However, we found that while PDMPs resulted in a decrease in opioid overprescription and an increase in provider confidence when prescribing medication, the evidence for their effectiveness in improving rural community health services or reducing opioid overdoses and opioid-related deaths was inconclusive. Our review highlights that the greatest challenge to overcome is a lack of legal mandates and proper education for healthcare providers on best practices for addressing the epidemic. To regulate and control opioids effectively, tracking and standardizing prescription models by federal agencies and medical institutions is necessary but not enough. Legal action is vital for the successful containment of the opioid crisis.

The association between prescription drug monitoring programs and controlled substance prescribing: a cross-sectional study using data from 2019 National Electronic Health Records Survey

OBJECTIVE

The use of controlled medications such as opioids, stimulants, anabolic steroids, depressants, and hallucinogens has led to an increase in addiction, overdose, and death. Given the high attributes of abuse and dependency, prescription drug monitoring programs (PDMPs) were introduced in the United States as a state-level intervention.

MATERIALS AND METHODS

Using cross-sectional data from the 2019 National Electronic Health Records Survey, we assessed the association between PDMP usage and reduced or eliminated controlled substance prescribing as well as the association between PDMP usage and changing a controlled substance prescription to a nonopioid pharmacologic therapy or nonpharmacologic therapy. We applied survey weights to produce physician-level estimates from the survey sample.

RESULTS

Adjusting for physician age, sex, type of medical degree, specialty, and ease of PDMP, we found that physicians who reported "often" PDMP usage had 2.34 times the odds of reducing or eliminating controlled substance prescriptions compared to physicians who reported never using the PDMP (95% confidence interval [CI] 1.12-4.90). Adjusting for physician age, sex, type of doctor, and specialty, we found that physicians who reported "often" use of the PDMP had 3.65 times the odd of changing controlled substance prescriptions to a nonopioid pharmacologic therapy or nonpharmacologic therapy (95% CI: 1.61-8.26).

DISCUSSION

These results support the continued use, investment, and expansion of PDMPs as an effective intervention for reducing controlled substance prescription and changing to nonopioid/pharmacologic therapy.

CONCLUSION

Overall, frequent usage of PDMPs was significantly associated with reducing, eliminating, or changing controlled substance prescription patterns.

Harm reduction and recovery services support (HRRSS) to mitigate the opioid overdose epidemic in a rural community

BACKGROUND

Rural areas in the United States (US) are ravaged by the opioid overdose epidemic. Oconee County, an entirely rural county in northwest South Carolina, is likewise severely affected. Lack of harm reduction and recovery resources (e.g., social capital) that could mitigate the worst outcomes may be exacerbating the problem. We aimed to identify demographic and other factors associated with support for harm reduction and recovery services in the community.

METHODS

The Oconee County Opioid Response Taskforce conducted a 46-item survey targeting a general population between May and June in 2022, which was mainly distributed through social media networks. The survey included demographic factors and assessed attitudes and beliefs toward individuals with opioid use disorder (OUD) and medications for OUD, and support for harm reduction and recovery services, such as syringe services programs and safe consumption sites. We developed a Harm Reduction and Recovery Support Score (HRRSS), a composite score of nine items ranging from 0 to 9 to measure level of support for placement of naloxone in public places and harm reduction and recovery service sites. Primary statistical analysis using general linear regression models tested significance of differences in HRRSS between groups defined by item responses adjusting for demographic factors.

RESULTS

There were 338 survey responses: 67.5% were females, 52.1% were 55 years old or older, 87.3% were Whites, 83.1% were non-Hispanic, 53.0% were employed, and 53.8% had household income greater than US$50,000. The overall HRRSS was relatively low at a mean of 4.1 (SD = 2.3). Younger and employed respondents had significantly greater HRRSS. Among nine significant factors associated with HRRSS after adjusting for demographic factors, agreement that OUD is a disease had the greatest adjusted mean difference in HRSSS (adjusted diff = 1.22, 95% CI=(0.64, 1.80), p < 0.001), followed by effectiveness of medications for OUD (adjusted diff = 1.11, 95%CI=(0.50, 1.71), p < 0.001).

CONCLUSIONS

Low HRRSS indicates low levels of acceptance of harm reduction potentially impacting both intangible and tangible social capital as it relates to mitigation of the opioid overdose epidemic. Increasing community awareness of the disease model of OUD and the effectiveness of medications for OUD, especially among older and unemployed populations, could be a step toward improving community uptake of the harm reduction and recovery service resources critical to individual recovery efforts.

Promoting Disposal of Left-Over Opioids After Surgery in Rural Communities: A Qualitative Description Study

BACKGROUND

Patients rarely dispose of left-over opioids after surgery. Disposal serves as a primary prevention against misuse, overdose, and diversion. However, current interventions promoting disposal have mixed efficacy. Increasing disposal in rural communities could prevent or reduce the harms caused by prescription opioids.

AIMS

Identify barriers and facilitators to disposal in the rural communities of the United States Mountain West region.

METHODS

We conducted a qualitative description study with 30 participants from Arizona, Idaho, Montana, Nevada, Oregon, Utah, and Wyoming. We used a phronetic iterative approach combining inductive content and thematic analysis with deductive interpretation through the Precaution Adoption Process Model (PAPM).

RESULTS

We identified four broad themes: (a) awareness, engagement, and education; (b) low perceived risk associated with nondisposal; (c) deciding to keep left-over opioids for future use; and (d) converting decisions into action. Most participants were aware of the importance of disposal but perceived the risks of nondisposal as low. Participants kept opioids for future use due to uncertainty about their recovery and future treatments, breakdowns in the patient-provider relationship, chronic illness or pain, or potential future injury. The rural context, particularly convenience, cost, and environmental contamination, contributes to decisional burden.

CONCLUSIONS

We identified PAPM stage-specific barriers to disposal of left-over opioids. Future interventions should account for where patients are along the spectrum of deciding to dispose or not dispose as well as promoting harm-reduction strategies for those who choose not to dispose.

Patient Willingness to Dispose of Leftover Opioids After Surgery: A Mixed Methods Study

We examined how convenience and financial incentives influence patient willingness to dispose of leftover prescription opioids after surgery. We also identified additional barriers and facilitators to disposal.

Background

In the United States, up to 70% of surgical patients are prescribed opioids and up to 92% will have leftover tablets. Most do not dispose of leftover opioids, increasing the risk for opioid-related harm. Current interventions promoting opioid disposal have shown mixed success.

Methods

We conducted a mixed methods study using a standard gamble survey and semi-structured interviews. Participants estimated willingness to dispose in 16 scenarios with varying convenience (time requirements of <5, 15, 30, and 60 minutes) and financial incentives ($0, $5, $25, $50). We estimated the likelihood of disposal using a multivariable mixed effects modified Poisson regression model. Semi-structured interviews explored how convenience, financial incentives, and other barriers and facilitators influenced decisions to dispose.

Results

Fifty-five participants were surveyed and 42 were interviewed. Most were willing to dispose when the time required was <15 minutes. Few were willing to dispose if the process required 60 minutes, although a $50 financial incentive increased rates from 9% to 36%. Anxiety about future pain, opioid scarcity, recreational use, family safety, moral beliefs, addiction, theft, and environmental harm also influenced decision-making.

Conclusions

Interventions promoting opioid disposal should focus on convenience, but the selective use of financial incentives can be effective. Tailoring interventions to individual barriers and facilitators could also increase disposal rates.

Histone H3 dopaminylation in ventral tegmental area underlies heroin-induced transcriptional and behavioral plasticity in male rats

Persistent transcriptional events in ventral tegmental area (VTA) and other reward relevant brain regions contribute to enduring behavioral adaptations that characterize substance use disorder. Recent data from our laboratory indicate that aberrant accumulation of the newly discovered histone post-translational modification (PTM), H3 dopaminylation at glutamine 5 (H3Q5dop), contributes significantly to cocaine-seeking behavior following prolonged periods of abstinence. It remained unclear, however, whether this modification is important for relapse vulnerability in the context of other drugs of abuse, such as opioids. Here, we showed that H3Q5dop plays a critical role in heroin-mediated transcriptional plasticity in midbrain regions, particularly the VTA. In rats undergoing abstinence from heroin self-administration (SA), we found acute and persistent accumulation of H3Q5dop in VTA. Attenuation of H3Q5dop during abstinence induced persistent changes in gene expression programs associated with neuronal signaling and dopaminergic function in heroin abstinence and led to reduced heroin-seeking behavior. Interestingly, the observed changes in molecular pathways after heroin SA showed significant yet reversed overlap with the same genes altered in cocaine SA. These findings establish an essential role for H3Q5dop, and its downstream transcriptional consequences, in heroin-induced functional plasticity in VTA.

Trends and characteristics of primary pyogenic spine infections among people who do and do not inject drugs: Northeast New York State, 2007 to 2018

Background:

Pyogenic spine infections (PSIs) are challenging to diagnose and treat. People who inject drugs (PWID) are at increased risk and contribute to rising PSI incidence.

Objective:

To analyze trends and characterize PSI in persons who do and do not inject drugs in northeast New York State (NYS), a predominantly rural region.

Methods:

A retrospective study of PSI patients at a regional tertiary care hospital from 2007 to 2018 was conducted. PSI incidence, population demographics, microbiology, surgical interventions, length of stay (LOS), and costs were compared between injection substance use disorder (ISUD) and non-ISUD cohorts.

Results:

Two hundred and seventy patients (59 ISUD and 211 non-ISUD) were included in this study. PSI incidence due to ISUD increased 1175% during the study time periods. The median age of the ISUD and non-ISUD cohorts was 39 and 65, respectively. Staphylococcus aureus was the most common causative organism, although a variety of bacterial and fungal pathogens were identified. Nearly half of the patients in each cohort required surgical intervention. Median acute care LOS was 12 days and comparable between cohorts. However, the ISUD cohort was frequently discharged against medical advice, or transferred back to acute care hospitals to complete antibiotic courses. Median inpatient hospital costs were approximately $25,000 and were comparable between cohorts. These costs do not reflect inpatient costs once the patient was transferred back to the referring hospital, nor costs for outpatient care. Medicaid and Medicare were the most common primary insurance payers for the ISUD and non-ISUD cohorts, respectively.

Conclusions:

Incidence of PSI has increased significantly coincident with the opioid epidemic and has had significant impact on a large, rural region of NYS. PSIs consume large amounts of healthcare resources. This study can inform hospitals and public health agencies regarding the need for substance abuse harm reduction strategies.

Barriers and facilitators associated with establishment of emergency department-initiated buprenorphine for opioid use disorder in rural Maine

PURPOSE

The opioid epidemic in the United States continues to grow, particularly impacting rural communities served by critical access hospitals (CAHs) in Maine. Buprenorphine is an effective medication for the treatment of opioid use disorder (OUD) that can be successfully initiated in the emergency department (ED). However, many EDs have not implemented programs to initiate buprenorphine. This study sought to identify barriers and facilitators to successful implementation of buprenorphine programs inCAH EDs.

METHODS

Semistructured interviews were conducted with ED directors of Maine CAHs regarding barriers and facilitators to developing programs for ED-initiated buprenorphine. Seventeen Maine CAH EDs exist and 11 of their directors agreed to participate and completed interviews, which were audio-recorded, transcribed, and analyzed using a thematic approach.

RESULTS

Four themes and 11 subthemes were identified, including (1) compelled to act-directors' personal experiences with patients facilitated the development of buprenorphine programs in their EDs; (2) leadership and mentorship-peer mentorship from other CAH ED directors facilitated, and senior hospital administrators facilitated, or created a barrier in some cases; (3) stigma-fear that EDs would be overcrowded by drug-seeking patients was a common barrier; and (4) follow-up-finding appropriate outpatient follow-up for OUD patients created the greatest logistical barrier.

DISCUSSION

ED directors' clinical experience with OUD patients, supportive hospital leadership, and peer mentorship facilitated ED-initiated buprenorphine programs in rural Maine CAH EDs. Overcoming stigma, developing community outreach, and appropriate follow-up were the greatest barriers. Future research should focus on enhancing peer mentorship, administrative support, community outreach, and staff education.

Spatial, temporal, and space-time clusters associated with opioid and cannabis poisoning events in U.S. dogs (2005–2014)

While a substantial amount of research has focused on the abuse of opioids and cannabinoids in human populations, few studies have investigated accidental poisoning events in pet populations. The objective of this study was to identify whether poisoning events involving opioids and cannabinoids clustered in space, time, and space-time, and compare the locations of clusters between the two toxicants. Data were obtained concerning reports of dog poisoning events from the American Society for the Prevention of Cruelty to Animals’ (ASPCA) Animal Poisoning Control Center (APCC), from 2005–2014. The spatial scan statistic was used to identify clusters with a high proportion of these poisoning events. Our analyses show that opioid and cannabinoid poisoning events clustered in space, time, and space-time. The cluster patterns identified for each toxicant were distinct, but both shared some similarities with human use data. This study may help increase awareness to the public, public health, and veterinary communities about where and when dogs were most affected by opioid and cannabinoid poisonings. This study highlights the need to educate dog owners about safeguarding opioid and cannabinoid products from vulnerable populations.

Development of opioid rapid response system: Protocol for a randomized controlled trial

BACKGROUND

Opioid overdoses require a rapid response, but emergency responders are limited in how quickly they can arrive at the scene for administering naloxone. If laypersons are trained to administer naloxone and are notified of overdoses, more lives can be saved.

OBJECTIVE

This study aimed to examine the feasibility of the Opioid Rapid Response System (ORRS) that recruits, trains, and links citizen responders to overdose events in their community in real-time to administer naloxone. Aim of this paper is to present the protocols for recruiting participants through multiple communication channels; developing and evaluating the online training which has both interactive and asynchronous modules; randomly assigning laypersons to either online naloxone training or waitlist control group; measuring participants' knowledge, skills, and attitudes before and after the training; and distributing intranasal naloxone kits to participants for use in events of overdose in their community.

METHODS

Sampling: Utilizing a combination of purposive sampling methods, laypersons from across five Indiana counties who did not self-identify as current first responders were invited to participate.

DESIGN

In this two-arm randomized waitlist-controlled study (N = 220), individuals were assigned into either online training or waitlist control that received the training two weeks later.

ANALYSIS

A linear mixed model will be used for determining the changes in targeted outcomes in the training group and accommodate for fixed and random effects.

IMPLICATIONS

While ORRS can become a community-engaged, cost-effective model for technology-based emergency response for opioid overdoses, study protocols can be useful for other emergency response programs that involve laypersons.

CLINICALTRIALS

gov Registration Number: NCT04589676.

PrEP Care Continuum Engagement Among Persons Who Inject Drugs: Rural and Urban Differences in Stigma and Social Infrastructure

Pre-exposure prophylaxis (PrEP) is a medication that prevents HIV acquisition, yet PrEP uptake has been low among people who inject drugs. Stigma has been identified as a fundamental driver of population health and may be a significant barrier to PrEP care engagement among PWID. However, there has been limited research on how stigma operates in rural and urban settings in relation to PrEP. Using in-depth semi-structured qualitative interviews (n = 57) we explore PrEP continuum engagement among people actively injecting drugs in rural and urban settings. Urban participants had more awareness and knowledge. Willingness to use PrEP was similar in both settings. However, no participant was currently using PrEP. Stigmas against drug use, HIV, and sexualities were identified as barriers to PrEP uptake, particularly in the rural setting. Syringe service programs in the urban setting were highlighted as a welcoming space where PWID could socialize and therefore mitigate stigma and foster information sharing.

Identifying unique barriers to implementing rural emergency department-based peer services for opioid use disorder through qualitative comparison with urban sites

BACKGROUND

In an effort to address the current opioid epidemic, a number of hospitals across the United States have implemented emergency department-based interventions for engaging patients presenting with opioid use disorder. The current study seeks to address gaps in knowledge regarding implementation of a sub-type of such interventions, emergency department-based peer support services, in rural areas by comparing implementation of rural and urban programs that participated in Indiana's Recovery Coach and Peer Support Initiative (RCPSI).

METHODS

We conducted a secondary analysis of qualitative semi-structured implementation interviews collected as part of an evaluation of 10 programs (4 rural and 6 urban) participating in the RCPSI. We conducted interviews with representatives from each program at 3 time points over the course of the first year of implementation. Our deductive coding process was guided by the Consolidated Framework for Implementation Research (CFIR) and an external context taxonomy.

RESULTS

We identified key differences for rural programs corresponding to each of the 5 primary constructs in the coding scheme. (1) Intervention characteristics: rural sites questioned intervention fit with their context, required more adaptations, and encountered unexpected costs. (2) External context: rural sites were not appropriately staffed to meet patient needs, encountered logistical and legal barriers regarding patient privacy, and had limited patient transportation options. (3) Inner setting: rural sites lacked strong mechanisms for internal communication and difficulties integrating with pre-existing culture and climate. (4) Characteristics of individuals: some rural providers resisted working with peers due to pre-existing attitudes and beliefs. (5) Implementation process: rural sites spent more time identifying external partners and abandoned more components of their initial implementation plans.

CONCLUSIONS

Findings demonstrate how rural programs faced greater challenges implementing emergency department-based peer services over time. These challenges required flexible adaptations to originally intended plans. Rural programs likely require flexibility to adapt interventions that were developed in urban settings to ensure success considering local contextual constraints that were identified by our analysis.

Comparing the feasibility of four web-based recruitment strategies to evaluate the treatment preferences of rural and urban adults who misuse non-prescribed opioids

This cross-sectional study examined the feasibility of using four different web-based strategies to recruit rural and urban adults who use opioids non-medically for a survey on opioid use disorder (OUD) treatment preferences, and compared the treatment preferences of rural versus urban participants. Preferences for medication for opioid use disorder (MOUD) formulation and OUD treatment models were assessed through an online survey. Recruitment advertisements were shown on Facebook, Google AdWords, Reddit, and Amazon Mechanical Turk (MTurk). Participants were categorized by zip code into urban versus rural residence using the Centers for Medicaid and Medicaid Health Resources and Services Administration definitions. OUD treatment preferences were compared using chi-square and t-tests. Among the 851 participants recruited, 815 provided zip codes and were classified as residing in rural (n = 200, 24.5%) or urban (n = 615, 75.4%) regions. A crowdsourcing service (MTurk) recruited the most rural participants, while posts on a social news website (Reddit) recruited the most urban participants (χ²₃ = 17.0, p < 0.01). While preferred MOUD formulation and OUD treatment model did not differ by rurality, rural participants were more likely to report a willingness to receive OUD treatment integrated with general medical care (χ²₁ = 18.9, p < 0.0001). This study demonstrated that web-based strategies are feasible for recruiting rural adults who misuse opioids. Results suggest OUD treatment preferences largely did not differ by rural residence, and highlight the importance of enhancing the availability and increasing education about MOUD formulations in rural regions.

What Are the Correlates of Global Variations in the Prevalence of Opioid Use Disorders? An Analysis of Data From the Global Burden of Disease Study, 2019

Introduction

The recent opioid crisis in North America has brought the problem of opioid use disorders (OUD) into clinical and public health focus, with experts warning that other countries or regions may be at future risk of experiencing such crises. The existing literature suggests that a wide range of social, cultural and economic factors may be associated with the onset, course and outcome of OUD in individuals. The current study uses data on the estimated prevalence of OUDs across 115 countries, obtained from the Global Burden of Disease Study, 2019, to examine the bivariate and multivariate associations between national prevalence of OUD and these factors.

Methods

Data on the estimated prevalence of OUDs was obtained via a database query from the Global Burden of Disease (GBD) Collaborative Network database for the year 2019. Recent (2018-2019) data on 10 relevant variables identified in the literature (gross national income, economic inequality, urbanization, social capital, religious affiliation and practice, unemployment, divorce, cultural individualism, and prevalence of depression) were obtained from the GBD, World Bank and Our World in Data databases. After transformation to a normal distribution, bivariate and univariate analyses were conducted to identify the significance and strength of the associations between these variables and the prevalence of OUD.

Results

Of the 10 variables studied, all variables except the divorce rate and religious affiliation were significantly correlated with the prevalence of OUD on bivariate analyses, though the strength of these associations was in the poor to fair range. On multivariate analysis, a significant association was observed only for the prevalence of depression, with trends towards a positive association for cultural individualism and unemployment, and a protective trend observed for religious practice.

Discussion

Though subject to certain limitations inherent in cross-sectional analyses, these results suggest that certain variables may be associated with a higher prevalence of OUD at the national level. Replication and refinement of these analyses may prove useful in identifying countries or regions at risk of a future opioid epidemic or crisis, which could facilitate the institution of preventive measures or early intervention strategies.

Women-centered drug treatment models for pregnant women with opioid use disorder: A scoping review

BACKGROUND

While there is a high unmet need for drug treatment services tailored to the needs of pregnant women, fewer than half of the opioid use disorder (OUD) treatment programs in the U.S. offer such services. We conducted a scoping review of the literature to identify women-centered drug treatment models that address access, coordination, and quality of care, and their facilitators and barriers.

METHODS

We searched PubMed, EMBASE, PsycInfo, Sociology Database, Web of Science, CINAHL, EBSCO Open Dissertations, Health Services Research Projects in Progress, and relevant agency websites from 1990 to 2020. We included studies that evaluated multicomponent models of care that provided medication for OUD (MOUD) to pregnant women in the U.S.

RESULTS

Of the 1,578 unduplicated articles screened, 26 articles met the inclusion criteria, which reported on 19 different studies and included 3,193 women. We identified seven different models of care and found that: (1) access was improved by co-locating various services for drug treatment and care, (2) coordination was enhanced by inter-professional collaboration, (3) quality was improved by treating pregnant patients in groups, and (4) stigmatization and criminalization of substance use during pregnancy was a significant barrier to care.

CONCLUSIONS

There is an urgent need to bolster patient-provider relationships that are built on trust, are free of stigma, and that empower patients to make their own decisions. Improved policies and regulations to reduce stigma around the use of opioids and MOUD are needed, so that pregnant women with OUD can access high quality care.

A Demographic and Regional Comparison of Opioid-Related Hospital Visits within Community Type in the United States

BACKGROUND

The opioid epidemic is a complex national crisis in the United States with a 400% increase in related deaths over the past two decades with no signs of slowing. The purpose of this study was to assess the incidence of opioid use, based on the geographic and population characteristics.

METHODS

The opioid-related hospital inpatient stays and emergency department visits obtained from the 2010 to 2018 Healthcare Cost and Utilization Project and demographic confounders, including age, race, education, and income gathered from US Census data were analyzed through generalized linear mixed models and reported by community size and region.

RESULTS

Opioid use varies among population center sizes and the region analyzed. In general, opioid visits in the southwest region were greatest across the majority of population center sizes. Rural usage was greatest in the northeast, southeast, and southwest. Unemployment and diverse ethnicities were commonly associated with opioid use in the metro areas studied but these associations were not seen in rural areas.

CONCLUSION

Opioid use remains significant among diverse populations across the United States. Understanding the unique dynamics associated with opioid usage in populations within the regions studied is important in guiding future interventions to fight this crisis.

Bringing chronic-pain care to rural veterans: A telehealth pilot program description

Opioid-related harms disproportionately affect rural communities. Recent research-based policy changes have called for reductions in opioid prescribing and substitution of safe and effective alternatives to opioids for treating chronic pain, but such alternatives are often difficult to access in rural areas. Telehealth services can help address this disparity by bringing evidence-based, biopsychosocial chronic-pain services to rural and underserved patients with chronic pain. This article describes a 2-year pilot project for delivering chronic-pain care by pain specialists from central hubs at Veterans Health Administration (VA) medical centers to spokes at VA community-based outpatient clinics (CBOCs). The VA Puget Sound Pain Telehealth pilot program offered pain education classes, cognitive-behavioral therapy groups, opioid-safety education, and acupuncture education. The program delivered 501 encounters to patients from 1 hub to 4 CBOC spoke sites from 2016 to 2018, and supported training, administration, equipment acquisition, and grant-writing. The quality-improvement project was rolled out using existing local resources. We present initial findings about the patients who utilized Pain Telehealth, share lessons learned, and discuss future directions for expansion. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Rural Emergency Medical Service Providers Perceptions on the Causes of and Solutions to the Opioid Crisis: A Qualitative Assessment

Introduction:

The continuing opioid crisis poses unique challenges to remote and often under-resourced rural communities. Emergency medical service (EMS) providers serve a critical role in responding to opioid overdose for individuals living in rural or remote areas who experience opioid overdoses. They are often first at the scene of an overdose and are sometimes the only health care provider in contact with an overdose patient who either did not survive or refused additional care. As such, EMS providers have valuable perspectives to share on the causes and consequences of the opioid crisis in rural communities.

Methods:

EMS providers attending a statewide EMS conference serving those from greater Minnesota and surrounding states were invited to take a 2-question survey asking them to reflect upon what they believed to be the causes of the opioid crisis and what they saw as the solutions to the opioid crisis. Results were coded and categorized using a Consensual Qualitative Research approach.

Results:

EMS providers’ perceptions on causes of the opioid crisis were categorized into 5 main domains: overprescribing, ease of access, socioeconomic vulnerability, mental health concerns, and lack of resources and education. Responses focused on solutions to address the opioid crisis were categorized into 5 main domains: need for increased education, enhanced opioid oversight, increased access to treatment programs, alternative therapies for pain management, and addressing socioeconomic vulnerabilities.

Conclusion:

Along with the recognition that the opioid crisis was at least partially caused by overprescribing, rural EMS providers who participated in this study recognized the critical role of social determinants of health in perpetuating opioid-related harm. Participants in this study reported that education and increased access to treatment facilities and appropriate pain management, along with recognition of the role of social determinants of health in opioid dependency, were necessary steps to address the opioid crisis.

Estimating the burden of the opioid epidemic for adults and adolescents in Ohio counties

Quantifying the opioid epidemic at the local level is a challenging problem that has important consequences on resource allocation. Adults and adolescents may exhibit different spatial trends and require different interventions and resources so it is important to examine the problem for each age group. In Ohio, surveillance data are collected at the county level for each age group on measurable outcomes of the opioid epidemic, overdose deaths, and treatment admissions. However, our interest lies in quantifying the unmeasurable construct, representing the burden of the opioid epidemic, which drives rates of the outcomes. We propose jointly modeling adult and adolescent surveillance outcomes through a multivariate spatial factor model. A generalized spatial factor model within each age group quantifies a latent factor related to the number of opioid-associated treatment admissions and deaths. By assuming a multivariate conditional autoregressive model for the spatial factors of adults and adolescents, we allow the adolescent model to borrow strength from the adult model (and vice versa), improving estimation. We also incorporate county-level covariates to help explain spatial heterogeneity in each of the factors. We apply this approach to the state of Ohio and discuss the findings. Our framework provides a coherent approach for synthesizing information across multiple outcomes and age groups to better understand the spatial epidemiology of the opioid epidemic.

Assessing the Relationships Between COVID-19 Stay-at-Home Orders and Opioid Overdoses in the State of Pennsylvania

COVID-19 is compounding opioid use disorder throughout the United States. While recent commentaries provide useful policy recommendations, few studies examine the intersection of COVID-19 policy responses and patterns of opioid overdose. We examine opioid overdoses prior to and following the Pennsylvania stay-at-home order implemented on April 1, 2020. Using data from the Pennsylvania Overdose Information Network, we measure change in monthly incidents of opioid-related overdose pre- versus post-April 1, and the significance of change by gender, age, race, drug class, and naloxone doses administered. Findings demonstrate statistically significant increases in overdose incidents among both men and women, White and Black groups, and several age groups, most notably the 30–39 and 40–49 ranges, following April 1. Significant increases were observed for overdoses involving heroin, fentanyl, fentanyl analogs or other synthetic opioids, pharmaceutical opioids, and carfentanil. The study emphasizes the need for opioid use to be addressed alongside efforts to mitigate and manage COVID-19 infection.

Is telemedicine the answer to rural expansion of medication treatment for opioid use disorder? Early experiences in the feasibility study phase of a National Drug Abuse Treatment Clinical Trials Network Trial

Telemedicine (TM) enabled by digital health technologies to provide medical services has been considered a key solution to increasing health care access in rural communities. With the immediate need for remote care due to the COVID-19 pandemic, many health care systems have rapidly incorporated digital technologies to support the delivery of remote care options, including medication treatment for individuals with opioid use disorder (OUD). In responding to the opioid crisis and the COVID-19 pandemic, public health officials and scientific communities strongly support and advocate for greater use of TM-based medication treatment for opioid use disorder (MOUD) to improve access to care and have suggested that broad use of TM during the pandemic should be sustained. Nevertheless, research on the implementation and effectiveness of TM-based MOUD has been limited. To address this knowledge gap, the National Drug Abuse Treatment Clinical Trials Network (CTN) funded (via the NIH HEAL Initiative) a study on Rural Expansion of Medication Treatment for Opioid Use Disorder (Rural MOUD; CTN-0102) to investigate the implementation and effectiveness of adding TM-based MOUD to rural primary care for expanding access to MOUD. In preparation for this large-scale, randomized controlled trial incorporating TM in rural primary care, a feasibility study is being conducted to develop and pilot test implementation procedures. In this commentary, we share some of our experiences, which include several challenges, during the initial two-month period of the feasibility study phase. While these challenges could be due, at least in part, to adjusting to the COVID-19 pandemic and new workflows to accommodate the study, they are notable and could have a substantial impact on the larger, planned pragmatic trial and on TM-based MOUD more broadly. Challenges include low rates of identification of risk for OUD from screening, low rates of referral to TM, digital device and internet access issues, workflow and capacity barriers, and insurance coverage. These challenges also highlight the lack of empirical guidance for best TM practice and quality remote care models. With TM expanding rapidly, understanding implementation and demonstrating what TM approaches are effective are critical for ensuring the best care for persons with OUD.

Early implementation of screening for substance use in rural primary care: A rapid analytic qualitative study

Background: Few primary care patients are screened for substance use. As part of a phased feasibility study examining the implementation of electronic health record-integrated screening with the Tobacco, Alcohol, and Prescription Medication Screening (TAPS) Tool and clinical decision support (CDS) in rural primary care clinics, focus groups were conducted to identify early indicators of success and challenges to screening implementation. Method: Focus groups (n = 6) were conducted with medical assistants (MAs: n = 3: 19 participants) and primary care providers (PCPs: n = 3: 13 participants) approximately one month following screening implementation in three Federally Qualified Health Centers in Maine. Rapid analysis and matrix analysis using Proctor's Taxonomy of Implementation Outcomes were used to explore implementation outcomes. Results: There was consensus that screening is being used, but use of the CDS was lower, in part due to limited positive screens. Fidelity was high among MAs, though discomfort with the CDS surfaced among PCPs, impacting adoption and fidelity. The TAPS Tool's content, credibility and ease of workflow integration were favorably assessed. Challenges include screening solely at annual visits and self-administered screening for certain patients. Conclusions: Results reveal indicators of implementation success and strategies to address challenges to screening for substance use in primary care.

Opioid initiation and injection transition in rural northern New England: A mixed-methods approach

BACKGROUND

In rural northern New England, located in the northeastern United States, the overdose epidemic has accelerated with the introduction of fentanyl. Opioid initiation and transition to opioid injection have been studied in urban settings. Little is known about opioid initiation and transition to injection drug use in rural northern New England.

METHODS

This mixed-methods study characterized opioid use and drug injection in 11 rural counties in Massachusetts, Vermont, and New Hampshire between 2018 and 2019. People who use drugs completed audio computer-assisted self-interview surveys on substance use and risk behaviors (n = 589) and shared personal narratives through in-depth interviews (n = 22). The objective of the current study is to describe initiation of opioid use and drug injection in rural northern New England.

RESULTS

Median age of first injection was 22 years (interquartile range 18-28 years). Key themes from in-depth interviews that led to initiating drug injection included normalization of drug use in families and communities, experiencing trauma, and abrupt discontinuation of an opioid prescription. Other factors that led to a transition to injecting included lower cost, increased effect/ rush, greater availability of heroin/ fentanyl, and faster relief of withdrawal symptoms with injection.

CONCLUSIONS

Trauma, normalization of drug use, over-prescribing of opioids, and abrupt discontinuation challenge people who use drugs in rural northern New England communities. Inadequate opioid tapering may increase transition to non-prescribed drug use. The extent and severity of traumatic experiences described highlights the importance of enhancing trauma-informed care in rural areas.

Breaching Trust: A Qualitative Study of Healthcare Experiences of People Who Use Drugs in a Rural Setting

Background: Increased drug use has disproportionately impacted rural areas across the U.S. People who use drugs are at risk of overdose and other medical complications, including infectious diseases. Understanding barriers to healthcare access for this often stigmatized population is key to reducing morbidity and mortality, particularly in rural settings where resources may be limited. Methods: We conducted 20 semi-structured interviews with people who use drugs, including 17 who inject drugs, in rural southern Illinois between June 2018 and February 2019. Interviews were analyzed using a modified grounded theory approach where themes are coded and organized as they emerge from the data. Results: Participants reported breaches of trust by healthcare providers, often involving law enforcement and Emergency Medical Services, that dissuaded them from accessing medical care. Participants described experiences of mistreatment in emergency departments, with one account of forced catheterization. They further recounted disclosures of protected health information by healthcare providers, including communicating drug test results to law enforcement and sharing details of counseling sessions with community members without consent. Participants also described a hesitancy common among people who use drugs to call emergency medical services for an overdose due to fear of arrest. Conclusion: Breaches of trust by healthcare providers in rural communities discouraged people who use drugs from accessing medical care until absolutely necessary, if at all. These experiences may worsen healthcare outcomes and further stigmatize this marginalized community. Structural changes including reforming and clarifying law enforcement's role in Emergency Departments as well as instituting diversion policies during arrests may help rebuild trust in these communities. Other possible areas for intervention include stigma training and harm reduction education for emergency medicine providers, as well as developing and implementing referral systems between Emergency Departments and local harm reduction providers and medically assisted drug treatment programs.

Rural risk environments, opioid-related overdose, and infectious diseases: A multidimensional, spatial perspective

BACKGROUND

Much remains unknown in rural risk environments, despite a growing crisis in these areas. We adapt a risk environment framework to characterize rural southern Illinois and describe the relations of risk environments, opioid-related overdose, HIV, Hepatitis C, and sexually transmitted infection rates between 2015 and 2017.

METHODS

Over two dozen risk environment variables are summarized across zip-code (n = 128) or county levels (n = 16) based on availability and theoretical relevance. We calculate data attribute associations and characterize spatial and temporal dimensions of longitudinal health outcomes and the rural risk environment. We then use a "regional typology analysis" to generate data-driven risk regions and compare health outcomes.

RESULTS

Pervasive risk hotspots were identified in more populated locales with higher rates of overdose and HCV incidence, whereas emerging risk areas were isolated to more rural locales that had experienced an increase in analgesic opiate overdoses and generally lacked harm-reduction resources. At-risk areas were characterized with underlying socioeconomic vulnerability but in differing ways, reflecting a nuanced and shifting structural risk landscape.

CONCLUSIONS

Rural risk environment vulnerabilities and associated opioid-related health outcomes are multifaceted and spatially heterogeneous. More research is needed to better understand how refining geographies to more precisely define risk can support intervention efforts and further enrich investigations of the opioid epidemic.

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.