Motivation to Change and Treatment Participation Among Syringe Service Program Utilizers in Rural Kentucky

The ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder

The American Society of Addiction Medicine/American Academy of Addiction Psychiatry (ASAM/AAAP) Clinical Practice Guideline on the Management of Stimulant Use Disorder provides guidance on evidence-based strategies for the treatment of stimulant use disorders (StUDs), stimulant intoxication, and stimulant withdrawal, as well as secondary and tertiary prevention of harms associated with stimulant use. The Clinical Guideline Committee (CGC) comprised experts from ASAM and AAAP representing a range of clinical settings and patient populations. The guideline was developed following modified GRADE methodology. The process included a systematic literature review as well as several targeted supplemental searches. The CGC utilized Evidence to Decision tables to review available evidence and rate the strength of each recommendation. The clinical practice guideline was revised based on external stakeholder review. Key takeaways included: Contingency management represents the current standard of care for treatment of StUDs; Pharmacotherapies may be utilized off-label to treat StUDs; Acute stimulant intoxication can result in life-threatening complications that should be addressed in an appropriate level of care; Secondary and tertiary prevention strategies should be used to reduce harms related to risky stimulant use.

Kentucky Outreach Service Kiosk (KyOSK) Study protocol: a community-level, controlled quasi-experimental, type 1 hybrid effectiveness study to assess implementation, effectiveness and cost-effectiveness of a community-tailored harm reduction kiosk on HIV, HCV and overdose risk in rural Appalachia

INTRODUCTION

Many rural communities bear a disproportionate share of drug-related harms. Innovative harm reduction service models, such as vending machines or kiosks, can expand access to services that reduce drug-related harms. However, few kiosks operate in the USA, and their implementation, impact and cost-effectiveness have not been adequately evaluated in rural settings. This paper describes the Kentucky Outreach Service Kiosk (KyOSK) Study protocol to test the effectiveness, implementation outcomes and cost-effectiveness of a community-tailored, harm reduction kiosk in reducing HIV, hepatitis C and overdose risk in rural Appalachia.

METHODS AND ANALYSIS

KyOSK is a community-level, controlled quasi-experimental, non-randomised trial. KyOSK involves two cohorts of people who use drugs, one in an intervention county (n=425) and one in a control county (n=325). People who are 18 years or older, are community-dwelling residents in the target counties and have used drugs to get high in the past 6 months are eligible. The trial compares the effectiveness of a fixed-site, staffed syringe service programme (standard of care) with the standard of care supplemented with a kiosk. The kiosk will contain various harm reduction supplies accessible to participants upon valid code entry, allowing dispensing data to be linked to participant survey data. The kiosk will include a call-back feature that allows participants to select needed services and receive linkage-to-care services from a peer recovery coach. The cohorts complete follow-up surveys every 6 months for 36 months (three preceding kiosk implementation and four post-implementation). The study will test the effectiveness of the kiosk on reducing risk behaviours associated with overdose, HIV and hepatitis C, as well as implementation outcomes and cost-effectiveness.

ETHICS AND DISSEMINATION

The University of Kentucky Institutional Review Board approved the protocol. Results will be disseminated in academic conferences and peer-reviewed journals, online and print media, and community meetings.

TRIAL REGISTRATION NUMBER

NCT05657106.

Three decades of research in substance use disorder treatment for syringe services program participants: a scoping review of the literature

BACKGROUND

Syringe services programs (SSPs) provide a spectrum of health services to people who use drugs, with many providing referral and linkage to substance use disorder (SUD) treatment, and some offering co-located treatment with medications for opioid use disorder (MOUD). The objective of this study was to review the evidence for SSPs as an entry point for SUD treatment with particular attention to co-located (onsite) MOUD.

METHODS

We performed a scoping review of the literature on SUD treatment for SSP participants. Our initial query in PubMed led to title and abstract screening of 3587 articles, followed by full text review of 173, leading to a final total of 51 relevant articles. Most articles fell into four categories: (1) description of SSP participants' SUD treatment utilization; (2) interventions to link SSP participants to SUD treatment; (3) post-linkage SUD treatment outcomes; (4) onsite MOUD at SSPs.

RESULTS

SSP participation is associated with entering SUD treatment. Barriers to treatment entry for SSP participants include: use of stimulants, lack of health insurance, residing far from treatment programs, lack of available appointments, and work or childcare responsibilities. A small number of clinical trials demonstrate that two interventions (motivational enhancement therapy with financial incentives and strength-based case management) are effective for linking SSP participants to MOUD or any SUD treatment. SSP participants who initiate MOUD reduce their substance use, risk behaviors, and have moderate retention in treatment. An increasing number of SSPs across the United States offer onsite buprenorphine treatment, and a number of single-site studies demonstrate that patients who initiate buprenorphine treatment at SSPs reduce opioid use, risk behaviors, and have similar retention in treatment to patients in office-based treatment programs.

CONCLUSIONS

SSPs can successfully refer participants to SUD treatment and deliver onsite buprenorphine treatment. Future studies should explore strategies to optimize the implementation of onsite buprenorphine. Because linkage rates were suboptimal for methadone, offering onsite methadone treatment at SSPs may be an appealing solution, but would require changes in federal regulations. In tandem with continuing to develop onsite treatment capacity, funding should support evidence-based linkage interventions and increasing accessibility, availability, affordability and acceptability of SUD treatment programs.

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.

Pre-Exposure Prophylaxis Barriers, Facilitators and Unmet Need Among Rural People Who Inject Drugs: A Qualitative Examination of Syringe Service Program Client Perspectives

BACKGROUND

People who inject drugs (PWID) are at high risk for HIV infection, yet in rural areas PWID are understudied with respect to prevention strategies. Kentucky is notable for heavy rural HIV burden and increasing rates of new HIV diagnoses attributable to injection drug use. Despite high need and the strong evidence for Pre-Exposure Prophylaxis (PrEP) as a gold-standard biomedical HIV prevention tool, scale up has been limited among PWID in Kentucky and elsewhere. This paper explores individual, environmental, and structural barriers and facilitators of PrEP care from the perspective of PWID in rural Kentucky.

METHODS

Data are drawn from an ongoing NIH-funded study designed to adapt and integrate a PrEP initiation intervention for high-risk PWID at point of care in two rural syringe service programs (SSPs) in southeastern Kentucky. As part of this initiative, a qualitative study guided by PRISM (Practical, Robust, Implementation, and Sustainability Model) was undertaken to gather SSP client perspectives on intervention needs related to PrEP, competing needs related to substance use disorder, as well as tangible supports for and barriers to PrEP uptake. Recruitment and interviews were conducted during September-November 2021 with 26 SSP clients, 13 from each of the two SSP sites. A semi-structured guide explored injection behaviors, SSP use, knowledge of PrEP, perceived barriers to PrEP, as well as aspects of the risk environment (e.g., housing instability, community stigma) that may impact PrEP uptake. Interviews were digitally recorded, transcribed verbatim and verified by project staff. A detailed coding scheme was developed and applied by independent coders using NVivo. Coded transcripts were synthesized to identify salient themes in the data using the principles of thematic analysis All study procedures were approved by the University IRB.

RESULTS

Participants were 96% white, 42% female, with a median age of 41 years (range 21-62); all reported injection use within the past month. Overall, we found low PrEP awareness among this sample, yet interest in PrEP was high, with several indicating PrEP is urgently needed. Clients reported overwhelmingly positive experiences at the SSPs, considering them trusted and safe locations to receive health services, and were enthusiastic about the integration of co-located PrEP services. Lack of basic HIV and PrEP knowledge and health literacy were in evidence, which contributed to common misperceptions about personal risk for HIV. Situational risks related to substance use disorder, particularly in the context of withdrawal symptoms and craving, often lead to heightened HIV injection and sexual risk behaviors. Stigma related to substance use and HIV arose as a concern for PrEP uptake, with several participants reflecting that privacy issues would impact their preferences for education, prescribing and monitoring of PrEP. Noted tangible barriers included inconsistent access to phone service and transportation. Primary supports included high levels of insurance coverage, consistent pharmacy access, and histories with successful medication management for other health conditions.

CONCLUSIONS

Drawing on the critical perspectives of people with substance use disorder, our findings provide important and actionable information on individual and environmental barriers and facilitators of PrEP uptake among rural PWID at high risk for HIV infection. These data will drive the adaptation and implementation of a client-centered approach to integrated PrEP care within rurally located SSP settings to address unmet needs for PrEP care.

Characteristics associated with motivation to stop substance use and improve skin and needle hygiene among hospitalized patients who inject drugs

Background: Hospitalizations for people who inject drugs (PWID) are opportunities to address substance use. However, little is known about hospitalized PWIDs' motivation to stop substance use or improve skin and needle hygiene, common means for reducing injection sequelae. Methods: We used baseline data from a randomized controlled trial of a behavioral intervention to improve skin and needle hygiene among 252 hospitalized PWID between January 2014 and June 2018. We examined motivation (scale 1-10) to stop substance use, use new needles, and clean skin and used multiple linear regression models to evaluate characteristics associated with these outcomes. Results: PWID were recruited during injection-related (154, 61.1%) and non-injection-related hospitalizations (98, 38.9%). Motivation to stop substance use was 7.11 (SD = 2.67), use new needles was 7.8 (SD = 1.9), and clean skin was 6.7 (SD = 2.3). In adjusted models, experiencing an injection-related hospitalization was not significantly associated (p > 0.05) with motivation to stop substance use (β = -0.76, SE = 0.299), use new needles (β = 0.301, SE = 0.255), or clean skin (β = 0.476, SE = 0.323). Number of past-year skin and soft tissue infections was negatively associated with motivation to use new needles (β = -0.109, SE = 0.049, p < 0.05) and clean skin (β = -0.131, SE = 0.062, p < 0.05). Greater opioid withdrawal was associated with lower motivation to use new needles (β = -0.275, SE = 0.92, p < 0.01). Conclusions: Among hospitalized PWID, motivation to stop substance use and improve skin and needle hygiene was moderately high, but injection-related hospitalizations were not associated with greater motivation. Efforts to reduce injection sequelae for all hospitalized PWID are needed.

Syringe services programs in the Bluegrass: Evidence of population health benefits using Kentucky Medicaid data

PURPOSE

To evaluate whether Kentucky counties that established a new syringe services program realized a significant decline in the incidence rate of a set of infectious disease diagnoses commonly transmitted via injection drug use.

METHODS

Longitudinal count models of within-county rates of newly diagnosed infections among populations at risk were estimated using Medicaid claims/encounters data. Generalized estimating equation models were used to report incident rate ratios of 6 diagnoses: (1) HIV; (2) hepatitis C; (3) hepatitis B; (4) osteomyelitis; (5) endocarditis; and (6) skin/soft tissue infection. To investigate whether a delay in effect was present, separate models were fit to estimate the effects of establishing a syringe services program: at its opening date, and again at 1, 3, and 6 months postopening date.

FINDINGS

Taken together, the aggregated within-county incidence rate of these 6 diagnoses was significantly lower following the implementation of a syringe services program (P < .05). Our models estimated that counties which opted to open a syringe services program realized an approximate month-over-month decline in new diagnoses of 0.5% among the population at risk.

CONCLUSIONS

These results lend further support to previous conclusions made in the public health literature regarding the efficacy of syringe services programs. Specifically, declines in incidence rates were observable beginning at 1 month post syringe services program opening. These results are particularly notable due to the typical setting in which these syringe services programs operated-rural communities of fewer than 40,000 residents.

Community Meetings on the Rural Opioid Crisis: Setting a Path Forward by Learning from Others

Objectives:

This study implemented a series of meetings in one rural community struggling with the opioid crisis. Set in the town of Ardmore, Oklahoma, these meetings presented local residents who dealt with the crisis as part of their jobs with four categories of programs aimed at preventing and treating opioid-related issues. The ultimate goal was for the participants to develop a consensus about where resources should be appropriated in the future, based off the needs of the area.

Methods:

Three community meetings were held over a six-week period, with an average of 40 attendees. Data was collected through surveys, study circles, and a participant voting exercise. Surveys were distributed at the beginning and end of the meetings to determine if participant views changed over the course of the study. Study circles broke participants into small groups and prompted them with questions regarding the crisis to encourage group discussion. The participant voting exercise allowed participants to note where they would like future resources to be directed.

Findings:

Listening to experts and holding group discussions led to changes in opinions for some participants. Most felt that the most pressing need was to provide accessible opioid treatment options in their community. Youth-based prevention efforts were also noted as being a program that the community should focus on.

Conclusions:

Local perceptions of the most appropriate strategies for combatting the rural opioid crisis can change with group discussions alongside others who are actively involved with this issue. Future research should actively involve affected communities in order to develop relevant and accepted action plans.

Characterization of diverted buprenorphine use among adults entering corrections-based drug treatment in Kentucky

BACKGROUND

Illicit, medically unsupervised use of buprenorphine (i.e., "diverted use") among vulnerable and underserved populations, such as corrections-involved adults, remains underexplored.

METHODS

Survey data (2016-2017) collected as part of a clinical assessment of incarcerated adults entering corrections-based substance use treatment in Kentucky were analyzed. For years examined, 12,915 completed the survey. Removing cases for participants who did not reside in Kentucky for >6 months during the one-year pre-incarceration period (n = 908) resulted in a final sample size of 12,007.

RESULTS

Over a quarter of the sample reported past-year diverted buprenorphine use prior to incarceration and 21.8 % reported use during the 30-days prior to incarceration, using 6.5 months and 14.3 days on average, respectively. A greater proportion of participants who reported diverted buprenorphine use had previously been engaged with some substance use treatment (77.0 %) and reported greater perceived need for treatment (79.4 %) compared to those who did not report use. Use was more likely among participants who were younger, white, male, and who reported rural or Appalachian residence. Diverted buprenorphine users also evidenced extensive polydrug use and presented with greater substance use disorder severity. Non-medical prescription opioid, heroin, and diverted methadone use were associated with increased odds of diverted buprenorphine use while kratom was not. Diverted methadone use was associated with a 252.9 % increased likelihood of diverted buprenorphine use.

CONCLUSIONS

Diverted buprenorphine use among participants in this sample was associated with concerning high-risk behaviors and may indicate barriers to accessing opioid agonist therapies for corrections-involved Kentucky residents, particularly those in rural Appalachia.