Diversion of medications to treat opioid use disorder: Qualitative findings from formerly incarcerated adults in Massachusetts.

BACKGROUND: Carceral officials often cite diversion of medication for opioid use disorder (MOUD) (e.g., buprenorphine) as a reason for not offering MOUD treatment in jails and prisons with little understanding of patient perspectives. We aimed to understand patient perceptions of medication diversion from jail-based MOUD programs and the factors that contribute to and reduce diversion. METHODS: We conducted thematic analyses of semi-structured interviews held in 2021-22 with 38 adults who received MOUD treatment and were released from eight Massachusetts jails that had implemented a MOUD program on or after September 2019. RESULTS: Consistent with prior reports from carceral staff, patients perceived MOUD diversion to happen less frequently than expected, which they attributed to dosing protocols that have effectively reduced it. Patients reported that MOUD availability reduced the contraband buprenorphine market, although other contraband substances have entered jails (fentanyl, oxycodone, K2). Patients perceived Subutex to have greater misuse potential and added diversion risks. Patients valued graduated consequences and other efforts to reduce MOUD diversion and contraband for making jails safer and for enabling patients to receive treatment. Nearly all participants reported having heard about, witnessed, or been involved in actual or attempted diversion, with variation in reports by jail. Patients suggested that dispensing MOUD to all who need it immediately upon intake would be the most effective way to reduce MOUD diversion and contraband. CONCLUSION: Formerly incarcerated patients perceived MOUD diversion within jail medication programs as occurring less often than expected and that it can be reduced with appropriate protocols. To help limit medication diversion, patients recommended provision of MOUD upon intake to all individuals with opioid use disorder who need it. Findings have implications for MOUD program adaptation, successful routinization, and diffusion in carceral settings.

Evaluating Technologies to Identify Fentanyl and Adulterants in Street Drug Paraphernalia: Qualitative Perspectives of Service Providers and Their Clientele.

Background: Opioid overdose deaths continue to present major public health challenges in the U.S. Harm reduction agencies have begun using drug checking technologies to identify adulterants in the local drug supply and reduce overdose risk among people who use drugs (PWUD). Through qualitative and ethnographic methods, we assess the use of portable mass spectrometers at a harm reduction agency in a Northeastern U.S. city. Methods: We conducted participant observation, and on-the-spot qualitative interviews with harm-reduction staff members (n = 10) and their clientele (n = 17) between May 2019 and December 2020. Interviews explored emic views on drug checking (process, logistics, technology), and perceived benefits and challenges. We used thematic content analysis techniques to code and analyze interview transcriptions. Results: Implementation and use of drug checking devices were not free of challenges and malfunctions, often delaying drug checking opportunities and increasing suspicions and distrust among clients. Yet, staff members perceived that when working properly, or in conjunction with an additional device, they offered information about purchased drugs that could empower clients and potentially lead to positive behavior change. Use of these devices also enhanced engagement between harm reduction staff and PWUD, facilitating meaningful conversations around self-advocacy and harm reduction engagement. Conclusion: We report qualitative findings on the experiences and perceptions of drug checking devices among harm reduction staff and PWUD. Our findings indicate that use of this technology has the potential to decrease risk behaviors, expand health promotion services, and help reduce high rates of fentanyl-related overdose.

Perspectives of opioid prescribers in overdose hotspots and coldspots, Massachusetts, 2019.

BACKGROUND: Prescription opioids (POs) have had a devastating effect on people and public health systems in the U.S. Due to the urgency and complexity of the opioid crisis, there is a need to expand qualitative research on the medical community's perspectives on opioid prescribing practices and the role that prescription drug monitoring programs (PDMPs) have played in mitigating this crisis. METHODS: We conducted qualitative interviews with clinicians (n = 23) across specialties and a range of overdose hotspot and coldspot locations in Massachusetts during 2019. We aimed to capture their perspectives on the opioid crisis, changes in clinical practice, and experiences with opioid prescribing and PDMPs. RESULTS: Respondents consistently recognized the role clinicians played in the opioid crisis and reported reductions in their opioid prescribing, which were motivated by the crisis itself. The limitations of opioids in pain management were frequently discussed. While clinicians appreciated having greater awareness of their opioid prescribing and increased access to patient prescription histories, they also expressed concerns about surveillance of their prescribing and other unintended consequences. We observed that clinicians in opioid prescribing hotspots had more detailed and specific reflections on their experiences with the Massachusetts PDMP, MassPAT. CONCLUSION: Clinician perceptions of the severity of the opioid crisis in Massachusetts and thoughts on their role as prescribers were consistent across specialty, prescribing level, and practice location. Many clinicians in our sample cited use of the PDMP as an influence on their prescribing. Those practicing in opioid overdose hotspots had the most nuanced reflections about the system.

Jail-based reentry programming to support continued treatment with medications for opioid use disorder: Qualitative perspectives and experiences among jail staff in Massachusetts.

BACKGROUND: Individuals with opioid use disorder released to communities after incarceration experience an elevated risk for overdose death. Massachusetts is the first state to mandate county jails to deliver all FDA approved medications for opioid use disorder (MOUD). The present study considered perspectives around coordination of post-release care among jail staff engaged in MOUD programs focused on coordination of care to the community. METHODS: Focus groups and semi-structured interviews were conducted with 61 jail staff involved in implementation of MOUD programs. Interview guide development, and coding and analysis of qualitative data were guided by the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework. Deductive and inductive approaches were used for coding and themes were organized using the EPIS. RESULTS: Salient themes in the inner context focused on the elements of reentry planning that influence coordination of post-release care including timing of initiation, staff knowledge about availability of MOUD in community settings, and internal collaborations. Findings on bridging factors highlighted the importance of interagency communication to follow pre-scheduled release dates and use of bridge scripts to minimize the gap in treatment during the transition. Use of navigators was an additional factor that influenced MOUD initiation and engagement in community settings. Outer context findings indicated partnerships with community providers and timely reinstatement of health insurance coverage as critical factors that influence coordination of post-release care. CONCLUSIONS: Coordination of MOUD post-release continuity of care requires training supporting staff in reentry planning as well as resources to enhance internal collaborations and bridging partnerships between in-jail MOUD programs and community MOUD providers. In addition, efforts to reduce systemic barriers related to unanticipated timing of release and reinstatement of health insurance coverage are needed to optimize seamless post-release care.

Uncommon and preventable: Perceptions of diversion of medication for opioid use disorder in jail.

INTRODUCTION: Correctional officials often cite diversion of medication for opioid use disorder (MOUD) treatment (e.g., buprenorphine) as a reason for not offering MOUD treatment in jails and prisons, but it is poorly understood whether these fears are justified. We aimed to understand staff perceptions of medication diversion from jail-based MOUD programs and the factors that contribute to and prevent diversion. METHODS: We conducted qualitative analyses of semi-structured in-depth interviews and focus groups performed in 2019-20 with 61 administrative, security, behavioral health, and clinical staff who implement MOUD programming in seven Massachusetts jails. RESULTS: Contrary to staff expectations, buprenorphine diversion was perceived to occur infrequently during MOUD program implementation. The MOUD program changed staff views of buprenorphine, i.e., as legitimate treatment instead of as illicit contraband. Also, the program was perceived to have disrupted the illicit buprenorphine market in jail and reduced related coercion. Proactive strategies were essential to prevent and respond to buprenorphine diversion. Key components of diversion prevention strategies included: staff who distinguished among different reasons for diversion; comprehensive and routinized but flexible dosing protocols; communication, education, and monitoring; patient involvement in assessing reasons for diversion; and written policies to adjudicate diversion consequences. CONCLUSION: With appropriate protocols, buprenorphine diversion within correctional programs designed to provide MOUD treatment is perceived to be uncommon and preventable. Promising practices in program design help limit medication diversion and inform correctional officials and lawmakers as they consider whether and how to provide MOUD treatment in correctional settings.

Legislatively mandated implementation of medications for opioid use disorders in jails: A qualitative study of clinical, correctional, and jail administrator perspectives.

BACKGROUND: Individuals with legal involvement and opioid use disorders (OUD) are at an increased risk of overdose and premature death. Yet, few correctional systems provide all FDA approved medications for OUD (MOUD) to all qualifying incarcerated individuals. We report on the implementation of MOUD in seven Massachusetts' jails following a state legislative mandate to provide access to all FDA-approved MOUD and to connect with treatment upon release. METHODS/PARTICIPANTS: Based on the Exploration, Preparation, Implementation, and Sustainment framework, 61 clinical, corrections, and senior jail administrators participated in semi-structured interviews and focus groups between December 2019 and January 2020. Qualitative analyses focused on external and internal contexts and bridging factors. FINDINGS: Participants detailed how the outer context (i.e., legislative mandate) drove acceptance of MOUD and assisted with continuity of care. Salient inner context factors included decision-making around administration of agonist medications, staff perceptions and training, and changes to infrastructure and daily routines. Leadership was critical in flattening standard hierarchies and advocating for flexibility. System-based characteristics of incarcerated individuals, specifically those who were pre-sentenced, presented challenges with treatment initiation. Inter- and intra-agency bridging factors reduced duplication of effort and led to quick, innovative solutions. CONCLUSIONS: Implementation of MOUD in jails requires collaboration with and reliance on external agencies. Preparation for implementation should involve systematic reviews of available resources and connections. Implementation requires flexibility from institutional systems that are inherently rigid. Accordingly, leaders and policymakers must recognize the cultural shift inherent in such programs and allow for resources and education to assure program success.

Massachusetts Justice Community Opioid Innovation Network (MassJCOIN).

A major driver of the U.S. opioid crisis is limited access to effective medications for opioid use disorder (MOUD) that reduce overdose risks. Traditionally, jails and prisons in the U.S. have not initiated or maintained MOUD for incarcerated individuals with OUD prior to their return to the community, which places them at high risk for fatal overdose. A 2018 law (Chapter 208) made Massachusetts (MA) the first state to mandate that five county jails deliver all FDA-approved MOUDs (naltrexone [NTX], buprenorphine [BUP], and methadone). Chapter 208 established a 4-year pilot program to expand access to all FDA-approved forms of MOUD at five jails, with two more MA jails voluntarily joining this initiative. The law stipulates that MOUD be continued for individuals receiving it prior to detention and be initiated prior to release among sentenced individuals where appropriate. The jails must also facilitate continuation of MOUD in the community on release. The Massachusetts Justice Community Opioid Innovation Network (MassJCOIN) partnered with these seven diverse jails, the MA Department of Public Health, and community treatment providers to conduct a Type 1 hybrid effectiveness-implementation study of Chapter 208. We will: (1) Perform a longitudinal treatment outcome study among incarcerated individuals with OUD who receive NTX, BUP, methadone, or no MOUD in jail to examine postrelease MOUD initiation, engagement, and retention, as well as fatal and nonfatal opioid overdose and recidivism; (2) Conduct an implementation study to understand systemic and contextual factors that facilitate and impede delivery of MOUDs in jail and community care coordination, and strategies that optimize MOUD delivery in jail and for coordinating care with community partners; (3) Calculate the cost to the correctional system of implementing MOUD in jail, and conduct an economic evaluation from state policy-maker and societal perspectives to compare the value of MOUD prior to release from jail to no MOUD among matched controls. MassJCOIN made significant progress during its first six months until the COVID-19 pandemic began in March 2020. Participating jail sites restricted access for nonessential personnel, established other COVID-19 mitigation policies, and modified MOUD programming. MassJCOIN adapted research activities to this new reality in an effort to document and account for the impacts of COVID-19 in relation to each aim. The goal remains to produce findings with direct implications for policy and practice for OUD in criminal justice settings.

Does a Video Improve Knowledge of HIV/AIDS and HIV Testing among a Global Internet Audience?

The objectives of this study were to determine if a video improved HIV/AIDS and HIV testing knowledge among a global sample of Internet users, to discern if this improvement was the same for English and Spanish speakers, and to ascertain if the video was efficacious for those with lower health literacy. A worldwide sample of English- or Spanish-speaking Internet users was solicited. Participants completed a 25-item questionnaire to assess their HIV/AIDS and HIV testing knowledge before and after watching the video. Mean scores on the questionnaire improved after watching the video for both English speakers (after: 19.6 versus before: 16.4; Δ = 3.2; 95% confidence interval [CI]: 2.8-3.5) and Spanish speakers (20.7 versus 17.3; Δ = 3.4; 95% CI: 3.0-3.8). There was no difference in improvement of scores between English and Spanish speakers (Δ = -0.24; 95% CI: -0.79 to 0.31), and this video was equally efficacious for those with lower and higher health literacy skills.

VARIATIONS IN RECRUITMENT YIELD, COSTS, SPEED AND PARTICIPANT DIVERSITY ACROSS INTERNET PLATFORMS IN A GLOBAL STUDY EXAMINING THE EFFICACY OF AN HIV/AIDS AND HIV TESTING ANIMATED AND LIVE-ACTION VIDEO AMONG ENGLISH- OR SPANISH-SPEAKING INTERNET OR SOCIAL MEDIA USERS.

For a world-wide, Internet-based study on HIV/AIDS and HIV testing knowledge, we compared the yields, speed and costs of recruitment and participant diversity across free postings on 13 Internet or social media platforms, paid advertising or postings on 3 platforms, and separate free postings and paid advertisements on Facebook. Platforms were compared by study completions (yield), time to completion, completion to enrollment ratios (CERs), and costs/ completion; and by participants' demographic characteristics, HIV testing history, and health literacy levels. Of the 482 English-speaking participants, Amazon Mechanical Turk yielded the most participants, recruited participants at the fastest rate and had the highest CER (0.78) and lowest costs / completion. Of the 335 Spanish-speaking participants, Facebook yielded the most participants and recruited participants at the fastest rate, although Amazon Mechanical Turk had the highest CER (0.72) and lowest costs/completion. Across platforms participants differed substantially according to their demographic characteristics, HIV testing history and health literay skills. The study results highlight the need for researchers to strongly consider choice of Internet or social media plaforms when conducting Internet-based research. Because of the sample specifications and cost restraints of studies, specific Internet/ social media or participant selection plaforms will be much more effective or appropriate than others.

Efficacy of an HIV/AIDS and HIV testing video for Spanish-speaking Latinos in healthcare and non-healthcare settings.

We assessed the efficacy of a Spanish-language HIV/AIDS and HIV testing video as a substitute for comparable orally-delivered information in healthcare and non-health care settings for Spanish-speakers regardless of health literacy level. In a non-inferiority clinical trial, Spanish-speaking Latinos from an emergency department, a clinic, and community-based organizations were randomly assigned to receive HIV/AIDS and HIV testing information orally or from a video. Comprehension of the information was measured using a questionnaire. Of the 150 participants, 39 % met criteria for lower health literacy and 75 % previously had been tested for HIV. Mean scores on the questionnaire for the video (20.4; 95 % CI 19.5 ~ 21.3) and the orally-delivered information arms (20.6; 95 % CI 19.7 ~ 21.5) were similar (Δ = -0.15; 95 % CI -1.4 ~ 1.1). Mean scores among lower health literacy participants also were similar (18.3 (video) vs. 19.6 (in-person); p < 0.30). This Spanish-language video is a viable substitute for orally-delivered HIV/AIDS and HIV testing information.

A cultural model of infidelity among African American and Puerto Rican young adults.

Having concurrent sexual partners is a risk factor for STIs and HIV/AIDS, yet few studies have investigated the cultural meanings and functions of concurrency. A multi-method qualitative/quantitative study of sexual ideas, attitudes, and behaviors among inner-city Puerto Rican and African American emergent adults (age 18-25) in Hartford, Connecticut, USA, suggests that having concurrent partners is common in this population. Using data from 12 focus groups and 40 participants in systematic data collection techniques (e.g., pile sorts), the underlying cognitive structure of concurrency and cheating/infidelity are explored. Results suggest that participants are less tolerant of multiple partners in more committed relationships, but that very few relationships can be considered committed. Furthermore, participants see cheating as inevitable even in committed relationships. Sexual transgressions are considered the most severe form of cheating. Having an outside partner for emotional reasons or to have access to one's child were seen as more acceptable/forgivable than doing so for sexual satisfaction, social status or material goods. Multiple partnerships must be seen in the context of the inner city where resources and opportunities are scarce and young adults attempt to protect themselves from emotional injury. Documenting new and changing social constructions of infidelity is important for understanding the social context of sexual behavior in our global world and for designing culturally appropriate health interventions.

Doubts remain, risks persist: HIV prevention knowledge and HIV testing among drug users in Rio de Janeiro, Brazil.

Brazil has been recognized for being the first developing country to provide universal AIDS treatment. Brazil also implemented a comprehensive prevention initiative. These efforts have been successful, with about half the number of HIV/AIDS cases forecast in 1992 developing by 2000. However, HIV/AIDS continues to spread, including among not-in-treatment drug users. Questions have been raised about gaps in existing prevention efforts. Based on qualitative research in 2006-2008 with street drug users in Rio de Janeiro (focus groups, N=24; a pile sort, N=108; open-ended interviews, N=34), this paper examines enduring gaps in HIV knowledge and prevailing risk patterns and proposes strategies for strengthening prevention.

When the drug of choice is a drug of confusion: embalming fluid use in inner city Hartford, CT.

This paper examines the use of a new illicit drug--embalming fluid mixtures--in Hartford, CT based on a recent assessment of drug consumption in an outreach-recruited sample of 242 not-in-treatment active drug users. Sociodemographic, drug use, and health and social problems of drug users who do and do not use embalming fluid mixture are presented, revealing some notable differences between these two groups of street drug users. Despite regular consumption, we report that embalming fluid mixture users are often uncertain about what is in this new drug, despite experiencing often powerful effects. Urine toxicology findings from a subsample of individuals who used embalming fluid mixtures in the last 48 hours, reveal the frequent presence of phencyclidine (PCP) as well as other drugs. The public health implications of this new wave of PCP use are assessed.

Public health interventionists, penny capitalists, or sources of risk?: assessing street syringe sellers in Hartford, Connecticut.

Improved access to sterile syringes decreases risks related to blood-borne transmission of HIV and hepatitis among injection drug users (IDUs). While syringe exchange programs and pharmacy sales of over-the-counter syringes have received considerable attention from researchers and interventionists during the past decade, little is known about informal economy street syringe sellers. In Hartford, CT. as well as other regions throughout the United States a large percentage of IDUs utilize street sellers to facilitate their injection activities. A qualitative and ethnographic study was conducted in Hartford between 1999 and 2001 to help elucidate the public health risks and benefits of street syringe sellers.

Ethical dilemmas created by the criminalization of status behaviors: case examples from ethnographic field research with injection drug users.

The criminalization of behaviors such as the ingestion of certain mood-altering drugs creates ethical dilemmas for researchers studying those behaviors. The Syringe Access, Use, and Discard (SAUD) project is designed to uncover microcontextual factors that influence HIV and hepatitis risk behaviors of injection drug users. The article presents seven ethical dilemmas encountered using ethnographic methods: issues involving syringe replacement at injection locales, risks of participants' arrest, potential disruptions in participants' supply routes, risks of research staff arrest, threats to the protection of confidentiality, issues surrounding informed consent in working with addicts, and the confiscation of potentially incriminating information by police. The article concludes with a discussion of the limitations of traditional ethical frameworks, such as utilitarianism, for resolving these dilemmas and recommends instead improving public health professionals' capacity for practical reasoning (phronesis) through the greater use of case studies in public health curricula.