Illicit Drug Use, Illicit Drug Use Disorders, and Drug Overdose Deaths in Metropolitan and Nonmetropolitan Areas - United States

Impact of the Communities That HEAL Intervention on Buprenorphine-Waivered Practitioners and Buprenorphine Prescribing: A Prespecified Secondary Analysis of the HCS Randomized Clinical Trial

Importance

Buprenorphine significantly reduces opioid-related overdose mortality. From 2002 to 2022, the Drug Addiction Treatment Act of 2000 (DATA 2000) required qualified practitioners to receive a waiver from the Drug Enforcement Agency to prescribe buprenorphine for treatment of opioid use disorder. During this period, waiver uptake among practitioners was modest; subsequent changes need to be examined.

Objective

To determine whether the Communities That HEAL (CTH) intervention increased the rate of practitioners with DATA 2000 waivers and buprenorphine prescribing.

Design, Setting, and Participants

This prespecified secondary analysis of the HEALing Communities Study, a multisite, 2-arm, parallel, community-level, cluster randomized, open, wait-list-controlled comparison clinical trial was designed to assess the effectiveness of the CTH intervention and was conducted between January 1, 2020, to December 31, 2023, in 67 communities in Kentucky, Massachusetts, New York, and Ohio, accounting for approximately 8.2 million adults. The participants in this trial were communities consisting of counties (n = 48) and municipalities (n = 19). Trial arm randomization was conducted using a covariate constrained randomization procedure stratified by state. Each state was balanced by community characteristics including urban/rural classification, fatal opioid overdose rate, and community population. Thirty-four communities were randomized to the intervention and 33 to wait-list control arms. Data analysis was conducted between March 20 and September 29, 2023, with a focus on the comparison period from July 1, 2021, to June 30, 2022.

Intervention

Waiver trainings and other educational trainings were offered or supported by the HEALing Communities Study research sites in each state to help build practitioner capacity.

Main Outcomes and Measures

The rate of practitioners with a DATA 2000 waiver (overall, and stratified by 30-, 100-, and 275-patient limits) per 100 000 adult residents aged 18 years or older during July 1, 2021, to June 30, 2022, were compared between the intervention and wait-list control communities. The rate of buprenorphine prescribing among those waivered practitioners was also compared between the intervention and wait-list control communities. Intention-to-treat and per-protocol analyses were performed.

Results

A total of 8 166 963 individuals aged 18 years or older were residents of the 67 communities studied. There was no evidence of an effect of the CTH intervention on the adjusted rate of practitioners with a DATA 2000 waiver (adjusted relative rate [ARR], 1.04; 95% CI, 0.94-1.14) or the adjusted rate of practitioners with a DATA 2000 waiver who actively prescribed buprenorphine (ARR, 0.97; 95% CI, 0.86-1.10).

Conclusions and Relevance

In this randomized clinical trial, the CTH intervention was not associated with increases in the rate of practitioners with a DATA 2000 waiver or buprenorphine prescribing among those waivered practitioners. Supporting practitioners to prescribe buprenorphine remains a critical yet challenging step in the continuum of care to treat opioid use disorder.

Trial Registration

ClinicalTrials.gov Identifier: NCT04111939.

Implementing a clinical checklist for pregnant patients with opioid use disorder

BACKGROUND

Opioid use disorder (OUD) has been increasing in pregnant patients over the past two decades. Best practice guidelines that are available for these patients, must now be implemented by health care teams. Clinical checklists have been used for other complex patient cohorts with good success and are a potentially viable tool for ensuring best practices with this patient population as well.

LOCAL PROBLEM

Maine has seen a dramatic increase in the number of pregnant patients with OUD. Many of these patients seemed to "fall through the cracks" in the traditional prenatal care model. The obstetrical care team expressed feeling overwhelmed by the complex care needs of these patients and unsure of how to improve their care.

METHODS

To improve prenatal care delivery for patients with OUD, we implemented an evidence-based clinical checklist. This local, NP-led quality improvement project was done in partnership with a state-led initiative to improve perinatal care for patients with OUD.

INTERVENTIONS

An evidence-based checklist provided by the state initiative was implemented for prenatal patients with diagnosed OUD.

RESULTS

Use of a clinical checklist for patients with OUD increased the rate of several best practices during their prenatal care, including emergency naloxone prescription, tracking prescription monitoring reports, and contraceptive planning. Rates of completed prenatal screening for substance misuse, social determinants of health, and intimate partner violence also increased in our practice overall, as a result of this project.

CONCLUSIONS

To further improve perinatal care coordination for patients with OUD, we recommend future evaluation of clinical checklists within various practice settings.

Epidemiological Trends and Factors Associated With Mortality Rate in Psychoactive Substance Use-Related Mental and Behavioral Disorders: A CDC-WONDER Database Analysis

Background The persisting challenge of substance use disorder's impact on society prompts the need for insights into its mortality trends. This study examines epidemiological patterns and factors tied to mortality rates in individuals with psychoactive substance-related mental and behavioral disorders from 1999 to 2020. Methodology This study used a retrospective observational design. The study analyzed the Centers for Disease Control and Prevention's (CDC) Wide-ranging Online Data for Epidemiologic Research (WONDER) database information, encompassing mortality and population-based data. Data extraction focused on specific criteria such as age, sex, race/ethnicity, and geographic location. Descriptive statistics were employed to depict the study population and reveal epidemiological trends. Results The study encompassed data from 239,573 individuals who died due to psychoactive substance use-related mental and behavioral disorders between 1999 and 2020. The overall mortality rate was 3.55 per 100,000 individuals (95% confidence interval (CI) = 3.55-3.54) across the study period. Noticeable discrepancies in mortality rates emerged among various geographic regions, genders, races, and age groups. Males (5.32 per 100,000 individuals) experienced notably higher mortality rates than females (1.80 per 100,000 individuals), while the 55-64 age group faced elevated mortality risks (8.24 per 100,000 individuals) compared to the 25-34 age group (1.71 per 100,000 individuals). Significant variations in mortality rates were also evident across different racial and ethnic groups. Conclusions Between 1999 and 2020, the study explored mortality rates in individuals with psychoactive substance use-related mental and behavioral disorders. This analysis revealed variations in mortality across genders, ages (with the 55-64 age group facing higher risks compared to the 25-34 age group), and ethnicities. Notably, males exhibited higher mortality than females. Additionally, divergent rates were observed among different geographic regions. These insights can inform public health initiatives and support the development of targeted strategies to reduce mortality rates and improve the well-being of affected individuals.

Association of globalization with the burden of opioid use disorders 2019. A country-level analysis using targeted maximum likelihood estimation

BACKGROUND

The "opioid crisis" has been responsible for hundreds of thousands deaths in the US, and is at risk of dissemination worldwide. Within-country studies have demonstrated that the rise of opioid use disorders (OUD) is linked to increased access to opioid prescriptions and to so-called "diseases of despair". Both have been related to the emergence of globalization policies since the 1980s. First, globalized countries have seen a reorganization of healthcare practices towards quick and easy answers to complex needs, including increased opioid prescriptions. Second, despair has gained those suffering from the mutations of socio-economic systems and working conditions that have accompanied globalization policies (e.g. delocalization, deindustrialization, and the decline of social services). Here, using data with high quality ratings from the Global Burden of Disease database, we evaluated the country-based association between four levels of globalization and the burden of OUD 2019.

RESULTS

The sample included 87 countries. Taking into account potential country-level confounders, we found that countries with the highest level of globalization were associated with a 31% increase in the burden of OUD 2019 compared to those with the lowest level of globalization (mean log difference: 0.31; 95%CI, 0.04-0.57; p = 0.02). Additional analyses showed a significant effect for low back pain (mean log difference: 0.07; 95%CI, 0.02-0.12; p = 0.007). In contrast, despite sharing some of the risk factors of OUD, other mental and substance use disorders did not show any significant relationship with globalization. Finally, socio-cultural de jure globalization, which compiles indicators related to gender equality, human capital and civil rights, was specifically associated with the burden of OUD (mean log difference: 0.49; 95%CI: 0.23,0.75; p < 0.001).

CONCLUSIONS

These findings suggest that OUD may have inherent underpinnings linked to globalization, and more particularly socio-cultural aspects of globalization. Key factors may be increased rights to access prescriptions, as well as increased feelings of despair related to the erosion of local cultures and widening educational gaps.

Residence in urban or rural counties in relation to opioid overdose mortality among Kentucky hospitalizations before and during the COVID-19 pandemic

BACKGROUND

At the beginning of the opioid overdose epidemic, overdose mortality rates were higher in urban than in rural areas. We examined the association between residence in an urban or rural county and subsequent opioid overdose mortality in Kentucky, a state highly impacted by the opioid epidemic, and whether this was modified by the COVID-19 pandemic.

METHODS

We captured hospitalizations in Kentucky from 2016 to 2020, involving an opioid using ICD-10-CM codes T40.0-T40.4 and T40.6. Patient's county was classified as urban or rural based on the NCHS Urban-Rural Classification Scheme. Multivariable logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of opioid overdose mortality, adjusted for demographics, hospitalization severity, and zip code SES. We assessed effect modification by the COVID-19 pandemic.

RESULTS

Overall, patients living in urban counties had 46% higher odds of opioid overdose death than patients residing in rural counties (adjusted OR=1.46; 95% CI=1.22, 1.74). Before the pandemic, patients in urban counties had 63% increased odds of opioid overdose death (adjusted OR=1.63; 95% CI=1.34, 1.97); however, during the COVID-19 pandemic, patients in urban and rural counties became more similar in regard to opioid overdose mortality (adjusted OR=0.72; 95% CI=0.45, 1.16; p-value for interaction =0.02).

CONCLUSION

Before the pandemic, living in urban counties was associated with higher opioid overdose mortality among Kentucky hospitalizations; however, during the COVID-19 pandemic, opioid overdose mortality in rural areas increased, approaching rates in urban areas. COVID-19 posed social, economic, and healthcare challenges that may be contributing to worsening mortality trends affecting both urban and rural patients.

Prenatal substance use in the rural and Appalachian state: Project WATCH study 2020-2022

PURPOSE

To examine the prevalence, patterns, and correlates of prenatal substance use in the rural Appalachian state of West Virginia (WV).

METHODS

Population-based cohort (Project WATCH) of all women (N = 34,309) who gave birth between February 2020 and June 2022. A composite substance use variable included 9 categories: "no substance use," "opioids," "cannabis," "sedatives/hypnotics," "stimulants," "opioids and cannabis," "opioids and stimulants," "cannabis and stimulants," and "opioids, cannabis, and stimulants." These data were gathered through self-report, medical records, and/or positive drug screen at labor and delivery.

FINDINGS

12.4% of women used one or more substances (opioids, cannabis, stimulants, and sedatives/hypnotics) during their current pregnancy. The mean age of women using cannabis was 25.34 (SD = 5.31), stimulants was 28.88 (SD = 5.62), and opioid was 30.19 (SD = 4.78). White women were more likely to use opioids (aOR = 2.19, 95% CI 1.46, 3.28) and less likely to use cannabis (aOR = 0.39, 95% CI 0.34, 0.44) compared to minority racial groups. Women with cannabis use were more likely to live in urban versus rural regions (aOR = 1.47, 95% CI 1.33, 1.62). The odds of using any type of substance(s) were significantly higher in women who smoked (aOR range 4.17-30.85), had Medicaid (aOR range 1.52-7.65), and those receiving inadequate prenatal care (aOR range 1.96-16.83).

CONCLUSIONS

In this rural Appalachian state, 1 in 8 women used 1 or more substances (opioids, cannabis, stimulants, and/or sedatives/hypnotics) during pregnancy and the type of substance used varied by sociodemographic and health-related factors. These factors should inform state-level strategies and initiatives to address the substance use crisis for this population.

Opioid Use Disorder Stigma and Support for Harm Reduction in Rural Counties

Background: The opioid crisis is a public health emergency in the United States, particularly in rural Pennsylvania. Stigma in rural communities is a treatment barrier and impacts harm reduction programming availability.Objectives: The current study utilized an observational, cross-sectional design to examine latent subgroups of stigma and differences in support for harm reduction strategies (i.e., safe injection facilities, syringe services programs, fentanyl test strips, Naloxone distribution). Participants included rural Pennsylvanians (n = 252), taken from a statewide survey of opioid use disorder (OUD) stigma. Participants reported OUD public stigma (i.e., attitudes/perceptions about OUD, willingness to engage with individuals with OUD) and support for harm reduction strategies.Results: Latent class analysis identified 4 stigma classes: 1) high stigma (HS), 2) high judgment/low stigmatizing behavior (HJ/LB), 3) high stigmatizing behavior/low stigmatizing attitude (HB/LA), and 4) low stigma (LS). ANCOVAs identified subgroup differences in harm reduction support. The HS group indicated less support for safe injection sites, syringe services programs, and fentanyl test strips, compared to the HB/LA and LS groups. The HS group indicated less support for Naloxone distribution compared to the HJ/LB, HB/LA, and LS groups. Lastly, the HJ/LB group indicated less support for each program compared to the LS group.Conclusions/Importance: Findings highlight that OUD stigma profiles differ across rural Pennsylvania and are associated with varying support for harm reduction strategies. Individuals with less stigma report more support for harm reduction strategies. Interventions to implement harm reduction strategies should consider varying levels of stigma and use a targeted approach to inform implementation and messaging strategies.

Everybody Hurts: Intersecting and Colliding Epidemics and the Need for Integrated Behavioral Treatment of Chronic Pain and Substance Use

Chronic pain and substance use disorders are both common, debilitating, and often persist over the longer term. On their own, each represents a significant health problem, with estimates indicating a substantial proportion of the adult population has chronic pain or a substance use disorder (SUD), and their co-occurrence is increasing. Chronic pain and SUD are also both often invisible, stigmatized disorders and persons with both regularly have difficulty accessing evidence-based treatments, particularly those that offer coordinated and integrated treatment for both conditions. But there is hope. Research is unraveling the mechanisms of chronic pain and substance use, as well as their co-occurrence, integrated behavioral treatment options based on acceptance- and mindfulness-based approaches are increasingly being developed and tested, government agencies are devoting more funds and resources to increase research on chronic pain and SUD, and there have been growing efforts in training, dissemination, and implementation of evidence-based treatments. At the very heart of the matter, though, is to recognize that everybody hurts sometimes, and treatments must empower people to life effectively with these experiences of being human.

Cannabinoids and synthetic cannabinoids as a cause of death: Trends and their healthcare implications

INTRODUCTION

Cannabis remains one of the most widely used illicit substances globally, with 188 million users in 2017. In the United States, nearly 50 million people are reported to have used cannabis in 2020. More research is needed because of the dramatic increase in cannabis use and the perception that its use has minimal risk.

DESIGN

The researchers used a retrospective design for this study.

METHODS

We used the Florida Department of Law Enforcement data from 2014 to 2020 for this study. We used descriptive statistics to report the characteristics of decedents whose cause of death (COD) was associated with cannabinoid (CB) and synthetic cannabinoid (SC) use. We used a general linear model with repeated measures to examine CB and SC death rate trends.

RESULTS

A total of 386 decedents' COD in Florida was associated with CB and SC use. Nearly 28% of decedents were 45-54 years, male (87.8%), and non-Hispanic whites (65.3%). One hundred percent of CB-related decedents died in urban counties. In rural counties, SC decedents accounted for 28.3% of deaths. Of decedents in rural counties, 39.9% were African American. Most decedents (with CB and SC use) died from accidents (98.7%), with 12.6% of cases involving cardiovascular-related illnesses.

CONCLUSION

CBs and SCs as a COD pose a legitimate health problem to society. More people ages 45-54 died from CBs and SCs. Drug intoxications (from CBs and SCs) and motor vehicle collisions accounted for most of the accidents reported while under the influence of CBs and SCs. While most decedents from both CBs and SCs were non-Hispanic whites, a substantial proportion of African Americans died from SCs as a COD in rural counties. It is important that the public become aware of the risks for adverse effects of CB and SC. The public needs to be aware that CB and SC use can exacerbate cardiac-related conditions.

CLINICAL RELEVANCE

This study has clinical relevance to patient safety. CB and SC use contributes to motor vehicle accidents and can cause adverse effects including death.

Centering culture in the treatment of opioid use disorder with American Indian and Alaska Native Communities: Contributions from a National Collaborative Board

American Indian/Alaska Native (AI/AN) communities are disproportionally impacted by the opioid overdose epidemic. There remains a dearth of research evaluating methods for effectively implementing treatments for opioid use disorder (OUD) within these communities. We describe proceedings from a 2-day Collaborative Board (CB) meeting tasked with developing an implementation intervention for AI/AN clinical programs to improve the delivery of medications to treat OUD (MOUD). The CB was comprised of Elders, cultural leaders, providers, individuals with lived experience with OUD, and researchers from over 25 communities, organizations, and academic institutions. Conversations were audio-recorded, transcribed, and coded by two academic researchers with interpretation oversight provided by the CB. These proceedings provided a foundation for ongoing CB work and a frame for developing the program-level implementation intervention using a strength-based and holistic model of OUD recovery and wellbeing. Topics of discussion posed to the CB included engagement and recovery strategies, integration of extended family traditions, and addressing stigma and building trust with providers and clients. Integration of traditional healing practices, ceremonies, and other cultural practices was recommended. The importance of centering AI/AN culture and involving family were highlighted as priorities for the intervention.

Culturally tailored substance use interventions for Indigenous people of North America: a systematic review

Purpose–

The purpose of the current study is to conduct a systematic review of peer-reviewed work on culturally tailored interventions for alcohol and drug use in Indigenous adults in North America. Substance use has been reported as a health concern for many Indigenous communities. Indigenous groups experienced the highest drug overdose death rates in 2015, the largest percentage increase in the number of deaths over time from 1999 to 2015 compared to any other racial group. However, few Indigenous individuals report participating in treatment for alcohol or drug use, which may reflect the limited engagement that Indigenous groups have with treatment options that are accessible, effective and culturally integrative.

Design/methodology/approach–

Electronic searches were conducted from 2000 to April 21, 2021, using PsycINFO, Cumulative Index to Nursing and Allied Health Literature, MEDLINE and PubMed. Two reviewers classified abstracts for study inclusion, resulting in 18 studies.

Findings–

Most studies were conducted in the USA (89%). Interventions were largely implemented in Tribal/rural settings (61%), with a minority implemented in both Tribal and urban contexts (11%). Study samples ranged from 4 to 742 clients. Interventions were most often conducted in residential treatment settings (39%). Only one (6%) intervention focused on opioid use among Indigenous people. Most interventions addressed the use of both drugs and alcohol (72%), with only three (17%) interventions specifically intended to reduce alcohol use.

Originality/value–

The results of this research lend insight into the characteristics of culturally integrative treatment options for Indigenous groups and highlight the need for increased investment in research related to culturally tailored treatment across the diverse landscape of Indigenous populations.

Exploring substance use disorder discussions in Native American communities: a retrospective Twitter infodemiology study

BACKGROUND

The opioid epidemic has had a devastating impact on youth from American Indian and Alaska Native (AI/AN) Tribes and Villages, which also experience disparate suicide rates. The use of publicly available social media data originating from AI/AN communities may enhance public health response time to substance use disorder (SUD)-related overdose and augment Tribal public health surveillance systems, but these concepts have yet to be adequately explored. The goal of this exploratory analysis was to identify primary and secondary accounts of overdose and characterize relevant contextual factors in the AI/AN population on social media.

METHODS

The Twitter application programming interface was queried for all Tweets containing geocoded data between March 2014 and June 2020 and filtered for the keyword ['overdose']. This sample of Tweets (n = 146,236) was then restricted to those geolocated from US Tribal lands (n = 619). Tweets were manually annotated for primary or secondary accounts of overdose as well as suicidal ideation, substance(s) used, stigma of drug use, and community-wide incidents.

RESULTS

We collected a total of 146,235 tweets that were geocoded and contained the word 'overdose,' of which 9.5% were posted on Tribal lands (n = 619). 9.4% of these tweets (n = 58) met our study inclusion criteria and were mainly posted from Oklahoma (n = 26, 45%) and North Carolina (n = 13, 22.4%). Most Tweets (n = 41, 71%) described a primary account of an overdose and were mostly posted from 2014 to 2015. Less than half of the Tweets (n = 27, 46.5%) referenced a specific substance. Those substances mentioned included alcohol, marijuana, methamphetamine, heroin, laundry softener, cocaine, K2-Spice (synthetic cannabinoid), codeine, morphine, Nyquil, and Xanax.

DISCUSSION

Though exploratory, our study identified SUD-related content self-reported by AI/AN communities on Twitter, especially in Oklahoma and North Carolina. These results may assist in the future design and detection of infodemiology trends and early warning signs that can better facilitate intervention specific to the ongoing Tribal opioid epidemic. While all data were collected from the public domain, additional care should be given to individual and community privacy.

Identifying and Managing Suicidality in Children and Adolescents with Chronic Pain: Evidence-Based Treatment Strategies

Children and adolescents with chronic pain are at an increased risk of suicidality. This narrative review article aims to inform clinical practice in the assessment and management of suicidality in youth with chronic pain. The article begins with a survey of the background and prevalence of youth with chronic pain. A review of the current evidence behind the increased risk of suicidality in youth with chronic pain follows. Contextualization of this data with general tenets of child and adolescent suicide risk and risk assessment is provided. Suicidology theory including the interpersonal theory of suicide is overviewed to help clinicians to conceptualize the reviewed data. Guiding parameters for the suicide risk assessment and management planning is presented. Concluding recommendations are made to guide clinical practice in the assessment and management of suicidality in youth with chronic pain.

"I'm an adult now": Health risk behaviors and identifying as an adult

Is identifying as an adult associated with lower rates of participation in risky behaviors? This study focuses on how identity affects health behaviors for young adults. We use an original sample of over 500 18- to 29-year-olds in the United States to explore how self-identification as an adult is associated with three clusters of health risk behaviors: substance use, risky sexual behavior, and risky driving behavior. Consistent with our predictions, we find that viewing oneself as an adult is associated with lower levels of participation in each of the health risk behavior outcomes.

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.

Postoperative Pain Management Following Orthopedic Spine Procedures and Consequent Acute Opioid Poisoning: An Analysis of New York State From 2009 to 2018

OBJECTIVE

Considering the high rates of opioid usage following orthopedic surgeries, it is important to explore this in the setting of the current opioid epidemic. This study examined acute opioid poisonings in postoperative spine surgery patients in New York and the rates of poisonings among these patients in the context of New York's 2016 State legislation limiting opioid prescriptions.

METHODS

Claims for adult patients who received specific orthopedic spine procedures in the outpatient setting were identified from 2009 to 2018 in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Patients were followed to determine if they presented to the emergency department for acute opioid poisoning postoperatively. Multivariable logistic regression was performed to evaluate the effect of patient demographic factors on the likelihood of poisoning. The impact of the 2016 New York State Public Health Law Section 3331, 5. (b), (c) limiting opioid analgesic prescriptions was also evaluated by comparing rates of poisoning prelegislation and postlegislation enactment.

RESULTS

A total of 107,456 spine patients were identified and 321 (0.3%) presented postoperatively to the emergency department with acute opioid poisoning. Increased age [odds ratio (OR)=0.954, P <0.0001] had a decreased likelihood of poisoning. Other race (OR=1.322, P =0.0167), Medicaid (OR=2.079, P <0.0001), Medicare (OR=2.9, P <0.0001), comorbidities (OR=3.271, P <0.0001), and undergoing multiple spine procedures during a single operative setting (OR=1.993, P <0.0001) had an increased likelihood of poisoning. There was also a significant reduction in rates of postoperative acute opioid poisoning in patients receiving procedures postlegislation with reduced overall likelihood (OR=0.28, P <0.0001).

CONCLUSION

There is a higher than national average rate of acute opioid poisonings following spine procedures and increased risk among those with certain socioeconomic factors. Rates of poisonings decreased following a 2016 legislation limiting opioid prescriptions. It is important to define factors that may increase the risk of postoperative opioid poisoning to promote appropriate management of postsurgical pain.

Patient evaluation of a smartphone application for telehealth care of opioid use disorder

Background

People with opioid use disorder (OUD) face barriers to entering and remaining in life-saving treatment (e.g., stigma, detrimental interactions with health care, and privacy concerns). Telehealth and related technology can reduce barriers to entering and staying in care. Patient feedback is critical to the development of these newer treatment approaches to ensure they are usable and do not inadvertently recreate treatment barriers.

Purpose

Evaluate the perceived usability of existing and planned features of a mobile application (app) that facilitates delivery of OUD treatment via telehealth.

Methods

People with current or prior experience with OUD treatment were eligible for the study. Participants (n = 31; 55% women) provided feedback on an interactive prototype demonstration via individual qualitative interviews and completed a quantitative survey on the app’s perceived usability. Descriptive statistics summarized the usability survey. We analyzed qualitative interview transcripts to elicit common themes.

Results

Participants were primarily white (77%) with a mean age of 42.2 years (range 22–69). Participants rated the six major features of the current app as helpful (median response 5 out of 5) and appreciated the flexibility of conducting a visit from a place of their choosing. Participants regarded the five proposed components of the app, such as daily affirmations and medication treatment-related reminders (e.g., pick up medication at pharmacy, medication schedule), as useful features with medians 5 out of 5, and reported they would recommend the app to others for OUD care. Participant qualitative interviews provided additional information on perceived usability of existing and proposed app features.

Conclusion

Our study suggests that an appealing, easy-to-use app—with tools and features that effectively support care—could circumvent existing barriers and foster sustained recovery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-022-00331-4.

Factors associated with readmission to alcohol and opioid detoxification in the Alaska Interior

BACKGROUND AND OBJECTIVES

A "revolving door" of repeated admissions to detoxification treatment facilities has long plagued alcohol and drug use patients, yet few studies examine factors associated with readmission. This study examined risk factors for readmission to alcohol and opioid detoxification in a sample from the Alaska Interior.

METHODS

Data were extracted from electronic medical records for admissions between 2012 and 2016 at an inpatient detoxification facility in Fairbanks, Alaska. Data from 1014 patients admitted for alcohol detoxification and 267 patients admitted for opioid detoxification were analyzed. The analysis employed descriptive statistics for risk factors (substance use history, adverse life experiences, and psychosocial functioning) and prevalence of readmission to either alcohol or opioid detoxification. Inferential analyses used marginal standardization to calculate differences in readmission risk by patient characteristics.

RESULTS

Male, Alaska Native/American Indian, single-never married patients, and those seeking work were at higher risk for readmission to alcohol detoxification, while those with stable housing were at reduced risk. Being single-never married and completing detoxification treatment reduced readmission to opioid detoxification. Family involvement in detoxification reduced readmission risk for both alcohol and opioid patients.

DISCUSSION AND CONCLUSIONS

Further research that investigates the mechanism(s) by which family may act as a protective factor may be efficacious in eliminating the "revolving door" of detoxification.

SCIENTIFIC SIGNIFICANCE

This study is the first to examine both alcohol and opioid use risk and protective factors in the Alaska Interior. The results can be used in the development of interventions for subpopulations with high detoxification readmission rates.

Perceptions of prescription opioid use among rural farming and ranching communities: Preliminary implications for outreach and treatment

Background: In 2017, 45% of rural adults reported being directly impacted by the opioid epidemic. While research on the experiences of those using prescription opioids in rural communities is increasing, less is known about a unique sub-population who may have high rates of exposure: rural agricultural workers. The purpose of this study was to explore the prevalence and perceptions related to prescription opioids among rural producers and farmworkers. Methods: A questionnaire was mailed in spring 2019 and spring 2020 to rural residents living in one of two agricultural-based states in the Upper Midwest. Individuals were eligible to participate if any member of their family was involved in the agricultural industry. A total of 1116 questionnaires were returned for a 27.9% response rate. Results: Participants were 68.1 years old on average. The majority identified as white, male, and married. Prescription opioid use was found in 8.2% of households currently, and 15.7% in the past year. There were no gender differences in prevalence of use, but women and older individuals reported significantly more perceived risk than men and younger individuals. Nearly half used alternative pain management, and received most information about prescription opioids from the radio (65.5%) and newsletters (13.5%). Conclusions. Despite their elevated age and working in an occupation at high risk of injury and chronic pain, study participants reported few opioid prescriptions and moderate use of alternative pain management. Perceived risk of prescription opioids may explain low prevalence. Outreach efforts that increase access to healthcare services and alternative pain management treatments for agricultural workers may mitigate the experience of chronic pain that can interfere with their overall quality of life.

A qualitative study of services accessibility for indigenous persons who use injection drugs across three communities in the United States

Aims: This study concerns the perspectives of Indigenous persons who use injection drugs (IPWIDs) and key stakeholders across multiple sectors regarding healthcare service and treatment accessibility in the United States.Methods: Sixty in-depth interviews were undertaken with selected participants (30 people who use injection drugs and 30 stakeholders) across three non-urban locations in the United States. An inductive analytic approach was used to explore perspectives regarding healthcare accessibility gaps.Results: IPWIDs described injecting stimulants, opioids, and diverted medications for opioid use disorder, as well as having unstable access to sterile syringes. Often, the most accessible treatment for IPWID substance use was engagement with punitive aspects of the criminal justice system. While local health and social services were described as providing limited or inadequate services for IPWIDs, human capital deficiencies in those agencies and institutions often reinforced barriers to accessibility for IPWIDs, further aggravating the epidemics of Hepatitis C Virus infection and overdose risk in Indigenous communities. Conclusions: Decolonizing approaches to IPWID-centered services are urgently needed to reduce disparities in transmission of infectious diseases and other health consequences of injection drug use among American Indian people. Potential pathways forward include moving away from punitive treatment of IPWIDs by the criminal justice system and toward local, tribally-centered, culturally appropriate treatment models. We identify an urgent need to provide reliable and local access to sterile injection equipment and opioid substitution treatment on or near reservations.

Opioid use in indigenous populations: indigenous perspectives and directions in culturally responsive care

In this work, we outline the necessary components for culturally responsive treatment to opioid use disorders in Indigenous communities. First, we examine the context of historical trauma faced by Indigenous groups in the U.S. and how this context may affect successful implementation of treatment. We then outline the strategies of Penobscot Nation and Little Earth in developing holistic treatment regimens for Indigenous peoples, and list policy interventions suited to improve outcomes for Indigenous groups related to opioid use disorders. We conclude with suggestions for future directions in anticolonial strategies for addressing opioid use in Indigenous communities. The combination of culturally responsive treatment, tribal sovereignty in the treatment of opioid use disorders, and effective resource allocation is necessary to affect positive change in Indigenous substance use trajectories.

Hearing and Vestibular Loss with Misuse of Opioids and Illicit Drugs: A Review of the Literature

BACKGROUND

The purpose of this review was to summarize the literature regarding the effects of opioids and illicit drugs on the auditory and vestibular systems.

METHODS

Data were sourced from published papers reporting hearing loss (HL) and/or vestibular loss (VL) following misuse or overdose of opioids or illicit drugs. Most papers consisted of retrospective single-case reports, with few retrospective reviews or prospective cohort studies. Search terms included variations of HL, VL, opioids, and illicit drugs. Search results yielded 51 articles published between 1976 and 2021. A total of 44 articles were reviewed after excluding studies that were not available in English (n = 3), only described acute effects in healthy cohorts (n = 3) or only described general health aspects in a group on methadone maintenance (n = 1).

RESULTS

Sixteen studies reported ototoxicity from illicit drugs, 27 from prescription opioids, and 1 was unspecified. This review shows that HL associated with amphetamines and cocaine was typically sudden, bilateral, and temporary. HL from cocaine/crack and heroin often presented with greatest losses in the mid-frequency range. HL associated with opioids was typically sudden, bilateral, moderately severe to profound, and in most cases permanent. The literature is sparse regarding VL from illicit drugs and opioids.

CONCLUSION

Practitioners who see patients for sudden or rapidly progressive HL or VL with no apparent cause should inquire about misuse of illicit drugs and opioids, particularly when the HL does not respond to steroid treatment.

Self-Reported Treatment Need and Barriers to Care for Adults With Opioid Use Disorder: The US National Survey on Drug Use and Health, 2015 to 2019

Objectives. To explore barriers to care and characteristics associated with respondent-reported perceived need for opioid use disorder (OUD) treatment and National Survey on Drug Use and Health (NSDUH)‒defined OUD treatment gap. Methods. We performed a cross-sectional study using descriptive and multivariable logistic regression analyses to examine 2015-2019 NSDUH data. We included respondents aged 18 years or older with past-year OUD. Results. Of 1 987 961 adults, 10.5% reported a perceived OUD treatment need, and 71% had a NSDUH-defined treatment gap. There were significant differences in age distribution, health insurance coverage, and past-year mental illness between those with and without a perceived OUD treatment need. Older adults (aged ≥ 50 years) and non-White adults were more likely to have a treatment gap compared with younger adults (aged 18-49 years) and White adults, respectively. Conclusions. Fewer than 30% of adults with OUD receive treatment, and only 1 in 10 report a need for treatment, reflecting persistent structural barriers to care and differences in perceived care needs between patients with OUD and the NSDUH-defined treatment gap measure. Public Health Implications. Public health efforts aimed at broadening access to all forms of OUD treatment and harm reduction should be proactively undertaken. (Am J Public Health. 2022;112(2):284-295. https://doi.org/10.2105/AJPH.2021.306577).

Intensity of Social Support Matters: A Latent Class Analysis to Identify Levels of Social Support Associated with Optimal Health Outcomes Among Women Living with HIV

Social support is associated with improved HIV care and quality of life. We utilized latent class analysis to identify three classes of baseline emotional and tangible perceived social support, termed "Strong", "Wavering" and "Weak". "Weak" vs. "Strong" perceived social support was associated over time with an 8% decreased risk of optimal antiretroviral therapy (ART) adherence for emotional and 6% decreased risk for tangible perceived social support. Importantly, "Wavering" vs "Strong" social support also showed a decreased risk of ART adherence of 6% for emotional and 3% for tangible support. "Strong" vs. "Weak" perceived support had a similar association with undetectable viral load, but the association for "Strong" vs. "Wavering" support was not statistically significant. Intensity of social support is associated with HIV care outcomes, and strong social support may be needed for some individuals. It is important to quantify the level or intensity of social support that is needed to optimize HIV outcomes.

Factors Associated with Likelihood of Initiating Others into Injection Drug Use Among People Who Inject Drugs in West Virginia

People who inject drugs (PWID) play a critical role in injection-naïve individuals transitioning to injection drug use. We investigated factors associated with future likelihood of initiating injection-naïve individuals using multivariable logistic regression among 418 PWID in rural Appalachia (Cabell County, West Virginia). Less than 10% reported they were likely to initiate someone in the future. Acquiring syringes from a syringe services program was associated with decreased odds of being likely to initiate someone in the future (adjusted odds ratio [aOR] 0.46, 95% CI 0.23, 0.95), while having previously initiated someone into injection drug use was associated with increased odds (aOR 8.65, 95% CI 4.07, 18.41). Among our sample of PWID in Appalachia, a small proportion reported that they would be likely to initiate an injection-naïve individual in the future. Efforts to reduce injection initiation assistance should focus on this subpopulation of PWID who indicate a willingness to engage in this behavior.

Co-occurring Mental Disorders in Transitional Aged Youth With Substance Use Disorders - A Narrative Review

Adolescence and emerging adulthood are often referred to as youth. Transitional psychiatry addresses this target group, which considers patients between 15 and 25 years of age. Substance use usually begins and peaks at this stage of life. Psychiatric disorders, foremost attention-deficit/hyperactivity disorder, and affective disorders, conduct disorders, and first-episodes psychosis frequently appear in early life stages. This review aims to provide a broad overview of transitional-aged youth's most common psychiatric comorbidities with substance use disorders. A literature search was conducted in Embase and Pubmed, and the main findings are described narratively. We present main findings for the following comorbidities: attention-deficit/hyperactivity disorder, conduct disorder, personality disorders, affective disorders, psychotic disorders, and the phenomena of overdose and suicidality. In conclusion, co-occurring mental health disorders are common and appear to facilitate the development of substance use disorders and exacerbate their overall course. Substance use also affects the severity and course of comorbid psychiatric disorders. Overall, data on transition-age youth with substance use disorders are highly inconsistent. Universal screening and treatment guidelines do not yet exist but should be aimed for in the future.

Comparing mortality from covid-19 to mortality due to overdose: A micromort analysis

OBJECTIVE

To compare the mortality risk due to covid-19 with death due to overdose in British Columbia, Canada. The opioid epidemic was declared a public health emergency in 2016.

METHODS

Mortality risk was calculated in micromorts with covid-19 data for January-October 2020, derived from the BC center for Disease Control, and illicit drug toxicity deaths for January 2010-September 2020, derived from the BC Coroners Service. Age-stratified covid-19 incidence and deaths per 100,000 population and age-stratified illicit drug toxicity death rates per 100,000 population were calculated. A micromort is a unit of risk equivalent to a one-in-a-million chance of death.

RESULTS

During the covid-19 pandemic, illicit drug toxicity deaths reached 1.0 micromorts per day, representing an increase of 0.5 micromorts per day relative to 2019 rates. In comparison, covid-19 mortality risk was 0.05 micromorts per day among individuals from the general population living in British Columbia and 21.1 micromorts per day among those infected with covid-19. Covid-related mortality risk was significantly lower among individuals aged <60 years, relative to older adults, whereas drug toxicity-related mortality was highest for individuals aged 30-59 years.

CONCLUSIONS

The mortality associated with covid-19 is apparent and distributed unevenly across subpopulations. The mortality due to overdose has increased during covid-19 and exceeds mortality due to covid-19. Our results instantiate the triple threat caused by covid-19 (i.e., public health crisis, economic crisis and mental health crisis) and quantitatively highlight the externality of increased mortality due to deaths of despair in response to public health efforts to reduce covid-related mortality.

Kratom Use in the US: Both a Regional Phenomenon and a White Middle-Class Phenomenon? Evidence From NSDUH 2019 and an Online Convenience Sample

Kratom products available in the United States are becoming increasingly diverse both in terms of content and in terms of how they are marketed. Prior survey research indicates that kratom has been primarily used in the US to self-treat anxiety, depression, pain, fatigue, and substance use disorder (SUD) symptoms. Kratom is also well-known for its use as a short- or long-term full opioid agonist substitute. Therefore, use may be greater in regions particularly impacted by addiction to prescription opioids. Use may also be greater in demographic groups targeted by media outlets (such as specific podcasts) in which kratom is touted. Here, we aimed to determine whether lifetime and past-year kratom use were associated with region of residence and with being young, White, post-secondary educated, and employed. To strengthen confidence in our findings, we analyzed data from two sources: our own crowdsourced online convenience sample and the 2019 National Survey on Drug Use and Health (NSDUH). In our sample (N = 2,615), 11.1% reported lifetime and 6.7% reported past-year kratom use, and the odds of kratom use were higher among people who were White, younger, at least high school educated, employed, and above the poverty line, as well as those reporting nonmedical opioid use, past-year SUD, or lifetime SUD treatment; residence was not a significant predictor. In NSDUH data, suburban residence and other demographic factors, concordant with those from the crowdsourced sample, were associated with kratom use. Taken together, the findings support a general "White middle-class suburban" profile of the modal kratom user, but more research is needed to understand it. In the interim, focus should be on our finding that lifetime nonmedical opioid use was associated with an up to five times greater likelihood of past-year kratom use, suggesting that drug-use history may presently be the strongest predictor of kratom use.

Characterizing opioid-involved overdose risk in local communities: An opioid overdose vulnerability assessment across Indiana, 2017

The objective of this initiative was to conduct a comprehensive opioid overdose vulnerability assessment in Indiana and evaluate spatial accessibility to opioid use disorder treatment, harm reduction services, and opioid response programs. We compiled 2017 county-level (n = 92) data on opioid-related and socioeconomic indicators from publicly available state and federal sources. First, we assessed the spatial distribution of opioid-related indicators in a geographic information system (GIS). Next, we used a novel regression-weighted ranking approach with mean standardized covariates and an opioid-involved overdose mortality outcome to calculate county-level vulnerability scores. Finally, we examined accessibility to opioid use disorder treatment services and opioid response programs at the census tract-level (n = 1511) using two-step floating catchment area analysis. Opioid-related emergency department visit rate, opioid-related arrest rate, chronic hepatitis C virus infection rate, opioid prescription rate, unemployment rate, and percent of female-led households were independently and positively associated with opioid-involved overdose mortality (p < 0.05). We identified high-risk counties across the rural-urban continuum and primarily in east central Indiana. We found that only one of the 19 most vulnerable counties was in the top quintile for treatment services and had naloxone provider accessibility in all of its census tracts. Findings from our vulnerability assessment provide local-level context and evidence to support and inform future public health policies and targeted interventions in Indiana in areas with high opioid overdose vulnerability and low service accessibility. Our approach can be replicated in other state and local public health jurisdictions to assess opioid-involved public health vulnerabilities.

Syringe Coverage Among People Who Inject Drugs in West Virginia, USA

Ensuring people who inject drugs (PWID) have ≥ 100% sterile syringe coverage (i.e., persons have access to a sterile syringe for all injections) is optimal for HIV prevention. Existing syringe coverage literature is informative, yet little work has examined syringe coverage among PWID in rural communities. Using data from a 2018 PWID population estimation study conducted in a rural county in West Virginia, we used logistic regression to identify correlates of adequate sterile syringe coverage (at least 100%). A minority (37%) of PWID reported having adequate syringe coverage. Factors inversely associated with adequate syringe coverage included having recently (past 6 months): engaged in transactional sex work, shared syringes, and injected fentanyl. Having exclusively acquired syringes from a syringe services program was associated with increased odds of adequate syringe coverage. Rural PWID may benefit from tailored interventions designed to increase sterile syringe access.

Pediatric surgery and future risk of cocaine, opioid, cannabis, and other substance use in women: longitudinal cohort study

BACKGROUND

Substance use is problematic in young women, particularly in pregnancy. We sought to determine whether pediatric surgery is associated with the subsequent risk of adolescent or pregnancy-related illicit drug use, including cocaine, opioids, cannabis, and other drugs.

METHODS

We analyzed a cohort of 167,119 girls aged five years or less in Canada with 4,693,444 person-years of follow-up. We tracked the girls over time between 1989 and 2018. The main exposure measure was pediatric surgery before 20 years of age. The main outcome included subsequent hospitalizations for substance use disorders and substance use in pregnancy. We estimated hazard ratios and 95% confidence intervals (CI) for the association of pediatric surgery with the later risk of substance use, using Cox proportional hazards regression models adjusted for patient characteristics.

RESULTS

Pediatric surgery was associated with 2.08 times the risk of future hospitalization for substance use disorders (95% CI 1.96-2.22) and 1.48 times the risk of substance use in pregnancy (95% CI 1.35-1.62), compared with no surgery. Associations were stronger for girls who had surgery under general anesthesia and were present regardless of age at first surgery or total number of surgeries. Pediatric surgery was associated with the use of cocaine, opioids, cannabis, and other illicit substances later in life.

CONCLUSIONS

This study suggests that pediatric surgery may be associated with future substance use disorders in women, including substance use at pregnancy. Further study is needed to determine whether surgery may have a causal role in later drug abuse by women.

Sociodemographic and Clinical Predictors of Prescription Opioid Use in a Longitudinal Community-Based Cohort Study of Middle-Aged and Older Adults

Objectives

Identifying factors associated with opioid use in middle-aged and older adults is a fundamental step in the mitigation of potentially unnecessary opioid consumption and opioid-related harms.

Methods

Using longitudinal data on a community-based cohort of adults aged 50–90 years residing in Johnston County, North Carolina, we examined sociodemographic and clinical factors in non-opioid users (n = 786) at baseline (2006–2010) as predictors of opioid use at follow-up (2013–2015). Variables included age, sex, race, obesity, educational attainment, employment status, household poverty rate, marital status, depressive symptoms, social support, pain catastrophizing, pain sensitivity, insurance status, polypharmacy, and smoking status.

Results

At follow-up, 13% of participants were using prescription opioids. In the multivariable model, high pain catastrophizing (adjusted odds ratio; 95% confidence interval = 2.14; 1.33–3.46), polypharmacy (2.08; 1.23–3.53), and history of depressive symptoms (2.00; 1.19–3.38) were independent markers of opioid use.

Discussion

Findings support the assessment of these modifiable factors during clinical encounters in patients ≥ 50 years old with chronic pain.

Longitudinal Dose Trajectory Among Patients Tapering Long-Term Opioids

OBJECTIVE

To evaluate the dose trajectory of new opioid tapers and estimate the percentage of patients with sustained tapers at long-term follow-up.

DESIGN

Retrospective cohort study.

SETTING

Data from the OptumLabs Data Warehouse® which includes de-identified medical and pharmacy claims and enrollment records for commercial and Medicare Advantage enrollees, representing a diverse mixture of ages, ethnicities, and geographical regions across the United States.

SUBJECTS

Patients prescribed stable, higher-dose opioids for ≥12 months from 2008 to 2018.

METHODS

Tapering was defined as ≥15% relative reduction in average MME/day during any of six overlapping 60-day periods in the initial 7 months of follow-up after the period of stable baseline dosing. Average monthly dose was ascertained during consecutive 60-day periods up to 16 months of follow-up. Linear regression estimated the geometric mean relative dose by tapering status and follow-up duration. Poisson regression estimated the percentage of tapered patients with sustained dose reductions at follow-up and patient-level predictors of failing to sustain tapers.

RESULTS

The sample included 113,618 patients with 203,920 periods of stable baseline dosing (mean follow-up = 13.7 months). Tapering was initiated during 37,170 follow-up periods (18.2%). After taper initiation, patients had a substantial initial mean dose reduction (geometric mean relative dose .73 [95% CI: .72-.74]) that was sustained through 16 months of follow-up; at which point, 69.8% (95% CI: 69.1%-70.4%) of patients who initiated tapers had a relative dose reduction ≥15%, and 14.2% (95% CI: 13.7%-14.7%) had discontinued opioids. Failure to sustain tapers was significantly less likely among patients with overdose events during follow-up (adjusted incidence rate ratio [aIRR]: .56 [95% CI: .48-.67]) and during more recent years (aIRR: .93 per year after 2008 [95% CI: .92-.94]).

CONCLUSIONS

In an insured and Medicare Advantage population, over two-thirds of patients who initiated opioid dose tapering sustained long-term dose reductions, and the likelihood of sustaining tapers increased substantially from 2008 to 2018.

Contextual challenges in police-assisted substance use referral programs: Impact of COVID-19 and Black Lives Matter movement

Background: Police assisted referral (PAR) programs provide people with substance use disorders (SUD) with a non-arrest treatment pathway, yet systemic barriers, including stigma and access to treatment services, may limit engagement. We sought to understand how the dual contextual challenges of COVID-19 and the Black Lives Matter movement have impacted PAR programs. Methods: Participants completed semi-structured interviews between July and September 2020. Transcribed interviews were analyzed qualitatively to extract emergent codes and themes. Results: Key themes included: adoption and reach of adapted remote services, and barriers to access; and questions on the role of police as health service providers, including police embeddedness in the community. COVID-related social distancing demands undermined police engagement with people with SUD. Treatment providers and advocates reported moderate success in utilizing remote interventions as workarounds. While participants acknowledged the Black Lives Matter movement's criticism of police, many saw continued value in police involvement in substance use interventions, due to their accessibility in communities and capacity for rapid response. Conclusions: PAR programs quickly adapted to a largely remote format, increasing longer-term accessibility. While Black Lives Matter had little direct impact on PAR programs, concerns about police-community relations were acknowledged. Recommendations include further police training to enhance trust and reduce stigma, and wider integration of digitally-based substance use referral options.

Rural-Urban Residence and Maternal Hepatitis C Infection, U.S.: 2010-2018

INTRODUCTION

The prevalence of hepatitis C virus infection among women delivering live births in the U.S. may be higher in rural areas where county-level estimates may be unreliable. The aim of this study is to model county-level maternal hepatitis C virus infection among deliveries in the U.S.

METHODS

In 2020, U.S. natality files (2010-2018) with county-level maternal residence information were used from states that had adopted the 2003 revised U.S. birth certificate, which included a field for hepatitis C virus infection present during pregnancy. Hierarchical Bayesian spatial models with spatiotemporal random effects were applied to produce stable annual county-level estimates of maternal hepatitis C virus infection for years when all states had adopted the revised birth certificate (2016-2018). Models included a 6-Level Urban-Rural County Classification Scheme along with the birth year and county-specific covariates to improve posterior predictions.

RESULTS

Among approximately 32 million live births, the overall prevalence of maternal hepatitis C virus infection was 3.5 per 1,000 births (increased from 2.0 in 2010 to 5.0 in 2018). During 2016-2018, posterior predicted median county-level maternal hepatitis C virus infection rates showed that nonurban counties had 3.5-3.8 times higher rates of hepatitis C virus than large central metropolitan counties. The counties in the top 10th percentile for maternal hepatitis C virus rates in 2018 were generally located in Appalachia, in Northern New England, along the northern border in the Upper Midwest, and in New Mexico.

CONCLUSIONS

Further implementation of community-level interventions that are effective in reducing maternal hepatitis C virus infection and its subsequent morbidity may help to reduce geographic and rural disparities.

Age-based preferences for risk communication in the fentanyl era: 'A lot of people keep seeing other people die and that's not enough for them'

AIMS

To explore how people who use fentanyl and health-care providers engaged in and responded to overdose risk communication interactions, and how these engagements and responses might vary by age.

DESIGN

A single-site qualitative in-depth interview study.

SETTING

Boston, MA, United States.

PARTICIPANTS

The sample included 21 people (10 women, 11 men) who were either 18-25 or 35+, English-speaking, and reported illicit fentanyl use in the last year and 10 health-care providers who worked directly with people who use fentanyl (PWUF) in clinical and community settings.

MEASUREMENTS

Open-ended, flexible interview questions guided by a risk communication framework were used in all interviews. Codes used for thematic analysis included deductive codes related to the risk communication framework and inductive, emergent codes from interview content.

FINDINGS

We identified potential age-based differences in perceptions of fentanyl overdose, including that younger participants appeared to display more perceptions of an immunity to fentanyl's lethality, while older people seemed to express a stronger aversion to fentanyl due to its heightened risk of fatal overdose, shorter effects and potential for long-term health consequences. Providers perceived greater challenges relaying risk information to young PWUF and believed them to be less open to risk communication. Compassionate harm reduction communication was preferred by all participants and perceived to be delivered most effectively by community health workers and peers. PWUF and providers identified structural barriers that limited compassionate harm reduction, including misalignment of available treatment with preferred options and clinical structures that impeded the delivery of risk communication messages.

CONCLUSIONS

Among people who engage in illicit fentanyl use, fentanyl-related risk communication experiences and preferences may vary by age, but some foundational elements including compassionate, trust-building approaches seem to be preferred across the age spectrum. Structural barriers in the clinical setting such as provider-prescribing power and infrequent encounters may impede the providers' ability to provide compassionate harm reduction communication.

Alcohol outlets, drug paraphernalia sales, and neighborhood drug overdose

BACKGROUND

Alcohol outlets have been associated with various forms of injury and may contribute to neighborhood disparities in drug overdose. Few studies have examined the associations between alcohol outlets and drug overdose. This study investigated whether alcohol outlets were associated with the neighborhood drug overdose rate and whether the sale of drug paraphernalia contributes to this association.

METHODS

A cross-sectional ecological spatial analysis was conducted within census block groups in Baltimore City (n = 653). Outcomes were counts of EMS calls for any drug overdose in 2015 (n = 3,856). Exposures of interest were counts of alcohol outlets licensed for off-premise and on-premise consumption and the proportion of off-premise outlets selling drug paraphernalia (e.g., blunt wrappers, baggies, pipes). Negative binomial regression was used to assess the relationship between outlet count and overdose rate, and if paraphernalia sales altered this relationship, controlling for other neighborhood factors. Spatial autocorrelation was assessed and regression inference adjusted accordingly.

RESULTS

Each additional off-premise alcohol outlet was associated with a 16.6% increase in the neighborhood overdose rate (IRR=1.17, 95%CI=(1.11, 1.23)), adjusted for other neighborhood variables. On-premise alcohol outlets were not significantly associated with overdose rate when adjusting for off-premise alcohol outlets (IRR=1.01, 95% CI=(0.97, 1.06)). The proportion of off-premise outlets that sold drug paraphernalia was negatively associated with overdose rate (IRR=0.55, 95% CI=(0.41, 0.74)) and did not alter the relationship between off-premise outlets and overdose.

CONCLUSION

This study provides preliminary public health evidence for informing policy decisions about alcohol outlet licensing and zoning. Alcohol outlets could be potential community partners for harm reduction strategies such as health communication in identifying overdose symptoms or Good Samaritan Laws.

How Are Telehealth Laws Intersecting With Laws Addressing the Opioid Overdose Epidemic?

Opioid-involved drug overdose deaths have been a growing concern in the United States for several decades. The Centers for Disease Control and Prevention identified several strategies to address the opioid overdose epidemic, including increased availability of and access to medication-assisted treatment and guidance on safer opioid prescribing practices. Telehealth offers the potential for increasing access and availability to these strategies, and laws governing telehealth have implications for their utilization. To understand how state telehealth laws intersect with the opioid overdose epidemic, we conducted a legal mapping study, a type of legal epidemiological assessment, of statutes and regulations that intersect at telehealth and opioids. This search yielded 28 laws from 17 states. These laws intersect both telehealth and the opioid overdose epidemic in different ways including prescribing limitations, opioid treatment through medication and counseling, patient plan review, and professional collaboration. Continued legal and policy surveillance is needed to be able to evaluate the impact of law in addressing opioid overdose outcomes.

Hospital admissions and mortality due to complications of injection drug use in two hospitals in Regina, Canada: retrospective chart review

BACKGROUND

Infectious complications of injection drug use (IDU) often require lengthy inpatient treatment. Our objective was to identify the number of admissions related to IDU in Regina, Canada, as well as describe patient demographics and comorbidities, yearly mortality, readmission rate, and cumulative cost of these hospitalizations between January 1 and December 31, 2018. Additionally, we sought to identify factors that increased risk of death or readmission.

METHODS

This study is a retrospective chart review conducted at the two hospitals in Regina. Eligible study cases were identified by querying the discharge database for predetermined International Classification of Diseases code combinations. Electronic medical records were reviewed to assess whether each admission met inclusion criteria, and hospitalization and patient data were subsequently extracted for all included admissions. Mortality data were gleaned from hospital and Ministry of Health databases. Data were analyzed using Excel and IBM SPSS Statistics to identify common comorbidities, admission diagnoses, and costs, as well as to compare patients with a single admission during the study period to those with multiple admissions. Logistic regression analysis was used to identify the relationship between individual variables and in- and out-of-hospital annual mortality.

RESULTS

One hundred and forty-nine admissions were included, with 102 unique patients identified. Common comorbidities included hepatitis C (47%), human immunodeficiency virus (HIV) (25%), and comorbid psychiatric disorders (19%). In 23% of all admissions, patients left hospital prior to treatment completion, and 27% of patients experienced multiple admissions. Female patients and those with chronic pain were more likely to be readmitted (p = 0.024 and p = 0.029, respectively). Patients admitted with infective endocarditis were more likely to die during hospitalization (p = 0.0001). The overall mortality was 15% in our cohort. The estimated cumulative cost of inpatient treatment of complications of IDU in Regina was $3.7 million CAD in 2018.

CONCLUSION

Patients with history of IDU and hospital admission experience high mortality rates in Regina, a city with paucity of inpatient supports for persons who use injection drugs. Needle syringe programs, opioid agonist therapy, and safe consumption sites have been shown to improve outcomes as well as reduce healthcare costs for this patient population. We will use our findings to advocate for increased access to these harm reduction strategies in Regina, particularly for inpatients.

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

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

Postmortem screening of opioids, benzodiazepines, and alcohol among rural and urban suicide decedents

PURPOSE

Fatal suicides involving opioids are increasingly common, particularly in rural areas. As co-use of opioids with other substances contributes significantly to mortality risk, we examined whether positive screens for opioids with other substances is more prevalent among rural versus urban suicide deaths, as this could have implications for public health strategies to reduce overdose suicides.

METHODS

Data from all states reporting opioid-related overdose suicides in the National Violent Death Reporting System from 2012 to 2015 were used. Relative risk ratios were obtained using multinomial logistic regression, comparing opioid-only to (1) opioid and alcohol, (2) opioid and benzodiazepines, and (3) opioid, alcohol, and benzodiazepines suicides across rurality. Models were fit using robust standard errors and fixed effects for year of death, adjusting for individual, county, and state-level covariates.

FINDINGS

There were 3,781 opioid-overdose suicide decedents (42% female) tested for all 3 substances during the study period. Unadjusted prevalence of positive screens in decedents varied across rurality (P = .022). Urban decedents were more likely to test positive for opioids alone, while rural decedents were more to likely test positive for opioids and benzodiazepines.

CONCLUSIONS

Rural suicides are associated with increased opioid and benzodiazepine positive screens. These findings suggest the need for rural-focused interventions to support appropriate co-prescribing, better health education for providers about risks associated with drug mixing, and more linkages with mental health services.

A 2019 evaluation of opioid use disorder treatment resources in rural Utah counties

OBJECTIVES

The opioid crisis significantly affects residents of rural communities who already experience poor health outcomes based on social determinants. Therefore, this project evaluated the reported availability and accessibility of opioid use disorder (OUD) treatment resources in rural Utah county pharmacies through a multistep process intended to estimate the distance (miles) to registered (waivered) OUD care providers and community pharmacies and, thus, the ability to fill prescriptions for OUD treatment medications.

METHODS

First, the United States Department of Agriculture Economic Research Service dichotomous classification scheme was used to identify nonmetropolitan counties. Second, online resources were used to identify the volume of waivered treatment providers and community pharmacies by county. Third, the driving distances to both resources were estimated according to ZIP Code and county. Finally, the immediate availability of filling a prescription for OUD treatment medications was determined by surveying community pharmacists in rural Utah counties.

RESULTS

Nineteen of the 29 Utah counties were identified as rural and included in the study. Pharmacists in 50 of the 75 viable pharmacies completed surveys (66.7% usable response rate). OUD treatment medications were immediately available for dispensing in 90% (45 of 50) of the responding pharmacies. Two of the 19 counties (10.5%) lacked a pharmacy, and 6 of the 19 counties (31.6%) lacked a registered OUD treatment provider. Driving distances ranged from 1 mile to 71 miles to the nearest pharmacy and from 1 mile to 96 miles to the nearest waivered treatment provider.

CONCLUSION

OUD treatment medications were readily available in some but not all rural Utah pharmacies. However, geographic barriers may prevent reasonable access to treatment providers and pharmacies for residents of smaller, remote communities.

The Emerging Intersection Between Injection Drug Use and Early Syphilis in Nonurban Areas of Missouri, 2012-2018

BACKGROUND

The national rate of syphilis has increased among persons who inject drugs (PWID). Missouri is no exception, with increases in early syphilis (ES), congenital syphilis, and PWID, especially in nonurban counties.

METHODS

Disease intervention specialist records for ES cases in Missouri (2012-2018) were examined. Drug use was classified as injection drug use (IDU) (opioid or methamphetamine) or non-IDU (opioid, methamphetamine, or cocaine). Rates were compared based on residence, sex of sex partner, and drug use.

RESULTS

Rates of ES in Missouri increased 365%, particularly in small metropolitan and rural areas (1170%). Nonurban areas reported a higher percentage of persons with ES who used injection drugs (12%-15%) compared with urban regions (2%-5%). From 2012 to 2018, women comprised an increasing number of ES cases (8.3%-21%); 93% of women were of childbearing age. Increasingly more women in rural areas with ES also reported IDU during this time (8.4%-21.1%).

CONCLUSIONS

As syphilis increases in small metropolitan and rural regions, access to high-quality and outreach-based sexual health services is imperative. Healthcare policy to equip health departments with harm reduction services and drug treatment resources offers an opportunity to impact both syphilis increases as well as health outcomes associated with IDU.

"One size does not fit all" and other lessons learned from grants for implementation of the AHRQ medication assisted treatment for opioid use disorder in rural primary care

Purpose: This article summarizes lessons learned from five AHRQ grants to implement Medication for Opioid Use Disorder (MOUD) in rural primary care practices. Methods: Lessons learned were extracted from quarterly and annual grantee progress reports, minutes from quarterly virtual meetings, and minutes and notes from annual grantee in-person meetings. The lessons learned were drafted by the authors and reviewed by the grantees for accuracy. Results: The experience of these projects suggest that recruiting providers in rural areas and engaging them to initiate and sustain provision of MOUD is very difficult. Innovative approaches and providing supports are required for supporting providers to overcome barriers. Implications: Implementation of MOUD in rural primary care is challenging but success is more likely if implementers are attentive to the needs of individual providers, are flexible and tailor implementation to the local situation, and provide on-going support.

A large-scale retrospective study of opioid poisoning in New York State with implications for targeted interventions

Opioid overdose related deaths have increased dramatically in recent years. Combating the opioid epidemic requires better understanding of the epidemiology of opioid poisoning (OP). To discover trends and patterns of opioid poisoning and the demographic and regional disparities, we analyzed large scale patient visits data in New York State (NYS). Demographic, spatial, temporal and correlation analyses were performed for all OP patients extracted from the claims data in the New York Statewide Planning and Research Cooperative System (SPARCS) from 2010 to 2016, along with Decennial US Census and American Community Survey zip code level data. 58,481 patients with at least one OP diagnosis and a valid NYS zip code address were included. Main outcome and measures include OP patient counts and rates per 100,000 population, patient level factors (gender, age, race and ethnicity, residential zip code), and zip code level social demographic factors. The results showed that the OP rate increased by 364.6%, and by 741.5% for the age group > 65 years. There were wide disparities among groups by race and ethnicity on rates and age distributions of OP. Heroin and non-heroin based OP rates demonstrated distinct temporal trends as well as major geospatial variation. The findings highlighted strong demographic disparity of OP patients, evolving patterns and substantial geospatial variation.

Rural adults' perceived role of family members in prescription opioid misuse prevention: Implications for family-based approaches

PURPOSE

This study explored and documented rural adults' perceptions of family roles in prescription opioid misuse prevention and the predisposing, reinforcing, and enabling factors that influence family members from taking those roles.

METHODS

Nine focus groups with rural adults (n = 55) were conducted to evoke discussion about family roles in prescription opioid misuse prevention. Transcripts were coded based on common ideas that arose during the focus groups, previous literature, and the PRECEDE-PROCEED program planning model.

FINDINGS

Findings suggest that rural adults perceive the opioid epidemic as partially a family problem. Additionally, rural adults perceive themselves as having a critical role in preventing prescription opioid misuse among family members. Participants identified specific predisposing, reinforcing, and enabling factors that influence whether or not family members take responsibility in preventing prescription opioid misuse within their families. Rural adults also perceive that family-based education is important in preventing prescription opioid misuse.

CONCLUSIONS

These results suggest that there is an interest in family-based approaches that enable or foster the skills and resources necessary to engage in prescription opioid misuse prevention behaviors. Specifically, family-based prevention programming should include efforts to shape knowledge and attitudes about prescription opioid misuse, increase resources to facilitate prevention behaviors, and build skills related to prevention.

Within-subject evaluation of interim buprenorphine treatment during waitlist delays

BACKGROUND

The effectiveness of opioid agonist treatment for opioid use disorder (OUD) is well established, and delays to treatment are still common, particularly in rural geographic areas. In a randomized 12-week pilot study, we demonstrated initial efficacy of a technology-assisted Interim Buprenorphine Treatment (IBT) vs. continued waitlist control (WLC) for reducing illicit opioid use and other risk behaviors during waitlist delays. Upon completion of that parent trial, WLC participants were given the opportunity to receive 12 weeks of IBT, permitting an additional within-subject examination of IBT effects.

METHODS

Sixteen WLC participants crossed over to receive IBT, involving buprenorphine maintenance with bi-monthly visits, medication administration at home via a computerized device, daily monitoring calls using an Interactive Voice Response (IVR) phone system, and IVR-generated random call-backs. Biochemically-verified illicit opioid abstinence, changes in psychosocial functioning, and HIV + HCV knowledge were examined among participants originally randomized to the WLC phase and who subsequently crossed over to IBT (IBTc).

RESULTS

Participants submitted a higher percentage of illicit opioid negative specimens at Weeks 4, 8, and 12 during IBT (75 %, 63 %, and 50 %) vs. WLC (0%, 0%, and 0%), respectively (p's<.01). Participants also demonstrated improvements in anxiety, depression, and HIV and HCV knowledge (p's<.01). Medication administration, daily IVR call and random call-back adherence and treatment satisfaction were also favorable.

CONCLUSIONS

This within-subject evaluation provides additional support for interim buprenorphine's efficacy in reducing illicit opioid use and improving health outcomes during waitlist delays for more comprehensive treatment.

Impact of benzodiazepines and polysubstance status on repeat non-fatal drug overdoses

Research has shown that benzodiazepines and mental health disorders can increase the likelihood of repeat overdose, but researchers have not explored this association in Tennessee (TN). We examined benzodiazepines, polysubstance overdose status with/without benzodiazepines, and mental health comorbidities with repeat overdose using statewide data in TN. This study analyzed TN hospital discharge data on nonfatal overdoses for patients ages 18-64 from 2012 to 2016 for 21,066 patients with an initial inpatient visit and 36,244 patients with an initial outpatient visit. The study assessed each patient at one year after initial overdose to determine likelihood of repeat overdose. We used a Cox proportional hazards model to compute hazard ratios (HRs) and 95% confidence intervals (CIs) to determine the factors associated with repeat nonfatal overdose. Repeat overdose rates, by one year after index overdose, were 12.9% of the sample for inpatients and 13.9% of the sample for outpatients. The visit factors (overdose characteristics and comorbidities determined from the initial visit) that the study found to be independently associated with repeat overdoses among inpatients were polysubstance status (HR: 0.88, 95% CI 0.78-0.99), benzodiazepine/polysubstance interaction (HR: 1.29, 95% CI 1.02-1.64), and presence of any mental health disorder (HR: 1.28, 95% CI: 1.18-1.39). For outpatients, the benzodiazepine/polysubstance interaction (HR: 1.21, 95% CI 1.01-1.44) was significant without adjusting for demographic factors. We found evidence that benzodiazepine/polysubstance status and mental health disorders were associated with repeat overdose for inpatients, and that benzodiazepine/polysubstance status was associated with repeat overdose for outpatients. Findings support the need to include polysubstance status and mental health in overdose prevention efforts.