Community-level determinants of stakeholder perceptions of community stigma toward people with opioid use disorders, harm reduction services and treatment in the HEALing Communities Study

Impact of Fentanyl Test Strips as Harm Reduction for Drug-Related Mortality

This study examines the impact of legalizing fentanyl test strips (FTSs) on drug-related mortality in the United States from 2018 to 2022. Using a difference-in-differences approach with state-level data, we find that FTS legalization is associated with a significant reduction in drug-overdose deaths. Across the population, FTS legalization corresponds to a 7% decrease in overdose mortality, with an even more pronounced 13.5% reduction among Black individuals. Our analysis employs two-way fixed effects models and triple differences specifications to isolate the effect of FTS legalization from other factors. The results suggest that FTS legalization is particularly effective in reducing unintentional drug-overdose deaths. These findings underscore the potential of FTS as a critical harm reduction tool in addressing the opioid crisis, especially in mitigating racial disparities in overdose mortality. The study provides evidence to support expanding access to FTS as part of comprehensive public health strategies.

Organizational perspectives on the impacts of scaling up overdose education and naloxone distribution in Kentucky

BACKGROUND

Efforts to scale up overdose education and naloxone distribution (OEND), an evidence-based practice for reducing opioid overdose mortality, was a major focus of the HEALing Communities Study (HCS). The aim of this analysis is to describe the qualitative perspectives of partner organizations regarding the impacts of implementing OEND in a state that used a naloxone "hub with many spokes" model for scaling up this strategy.

METHODS

Small group (n = 20) and individual (n = 24) qualitative interviews were conducted with staff from 44 agencies in eight Kentucky counties that implemented OEND from April 2020 to June 2022. Interviews were conducted between 6 and 8 months after the end of the intervention. Initial deductive coding used the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework, and then additional inductive sub-coding focused on passages within the OEND Effectiveness code. Thematic analysis was then utilized to identify themes regarding the impacts of implementing OEND.

RESULTS

Participants identified multi-level impacts of implementing OEND. At the individual-level, participants described lives being saved, greater access to naloxone for individuals served by the agency, reduced stigma toward OEND by clients, and greater client-level self-efficacy to respond to overdoses. Organizational impacts included improved staff readiness for overdose response, enhanced clinical relationships between staff and clients, and reduced staff stigma. Participants described positive impacts on their organizational networks and clients' social networks. Community-level impacts included greater overall access and reduced stigma toward OEND.

CONCLUSIONS

These qualitative data revealed that staff from agencies involved in a community-wide effort to scale up OEND perceived multi-level benefits, including saving lives, reducing stigma, improving naloxone access, and enhancing staff and client readiness, while strengthening organizational and community networks.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04111939. Registered 30 September 2019, https://clinicaltrials.gov/ct2/show/NCT04111939.

A digital citizen science intervention to reduce HIV stigma and promote HIV testing: a randomized clinical trial among adolescents and young adults in Kazakhstan

Background Kazakhstan has a high HIV incidence among adolescents and young adults (AYA), and high HIV stigma contributing to low HIV testing uptake. We examined whether an AYA-developed digital crowdsourced intervention reduced HIV stigma compared with conventional public health materials among AYA in Almaty, Kazakhstan. Methods A total of 216 AYA (females:116/males:110) aged 16-24 years were recruited to the online study cohort and randomized 1:1 to the intervention or control arm. AYA were exposed to the crowdsourced intervention or control materials once a week for 5weeks, with equivalent exposures between arms. Outcomes included a total HIV stigma score assessed at baseline, immediately post-intervention and 2months post-intervention from January to August 2023. We conducted multilevel mixed models to compare changes over time by arm and sex. Results AYA in the intervention arm had significantly lower HIV testing stigma 2months post-intervention (adjusted mean change (AMC): -0.73 (-1.07, -0.39)) than AYA in the control arm (AMC: -0.06 (-0.42, 0.30); P =0.032). Female AYA in the intervention arm had significantly lower total HIV stigma immediately post-intervention (AMC: -4.91 (-7.25, -2.58)) and 2months post-intervention (AMC: -5.16 (-7.48, -2.84)) than females in the control arm (immediately post-intervention AMC: -0.03 (-2.63, 2.57) and 2-months post-intervention AMC: -0.07 (-2.70, 2.56); P =0.012, P =0.012). Conclusions The AYA-developed crowdsourced intervention decreased HIV testing stigma, although this effect was moderated by sex, and decreased total HIV stigma among female AYA. Crowdsourced interventions may be a promising way to engage communities to develop interventions to decrease HIV stigma.

What substance use services are advertised by local governments? An analysis of data from county websites in New York state

OBJECTIVE

To assess the substance use disorder (SUD) prevention and response activities that county governments in New York advertise.

STUDY DESIGN

Cross-sectional study.

METHODS

We coded websites of county public health, mental health, emergency, and social service departments to identify whether any government agency provided information about ten evidence-based SUD services. We calculated the number and percentage of counties advertising each service, overall and by county size (medium/large and small).

RESULTS

The most common services advertised on county websites were Resource Lists (91.4 %), Naloxone Training, Education, or Distribution (74.1 %), and Addiction/Overdose Education (62.1 %), and the least common were Syringe Exchange (31.0 %) and Anti-Stigma Training or Resources (13.8 %). When counties were assessed by population size, each service was advertised by a higher percentage of medium/large counties than small counties.

CONCLUSIONS

Despite public health researchers recommending that government responses to the overdose crisis include the SUD services examined here, many counties do not provide information to their constituents about several important services. Thus, even if these services are available, they may be unknown to residents.

An interrupted time series analysis of fentanyl, naloxone, and opioid-involved deaths in five counties in Eastern Missouri

INTRODUCTION

Rates of opioid overdose deaths (OOD) have increased since the introduction of illicitly manufactured fentanyl in the U.S. drug supply. Though community-based naloxone distribution efforts have been found to effectively reduce OOD, no studies to date have examined their effects during the fentanyl era, nor in the epicenter of a state's overdose crisis. Thus, the current study assessed the impacts of both fentanyl and of subsequent grant-funded community-based naloxone distribution on OOD across Missouri's St. Louis region.

METHODS

Medical examiner data includes individuals who died within one of the five study counties (St. Louis City, St. Louis County, and Franklin, Jefferson, St. Charles counties [combined as "Collar Counties"]) between 2011 and 2022 due to an opioid overdose (N = 6,799). Naloxone distribution date and location data came from Missouri's university-based naloxone distribution team. We conducted a controlled interrupted time series using an autoregressive model via proc ARIMA to examine changes over time in the rate of OOD associated with the introduction of fentanyl (defined to be present in 25% of opioid overdose deaths; June 2015) and the start of naloxone distribution for each location (August 2017, October 2017, and January 2018, respectively).

RESULTS

The introduction of fentanyl into the drug supply of St. Louis City was associated with an increased rate of OOD over time (p < .001). Naloxone distribution in the City was associated with an immediate decrease in OOD (p < .001) followed by a slowed increase in OOD (p < .001). These findings were not replicated in St. Louis County nor the Collar Counties.

CONCLUSIONS

The effects of fentanyl and naloxone on OOD varied by region in Eastern Missouri. Specifically, fentanyl and naloxone effects were only found in a high-need urban area with existing harm reduction and street outreach programs, but not in surrounding suburban or rural areas. State-level naloxone distribution decision-makers should prioritize funding harm reduction services in both urban and non-urban settings to help increase targeted naloxone distribution to those actively using drugs. Additionally, interventions tailored for people who engage in solitary drug use - such as safe consumption spaces and overdose detection technologies - should receive increased investment and implementation, particularly in rural areas where harm reduction infrastructure is more scarce.

Spatial-Structural Mechanisms of Racialized Disparities in Overdose Mortality: A Spatiotemporal Analysis

Efforts to understand and respond to the opioid crisis have focused on overdose fatalities. Overdose mortality rates (ratios of overdoses resulting in death) are rarely examined though they are important indicators of harm reduction effectiveness. Factors that vary across urban communities likely determine which community members are receiving the resources needed to reduce fatal overdose risk. Identifying communities with higher risk for overdose mortality and understanding influential factors is critical for guiding responses and saving lives. Using incident reports and mortality data from 2018 to 2021, we defined overdose mortality ratios across Milwaukee at the census tract level. To identify neighborhoods displaying higher mortality than predicted, we used Integrated nested Laplace approximation to define standardized mortality ratios (SMRs) for each tract. Geospatial and spatiotemporal analyses were used to identify emerging hotspots for high mortality risk. Overall, mortality was highest in Hispanic and lowest in White communities. Communities with unfavorable SMRs were predominantly Black or Hispanic, younger, less employed, poorer, less educated, and had higher incarceration rates and worse mental and physical health. Communities identified as hotspots for overdoses were predominantly non-White, poorer, and less employed and educated with worse mental and physical health, higher incarceration rates, and less housing stability. The findings demonstrate that overdose mortality rates vary across urban communities and are influenced by racial disparities. A framework that enables identification of challenged communities and guides community responses is needed.

Solving the "last mile" problem in overdose prevention: Lessons from the HEALing Communities Study

The concept of the "last mile," crucial in logistics for its complexity and cost, has a parallel in public health services. The last mile in public health is fraught with issues such as fragmented services, regulatory barriers, and resistance to evidence-based interventions. This commentary draws parallels between the challenges in delivering goods to consumers' doorsteps and the difficulties in delivering interventions to reduce overdoses in the community. The HEALing Communities Study (HCS), a large implementation science research study, provides an example of how to navigate some of these last-mile challenges. HCS used a community-driven process that considered local characteristics and preferences, and engaged people with lived experience to create effective and sustainable solutions. However, the study also encountered significant challenges in building a delivery infrastructure, working with delayed and incomplete data, and overcoming stigma around substance use interventions. Lessons from the logistics sector can help improve the efficiency and equity of overdose prevention efforts, ensuring that people receive the life-saving interventions they need.

A place of encounter: Health and social care workers' perspectives on public gathering spaces for people using drugs

Background: The use of drugs is an escalating concern, with significant implications for the health and daily functionality for individuals. It has proven challenging to provide accessible health and social services. In the context of addressing substance use issues in urban areas, public gathering places for individuals who use drugs play a multifaceted role, serving as sites of belonging, support and potential illicit activity. This qualitative study explores the experiences of healthcare and social workers regarding a public gathering place, referred to as "the Bench", in a medium-sized Norwegian city. Methods: A qualitative research design consisting of semi-structured focus group interviews and individual interviews with 13 participants representing various support agencies. Results: The analysis resulted in four thematic areas: (1) belonging and a gateway to support and services; (2) balancing user autonomy at the Bench and systems support; (3) the role of a centralised location; and (4) the preventive role of support workers at the Bench. Conclusion: While the Bench fosters a sense of community and provides access to vital services, concerns about illicit activities persist due to its visibility. Nevertheless, its central location facilitates outreach efforts and ensures easy access to support services. The study underscores the preventive role of healthcare and social workers in stabilising the environment and mitigating conflicts. Furthermore, it highlights the importance of central locations for public gathering places, emphasising the proximity to low-threshold services. The Bench represents a crucial venue for establishing relationships and providing assistance to individuals who use drugs, contributing to harm reduction efforts in the community.

Reducing perceived barriers to scaling up overdose education and naloxone distribution and medications for opioid use disorder in the United States in the HEALing (Helping End Addiction Long-Term®) communities study

BACKGROUND

Scaling up overdose education and naloxone distribution (OEND) and medications for opioid use disorder (MOUD) is needed to reduce opioid overdose deaths, but barriers are pervasive. This study examines whether the Communities That HEAL (CTH) intervention reduced perceived barriers to expanding OEND and MOUD in healthcare/behavioral health, criminal-legal, and other/non-traditional venues.

METHODS

The HEALing (Helping End Addiction Long-Term®) Communities Study is a parallel, wait-list, cluster randomized trial testing the CTH intervention in 67 communities in the United States. Surveys administered to coalition members and key stakeholders measured the magnitude of perceived barriers to scaling up OEND and MOUD in November 2019-January 2020, May-June 2021, and May-June 2022. Multilevel linear mixed models compared Wave 1 (intervention) and Wave 2 (wait-list control) respondents. Interactions by rural/urban status and research site were tested.

RESULTS

Wave 1 respondents reported significantly greater reductions in mean scores for three outcomes: perceived barriers to scaling up OEND in Healthcare/Behavioral Health Venues (-0.26, 95% confidence interval, CI: -0.48, -0.05, p = 0.015), OEND in Other/Non-traditional Venues (-0.53, 95% CI: - 0.84, -0.22, p = 0.001) and MOUD in Other/Non-traditional Venues (-0.34, 95% CI: -0.62, -0.05, p = 0.020). There were significant interactions by research site for perceived barriers to scaling up OEND and MOUD in Criminal-Legal Venues. There were no significant interactions by rural/urban status.

DISCUSSION

The CTH Intervention reduced perceived barriers to scaling up OEND and MOUD in certain venues, with no difference in effectiveness between rural and urban communities. More research is needed to understand facilitators and barriers in different venues.

Effects of the Communities that Heal (CTH) intervention on perceived opioid-related community stigma in the HEALing Communities Study: results of a multi-site, community-level, cluster-randomized trial

Background

Community stigma against people with opioid use disorder (OUD) and intervention stigma (e.g., toward naloxone) exacerbate the opioid overdose crisis. We examined the effects of the Communities that HEAL (CTH) intervention on perceived opioid-related community stigma by stakeholders in the HEALing Communities Study (HCS).

Methods

We collected three surveys from community coalition members in 66 communities across four states participating in HCS. Communities were randomized into Intervention (Wave 1) or Wait-list Control (Wave 2) arms. We conducted multilevel linear mixed models to compare changes in primary outcomes of community stigma toward people treated for OUD, naloxone, and medication for opioid use disorder (MOUD) by arm from time 1 (before the start of the intervention) to time 3 (end of the intervention period in the Intervention arm).

Findings

Intervention stakeholders reported a larger decrease in perceived community stigma toward people treated for OUD (adjusted mean change (AMC) -3.20 [95% C.I. -4.43, -1.98]) and toward MOUD (AMC -0.33 [95% C.I. -0.56, -0.09]) than stakeholders in Wait-list Control communities (AMC -0.18 [95% C.I. -1.38, 1.02], p = 0.0007 and AMC 0.11 [95% C.I. -0.09, 0.31], p = 0.0066). The relationship between intervention status and change in stigma toward MOUD was moderated by rural-urban status (urban AMC -0.59 [95% CI, -0.87, -0.32], rural AMC not sig.) and state. The difference in stigma toward naloxone between Intervention and Wait-list Control stakeholders was not statistically significant (p = 0.18).

Interpretation

The CTH intervention decreased stakeholder perceptions of community stigma toward people treated for OUD and stigma toward MOUD. Implementing the CTH intervention in other communities could decrease OUD stigma across diverse settings nationally.

Funding

US National Institute on Drug Abuse.