File Name: substance abuse among rural and very rural drug users at treatment entry .zip
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- The American Opioid Epidemic in Special Populations: Five Examples
- Prevalence updates of substance use among Egyptian adolescents
This study identifies predictors of substance abuse treatment entry over 24 months among illicit stimulant users in rural areas of Ohio, Arkansas, and Kentucky. Participants completed structured interviews at baseline and follow-up questionnaires every 6 months for 24 months.
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The United States is in the midst of an unprecedented crisis of prescription and illicit opioid misuse, use disorder, and overdose. In , nearly 47, Americans died from an overdose involving opioids .
In , Although the crisis has affected large swaths of the U. Other than for persons who inject drugs, little research to date has been dedicated toward understanding the specific needs of these special populations, including building the evidence base for targeted approaches and solutions.
Research has clearly shown that solutions for the opioid overdose epidemic are not one size fits all, and special attention should be paid to these populations that may be suffering unduly. For each identified population, this manuscript reviews why it is an important area of focus, current barriers encountered in accessing care, promising approaches in supporting this population, and high-impact research and action priorities.
Economic decline, incarceration, and drug-related mortality are tightly connected at a population level . More than ten million people pass through the justice system each year and over two million people are confined in U. Among those who encounter the justice system, rates of opioid use are significantly higher than in the general population .
This linkage is not surprising: possession and use of many drugs are illegal and people who experience substance use disorder may commit crimes in order to acquire their desired addictive substance. Justice involvement may include a range of experiences, including detention in local jails, state prisons, or federal prisons, as well as monitoring while in the community as part of community corrections i.
From through , more than a quarter of those who were detained in state prisons or jails reported a history of opioid use .
In the intervening years, rates of opioid use and overdose have risen sharply , suggesting that the current rates of illicit opioid use and opioid use disorder OUD among individuals involved in the justice system are likely significantly higher in Another recent analysis also demonstrated that as the intensity of opioid use increases, the likelihood of justice involvement increases .
Further, a recent review of fatality records found that individuals with adjudicated arrest records experienced fatal overdoses at a significantly elevated rate relative to state residents without arrest records . Given the high prevalence of substance use in justice-involved populations, including opioid use and OUD, jails and prisons represent one of the largest providers of treatment for substance use disorders SUDs in the United States and a location where evidence-based interventions and solutions could make the biggest impact.
Prisons and jails present different challenges in ensuring provision of care to those in detention. In particular, most jail stays are relatively short compared to the many years individuals typically spend in prison.
The average jail stay in was 25 days , which poses challenges for screening and initiating treatment, as well as a risk of disruption of ongoing treatment. It is therefore important that as individuals are being processed toward a jail stay, substance use treatment needs are identified and appropriate care is provided, including continuity of any treatment that an individual may have been receiving prior to their arrest. Timing of release from jail can also be unpredictable for short stays, particularly for people being held prior to a conviction i.
Jails are typically managed at a county level, which can result in significant resource challenges due to a lack of federal funding. Nonetheless, many jails across the United States are embracing these challenges and developing new models for providing medications for opioid use disorder MOUD in this dynamic environment.
In the coming years, new data should be available to provide insight into how effective these models are. For longer stays in both jails and prisons, concerns about costs of treatment, logistics of providing care e. Continuity of care is essential as people exit the jail and return to their community.
This transition is a critical period of vulnerability for people with OUD. Overdose-related mortality risk is very high fold increased risk during the first weeks of re-entry as individuals exit the jail and return home . Ensuring continuity of care during re-entry requires relationships between justice systems and community-based providers, including managing cross-agency information sharing.
It is also critical to address the logistics of helping individuals navigate what can be a chaotic time, as life chaos is predictive of poor general health outcomes in justice-involved populations . Further, the needs of individuals with OUD tend to be quite complex; mental and physical health comorbidities, including human immunodeficiency virus HIV and hepatitis C virus HCV , are common in this population .
In addition, electronic records in prisons and jails are relatively rare, and thus it can be difficult to acquire records of treatment received during periods of incarceration.
Justice-involved individuals may experience numerous obstacles when trying to access treatment in their communities, including lack of insurance or limited community capacity to provide MOUD.
These challenges may be exacerbated by the stigma of both their addiction and their involvement in the justice system. Justice-involved individuals are less likely to have health insurance coverage, though recent data suggest that the expansion of eligibility under the Affordable Care Act has reduced these disparities . Even in outpatient treatment for OUD, justice-referred individuals are only one-tenth as likely as their non-justice- involved peers to receive agonist MOUD .
Further, it is typical to experience significant delays when trying to set up appointments with community-based providers, and these delays in treatment can lead to a return to use of opioids. Ensuring access to MOUD for justice-involved populations is important both when people are incarcerated as well as when they have returned to their communities.
A smooth connection to community-based services as individuals are being discharged from incarceration can dramatically reduce the risk of opioid-related mortality upon community re-entry . Often, however, these programs have been characterized by offering only a single medication, rather than all three FDA-approved forms of MOUD. This has slowly begun to change, with positive results.
An important aspect of the Rhode Island model is that it offered all three FDA-approved medications to patients, allowing them to choose the medication best suited to their needs.
When offered this choice, almost none selected naltrexone. It is interesting that so few patients selected naltrexone when given the opportunity to select their preferred treatment. Many jail administrators prefer naltrexone and may offer this as the only MOUD . There are also pragmatic reasons for this preference among jail administrators: unlike buprenorphine and methadone, naltrexone does not require special training or approvals for medical staff to deliver and is perceived as low-risk for diversion in secure settings.
Even so, these considerations must be weighed against the fact that naltrexone does not have as robust of an evidence base as methadone and buprenorphine in justice settings . Naltrexone has been shown to have a benefit for those who can be successfully inducted [99,], but many people are not successfully inducted, and successful induction can be particularly challenging in jail settings, where stays are very brief.
Other promising approaches focus on re-directing people with an SUD away from the justice system, and in particular reducing the number of people incarcerated for drug-related offenses and connecting them instead to treatment. This process may not only save lives, but also result in significant cost savings . This re-direction has begun to happen through policy changes at both state and local levels. Innovative practices in drug courts also show promise.
Like jails, many courts have been historically opposed to MOUD treatment, but this is changing. The utilization and prescription of MOUD in justice settings not only reduce mortality but are also potentially very cost effective.
Another promising tool for reducing overdose mortality is providing overdose education and distributing naloxone in justice settings. Community re-entry is a period of heightened risk for overdose and providing naloxone may signifi cantly reduce risk during this time . To improve care for justice-involved people, it is important to develop processes to systematically identify treatment needs and connections to care prior to incarceration, while incarcerated, and upon return to the community.
Drug courts divert people with OUD to treatment. Although drug courts are a promising approach to ensure that those with OUD receive treatment instead of detention, there are still significant barriers to integrating MOUD into drug courts, and these barriers must be addressed for drug courts to reach their full potential. Research focused on standardizing quality of treatment and ensuring standardized support infrastructure through drug courts could significantly advance the effectiveness of this intervention.
It has not been standard practice to offer MOUD in jails and prisons, but several court rulings in suggest that this may rapidly change. Rhode Island offers a powerful example of the potential of this approach, though the state has a relatively uncommon structure in that its jail and prison systems are unified. The initiative, which includes treatment initiation and continuation during incarceration, and continuation of treatment upon return to the community, represents an important partnership between justice-involved stakeholders and community-based providers.
To address the challenges of continuity of treatment, it is critical that services and needs are coordinated as the individual exits the jail and returns to their community. One option is low-threshold approaches to treatment, including models that bring care to individuals via mobile vans, peer recovery support, and immediate access to MOUD . Another promising approach is data-driven collaborations between justice systems and community-based health care providers that could provide a powerful tool for reducing gaps in care.
It is critical to ensure continuity of care and engagement in care in the community, as both have been associated with reductions in criminal activity. Suspending Medicaid coverage, rather than terminating it, helps facilitate continuity of care after release . Some states are further experimenting with Medicaid Managed Care organizations to facilitate continuity of treatment after release .
This continuous care approach is an important tool for addressing the public health and public safety risks that emerge during transitions between justice-involved and community settings. Attending to OUD in justice-involved populations requires attending not just to their substance use problems, but to the full spectrum of their needs, including comorbid physical and mental health needs.
Thus, effectively addressing substance use within justice-involved populations requires a multi-level or multi-system approach, engaging multiple organizations within a community e. Even within a jail, multiple vendors may provide services and require significant effort to coordinate, so often individuals who are incarcerated receive fragmented care throughout their stay.
The Transitions Clinic model, which focuses on providing health care in primary care settings for people returning to communities, is a promising model for truly integrated care . In short, partnerships between community-based health and justice systems are essential to effectively improving outcomes for this population, which drives many of the societal costs of the opioid epidemic. Despite a decline in opioid prescribing dating back to , rural opioid prescribing rates continue to be higher than urban counterparts at both the individual and community levels .
In , 14 of the 15 counties with the highest opioid prescribing rate were rural [31,64]. More opioid prescriptions in rural areas ultimately contributed to more prescription opioid-involved deaths than in urban areas .
Opioid-involved deaths do not affect all rural communities equally. Counties facing greater economic distress have higher drug overdose mortality rates than more stable areas , contributing to increased deaths among rural  working-class whites.
This may help explain the clustering of rural opioid-involved deaths from — in states e. However, the pattern does not hold in rural New England, where fewer individuals live in poverty but more per capita die from opioids than in other regions, or the rural South, where more individuals live in poverty but fewer die as a result of opioid misuse .
Rural populations face numerous barriers to treatment, including a lack of appropriate providers and opioid treatment programs OTPs and complications due to relatively smaller social networks and greater transportation distances to treatment. Compared to their urban counterparts, rural residents often travel longer distances to health care, including more than 20 miles to specialized treatment for OUD in Kentucky .
The recent inclusion of certain non-physician practitioners NPPs as waivered providers  expanded treatment availability in 43 rural counties . However, 28 states prohibit certain NPPs from prescribing buprenorphine without a waivered supervising physician , which does not remove the barrier that allowing NPPs to prescribe buprenorphine was intended to reduce.
Further, in , Residents of rural counties in five states had to drive 40 minutes longer than their urban peers to reach an OTP in . The availability of fewer treatment providers in rural communities likely contributes to worse consequences for opioid misuse than in urban communities . To address this, recently proposed regulations from the DEA would ease registration requirements for OTPs that dispense methadone in remote locations .
Social networks tend to be much closer-knit in rural than in urban communities, and these relationships facilitate faster and broader diversion of prescription opioids for misuse [91,]. More intimate community relationships are also associated with higher opioid prescribing rates among rural providers . Lack of anonymity and higher chances of personal recognition likely contribute to the stigma that may also hinder rural patients, particularly pregnant women, from seeking treatment, especially in highly visible, traditional delivery settings for behavioral health care [78,].
When naloxone is more readily available and those who have it know how to use it, overdose mortality can decrease significantly. Various individuals and organizations have effectively distributed naloxone in rural communities, including community-based programs, pharmacies, first responders, bystanders, and harm reduction programs such as syringe service programs SSPs [53,,].
SSPs also seek to reduce instances of drug overdose through overdose education, naloxone distribution, and information sharing on overdose prevention strategies. Comprehensive SSPs provide additional social and medical services, such as vaccinations, referral to treatment, and health education. Expanding comprehensive SSPs to more rural communities can prevent opioid-involved overdose deaths and may also help reduce related infections, primarily HIV and HCV, among people who inject drugs .
The American Opioid Epidemic in Special Populations: Five Examples
The United States is in the midst of an unprecedented crisis of prescription and illicit opioid misuse, use disorder, and overdose. In , nearly 47, Americans died from an overdose involving opioids . In , Although the crisis has affected large swaths of the U. Other than for persons who inject drugs, little research to date has been dedicated toward understanding the specific needs of these special populations, including building the evidence base for targeted approaches and solutions.
Request PDF | Rural-urban differences in substance use and treatment utilization Chronic drug abusers from rural and very rural areas have and treatment admission for methamphetamine use are higher in rural areas.
Prevalence updates of substance use among Egyptian adolescents
J Addict Dis. J Opioid Manag. Am J Drug Alcohol Abuse. Knudsen HK, Ducharme LJ, Roman PM: Controlled-release oxycodone admissions in public and private substance abuse treatment: associations with organizational characteristics. National Drug Intelligence Center: Kentucky drug threat assessment.
Not a MyNAP member yet? Register for a free account to start saving and receiving special member only perks. The quality of the rural health care delivery system is determined by the availability of providers and health care facilities to rural residents and the ability of those providers and organizations to give care that is needed and effective in generating positive health outcomes Gregg and Moscovice, ; Rosenblatt,
Metrics details. The problem of substance use is becoming one of the most serious and rapidly growing phenomena all over the world. Efficient and well-designed prevalence studies for mental illnesses including substance use problems need to be regularly updated, in order to rearrange the prevention and management plans on a scientific basis. The aim of the study is to detect the prevalence of substance use and dependence among secondary school students, as they are one of the high-risk populations for drug use, targeting a representative sample of 10, of students.
Metrics details. Cross-sectional and prospective cohort designs were employed to examine the study aims. There were large decreases after treatment in heavy alcohol and illegal drug use, crime, and gang related risk activities. Alcohol use is the drug of choice among DAT patients in El Salvador with gang member patients having used illegal drugs more than non-gang members. The study shows that DAT centers successfully reduced the use of illegal drugs and alcohol among gang and non-gang members. Although our study could not include a control group, we believe that the DAT treatment centers in El Salvador contributed to producing this treatment success among former patients.
Data were collected from face-to-face interviews with drug users in rural areas of Ohio, Arkansas, and Kentucky. A negative binomial regression model indicated that selected predisposing, historical health, and enabling factors were significantly associated with the utilization of substance abuse treatment among rural drug users. Despite high levels of recent and lifetime self-reported substance use among these rural drug users, treatment services were underutilized. Future studies are needed to examine the impact of the health care system and characteristics of the external environment associated with rural substance abuse treatment in order to increase utilization among drug users. The health service utilization patterns, including those for substance abuse treatment, among illicit drug users are not well known. Therefore, it is important to examine the factors associated with utilization of substance abuse treatment by rural drug users who meet lifetime DSM-IV criteria for substance dependence. According to the National Institute on Drug Abuse NIDA , , , stimulants are psychoactive substances that increase activity in the central nervous system and can produce physical dependence.
Long-standing systemic health and social inequities have put some rural residents at increased risk of getting COVID or having severe illness. In general, rural Americans tend to have higher rates of cigarette smoking, high blood pressure, and obesity as well as less access to healthcare which can negatively affect health outcomes. They are also less likely to have health insurance. Rural communities are also becoming more diverse racially and ethnically. Rural areas can face different health challenges depending on where they are located. Each rural community should assess their unique susceptibility pdf icon external icon and social vulnerability to COVID
This study uses a functional perspective to examine the reasons young people cite for using psychoactive substances.