Attitudes of Black American Christian church leaders toward Opioid Use Disorder, overdoses, and harm reduction: a qualitative study.

Introduction: Black American Christian church leaders are trusted community members and can be invaluable leaders and planners, listeners, and counselors for Opioid Use Disorder (OUD) sufferers in the opioid overdose crisis disproportionately affecting the Black community. This qualitative study examines the extent to which the knowledge, attitudes, practices, and beliefs of Black American church leaders support medical and harm reduction interventions for people with OUD. Methods: A semi-structured interview guide was used to conduct in-depth interviews of 30 Black Rhode Island church leaders recruited by convenience and snowball sampling. Results: Thematic analysis of the interviews identified four themes: Church leaders are empathetic and knowledgeable, believe that hopelessness and inequity are OUD risk factors, are committed to helping people flourish beyond staying alive, and welcome collaborations between church and state. Conclusion: Black American Christian church leaders are a critical resource in providing innovative and culturally sensitive strategies in the opioid overdose crisis affecting the Black American communities. As such, their views should be carefully considered in OUD policies, collaborations, and interventions in the Black American community.

Mental and physical health morbidity among people in prisons: an umbrella review.

BACKGROUND: People who experience incarceration are characterised by poor health profiles. Clarification of the disease burden in the prison population can inform service and policy development. We aimed to synthesise and assess the evidence regarding the epidemiology of mental and physical health conditions among people in prisons worldwide. METHODS: In this umbrella review, five bibliographic databases (Web of Science, PubMed, PsycINFO, Embase, and Global Health) were systematically searched from inception to identify meta-analyses published up to Oct 31, 2023, which examined the prevalence or incidence of mental and physical health conditions in general prison populations. We excluded meta-analyses that examined health conditions in selected or clinical prison populations. Prevalence data were extracted from published reports and study authors were contacted for additional information. Estimates were synthesised and stratified by sex, age, and country income level. The robustness of the findings was assessed in terms of heterogeneity, excess significance bias, small-study effects, and review quality. The study protocol was pre-registered with PROSPERO, CRD42023404827. FINDINGS: Our search of the literature yielded 1909 records eligible for screening. 1736 articles were excluded and 173 full-text reports were examined for eligibility. 144 articles were then excluded due to not meeting inclusion criteria, which resulted in 29 meta-analyses eligible for inclusion. 12 of these were further excluded because they examined the same health condition. We included data from 17 meta-analyses published between 2002 and 2023. In adult men and women combined, the 6-month prevalence was 11·4% (95% CI 9·9-12·8) for major depression, 9·8% (6·8-13·2) for post-traumatic stress disorder, and 3·7% (3·2-4·1) for psychotic illness. On arrival to prison, 23·8% (95% CI 21·0-26·7) of people met diagnostic criteria for alcohol use disorder and 38·9% (31·5-46·2) for drug use disorder. Half of those with major depression or psychotic illness had a comorbid substance use disorder. Infectious diseases were also common; 17·7% (95% CI 15·0-20·7) of people were antibody-positive for hepatitis C virus, with lower estimates (ranging between 2·6% and 5·2%) found for hepatitis B virus, HIV, and tuberculosis. Meta-regression analyses indicated significant differences in prevalence by sex and country income level, albeit not consistent across health conditions. The burden of non-communicable chronic diseases was only examined in adults aged 50 years and older. Overall, the quality of the evidence was limited by high heterogeneity and small-study effects. INTERPRETATION: People in prisons have a specific pattern of morbidity that represents an opportunity for public health to address. In particular, integrating prison health within the national public health system, adequately resourcing primary care and mental health services, and improving linkage with post-release health services could affect public health and safety. Population-based longitudinal studies are needed to clarify the extent to which incarceration affects health. FUNDING: Research Foundation-Flanders, Wellcome Trust, National Institutes of Health.

Pharmacy-based expansion of buprenorphine access.

INTRODUCTION: Access to evidence-based medication treatment is a challenge for most Americans with opioid use disorder. New models of collaborative care that actively incorporate pharmacists are being trialed. METHODS: We author a commentary based on our experiences providing clinical care as part of a randomized controlled trial of pharmacy-based addiction care. RESULTS: This commentary describes some of the experiences of working with a Collaborative Practice Agreement between pharmacists and physicians to provide pharmacy-based, low-threshold buprenorphine access. CONCLUSION: Given that 87 % of Americans with opioid use disorder are not getting access to buprenorphine or methadone, establishing a pharmacy-based buprenorphine treatment program is a promising strategy to address that gap and should be explored promptly.

Reimbursing incarcerated individuals for participation in research: A scoping review.

BACKGROUND: Little is known about global practices regarding the provision of reimbursement for the participation of people who are incarcerated in research. To determine current practices related to the reimbursement of incarcerated populations for research, we aimed to describe international variations in practice across countries and carceral environments to help inform the development of more consistent and equitable practices. METHODS: We conducted a scoping review by searching PubMed, Cochrane library, Medline, and Embase, and conducted a grey literature search for English- and French-language articles published until September 30, 2022. All studies evaluating any carceral-based research were included if recruitment of incarcerated participants occurred inside any non-juvenile carceral setting; we excluded studies if recruitment occurred exclusively following release. Where studies failed to indicate the presence or absence of reimbursement, we assumed none was provided. RESULTS: A total of 4,328 unique articles were identified, 2,765 were eligible for full text review, and 426 were included. Of these, 295 (69%) did not offer reimbursement to incarcerated individuals. A minority (n = 13; 4%) included reasons explaining the absence of reimbursement, primarily government-level policies (n = 7). Among the 131 (31%) studies that provided reimbursement, the most common form was monetary compensation (n = 122; 93%); five studies (4%) offered possible reduced sentencing. Reimbursement ranged between $3-610 USD in total and 14 studies (11%) explained the reason behind the reimbursements, primarily researchers' discretion (n = 9). CONCLUSIONS: The majority of research conducted to date in carceral settings globally has not reimbursed incarcerated participants. Increased transparency regarding reimbursement (or lack thereof) is needed as part of all carceral research and advocacy efforts are required to change policies prohibiting reimbursement of incarcerated individuals. Future work is needed to co-create international standards for the equitable reimbursement of incarcerated populations in research, incorporating the voices of people with lived and living experience of incarceration.

Cruel and Unusual: Reforming Carceral Systems to Protect and Affirm Transgender and Gender-Diverse Communities.

Transgender and gender-diverse communities are disproportionately incarcerated in the USA. Incarcerated gender minority populations are detained within carceral systems constructed around a cisgender (gender identity matches sex assigned at birth) binary (only male and female identities recognized) understanding of gender. This leads to marginalizing experiences while perpetuating the extreme vulnerability individuals experience in the community. In order to address this cruel and unusual experience, carceral systems should undergo "whole-setting" reforms to protect and affirm transgender and gender-diverse populations. This includes ensuring access to gender-affirming clinical care that aligns with community health standards recommended by medical professional associations. Implementing gender-affirming reforms reduces security issues and will likely improve health outcomes providing mutual benefit for both correctional staff and gender minority populations. Given the current divisive political and social environment for gender minority populations in the USA, evidence-based person-centered reforms in corrections are needed now more than ever.

Prescribe to Save Lives: An Intervention to Increase Naloxone Prescribing Among HIV Clinicians.

OBJECTIVES: Overdose is a major cause of preventable death among persons living with HIV. This study aimed to increase HIV clinicians' naloxone prescribing, which can reduce overdose mortality. METHODS: We enrolled 22 Ryan White-funded HIV practices and implemented onsite, peer-to-peer training, posttraining academic detailing, and pharmacy peer-to-peer contact around naloxone prescribing in a nonrandomized stepped wedge design. Human immunodeficiency virus clinicians completed surveys to assess attitudes toward prescribing naloxone at preintervention and 6 and 12 months postintervention. Aggregated electronic health record data measured the number of patients with HIV prescribed and the number of HIV clinicians prescribing naloxone by site over the study period. Models controlled for calendar time and clustering of repeated measures among individuals and sites. RESULTS: Of 122 clinicians, 119 (98%) completed a baseline survey, 111 (91%) a 6-month survey, and 93 (76%) a 12-month survey. The intervention was associated with increases in self-reported "high likelihood" to prescribe naloxone (odds ratio [OR], 4.1 [1.7-9.4]; P = 0.001). Of 22 sites, 18 (82%) provided usable electronic health record data that demonstrated a postintervention increase in the total number of clinicians who prescribed naloxone (incidence rate ratio, 2.9 [1.1-7.6]; P = 0.03) and no significant effects on sites having at least one clinician who prescribed naloxone (OR, 4.1 [0.7-23.8]; P = 0.11). The overall proportion of all HIV patients prescribed naloxone modestly increased from 0.97% to 1.6% (OR, 2.2 [0.7-6.8]; P = 0.16). CONCLUSION: On-site, practice-based, peer-to-peer training with posttraining academic detailing was a modestly effective strategy to increase HIV clinicians' prescribing of naloxone.

Integrating long-acting injectable treatment to improve medication adherence among persons living with HIV and opioid use disorder: study protocol.

BACKGROUND: Oral antiretroviral therapy (ART) has been effective at reducing mortality rates of people with HIV. However, despite its effectiveness, people who use drugs face barriers to maintaining ART adherence. Receipt of opioid agonist treatment, in the context of HIV care, is associated with medication adherence and decreased HIV viral loads. Recent pharmacological advancements have led to the development of novel long-acting, injectable, medications for both HIV (cabotegravir co-administered with rilpivirine) and OUD (extended-release buprenorphine). These therapies have the potential to dramatically improve adherence by eliminating the need for daily pill-taking. Despite the extensive evidence base supporting long-acting injectable medications for both HIV and OUD, and clinical guidelines supporting integrated care provision, currently little is known about how these medications may be optimally delivered to this population. This paper presents the study design for the development of a clinical protocol to guide the delivery of combined treatment for HIV and OUD using long-acting injectable medications. METHODS: The study aims are to: (1) develop a clinical protocol to guide the delivery of combined LAI for HIV and OUD by conducting in-depth interviews with prospective patients, clinical content experts, and other key stakeholders; and (2) conduct This single group, open pilot trial protocol to assess feasibility, acceptability, and safety among patients diagnosed with HIV and OUD. Throughout all phases of the study, information on patient-, provider-, and organizational-level variables will be collected to inform future implementation. DISCUSSION: Findings from this study will inform the development of a future study to conduct a fully-powered Hybrid Type 1 Effectiveness-Implementation design.

Overdose Detection Technologies-A New Frontier in Preventing Solitary Drug Overdose Deaths.

This Viewpoint examines current opioid overdose detection technologies and their utility in detecting potential drug overdose episodes and preventing solitary overdose deaths in the US.

Heat-related mortality in U.S. state and private prisons: A case-crossover analysis.

Rising temperatures and heatwaves increase mortality. Many of the subpopulations most vulnerable to heat-related mortality are in prisons, facilities that may exacerbate temperature exposures. Yet, there is scare literature on the impacts of heat among incarcerated populations. We analyzed data on mortality in U.S. state and private prisons from 2001-2019 linked to daily maximum temperature data for the months of June, July, and August. Using a case-crossover approach and distributed lag models, we estimated the association of increasing temperatures with total mortality, heart disease-related mortality, and suicides. We also examined the association with extreme heat and heatwaves (days above the 90th percentile for the prison location) and assessed effect modification by personal, facility, and regional characteristics. There were 12,836 deaths during summer months. The majority were male (96%) and housed in a state-operated prison (97%). A 10°F increase was associated with a 5.2% (95% CI: 1.5%, 9.0%) increase in total mortality and a 6.7% (95% CI: -0.6%, 14.0%) increase in heart disease mortality. The association between temperature and suicides was delayed, peaking around lag 3 (exposure at three days prior death). Two- and three-day heatwaves were associated with increased total mortality of 5.5% (95% CI: 0.3%, 10.9%) and 7.4% (95% CI: 1.6%, 13.5%), respectively. The cumulative effect (lags 1-3) of an extreme heat day was associated with a 22.8% (95% CI: 3.3%, 46.0%) increase in suicides. We found the greatest increase in mortality among people ≥ 65 years old, incarcerated less than one year, held in the Northeast region, and in urban or rural counties. These findings suggest that warm temperatures are associated with increased mortality in prisons, yet this vulnerable population's risk has largely been overlooked.

Post-incarceration outcomes of a comprehensive statewide correctional MOUD program: a retrospective cohort study.

Background: As opioid overdoses surge, medications for opioid use disorder (MOUD) remain underutilized. MOUD is rarely offered in correctional facilities although individuals involved in the criminal justice system have higher rates of OUD and mortality relative to the general population. Methods: A retrospective cohort design examined the effect of MOUD while incarcerated on 12 months post-release treatment engagement and retention, overdose mortality, and recidivism. Individuals (N = 1600) who participated in the Rhode Island Department of Corrections (RIDOC) MOUD program (the United States' first statewide program) and were released from incarceration from December 1, 2016, to December 31, 2018, were included. The sample was 72.6% Male (27.4% female) and 80.8% White (5.8% Black, 11.4% Hispanic, 2.0% another race). Findings: 56% were prescribed methadone, 43% buprenorphine, and 1% naltrexone. During incarceration, 61% were continued on MOUD from the community, 30% were inducted onto MOUD upon incarceration, and 9% were inducted pre-release. At 30 days and 12 months post-release, 73% and 86% of participants engaged in MOUD treatment, respectively, and those newly inducted had lower post-release engagement than those who continued from the community. Reincarceration rates (52%) were similar to the general RIDOC population. Twelve overdose deaths occurred during the 12-month follow-up, with only one overdose death during the first two weeks post-release. Interpretations: Implementing MOUD in correctional facilities, with seamless linkage to community care is a needed life-saving strategy. Funding: Rhode Island General Fund, the NIH of Health HEAL Initiative, the NIGMS, and the NIDA.

Multi-level influences on increased overdose risk behaviors during the COVID-19 pandemic among people who use drugs in Rhode Island: a qualitative investigation.

BACKGROUND: The ongoing COVID-19 pandemic has disproportionately affected structurally vulnerable populations including people who use drugs (PWUD). Increased overdose risk behaviors among PWUD during the pandemic have been documented, with research underscoring the role of influencing factors such as isolation and job loss in these behaviors. Here, we use qualitative methods to examine the impact of the COVID-19 pandemic and pandemic-related response measures on drug use behaviors in a sample of PWUD in Rhode Island. Using a social-ecological framework, we highlight the nested, interactive levels of the pandemic's influence on increased overdose risk behaviors. METHODS: From July to October 2021, semi-structured interviews were conducted with 18 PWUD who self-reported any increase in behaviors associated with overdose risk (e.g., increased use, change in drug type and/or more solitary drug use) relative to before the pandemic. Thematic analysis was conducted using a codebook with salient themes identified from interview guides and those that emerged through close reading of transcribed interviews. Guided by a social-ecological framework, themes were grouped into individual, network, institutional, and policy-level influences of the pandemic on drug use behaviors. RESULTS: Individual-level influences on increased overdose risk behaviors included self-reported anxiety and depression, isolation and loneliness, and boredom. Network-level influences included changes in local drug supply and changes in social network composition specific to housing. At the institutional level, drug use patterns were influenced by reduced access to harm reduction or treatment services. At the policy level, increased overdose risk behaviors were related to financial changes, job loss, and business closures. All participants identified factors influencing overdose risk behaviors that corresponded to several nested social-ecological levels. CONCLUSIONS: Participants identified multi-level influences of the COVID-19 pandemic and pandemic-related response measures on their drug use behavior patterns and overdose risk. These findings suggest that effective harm reduction during large-scale crises, such as the COVID-19 pandemic, must address several levels of influence concurrently.

Overdose Detection Technologies to Reduce Solitary Overdose Deaths: A Literature Review.

Drug overdoses were a leading cause of injury and death in the United States in 2021. Solitary drug use and solitary overdose deaths have remained persistent challenges warranting additional attention throughout the overdose epidemic. The goal of this narrative review is to describe recent global innovations in overdose detection technologies (ODT) enabling rapid responses to overdose events, especially for people who use drugs alone. We found that only a small number of technologies designed to assist in overdose detection and response are currently commercially available, though several are in the early stages of development. Research, development, and scale-up of practical, cost-effective ODTs remains a public health imperative. Equipping places where people live, learn, work, worship, and play with the necessary tools to detect and prevent overdose deaths could complement ongoing overdose prevention efforts.

Anticipated Barriers to Sustained Engagement in Treatment With Medications for Opioid Use Disorder After Release From Incarceration.

BACKGROUND: Although the burden of opioid use disorder is disproportionately high among persons who are incarcerated, medications for opioid use disorder are often unavailable in correctional settings. The Rhode Island Department of Corrections provides all 3 classes of medications for opioid use disorder to clinically eligible persons who are incarcerated. Despite a decrease in fatal overdoses among persons with recent criminal legal system involvement since the program's implementation, barriers to continued engagement in treatment after release from incarceration still exist. METHODS: We conducted 40 semistructured, qualitative interviews with people who were incarcerated and enrolled in the comprehensive medications for opioid use disorder program at the Rhode Island Department of Corrections. Analysis applied a general, inductive approach using NVivo 12. RESULTS: Participants discussed barriers to treatment engagement before incarceration, as well as anticipated barriers to medications to treat opioid use disorder continuation after release from incarceration. Structural factors including housing, health insurance, transportation, and the treatment program structure, as well as social factors such as social support networks were perceived to influence retention in medications to treat opioid use disorder post-release. CONCLUSION: Our findings suggest that people with opioid use disorder who are incarcerated encounter unique challenges upon community reentry. Addressing structural factors that pose barriers to post-release engagement is essential to sustaining retention. We recommend utilization of peer recovery specialists to alleviate some of the stress of navigating the structural barriers identified by participants.

Provision of Air Conditioning and Heat-Related Mortality in Texas Prisons.

Importance: There is a large body of epidemiologic evidence that heat is associated with increased risk of mortality. One of the most effective strategies to mitigate the effects of heat is through air conditioning (AC); Texas regulates the internal temperature of jails to stay between 65 and 85 °F degrees, but these same standards do not apply to state and private prisons. Objective: To analyze whether heat during warm months is associated with an increased risk of mortality in Texas prisons without AC. Design, Setting, and Participants: This case-crossover study included individuals who died in Texas prisons between 2001 and 2019. The association of heat in warm months with mortality in Texas prisons with and without AC was estimated. Data analysis was conducted from January to April 2022. Exposures: Increasing daily heat index above 85 °F and extreme heat days (days above the 90th percentile heat index for the prison location). Main Outcomes and Measures: Daily mortality in Texas prisons. Results: There were 2083 and 1381 deaths in prisons without and with AC, respectively, during warm months from 2001 to 2019. Most of the deceased were male (3339 of 3464 [96%]) and the median (IQR) age at death was 54 (45-62) years. A 1-degree increase above 85 °F heat index and an extreme heat day were associated with a 0.7% (95% CI, 0.1%-1.3%) and a 15.1% (95% CI, 1.3%-30.8%) increase in the risk of mortality in prisons without AC, respectively. Approximately 13% of mortality or 271 deaths may be attributable to extreme heat during warm months between 2001 to 2019 in Texas prison facilities without AC. In prisons with AC, a negative percentage change in mortality risk was observed, although the 95% CI crossed zero (percentage change in mortality risk: -0.6%; 95% CI, -1.6% to 0.5%). The estimates in prisons without AC were statistically different than the estimates in prisons with AC (P = .05). Conclusions and Relevance: This study found an average of 14 deaths per year between 2001 to 2019 were associated with heat in Texas prisons without AC vs no deaths associated with heat in prisons with AC. Adopting an AC policy in Texas prisons may be important for protecting the health of one of our most vulnerable populations.

How do US orthopaedic surgeons view placebo-controlled surgical trials? A pilot online survey study.

Randomised placebo-controlled trials (RPCTs) are the gold standard for evaluating novel treatments. However, this design is rarely used in the context of orthopaedic interventions where participants are assigned to a real or placebo surgery. The present study examines attitudes towards RPCTs for orthopaedic surgery among 687 orthopaedic surgeons across the USA. When presented with a vignette describing an RPCT for orthopaedic surgery, 52.3% of participants viewed it as 'completely' or 'mostly' unethical. Participants were also asked to rank-order the value of five different types of evidence supporting the efficacy of a surgery, ranging from RPCT to an anecdotal report. Responses regarding RPCTs were polarised with 26.4% viewing it as the least valuable (even less valuable than an anecdote) and 35.7 .% viewing it as the most valuable. Where equipoise exists, if we want to subject orthopaedic surgeries to the highest standard of evidence (RPCTs) before they are implemented in clinical practice, it will be necessary to educate physicians on the value and ethics of placebo surgery control conditions. Otherwise, invasive procedures may be performed without any benefits beyond possible placebo effects.

Use of long-acting injectable buprenorphine in the correctional setting.

BACKGROUND: As overdoses due to opioids rise, medications for opioid use disorder (MOUD) continue to be underemployed, resulting in limited access to potentially life-saving treatment. Substance use disorders are prevalent in individuals who are incarcerated, and these individuals are at increased risk for death postrelease due to overdose. Few jails and prisons offer MOUD and most limit access. Extended-release buprenorphine (XR-BUP), a novel monthly injectable MOUD formulation, could be uniquely poised to address treatment access in correctional settings. METHODS: This study linked a retrospective cohort design of statewide datasets to evaluate the real-world use of XR-BUP. The study included individuals (N = 54) who received XR-BUP while incarcerated from January 2019 through February 2022. The study was conducted at the Rhode Island Department of Corrections, with the nation's first comprehensive statewide correctional MOUD program. RESULTS: Fifty-four individuals received a combined total of 162 injections during the study period. The study found no evidence of tampering with the injection site, indicating no attempts by participants to remove, hoard, or divert the medication. Sixty-one percent reported at least one adverse effect after injections were received, with an average of 2.8 side effects. Sixty-one percent of those released on XR-BUP engaged in MOUD after release, 30 % continued with XR-BUP. CONCLUSIONS: XR-BUP is feasible and acceptable in correctional settings. XR-BUP addresses administrative concerns of diversion that obstruct lifesaving MOUD and offers another safe and effective treatment option. Further studies and trials should continue to assess this novel medication's ability to treat opioid addiction in the correctional setting and upon release to the community.

Drug use behaviors, trauma, and emotional affect following the overdose of a social network member: A qualitative investigation.

BACKGROUND: Scant research has examined the influence of overdoses occurring in social networks (i.e., knowing someone who has overdosed) on individual overdose risk. We sought to characterize drug use behaviors of individuals following the overdose of someone in their social network. METHODS: We conducted semi-structured interviews with 25 people who use drugs and knew someone who overdosed in the prior 90 days. All interviews were conducted in person in Rhode Island from July to October 2021. Data were stratified by drug use behaviors following the overdose of a network member (i.e., risk behaviors, protective behaviors, no change; selected a priori) and analyzed using a thematic analysis variation to identify salient themes. RESULTS: We identified variation in the effect of knowing someone who overdosed on subsequent drug use behaviors and emotional affect. Several participants described increasing their drug use or using more types of drugs than usual to manage feelings of bereavement and trauma, and a subset of these participants described increased drug use with suicidal intention and increased suicidal ideations following the overdose event. Other participants described reducing their drug use and engaging in protective behaviors in response to heightened perceived overdose risk, protection motivation (i.e., increased motivation to protect oneself), and concern for others. Additionally, some participants reported no change in drug use behaviors, and these participants described already engaging in harm reduction practices, feeling desensitized due to frequent or repeated exposure to overdose, and ambivalence about living. CONCLUSIONS: Findings suggest a need for enhanced investment in network-based overdose prevention interventions, as well as more robust integration of bereavement support and mental health services in settings that serve people who use drugs. The findings also suggest a need for future research to identify mediators of the effect of overdose occurring in social networks on individual overdose risk.