People, places, and stigma: A qualitative study exploring the overdose risk environment in rural Kentucky

The Police Opioid Seizure Temporal Risk (POSTeR) model of increased exposure to fatal overdose

CONTEXT

Police seizures of illicit opioids remain a dominant strategy for addressing problematic substance use and overdose in the United States and throughout the world, yet qualitative accounts and quantitative analyses exhibit positive associations between police opioid seizures and ensuing risk of fatal overdose at the local level of individual incidents. Since these associations run counter to the commonly held belief that removing potent illicit substances from the community is protective of overdose, a causal model is needed to demonstrate this association and convey the overdose risks that follow from police opioid seizures.

METHODS

Leveraging well-established biological and psychological outcomes of opioid use disorder and opioid supply interruption, our analysis presents the Police Opioid Seizure Temporal Risk (POSTeR) Model, an individual-level casual model that begins at the point of opioid dependence, introduces an interruption to an individual's supply of opioids as the result of a police drug seizure, and presents the physical and behavioral outcomes that increase the ensuing temporal risk of fatal overdose.

RESULTS

The aftermath of a police opioid seizure can increase a person's risk of fatal overdose. The urgent need to prevent or reduce acute opioid withdrawal symptoms leads people to seek a replacement supply, while reduced opioid tolerance resulting from post-seizure involuntary abstinence combines with the uncertain potency of a replacement supply of illicit opioids to significantly increase the difficulty of administering a safe but effective dose. In the face of these hazards, people in withdrawal often have a reduced aversion to risk, prompting them to consume this uncertain dose in a manner that increases their exposure to overdose.

CONCLUSIONS

Strategies that emphasize police opioid seizures as an acceptable way to reduce the prevalence of illicit drugs in a community without accounting for the elevated risk of fatal overdose that results can worsen one of the most significant problems they are meant to address.

Mapping the lived experience of rural substance use stigma: A conceptual framework of salient attitudes, beliefs, and behaviors in people who use drugs

BACKGROUND

Stigma directly contributes to physical, social, and psychic harm in people who use drugs. Current stigma frameworks privilege perspectives of stigmatizers, discounting the subjective lived experience of the stigmatized. Acknowledging that stigma is a universal phenomenon that manifests locally, we aimed to identify salient stigma-related attitudes, beliefs, behaviors, and experiences among people who use drugs in the rural Appalachian region of the United States.

METHODS

Twenty-two people who use drugs residing in rural Ohio participated in qualitative interviews, sharing perspectives on and experiences with substance use stigma. Data were analyzed in three iterative rounds (using Rigorous and Accelerated Data Reduction, reflexive thematic analysis, in-vivo coding and analysis) then summarized in an experiential framework.

RESULTS AND DISCUSSION

We organize and describe three salient facets of rural substance use stigma shared by participants: manifestations (stereotypes, prejudice, discrimination), outcomes (immediate reactions and personal consequences), and responses (adaptive and maladaptive coping styles). We discuss how these experiences are situated in cultural context and may be shaped by values like family, community, and self-reliance.

CONCLUSION

Our study provides a conceptual framework for understanding the lived experience of substance use stigma in one sociocultural context. This framework has immediate utility for informing stigma reduction efforts in rural Appalachia and may be adapted to other contexts where the local character of stigma is of theoretical or practical import.

"I don't know how you can overdose smoking them:" Perceptions of overdose risks among persons who use illicit fentanyl-laced counterfeit pills

AIMS

Illicitly manufactured fentanyl (IMF) remains the primary driver of overdose mortality in the US. Western states saw significant increases in IMF-laced counterfeit pain pills ("blues"). This qualitative study, conducted in Phoenix, Arizona, provides an in-depth understanding of how overdose-related risks are viewed and experienced by people who use "blues."

METHODS

Between 11/2022-12/2023, the study recruited 60 individuals who used "blues" using targeted and network-based recruitment. Qualitative interviews were recorded, transcribed, and analyzed using NVivo.

RESULTS

The sample included 41.7 % women, and 56.7 % whites. 55.3 % had prior overdose, but most (62.2 %) rated their current risk as none/low. Risk perceptions centered on a multi-level calculus of drug market conditions, individual vulnerabilities, and behavioral factors. Smoking was considered a "normative" way of using "blues", and most viewed it as protective against overdose in comparison to injection and other routes of use. Drug market conditions and the unpredictability of "blues" were emphasized as important factor of overdose risk. However, some believed that over time, the quality/consistency of "blues" improved, and they became less risky. Many also expressed fears about the emerging local availability of powder fentanyl and its risk. Views about safer dosing, polydrug use, tolerance, and health emphasized personal responsibility and individual vulnerability to overdose risks. Discussions of protective behaviors, including take-home naloxone, varied bases on the perceptions of overdose risks.

CONCLUSIONS

The findings emphasize the need for close monitoring of local IMF markets and design of comprehensive interventions and risk communication strategies to address perceptions that minimize IMF-laced counterfeit pill risks.

A descriptive analysis of rural-urban overdose experiences among incarcerated women with opioid use disorder

BACKGROUND AND OBJECTIVES

Despite elevated overdose risk in rural communities, rural/urban differences in overdose risk factors are understudied among women with criminal legal system involvement. This study examines substance use and overdose among incarcerated women.

METHODS

Women (N = 900) were randomly selected from nine Kentucky jails, screened, and interviewed as part of a larger study. Bivariate analyses were used to identify group differences.

RESULTS

Rural women were less likely to report pre-incarceration overdose and to receive emergency services post-overdose. Substance use also varied.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Results underscore the importance of Opioid Overdose Education and Naloxone Distribution in rural communities.

Mapping the risk environment for peers with lived-living experience working in the alcohol and other drugs sector in Queensland

INTRODUCTION

Peer workers in the Alcohol and Other Drugs (AOD) sector play a vital role in harm reduction for people who use drugs (PWUDs); however, their experiences are often shaped by complex macro- and micro-risk environments. This study explores these environments and their implications for peer workers, particularly concerning stigma, legal barriers, and organisational culture.

METHODS

Semi-structured interviews were conducted with 18 peers with lived-living experience of illicit drug use. Purposive sampling was employed, leveraging established peer networks and community organisations. Interviews (range = 42-90 mins) were conducted via Microsoft Teams, transcribed, and analysed. The iterative coding process involved deductive codes based on predetermined topics and inductive codes derived from identified themes.

RESULTS

Participants identified key systemic challenges, including peer stigma, limited career prospects, and the complexities of navigating legal frameworks that criminalise drug use, thereby undermining the efficacy of peer work. The interplay between regulatory frameworks and societal attitudes creates barriers to employment, which disproportionately affects people with drug-related offenses. The significance of collective connection as a source of safety and support was also highlighted, particularly through peer supervision, which fosters enabling environments that promote wellbeing.

DISCUSSION

Findings highlight the need for advocacy towards legal reform and the creation of inclusive organisational cultures. Recognising and valuing the LLE of peer workers is essential for enhancing harm reduction initiatives and promoting the wellbeing of PWUDs. Addressing these macro- and micro-risk factors, including the importance of peer supervision, can improve peer workers' efficacy in providing meaningful support within their communities.

Rural houselessness among people who use drugs in the United States: Results from the National Rural Opioid Initiative

BACKGROUND

Over the last two decades, houselessness and drug-related epidemics both have expanded from urban to rural regions across the United States (US). However, our understanding of the relationship between rural houselessness, drug use, and drug-related harms has not kept pace. The current study addresses this gap by describing houselessness among a large cohort of people who use drugs (PWUD) from rural communities across 10 states.

DESIGN

PWUD were recruited using modified chain-referral sampling for a cross-sectional survey capturing houselessness in the prior six months, drug use, drug-related harms, stigma, health service access, and sociodemographic characteristics. Using bivariate logistic regressions, we assessed associations between houselessness and participant characteristics. We also compare site-specific houselessness prevalence to Housing and Urban Development Point-in-Time (PIT) estimates, which are based on counts of sheltered and unsheltered people experiencing houselessness on a single night.

RESULTS

Among 3000 PWUD, 53.7 % reported experiencing houselessness. Houselessness was associated with multiple drug-related behaviors that increase the risk of overdose and acquisition of bloodborne infections. Houselessness prevalence was comparable and exceeded PIT estimates for several sites, even though study participants constituted <1 % of each site's adult population and were restricted to PWUD.

CONCLUSIONS

Our findings highlight that houselessness - historically considered an urban issue - is a significant public health concern for PWUD in rural areas. This demonstrates that addressing drug-related HIV, hepatitis C, and overdose epidemics, among others, in the rural US will require the provision of stable housing and harm reduction services as a pathway to treatment and recovery.

It's Risky Out Where We Are: Exploring Intersectional Factors of Intentional Overdose Among People Who Use Drugs in Regional Queensland, Australia

OBJECTIVE

Globally, drug-related deaths impact both urban and non-urban areas. In Australia, regional areas face a concerning rise in drug-induced fatalities and suicides, exacerbated by structural factors like limited services and stigma. We sought to explore the experiences of people who use drugs (PWUDs) in regional Queensland to understand the structural vulnerabilities influencing drug-induced deaths.

METHODS

The sample comprised 19 PWUDs from regional Queensland, Australia who had experienced overdose. Semi-structured interviews explored participants' overdose experiences and contributing factors, focusing on regionality. Iterative coding was used to develop thematic categories.

RESULTS

Participants highlighted the complex interplay of trauma, coping and drug use influencing overdose dynamics. Regional challenges, including limited access to support services, exacerbate risks for PWUDs. Structural inequalities perpetuate cycles of harm, with rural areas disproportionately affected. Participants emphasized the need for systemic changes to facilitate effective suicide prevention efforts, advocating for enhanced service engagement and legislative reforms.

CONCLUSIONS

These findings challenge systemic factors such as stigma and healthcare accessibility, which appear to be driving drug-related harm. Based on the findings, recommendations are made for systemic change, represented by comprehensive, community-driven interventions to address structural inequalities, and improve access to support services.

How do relational practices co-constitute care for people who use drugs? The social and political dimensions of peer-led harm reduction

INTRODUCTION

People who use drugs have a long history of mobilising to reduce harm within their communities, significantly influencing harm reduction efforts globally. Peers with lived experience contribute through needle exchange programs, harm reduction education, and community-based research. Despite facing stigma, their initiatives have generated multiple benefits for communities. Collaborations between peers and researchers are increasingly recognised, emphasising meaningful participation in decisions affecting their lives. This paper focuses on the role of peers in mitigating drug-related risks and harms through community care.

METHODS

Semi-structured interviews were conducted with 30 people who use drugs, exploring peer support and harm reduction. Data were analysed by the lead author and a coding framework was developed in which key theme-categories were organised. Theoretical framing from science and technology studies informed analysis, recognising the political dimensions of research.

RESULTS

Peers play a crucial role in bridging gaps in formal services, offering stigma-free, relational care spaces. These spaces, both physical and social, affirm dignity and solidarity, countering marginalisation. Participants highlight the importance of peer involvement in driving change, promoting safer use practices, and advocating for a holistic harm reduction approach that considers systemic factors.

CONCLUSIONS

Our data highlight the vital role of peer connections and peer-led harm reduction practices in fostering safety, solidarity, and connection among communities of people who use drugs. Future research should continue to explore peer-led initiatives within evolving healthcare contexts, considering broader social dynamics and employing innovative conceptual frameworks to promote equitable peer-led harm reduction strategies.

Implementation of an EMS-based naloxone distribution program: A qualitative evaluation

Objectives

We evaluated a novel leave-behind naloxone (LBN) program that allows Emergency Medical Services (EMS) personnel to distribute naloxone after an opioid overdose. Our objective was to explore EMS engagement and experiences with the program, as well as interest in education on addiction and harm reduction. We also assessed the acceptability of LBN programs among people who use drugs (PWUD).

Methods

We conducted telephone interviews with EMS personnel and residents of substance use recovery housing between February and September 2023. EMS personnel described their direct experiences with the LBN program and perceived facilitating factors and barriers to naloxone distribution. First responder interactions and support for LBN were explored with PWUD. A rapid assessment method was used to analyze the interview data.

Results

Eighteen of the 23 EMS participants had distributed LBN; most agreed EMS agencies should have an LBN program. Barriers included forgetting, patient acuity, patients declining, and perceived liability. Facilitators included having a clear protocol, accessible kits, and minimal documentation burden. The majority expressed interest in harm reduction education. Eight of the 11 PWUD participants reported recent involvement in an opioid overdose. The majority supported LBN and felt comfortable receiving naloxone training from EMS.

Conclusion

In this qualitative evaluation, we found broad support for EMS-based naloxone distribution among EMS personnel and PWUD. We identified several modifiable barriers to the success of such programs, which should be the subject of future investigation. EMS and harm reduction communities should support the expansion of LBN programs across the United States.

Barriers to calling emergency services amongst people who use substances in the event of overdose: A scoping review

BACKGROUND

North America is grappling with an ongoing drug overdose crisis. While harm reduction measures like take-home naloxone kits, and supervised consumption sites, have helped reduce mortality, other strategies to address this public health emergency are required. Good Samaritan Laws (GSLs) offer legal protection for individuals who report overdoses, yet people who use substances (PWUS) may still hesitate to seek help due to concerns about existing legislation. This scoping review explores barriers preventing PWUS from calling emergency services for overdoses, along with potential solutions and facilitators to address this challenge.

METHODS

PRISMA-ScR was used as a guide to conduct this study. Health sciences librarians searched Medline, Embase, PsychINFO, CINAHL, and SCOPUS to identify relevant articles. Six reviewers contributed to screening and extracting the articles through Covidence. Two reviewers performed thematic analysis using NVivo software to identify key barriers and facilitators.

RESULTS

An initial search found 6275 articles for title and abstract screening, resulting in 48 studies meeting the inclusion criteria. The primary barrier to calling 911 pertained to concerns about police arrivng with other first responders, especially regarding their presence and involvement at the scene of overdose. This was followed by legal repercussions, including fear of arrest, incarceration, and fear of eviction, amongst others. Some studies noted the lack of knowledge or trust in GSLs as a deterrent to seeking medical assistance. Additional barriers included concerns about privacy and confidentiality, preference to manage an overdose alone/receive help from another peer, confidence in naloxone effectiveness, limited access to cell phones, peer pressure to not call for help, and identifying as Black, Indigenous, or a Person of Colour (BIPOC). Facilitators include increased GSL awareness among PWUS and law enforcement, expanded legal safeguards for 911 callers, reduced police intervention in overdose cases, and enhanced naloxone availability at key access points.

CONCLUSION

Despite the good intentions of GSLs, PWUS continue to experience significant barriers to calling emergency services in the event of an overdose. Understanding these barriers and key facilitators is necessary to inform future drug policy and advocacy efforts.

Community-level Factors and their Associations with Changing Opioid Overdose Fatality Rates in Kentucky, 2019-2021

Introduction

Kentucky has one of the highest opioid overdose fatality rates in the United States, which has increased significantly from 2019 to 2020. The COVID-19 pandemic has caused lasting effects on mental health and health care, which have been linked with increased opioid overdose. These effects are exacerbated in Appalachian regions, where there is a lack of sufficient access to community pharmacies and adequate health care.

Purpose

In this study, we characterize changes in opioid overdose fatality rates in Kentucky from 2019 to 2021, with a specific focus on changes in Appalachian vs non-Appalachian counties. We aim to identify associations between community-level factors and opioid overdose fatality rates and how such associations may have changed from 2019 to 2021.

Methods

County-level data were used to fit a marginal GEE-type negative binomial model to determine factors associated with opioid overdose fatality rates in 2019 (before the COVID-19 pandemic) and 2021 (during the COVID-19 pandemic).

Results

Opioid overdose fatality rates increased from 2019 to 2021 (Rate Ratio: 1.82). This increase was much larger in adjacent-to-metropolitan (RR: 2.54) and Appalachian (RR: 2.38) counties. Age was associated with opioid overdose fatality rates in both 2019 and 2021, and the observed association for age was stronger in 2021. Appalachian status was associated with opioid overdose fatality rates in 2021. Metropolitan county status was associated with opioid overdose fatality rates in 2019, whereas adjacent-to-metropolitan county status was associated with opioid overdose fatality rates in 2021.

Implications

Adjacent-to-metropolitan status's association with overdose fatalities in 2021 may indicate a differential effect of COVID-19 on suburban communities. Future studies should investigate additional factors related to COVID-19 as well the lasting effects of the pandemic on the landscape of opioid overdose in Kentucky.

"Expected to happen": perspectives on post-release overdose from recently incarcerated people with opioid use disorder

BACKGROUND

Opioid-related overdose is the leading cause of death for people recently released from incarceration, however treatment with medications for opioid use disorder (MOUD) during incarceration can reduce the mortality risk. This study seeks to qualitatively analyze perceptions of post-release overdose risk from the perspectives of people who received MOUD while incarcerated in one of eight Massachusetts jails during 2021-2022 using the Risk Environment Framework to guide analyses.

METHODS

N = 38 participants with lived experience of MOUD treatment during incarceration who are now living in the community were interviewed on factors that may contribute to or protect against post-release overdose risk. Themes were identified inductively and deductively using the Risk Environment Framework and its domains, which organizes themes along physical, social, economic, and policy environments on both the micro- and macro- scales.

RESULTS

The physical risk environment included loss of opioid tolerance during incarceration, polysubstance use, and the toxicity of the regional drug supply as key producers of increased risk for post-release overdose. Social drivers of risk included peer group risk norms-including peer-driven harm reduction practices and interpersonal relationships between drug sellers and buyers-as well as macro-level social determinants of health such as housing insecurity and availability of mental health services. Economic drivers of post-release overdose risk included lack of income generation during incarceration and employment challenges. Participants discussed several aspects of policy that contribute to post-release overdose risk, including availability of harm reduction supplies, public health services, and broader policy around MOUD.

CONCLUSIONS

The perspectives of people with lived experience are vital to understanding the disproportionate risks of overdose for those recently released from incarceration. Our results highlight the intersectional factors that produce and reproduce the post-release overdose risk environment, providing support for interventions across each domain of the Risk Environment Framework. By capturing perspectives from people with lived experience of OUD and incarceration during this critical period of risk, we can better identify interventions that target and mitigate overdose-related harm in this population.

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.

Missouri's Overdose Field Report: descriptive analysis, survival trends, and naloxone dosing patterns from a community-based survey tool, 2018-2022

Background: Missouri's Overdose Field Report (ODFR) is a community-based reporting system which intends to capture overdoses which may not be otherwise recorded.Objectives: Describe the factors related to non-fatal overdoses reported to Missouri's ODFR.Methods: This study used a descriptive epidemiological approach to examine the demographics and circumstances of overdoses reported to the ODFR. We used binary logistic regression to evaluate factors associated with survival and ordinal logistic regression to evaluate factors associated with number of doses used. Factors were chosen based on their relevance to overdose education and survival, and naloxone distribution.Results: Between 2018 and 2022, 12,225 overdoses (67% male; 78% White) were reported through the ODFR, with a 96% (n = 11,225) survival rate. Overdose survival (ps < .02) was associated with younger age (OR = .58), no opioid and stimulant co-involvement (OR = .61), and private location (OR = .48). Intramuscular naloxone in particular was associated with a significantly higher odds of survival compared to nasal naloxone (OR = 2.11). An average of 1.6 doses of naloxone per incident were administered. Additional doses were associated (ps < .02) with being older (OR = .45), female (OR = .90), nasal naloxone (versus intravenous) (OR = .65), and the belief fentanyl was present (OR = 1.49).Conclusion: Our reporting form provides a comprehensive picture of the events surrounding reported overdoses, including factors associated with survival, how much naloxone was used, and the effects of respondents believing fentanyl was involved. Missouri's report can provide support for current naloxone dosing, contextualize refusing post-overdose transport, and can be used to improve overdose response by community and first responders.

The paradox of high greenness and poor health in rural Central Appalachia

While many studies have found positive correlations between greenness and human health, rural Central Appalachia is an exception. The region has high greenness levels but poor health. The purpose of this commentary is to provide a possible explanation for this paradox: three sets of factors overwhelming or attenuating the health benefits of greenness. These include environmental (e.g., steep typography and limited access to green space used for outdoor recreation), social (e.g., chronic poverty, declining coal industry, and limited access to healthcare), and psychological and behavioral factors (e.g., perceptions about health behaviors, healthcare, and greenness). The influence of these factors on the expected health benefits of greenness should be considered as working hypotheses for future research. Policymakers and public health officials need to ensure that greenness-based interventions account for contextual factors and other determinants of health to ensure these interventions have the expected health benefits.

Correlates of overdose among 2711 people who use drugs and live in 7 rural US sites

BACKGROUND

Overdose rates in rural areas have been increasing globally, with large increases in the United States. Few studies, however, have identified correlates of non-fatal overdose among rural people who use drugs (PWUD). The present analysis describes correlates of nonfatal overdose among a large multistate sample of rural PWUD.

METHODS

This is a cross-sectional analysis of data gathered via surveys with PWUD recruited through seven Rural Opioid Initiative (ROI) sites. Descriptive analyses were conducted to assess the prevalence of past 30-day overdose. Generalized estimating equations were used to estimate a series of multivariable models quantifying relationships of select factors to past-month overdose; factors were selected using the Risk Environment Framework.

RESULTS

The multisite sample included 2711 PWUD, 6% of whom reported overdosing in the past 30 days. In the fully adjusted model, houselessness (AOR=2.27, 95%CI[1.48, 3.48]), a positive test result for Hepatitis C infection (AOR=1.73 95%CI[1.18, 2.52]) and heroin/fentanyl use (AOR= 8.58 95%CI [3.01, 24.50]) were associated with an increased risk of reporting past 30-day overdose, while having a high-school education or less was associated with reduced odds of overdose (AOR=0.52, 95% CI[0.37, 0.74]).

CONCLUSION

As in urban areas, houselessness, Hepatitis C infection, and the use of heroin and fentanyl were significant correlates of overdose. Widespread access to overdose prevention interventions - including fentanyl test strips and naloxone - is critical in this rural context, with particular outreach needed to unhoused populations, people living with Hepatitis C, and people using opioids.

Overdosing in a Motor Vehicle: Examination of Human, Geographic, and Environmental Factors

BACKGROUND

Fentanyl, a type of opioid, in impaired driving cases increased across cities in the United States.

OBJECTIVES

No empirical studies have examined motor vehicle overdoses with fentanyl use. We investigated the magnitude of the motor vehicle overdose problem in Providence, RI, and the environmental, socioeconomic, and geographic conditions associated with motor vehicle overdose occurrence.

METHODS

This was a retrospective observational study of emergency medical services data on all suspected opioid overdoses between January 1, 2017, and October 31, 2020. The data contain forced-choice fields, such as age and biological sex, and an open-ended narrative in which the paramedic documented clinical and situational information. The overdoses were geocoded, allowing for the extraction of sociodemographic data from the U.S. Census Bureau's American Community Survey. Seven other data sources were included in a logistic regression to understand key risk factors and spatial patterns of motor vehicle overdoses.

RESULTS

Of the 1,357 opioid overdose cases in this analysis, 15.2% were defined as motor vehicle overdoses. In adjusted models, we found a 61% increase in the odds of a motor vehicle overdose involvement for men versus women, a 16.8% decrease in the odds of a motor vehicle overdose for a one-unit increase in distance to the nearest gas station, and a 10.7% decrease in the odds of a motor vehicle overdose for a one-unit increase in distance to a buprenorphine clinic.

CONCLUSION

There is a need to understand the interaction between drug use in vehicles to design interventions for decreasing driving after illicit drug use.

Opioid Overdoses and Take-Home Naloxone Interventions: Ethnographic Evidence for Individual-Level Barriers to Treatment of Opioid Use Disorders in Rural Appalachia

Introduction: Research indicates that take-home naloxone (THN) is saving lives across rural Appalachia, but whether it also results in treatment for opioid use disorders (OUDs) remains unclear. This study involves a detailed qualitative analysis of interviews with 16 individuals who had overdosed on opioids 61 times to understand why a THN intervention does not routinely lead to OUD treatment. Methods: This study builds upon a one-year (2018) qualitative study on community responses to opioid overdose fatalities in four adjacent rural counties in Western Pennsylvania. Using a semi-structured interview guide, 16 individuals who had experienced one or more overdoses were interviewed. Using NVivo, the transcribed audio-recorded interviews were coded, and a thematic analysis of the coded text was conducted. Findings: Findings reveal that of the 29 overdoses that included a THN intervention, only eight resulted in treatment. The analysis derives five individual-level barriers to treatment: (1) opioid dependence, (2) denial/readiness, (3) opioid withdrawal fears, (4) incarceration concerns, and (5) stigma and shame. These barriers impeded treatment, even though all the interviewees knew of treatment programs, how to access them, and in some cases had undergone treatment previously. Discussion and Conclusion: findings indicate that there is evidence that the five barriers make entering treatment after a THN intervention challenging and seemingly insurmountable at times. Recommendations based on the findings include increasing efforts to reduce stigma of OUDs in the community, including self-stigma resulting from misusing opioids, increasing informational efforts about Good Samaritan Laws, and increasing familiarity with medication-assisted treatments for OUDS.

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.

Identifying structural risk factors for overdose following incarceration: a concept mapping study

BACKGROUND

Currently, there are more than two million people in prisons or jails, with nearly two-thirds meeting the criteria for a substance use disorder. Following these patterns, overdose is the leading cause of death following release from prison and the third leading cause of death during periods of incarceration in jails. Traditional quantitative methods analyzing the factors associated with overdose following incarceration may fail to capture structural and environmental factors present in specific communities. People with lived experiences in the criminal legal system and with substance use disorder hold unique perspectives and must be involved in the research process.

OBJECTIVE

To identify perceived factors that impact overdose following release from incarceration among people with direct criminal legal involvement and experience with substance use.

METHODS

Within a community-engaged approach to research, we used concept mapping to center the perspectives of people with personal experience with the carceral system. The following prompt guided our study: "What do you think are some of the main things that make people who have been in jail or prison more and less likely to overdose?" Individuals participated in three rounds of focus groups, which included brainstorming, sorting and rating, and community interpretation. We used the Concept Systems Inc. platform groupwisdom for our analyses and constructed cluster maps.

RESULTS

Eight individuals (ages 33 to 53) from four states participated. The brainstorming process resulted in 83 unique factors that impact overdose. The concept mapping process resulted in five clusters: (1) Community-Based Prevention, (2) Drug Use and Incarceration, (3) Resources for Treatment for Substance Use, (4) Carceral Factors, and (5) Stigma and Structural Barriers.

CONCLUSIONS

Our study provides critical insight into community-identified factors associated with overdose following incarceration. These factors should be accounted for during resource planning and decision-making.

"The machine doesn't judge": Counternarratives on surveillance among people accessing a safer opioid supply via biometric machines

People who use illegal drugs experience routine surveillance, including in healthcare and harm reduction settings. The MySafe Project - a safer supply pilot project that dispenses prescription opioids via a biometric vending machine - exists in the Canadian province of British Columbia. The machine scans a participant's palmprint and has a built-in camera that records every machine interaction. The aim of this paper is to understand participants' experiences of surveillance, privacy, and personal security when accessing this novel program. An integrative case study and grounded theory methodology was employed. Qualitative one-to-one interviews were conducted with 46 MySafe participants across three different program sites in Vancouver. We used a team-based approach to code interview transcripts and utilized directed and conventional content analyses for deductive and inductive analyses. While participants described negative experiences of surveillance in other public and harm reduction settings, they did not have concerns regarding cameras, collection of personal information, tracking, nor staff issues associated with MySafe. Similarly, while some participants had privacy concerns in other settings, very few privacy and confidentiality concerns were expressed regarding accessing the machine in front of others. Lastly, while some participants reported being targeted by others when accessing the machines, most participants described how cameras, staff, and machine locations helped ensure a sense of safety. Despite negative experiences of surveillance and privacy issues elsewhere, participants largely lacked concern regarding the MySafe program and machines. The machine-human interaction was characterized as different than some human-human interactions as the machine is completing tasks in a manner that is acceptable and comfortable to participants, leading to a social preference toward the machines in comparison to other surveilled means of accessing medications. These findings provide an opportunity to rethink how we conceptualize surveillance, medication access, and harm reduction programs targeting people who use drugs.

Correlates of Recent HIV Testing Among People Who Inject Drugs in Rural Areas: A Multi-site Cross-Sectional Study, 2018-2020

The Rural Opioid Initiative surveyed 2693 people who inject drugs (PWID) in eight rural U.S. areas in 2018-2020 about self-reported HIV testing in the past 6 months. Correlates of interest included receipt of any drug-related services, incarceration history, and structural barriers to care (e.g., lack of insurance, proximity to syringe service programs [SSP]). Overall, 20% of participants reported receiving an HIV test within the past 6 months. Multivariable generalized estimating equations showed that attending substance use disorder (SUD) treatment (OR 2.11, 95%CI [1.58, 2.82]), having health insurance (OR 1.42, 95%CI [1.01, 2.00]) and recent incarceration (OR 1.49, 95%CI [1.08, 2.04]) were positively associated with HIV testing, while experiencing a resource barrier to healthcare (inability to pay, lack of transportation, inconvenient hours, or lack of child care) had inverse (OR 0.73, 95%CI [0.56, 0.94]) association with HIV testing. We found that the prevalence of HIV testing among rural PWID is low, indicating an unmet need for testing. While SUD treatment or incarceration may increase chances for HIV testing for rural PWID, other avenues for expanding HIV testing, such as SSP, need to be explored.

High-risk Individuals and Naloxone Use: Implications for THN Programs in Rural Appalachian Communities

Introduction

Take-home naloxone (THN) is being made available across rural Appalachia to curb opioid overdose fatalities. Despite this initiative, some opioid users do not possess naloxone, and if they do, do not administer it to others.

Purpose

Research findings on risk factors that contribute to opioid overdose are presented. These factors, identified in a sample of 16 overdose cases, are (1) early onset age of opioid use; (2) progressive opioid use; (3) a transition from pain medication to heroin and fentanyl; (4) fears of being arrested at a naloxone intervention if first responders are contacted, and (5) limited knowledge of Good Samaritan Laws.

Methods

The findings are based on a subsample 16 overdose victims who were identified during a one-year (2018) qualitative study on the decline of overdose fatalities in four rural counties in Western Pennsylvania. They were recruited from a larger sample of 50 current and former substance users and were interviewed a second time using a semi-structured interview guide about their overdose experiences. All interview data were analyzed using thematic analysis via NVivo.

Results

Findings reveal that risk factors contribute to a severe opioid dependence that interferes with naloxone use. These factors also hinder adherence to proper naloxone protocol, designed to place overdose victims in contact with treatment providers.

Implications

Recommendations are made for additional research and for pursuing measures to increase efficacy of naloxone interventions. They include developing naloxone campaigns aimed at high-risk individuals, improving their knowledge of Good Samaritan Laws, increasing adherence to THN protocols that improve the possibility of treatment, and using community harm reduction specialists for community outreach.

"I'm not going to lay back and watch somebody die": a qualitative study of how people who use drugs' naloxone experiences are shaped by rural risk environment and overdose education/naloxone distribution intervention

BACKGROUND

Overdoses have surged in rural areas in the U.S. and globally for years, but harm reduction interventions have lagged. Overdose education and naloxone distribution (OEND) programs reduce overdose mortality, but little is known about people who use drugs' (PWUD) experience with these interventions in rural areas. Here, we analyze qualitative data with rural PWUD to learn about participants' experiences with an OEND intervention, and about how participants' perceptions of their rural risk environments influenced the interventions' effects.

METHODS

Twenty-nine one-on-one, semi-structured qualitative interviews were conducted with rural PWUD engaged in the CARE2HOPE OEND intervention in Appalachian Kentucky. Interviews were conducted via Zoom, audio-recorded, and transcribed verbatim. Thematic analysis was conducted, guided by the Rural Risk Environment Framework.

RESULTS

Participants' naloxone experiences were shaped by all domains of their rural risk environments. The OEND intervention transformed participants' roles locally, so they became an essential component of the local rural healthcare environment. The intervention provided access to naloxone and information, thereby increasing PWUDs' confidence in naloxone administration. Through the intervention, over half of participants gained knowledge on naloxone (access points, administration technique) and on the criminal-legal environment as it pertained to naloxone. Most participants opted to accept and carry naloxone, citing factors related to the social environment (responsibility to their community) and physical/healthcare environments (overdose prevalence, suboptimal emergency response systems). Over half of participants described recent experiences administering intervention-provided naloxone. These experiences were shaped by features of the local rural social environment (anticipated negative reaction from recipients, prior naloxone conversations).

CONCLUSIONS

By providing naloxone paired with non-stigmatizing health and policy information, the OEND intervention offered support that allowed participants to become a part of the healthcare environment. Findings highlight need for more OEND interventions; outreach to rural PWUD on local policy that impacts them; tailored strategies to help rural PWUD engage in productive dialogue with peers about naloxone and navigate interpersonal conflict associated with overdose reversal; and opportunities for rural PWUD to formally participate in emergency response systems as peer overdose responders. Trial registration The ClinicalTrials.gov ID for the CARE2HOPE intervention is NCT04134767. The registration date was October 19th, 2019.

Spatial access to buprenorphine-waivered prescribers in the HEALing communities study: Enhanced 2-step floating catchment area analyses in Massachusetts, Ohio, and Kentucky

INTRODUCTION

The opioid overdose epidemic continues to impact a large swath of the population in the US. Medications for opioid use disorders (MOUD) are an effective resource to combat the epidemic; however, there is limited research on MOUD treatment access that accounts for both supply of and demand for services. We aimed to examine access to buprenorphine prescribers in the HEALing Communities Study (HCS) Wave 2 communities in Massachusetts, Ohio, and Kentucky during 2021, and the association between buprenorphine access and opioid-related incidents, specifically fatal overdoses and opioid-related responses by emergency medical services (EMS).

METHODS

We calculated Enhanced 2-Step Floating Catchment Area (E2SFCA) accessibility indices for each state, as well as Wave 2 communities in each state, based on the location of providers (buprenorphine-waivered clinicians from the US Drug Enforcement Agency Active Registrants database), population-weighted centroids at the census block group level, and catchment areas defined by the state or community's average commute time. In advance of intervention initiation, we quantified the opioid-related risk environment of communities. We assessed gaps in services by using bivariate Local Moran's I analysis, incorporating accessibility indices and opioid-related incident data.

RESULTS

Massachusetts Wave 2 HCS communities had the highest rates of buprenorphine prescribers per 1000 patients (median: 165.8) compared to Kentucky (38.8) and Ohio (40.1). While urban centers in all three states had higher E2SFCA index scores compared to rural communities, we observed that suburban communities often had limited access. Through bivariate Local Moran's I analysis, we identified numerous locations with low buprenorphine access surrounded by high opioid-related incidents, particularly in communities that surrounded Boston, Massachusetts; Columbus, Ohio; and Louisville, Kentucky.

CONCLUSION

Rural communities demonstrated a great need for additional access to buprenorphine prescribers. However, policymakers should also direct attention toward suburban communities that have experienced significant increases in opioid-related incidents.

Barriers and facilitators of naloxone and safe injection facility interventions to reduce opioid drug-related deaths: A qualitative analysis

BACKGROUND

Opioid drug-related deaths continue to be a significant public health concern in the Republic of Ireland (ROI) and Northern Ireland (NI). While both regions have implemented naloxone to reduce drug related deaths, there remains a gap in the implementation of a supervised injection facility (SIF). This study aimed to identify barriers and facilitators to implementing naloxone and a SIF to reduce opioid drug-related deaths in ROI and NI.

METHODS

Semi-structured interviews (n=23) were conducted in ROI and NI with experts by experience (n=8), staff from low threshold services (n=9), and individuals involved in policy making (n= 6). Data were analyzed using coding reliability Thematic Analysis and were informed by the Risk Environmental Framework.

RESULTS

The findings illustrated that stigma within the media, health centers, and the community was a significant barrier to naloxone distribution and SIF implementation. Policing and community intimidation were reported to hinder naloxone carriage in both the ROI and NI, while threats of paramilitary violence towards people who use drugs were unique to NI. Municipal government delays and policy maker apathy were reported to hinder SIF implementation in the ROI. Participants suggested peer-to-peer naloxone delivery and amending legislation to facilitate non-prescription naloxone would increase naloxone uptake. Participants recommended using webinars, Town Halls, and a Citizens' Assembly as tools to advocate for SIF implementation.

CONCLUSION

Local and regional stigma reduction campaigns are needed in conjunction with policy changes to advance naloxone and a SIF. Tailoring stigma campaigns to incorporate the lived experience of people who use drugs, their family members, and the general community can aid in educating the public and change negative perceptions. This study highlights the need for ongoing efforts to reduce stigma and increase accessibility to evidence-based interventions to address opioid drug-related deaths in the ROI, NI, and internationally.

National survey findings on law enforcement agency drug response practices, overdose victim outcomes, and Good Samaritan Laws

BACKGROUND

The United States continues to experience unprecedented rates of overdose mortality. Addressing the overdose epidemic has been challenging for policy makers given the lack of effectiveness of existing drug control policy measures. More recently, the implementation of harm reduction-based policies such as Good Samaritan Laws has led to increasing scholarly attention aimed at evaluating their effectiveness at reducing the likelihood of criminal justice-related sanctions for individuals following an overdose incident. The results of these studies, however, have been mixed.

METHODS

This study utilizes data from a nationally representative survey of law enforcement agencies designed to provide national information on services, policies, practices, operations, and resources of law enforcement drug response around overdoses to assess whether state Good Samaritan Laws reduce the likelihood of overdose victims being cited or being jailed following an overdose incident.

RESULTS

In general, findings indicate that although most agencies reported that overdose victims were not incarcerated or cited following an overdose incident, that this did not vary by whether agencies were in a state that had a GSL arrest protection for possession of controlled substances.

CONCLUSIONS

GSLs are often written in complex and confusing language that officers and people who use drugs do not fully understand, which may deter their being used for their intended purpose. Although GSLs are well-intentioned, these findings highlight the need for training and education for law enforcement and people who use drugs around the scope of these laws.

A qualitative analysis of rural syringe service program fidelity in Appalachian Kentucky: Staff and participant perspectives

PURPOSE

As drug-related epidemics have expanded from cities to rural areas, syringe service programs (SSPs) and other harm reduction programs have been slow to follow. The recent implementation of SSPs in rural areas demands attention to program fidelity based on core components of SSP success.

METHODS

Semistructured interviews conducted with clients and staff at 5 SSPs in 5 counties within 2 Central Appalachian health districts. Interviews covered fidelity of SSP implementation to 6 core components: (1) meet needs for harm reduction supplies; (2) education and counseling for sexual, injection, and overdose risks; (3) cooperation between SSPs and local law enforcement; (4) provide other health and social services; (5) ensure low threshold access to services; and (6) promote dignity, the impact of poor fidelity on vulnerability to drug-related harms, and the risk environment's influence on program fidelity. We applied thematic methods to analyze the data.

FINDINGS

Rural SSPs were mostly faithful to the 6 core components. Deviations from core components can be attributed to certain characteristics of the local rural risk environment outlined in the risk environment model, including geographic remoteness, lack of resources and underdeveloped infrastructure, and stigma against people who inject drugs (PWID) CONCLUSIONS: As drug-related epidemics continue to expand outside cities, scaling up SSPs to serve rural PWID is essential. Future research should explore whether the risk environment features identified also influence SSP fidelity in other rural areas and develop and test strategies to strengthen core components in these vulnerable areas.

Pathways connecting socioeconomic marginalization and overdose: A qualitative narrative synthesis

PURPOSE

This qualitative narrative synthesis sought to identify pathways connecting socioeconomic marginalization (SEM) and overdose for people who use drugs.

METHODS

We included studies with qualitative examination of SEM and fatal and non-fatal overdose published in English between 2000 and 2021. Studies were systematically identified and screened by searching MEDLINE (Ovid), Embase (Ovid), PsycINFO (EBSCOhost), CINAHL (EBSCOhost), Google Scholar, Cochrane Central Registry of Controlled Trials (CENTRAL), and Cochrane Drug and Alcohol Group (CDAG) Specialized Registry, citations, and contacting experts. Risk of bias and quality assessments were performed using the Critical Appraisal Skills Programme checklist and the Confidence in the Evidence from Reviews of Qualitative Research approach. Data were synthesized using a thematic synthesis approach.

RESULTS

The primary search strategy found 5909 articles that met the initial screening criteria. The review and screening process led to a final dataset of 27 qualitative articles. The four key findings of this narrative synthesis revealed aspects of SEM which shaped drug poisoning risk for people who use drugs: (1) resource insufficiency, labor market exclusion and deindustrialization, (2) homelessness and housing, (3) policing, criminalization, and interactions with emergency services, and (4) gendered and racialized dimensions of inequality. Findings led to creating a typology that includes material, behavioral, psychological, social, and environmental pathways that contain multiple mechanisms connecting SEM to overdose. This review revealed reciprocal connections between overdose and SEM via institutional pathways with reinforcing mechanisms, and interrelationships present within and between pathways. Quality assessments indicated moderate confidence in three of four findings (Findings 2,3, and 4 above) and high confidence in one finding (Finding 1).

CONCLUSION

SEM is strongly linked to drug poisoning, and the mechanisms establishing these connections can be classified within four pathways. The interconnectedness of these mechanisms can lead to intensification of overdose risk and reinforcement of SEM itself.

Opioid-related deaths in Kingston, Frontenac, Lennox and Addington in Ontario, Canada: the shadow epidemic

INTRODUCTION

In the Kingston, Frontenac, Lennox and Addington (KFL&A) health unit, opioid overdoses are an important preventable cause of death. The KFL&A region differs from larger urban centres in its size and culture; the current overdose literature that is focussed on these larger areas is less well suited to aid in understanding the context within which overdoses take place in smaller regions. This study characterized opioidrelated mortality in KFL&A, to enhance understanding of opioid overdoses in these smaller communities.

METHODS

We analyzed opioid-related deaths that occurred in the KFL&A region between May 2017 and June 2021. Descriptive analyses (number and percentage) were performed on factors conceptually relevant in understanding the issue, including clinical and demographic variables, as well as substances involved, locations of deaths and whether substances were used while alone.

RESULTS

A total of 135 people died of opioid overdose. The mean age was 42 years, and most participants were White (94.8%) and male (71.1%). Decedents often had the following characteristics: being currently or previously incarcerated; using substances alone; not using opioid substitution therapy; and having a prior diagnosis of anxiety and depression.

CONCLUSION

Specific characteristics such as incarceration, using alone and not using opioid substitution therapy were represented in our sample of people who died of an opioid overdose in the KFL&A region. A robust approach to decreasing opioid-related harm integrating telehealth, technology and progressive policies including providing a safe supply would assist in supporting people who use opioids and in preventing deaths.

I Don't Believe a Person Has to Die When Trying to Get High: Overdose Prevention and Response Strategies in Rural Illinois

BACKGROUND

Overdose is a leading cause of morbidity and mortality among people who inject drugs. Illicitly manufactured fentanyl is now a major driver of opioid overdose deaths.

METHODS

Semi-structured interviews were conducted with 23 participants (19 persons who inject drugs and 4 service providers) from rural southern Illinois. Data were analyzed using constant comparison and theoretical sampling methods.

RESULTS

Participants were concerned about the growing presence of fentanyl in both opioids and stimulants, and many disclosed overdose experiences. Strategies participants reported using to lower overdose risk included purchasing drugs from trusted sellers and modifying drug use practices by partially injecting and/or changing the route of transmission. Approximately half of persons who inject drugs sampled had heard of fentanyl test strips, however fentanyl test strip use was low. To reverse overdoses, participants reported using cold water baths. Use of naloxone to reverse overdose was low. Barriers to naloxone access and use included fear of arrest and opioid withdrawal.

CONCLUSIONS

People who inject drugs understood fentanyl to be a potential contaminant in their drug supply and actively engaged in harm reduction techniques to try to prevent overdose. Interventions to increase harm reduction education and information about and access to fentanyl test strips and naloxone would be beneficial.

"I've been to more of my friends' funerals than I've been to my friends' weddings": Witnessing and responding to overdose in rural Northern New England

PURPOSE

Overdose is a leading cause of death among people who use drugs (PWUDs), but policies to reduce fatal overdose have had mixed results. Summaries of naloxone access and Good Samaritan Laws (GSLs) in prior studies provide limited information about local context. Witnessing overdoses may also be an important consideration in providing services to PWUDs, as it contributes to post traumatic stress disorder (PTSD) symptoms, which complicate substance use disorder treatment.

METHODS

We aim to estimate the prevalence and correlates of witnessing and responding to an overdose, while exploring overdose context among rural PWUD. The Drug Injection Surveillance and Care Enhancement for Rural Northern New England (DISCERNNE) mixed-methods study characterized substance use and risk behaviors in 11 rural Massachusetts, Vermont, and New Hampshire counties between 2018 and 2019. PWUD completed surveys (n = 589) and in-depth interviews (n = 22).

FINDINGS

Among the survey participants, 84% had ever witnessed an overdose, which was associated with probable PTSD symptoms. Overall, 51% had ever called 911 for an overdose, though some experienced criminal legal system consequences despite GSL. Although naloxone access varied, 43% had ever used naloxone to reverse an overdose.

CONCLUSIONS

PWUD in Northern New England commonly witnessed an overdose, which they experienced as traumatic. Participants were willing to respond to overdoses, but faced barriers to effective overdose response, including limited naloxone access and criminal legal system consequences. Equipping PWUDs with effective overdose response tools (education and naloxone) and enacting policies that further protect PWUDs from criminal legal system consequences could reduce overdose mortality.

The "goldfish bowl": a qualitative study of the effects of heightened surveillance on people who use drugs in a rural and coastal Canadian setting

BACKGROUND

A growing body of research has focused on contextual factors that shape health and well-being of people who use drugs (PWUD). However, most of this research focuses on large cities and less is known about the effects of social and structural contexts on drug use and associated risks in rural Canadian settings. Therefore, we undertook this study to examine rural-specific contextual factors that affect the day-to-day experiences of PWUD.

METHODS

Twenty-seven qualitative semi-structured interviews were conducted with PWUD in a rural and coastal setting in British Columbia, Canada. Participants had to be ≥ 19 years old, used illegal opioids and/or stimulants regularly, and lived in the qathet region. Interview transcripts were coded based on themes identified by the research team.

RESULTS

Participants described progressive shifts in politics and culture in the qathet region while also identifying resource scarcity, homelessness, and changes in the drug supply, where illicit drug contents have become highly toxic and unpredictable. Participants discussed the qualities of a small community where everyone knows each other and there is a lack of privacy and confidentiality around drug use, which resulted in experiences of stigma, discrimination, and surveillance. Participants also reported rural-specific policing issues and experiences of surveillance on ferries when traveling to larger cities to purchase drugs. This led to significantly higher drug prices for PWUD due to the time dedication and criminalized risks associated with drug possession and trafficking.

CONCLUSIONS

Our findings illustrate the unique experiences faced by PWUD in a rural and coastal setting. The "goldfish bowl" effect in this rural community created heightened social and structural surveillance of PWUD, which led to a variety of negative consequences. There is a clear need for interventions to address the larger contextual drivers affecting people who use drugs in rural settings, including decriminalization and peer-led anti-stigma strategies, in order to improve the lives of PWUD.

Overdose Experiences among People Who Inject Drugs in West Virginia: Personal Loss, Psychological Distress, Naloxone, and Fentanyl

Background: As overdose remains a major public health concern in the United States, it is important to understand the experiences people who inject drugs (PWID) have with overdose. Past experiences during such emergencies are an important determinant of future behavior, including help seeking, which can be lifesaving. Methods: We explored experiences with overdose, using data from 21 in-depth interviews collected from PWID in a rural county in West Virginia (Cabell County). We used an iterative, modified constant comparison approach to synthesize resulting interview data. Results: Participants reported pervasive experiences with overdose, including through their own personal overdose experiences, witnessing others overdose, and losing loved ones to overdose fatalities. Experiencing emotional distress when witnessing an overdose was common among our participants. Many participants reported regularly carrying naloxone and using it to reverse overdoses. Multiple participants described believing the myth that people grow immune to naloxone over time. Concerns about the presence of fentanyl in drugs were also common, with many participants attributing their own and others' overdoses to fentanyl. Conclusions: Our findings have important implications for naloxone access and education, as well as policies and practices to encourage help seeking during overdose events among rural PWID. Participant concerns about fentanyl in the drug supply highlight the need for access to drug checking technologies.

Relationships between places of residence, injury, and death: Spatial and statistical analysis of fatal opioid overdoses across Massachusetts

Understanding the factors associated with where people who use opioids live, where their fatal overdoses occur, and where deaths are recorded can improve our knowledge of local risk environments and inform intervention planning. Through geospatial analyses of death certificate data between 2015 and 2017, we found that a majority of opioid-involved fatal overdoses in Massachusetts occurred at home. Age (adjusted odds ratio [AOR], 1.03; 95% confidence interval [CI], 1.02-1.04), living in a census tract with a higher percentage of crowded households (AOR, 1.04; 95% CI, 1.01-1.08), households without vehicles (AOR, 1.01; 95% CI, 1.00-1.02), and Hispanic ethnicity (AOR, 0.56; 95% CI, 0.42-0.74) were independently associated with fatal overdose at home. Using geographically weighted regression, we identified locations where these associations were stronger and could benefit most from home-based and culturally sensitive overdose prevention efforts, including expanded overdose education and naloxone distribution.

Polysubstance use and re-incarceration in the 12-months after release from jail: a latent transition analysis of rural Appalachian women

Background: Rural areas have high rates of opioid and stimulant involved polysubstance use which are known to contribute to overdose. Justice-involved women are likely to have multiple substance use disorders and are particularly vulnerable in rural areas where treatment is limited.Objectives: The research had three aims to (1) identify the patterns of polysubstance use of rural Appalachian justice-involved women, (2) examine how women's engagement in polysubstance use changed in the 12-months following initial release from jail, and (3) determine if women's changes in substance use patterns were associated with re-incarceration during the 12-months of post-release follow-up.Methods: A total of 339 women with recent substance use histories were randomly recruited from three rural jails. Latent transition analysis of women's substance use from baseline (in jail) to 6 and 12-months was examined, including the effect of re-incarceration on transitions (changes in substance use patterns).Results: Three latent classes were found: High Polysubstance/injection drug use (IDU) (36.3% baseline), Opioid/Benzo (Benzodiazepine) Involved Polysubstance Use (57.3% baseline), and Low Use (6.4% baseline). Polysubstance use classes were characterized by use of opioids and benzodiazepines; the High Polysubstance/IDU class was distinct in co-use and injection use of methamphetamine. Post-release, women transitioned to latent classes of reduced substance use and/or reduced injection drug use, particularly in the first six months. Women who were re-incarcerated during follow-up were likely to remain engaged in, or transition to, the High Polysubstance/IDU class (ORs: 3.14-46.56).Conclusion: Justice-involved women in Appalachia reported risky polysubstance use. The first six-months post-release were a critical period for changes in substance use.

Perspectives from law enforcement officers who respond to overdose calls for service and administer naloxone

BACKGROUND

Many law enforcement agencies across the United States equip their officers with the life-saving drug naloxone to reverse the effects of an opioid overdose. Although officers can be effectively trained to administer naloxone, and hundreds of law enforcement agencies carry naloxone to reverse overdoses, little is known about what happens on scene during an overdose call for service from an officer's perspective, including what officers perceive their duties and responsibilities to be as the incident evolves.

METHODS

The qualitative study examined officers' experiences with overdose response, their perceived roles, and what happens on scene before, during, and after an overdose incident. In-person interviews were conducted with 17 officers in four diverse law enforcement agencies in the United States between January and May 2020.

RESULTS

Following an overdose, the officers described that overdose victims are required to go to a hospital or they are taken to jail. Officers also described their duties on scene during and after naloxone administration, including searching the belongings of the person who overdosed and seizing any drug paraphernalia.

CONCLUSION

These findings point to a pressing need for rethinking standard operating procedures for law enforcement in these situations so that the intentions of Good Samaritan Laws are upheld and people get the assistance they need without being deterred from asking for future help.

Examining prevalence and correlates of smoking opioids in British Columbia: opioids are more often smoked than injected

BACKGROUND

British Columbia (BC) is in the midst of an opioid overdose crisis. Since 2017, smoking illicit drugs has been the leading mode of drug administration causing overdose death. Yet, little is known about people who smoke opioids, and factors underlying choice of mode of administration. The study objectives are to identify the prevalence and correlates associated with smoking opioids.

METHODS

The Harm Reduction Client Survey is a monitoring tool used by the BC Centre for Disease Control since 2012. This survey is disseminated to harm reduction sites across BC to understand drug use trends and drug-related harms. We examined data from the survey administered October-December 2019 and performed descriptive, univariate, and multivariate analyses to better understand factors associated with smoking opioids.

RESULTS

A total of 369 people who used opioids in the past 3 days were included, of whom 251 (68.0%) reported smoking opioids. A total of 109 (29.5%) respondents experienced an overdose in the past 6 months; of these 79 (72.5%) smoked opioids. Factors significantly associated with smoking opioids were: living in a small community (AOR =2.41, CI =1.27-4.58), being a woman (AOR = 1.84, CI = 1.03-3.30), age under 30 (AOR = 5.41, CI = 2.19-13.40) or 30-39 (AOR = 2.77, CI = 1.33-5.78) compared to age ≥ 50, using drugs alone (AOR = 2.98, CI = 1.30-6.83), and owning a take-home naloxone kit (AOR = 2.01, CI = 1.08-3.72). Reported use of methamphetamines within the past 3 days was strongly associated with smoking opioids (AOR = 6.48, CI = 3.51-11.96).

CONCLUSIONS

Our findings highlight important correlates associated with smoking opioids, particularly the recent use of methamphetamines. These findings identify actions to better respond to the overdose crisis, such as targeted harm reduction approaches, educating on safer smoking, advocating for consumption sites where people can smoke drugs, and providing a regulated supply of opioids that can be smoked.

Factors that influence enrollment in syringe services programs in rural areas: a qualitative study among program clients in Appalachian Kentucky

BACKGROUND

Enrolling sufficient number of people who inject drugs (PWID) into syringe services programs (SSP) is important to curtail outbreaks of drug-related harms. Still, little is known about barriers and facilitators to SSP enrollment in rural areas with no history of such programs. This study's purpose was to develop a grounded theory of the role of the risk environment and individual characteristics of PWID in shaping SSP enrollment in rural Kentucky.

METHODS

We conducted one-on-one semi-structured interviews with 41 clients of 5 SSPs that were established in rural counties in Appalachian Kentucky in 2017-2018. Interviews covered PWID needs, the process of becoming aware of SSPs, and barriers and facilitators to SSP enrollment. Applying constructivist grounded theory methods and guided by the Intersectional Risk Environment Framework (IREF), we applied open, axial and selective coding to develop the grounded theory.

RESULTS

Stigma, a feature of IREF's meso-level social domain, is the main factor hampering SSP enrollment. PWID hesitated to visit SSPs because of internalized stigma and because of anticipated stigma from police, friends, family and healthcare providers. Fear of stigma was often mitigated or amplified by a constellation of meso-level environmental factors related to healthcare (e.g., SSPs) and social (PWID networks) domains and by PWID's individual characteristics. SSPs mitigated stigma as a barrier to enrollment by providing low threshold services in a friendly atmosphere, and by offering their clients program IDs to protect them from paraphernalia charges. SSP clients spread positive information about the program within PWID networks and helped their hesitant peers to enroll by accompanying them to SSPs. Individual characteristics, including child custody, employment or high social status, made certain PWID more susceptible to drug-related stigma and hence more likely to delay SSP enrollment.

CONCLUSIONS

Features of the social and healthcare environments operating at the meso-level, as well as PWID's individual characteristics, appear to enhance or mitigate the effect of stigma as a barrier to SSP enrollment. SSPs opening in locations with high stigma against PWID need to ensure low threshold and friendly services, protect their clients from police and mobilize PWID networks to promote enrollment.

A free mailed naloxone program in Philadelphia amidst the COVID-19 pandemic

BACKGROUND

Access to naloxone is essential as the overdose crisis persists. We described barriers to accessing naloxone among individuals who requested and received the medication from a free mailed program and explored the relationship between how individuals with and without personal proximity to overdose learned about the program.

METHODS

Secondary analysis of data from a web-based form collected 1st March 2020 to 31st January 2021. Access barriers, personal proximity to overdose (broadly defined as personally overdosing or witnessing/worrying about others overdosing), and method of learning about the program were categorized and described.

RESULTS

Among 422 respondents, the most frequently reported barriers to accessing naloxone were: COVID quarantine (25.1%), lack of knowledge about access (13.2%), and cost (11.2%). Compared to those without personal proximity to overdose (38.2%), individuals with personal proximity (61.8%) heard about the program more often through an active online search (21.4% vs. 8.8%; p-value = 0.001) and less often through word of mouth (19.8% vs. 40.9%; p-value = <0.001).

CONCLUSIONS

Longstanding barriers to naloxone access are compounded by the COVID-19 pandemic, making mailing programs especially salient. Differences in ways that individuals with and without personal proximity to substance use and overdose learned about this program can inform how such programs can effectively reach their target audience.

In Their Own Words: How Opioids Have Impacted the Lives of "Everyday" People Living in Appalachia

Introduction

The opioid epidemic is ravaging people, families, and communities in Appalachia. However, limited research has examined how "everyday" people (e.g., not chronic pain patients, not medical professionals) living in these communities how opioids have impacted their lives.

Objective

Identify the perception of the opioid epidemic on individuals, families, and communities from people living in region most impacted regions.

Methods

Patients were recruited at Remote Area Medical clinics throughout Central and Southern Appalachia to complete interviews online (N = 169) or over the phone (N = 26), including one open-ended question about how opioids have impacted their lives.

Results

Using the qualitative method content analysis, several themes were identified, including both the positive and negative impact of opioids from the online interviews. Additionally, resiliency was found to be a common theme and a theme not often emphasized by scholars and the media. These themes also highlight the importance of social support in these communities. Further, in the phone interviews, we were able to replicate the themes, and an additional theme was identified: Systemic Cause of Opioids.

Conclusion

Opioid intervention must be comprehensive and include the cultural context that recognizes community ties, family and kinship support, resilience, and systemic barriers to addressing the opioid epidemic. Future interventions must harness the existing resiliency and social support in these communities to effectively combat the opioid crisis in Appalachia. Otherwise, opioids will remain the insider and further insulate Appalachian communities from systemic recovery.

Addiction stigma and the production of impediments to take-home naloxone uptake

Opioid overdose deaths are a major health issue in Australia and around the world. Programmes to provide opioid consumers with 'take-home' naloxone to reverse overdose exist internationally, but uptake by mainstream health services and consumers remains inconsistent. Researchers have identified a range of important educational, training and logistical impediments to take-home naloxone uptake and distribution, yet they have focused less on the social dynamics that can enhance or limit access, such as stigma. In this article, we also explore impediments to uptake, drawing on qualitative interview data gathered for an Australian research project on take-home naloxone. Mobilising a performative approach to stigma, we argue that overdose and prevention are shaped by the social dynamics of stigma and, as such, responsibility for dealing with overdose, as with take-home naloxone, should also be considered social (i.e. shared among peers, the public, communities and governments). Our interview data illuminate the various ways in which addiction stigma limits the possibilities and capacities of take-home naloxone and overdose prevention. First, we focus on how stigma may impede professional information provision about take-home naloxone by limiting the extent to which it is presented as a matter of interest for all opioid consumers, not just those who consume opioids illicitly. Second, we explore how stigma may limit the scale-up and expansion of programmes and access points. From here, we focus on how stigma co-constitutes the politics of overdose and prevention, rendering take-home naloxone ill-suited to many social settings of overdose. In closing, we point out that stigma is not just a post hoc impediment to access to and use of take-home naloxone but is central to opioid overdose production itself, and to effective prevention. While take-home naloxone is an excellent life-saving initiative, uncritically valorising it may divert attention from broader goals, such as the de-stigmatisation of drug consumption through decriminalisation, and other ambitious attempts to reduce overdose.

The Bell Tolls for Thee & Thine: Compassion Fatigue & the Overdose Epidemic

Non-fatal and fatal overdoses are traumatic events that have been increasing over the past 20 years and disproportionately impacting rural communities in the United States. The human suffering caused by the opioid epidemic is rarely described in the empirical literature. The purpose of this article is to 1) define individual- and community-level overdose-related compassion fatigue (OCF), 2) review measurement of compassion fatigue (CF) and interventions to reduce CF, 3) discuss strategies that may reduce OCF and 4) briefly discuss policy implications. OCF is distress resulting from knowledge of or exposure to overdose-related harms, which at the community-level may prohibit collaboration and adaptive agency to effectively respond. When OCF occurs at a community-level, it could have negative consequences by eroding support for evidence-based services and fueling stigma-driven policies that blame people who use drugs. Empathy underlies both OCF and vicarious resilience by allowing one to understand the suffering caused by overdose deaths and to witness the joy of addiction recovery. Using the risk environment framework, OCF at the micro- and macro-levels of the social environment, may increase rural communities' vulnerability to harm by emphasizing individual responsibility for reducing overdoses rather than community-level infrastructure and resource management. Additional research is needed to develop a measure of OCF and to confirm whether OCF is associated with increased stigma and decreased support for harm reduction in rural areas.

Syringe Service Program Utilization, Barriers, and Preferences for Design in Rural Appalachia: Differences between Men and Women Who Inject Drugs

Background People who inject drugs (PWID) in rural areas of the United States have had limited access to syringe service programs (SSP). Rural SSP have recently surged, but accompanying research is lacking about PWID utilization, barriers, and preferences for SSP design and how those preferences vary by gender. Methods: Interviewer-administered surveys elicited information about utilization, barriers, and preferences for SSP design from 234 PWID recruited using respondent-driven sampling in Appalachian, Kentucky. Gender differences among reported barriers to utilizing SSP and preferences for program design were explored using Mantel-Haenszel chi-square tests. Results: Overall, 49% of PWID had ever utilized an SSP. The most common reasons for not utilizing an SSP were lack of awareness (23%), fear of being seen or disclosing drug use (19%), and lack of need (19%). The most preferred SSP design was located within a health department (74%) and operating during afternoon hours (66%). Men were more likely than women to prefer SSP in health departments (80% vs. 65%, p = 0.01), while more women than men preferred staffing by health department personnel (62% vs. 46%, p = 0.02). Women were less likely to favor evening hours (55% vs. 70%, p = 0.02). Fewer women wanted SSP nurses (78% vs. 90%, p = 0.01), social workers (11% vs. 24%, p = 0.01), or people who use drugs (20% vs 34%, p = 0.02) to staff SSP. Conclusions: Despite recent scale-up, SSP in Appalachia remain under-utilized. PWID were open to a range of options for SSP design and staffing, though there were variations by gender. Implementation research that identifies best strategies for tailored SSP scale-up in rural settings should be considered.