Longitudinal trends in nonmedical prescription opioid use in a cohort of rural Appalachian people who use drugs

Prevalence of Opioid Use and Intimate Partner Violence among Pregnant Women in South-Central Appalachia, USA

Background: Recent research indicates that pregnant women in rural communities are at increased risk of experiencing IPV and comorbid illicit opioid use compared to urban-residing pregnant women. Few studies of the interactions among rurality, substance use, and victimization in pregnant women exist. The current study sought to examine the relationship between IPV and opioid use and the interaction effects of rurality in Appalachian pregnant women. Methods: A convenience sample of pregnant women who were enrolled in a smoking cessation research study was used for this analysis. Participants included 488 pregnant women from five prenatal clinics in South-Central Appalachia. Data were from self-reported assessments and semi-structured interviews on substance use and IPV conducted from first trimester of pregnancy through eight months postpartum. Results: Four hundred and ten participants reported experiencing any form of IPV in the past year. Logistic regression results indicated that physical IPV was associated with opioid use, but sexual and psychological IPV were not. The moderation model indicated direct effects between IPV and opioid use, but were not moderated by rurality. Conclusion: This study suggests a need to further understand the relationship between substance use, IPV, and rurality in pregnant women. The specific subtopic of opioid use by pregnant women living in rural communities, and its relationship to IPV victimization and adverse fetal and maternal health outcomes, continues to be an understudied, but critically important area. Limitations and future directions pertaining to IPV screenings and interventions for pregnant women are discussed.

A qualitative examination of recent increases in methamphetamine use in a cohort of rural people who use drugs

INTRODUCTION

Rising rates of methamphetamine use among populations using opioids is an escalating public health concern. The purpose of this manuscript is to identify socioecologic factors driving increases in methamphetamine use among Appalachian Kentucky adults with a history of opioid use.

METHODS

Semi-structured qualitative interviews were conducted among 20 Appalachian Kentuckians in the Social Network of Appalachian Peoples (SNAP) cohort who reported lifetime opioid use and past 30-day methamphetamine use. Interviews focused on initiation of methamphetamine use, factors that influence methamphetamine use at the individual, interpersonal, community and society levels.

RESULTS

Participants reported using methamphetamine to self-treat underlying issues, including withdrawal from opioids, chronic pain, and emotional distress. Initiation of use was most often facilitated through their drug networks. Participants reported that methamphetamine was widely available and affordable in their community. Several participants with extensive histories of non-medical prescription opioid (NMPO) use described transitioning to methamphetamine as their drug of choice as opioids became less available in their community. Participants also reported economic distress and lack of recreational opportunities as drivers of increased methamphetamine use.

DISCUSSION

Recent increases in methamphetamine use among those with a history of opioid use is facilitated by methamphetamine's relative availability and affordability. Methamphetamine use was also highly influenced by societal factors such as economic deprivation and policies that decreased availability of NMPOs. Surging methamphetamine use exacerbates inequities in addiction care brought to light by the opioid epidemic. Interventions aimed at addressing the socioecological drivers of methamphetamine use among people who use opioids are warranted.

Using conjoint analysis to study health policy changes: An example from a cohort of persons who use drugs

BACKGROUND

Historically, persons who use drugs (PWUDs) in the United States have often lacked health insurance, as Medicaid did not cover low-income adults. The Affordable Care Act of 2010 (ACA) increased access to insurance in states, such as Kentucky, that expanded their Medicaid programs. A cohort study of PWUDs in Kentucky found the prevalence of being insured increased from 34% pre-ACA to 87% post-ACA. However, changes to Medicaid were proposed that intended to restrict access to this program. This manuscript describes the feasibility and utility of conjoint analysis, an innovative method for studying decision-making, to identify potential impacts of health policy changes on PWUDs.

METHODS

IBM SPSS's "orthogonal design" command was used to construct 12 policy profiles that presented varying combinations of the proposed policy changes to Kentucky's Medicaid plan. Each policy profile presented information on (1) monthly premium costs, (2) penalties for not paying monthly premiums, (3) weekly work requirements, and (4) if their preferred physician accepted the plan for payment. Readability of the policy profiles was analyzed using the Readable.io application. The policy profiles were included in a recent follow-up of a longitudinal cohort of PWUDs in Appalachian Kentucky (n = 355). Participants rated the likelihood of enrolling in each policy profile's Medicaid plan, using a scale ranging from 0=not at all likely to 10=extremely likely. Data were analyzed using SPSS's conjoint analysis commands.

RESULTS

Readability results indicated the policy profiles required a 3^rd grade education. Nearly all participants responded to each of the 12 policy profiles. Across the policy profiles, the mean response for willingness to enroll was 3.43 (SD = 3.61), indicating relatively low willingness to enroll. Conjoint analysis revealed the two most influential factors on willingness to enroll were work requirements (importance score, IS = 77.63) and monthly premium costs (IS = 17.76). Penalties for nonpayment (IS = 0.43) and physician acceptance (IS = 4.13) had minimal influence.

CONCLUSIONS

This research demonstrates the feasibility of using conjoint analysis to study the impacts of potential policy changes on PWUDs.

Behavior change, health, and health disparities 2020: Some current challenges in tobacco control and regulatory science

This Special Issue of Preventive Medicine (PM) is the 7th in a series on behavior change, health, and health disparities. This series focuses on personal behavior patterns, including substance use disorders, physical inactivity/obesity, and non-adherence with medical regimens, which are among the most important modifiable causes of chronic disease and premature death. This 7th issue includes 17 commentaries, reviews, and original empirical studies, 16 of which are devoted to current tobacco control and regulatory science research and policy, topics critically important to protecting the public health from the longstanding and devastating harms of tobacco use. The challenge of balancing efforts to protect youth from e-cigarettes while allowing for evidence-based evaluation of their potential to reduce the harms of cigarette smoking among adults features prominently in many of these contributions, complemented by original studies on rural-urban disparities, tobacco harm perceptions, use patterns and toxin exposure, modeling of tobacco-related mortality, novel tobacco research methods, and reducing cigarette smoking through regulatory policies, including nicotine reduction in cigarettes, and novel clinical interventions. Continuing to give space in this series to the U.S. opioid epidemic, we also include an original empirical report on longitudinal trends of non-medical use of opioids from 2008 to 2020 in rural Appalachia, an epicenter in this epidemic. Across each of these topics we have recruited contributions from well-regarded investigators, clinicians, and policymakers to acquaint readers with recent advances and accomplishments while also noting knowledge gaps and unresolved challenges.