Comparing harm reduction and overdose response services between community-based and public health department syringe service programmes using a national cross-sectional survey.

Background: Syringe services programmes (SSPs) are an evidence-based strategy to reduce infectious diseases and deliver overdose prevention interventions for people who use drugs. They face regulatory, administrative, and funding barriers that limit their implementation in the US, though the federal government recently began providing funding to support these efforts. In this study we aim to understand whether the organisational characteristics of SSPs are associated with the provision of syringe and other overdose response strategies. Methods: We examine four outcomes using the National Survey of Syringe Services Programs (NSSSP) (N = 472): syringe distribution, naloxone distribution, fentanyl test strip (FTS) availability, and buprenorphine implementation. These outcomes are assessed across three organizational categories of SSPs-those operated by public health departments (DPH), community-based organizations (CBOs) with government funding, and CBOs without government funding-while adjusting for community-level confounders. Findings: The proportion of SSPs by organizational category was 36% DPH, 42% CBOs with government funding, and 22% CBOs without government funding. Adjusting for community-level differences, we found that CBO SSPs with government funding had significantly higher provision of all four syringe and overdose response services as compared to DPH SSPs and across three of the four services as compared to CBO SSPs without government funding. CBO SSPs without government funding still had significantly higher provision of three of the four services as compared to programmes maintained by the DPH. Interpretation: CBO SSPs have strong potential to expand overdose response services nationally, particularly if provided with sustained and adequate funding. Communities should aim to provide funding that does not hinder SSP innovation so they can remain flexible in responding to local needs. Funding: This study was supported by Arnold Ventures (20-05172).

Evaluation of a Police-Mental Health Co-response Team Relative to Traditional Police Response in Indianapolis.

OBJECTIVE: Criminal justice and emergency medical service (EMS) outcomes were compared for individuals experiencing a behavioral health crisis who received a response from a co-response team (CRT) or a usual response from the police after a 911 call. METHODS: A prospective, quasi-experimental design was used to examine outcomes of a CRT pilot tested in Indianapolis (August-December 2017). Weighted multivariable models examined effects of study condition (CRT group, N=313; usual-response group, N=315) on immediate booking, emergency detention, and subsequent jail bookings and EMS encounters. Sensitivity of outcomes to follow-up by a behavioral health unit (BHU) was also examined. RESULTS: Individuals in the CRT group were less likely than those in the usual-police-response group to be arrested immediately following the 911 incident (odds ratio [OR]=0.48, 95% confidence interval [CI]=0.25-0.92) and were more likely to experience any EMS encounter at 6- and 12-month follow-up (OR range=1.71-1.85, p≤0.015 for all). Response type was not associated with jail bookings at 6 or 12 months. Follow-up BHU services did not reduce bookings or EMS encounters. CRT recipients with BHU follow-up were more likely than those without BHU follow-up to have a subsequent EMS contact (OR range=2.35-3.12, p≤0.001 for all). These findings differed by racial group. CONCLUSIONS: CRT responses may reduce short-term incarceration risk but not long-term EMS demand or risk of justice involvement. Future research should consider the extent to which CRT and follow-up services improve engagement with stabilizing treatment services, which may reduce the likelihood of future crises.

Treatment provider perceptions of take-home methadone regulation before and during COVID-19.

BACKGROUND: The loosening of U.S. methadone regulations during the COVID-19 pandemic expanded calls for methadone reform. This study examines professional perceptions of methadone take-home dose regulation before and during the COVID-19 pandemic to understand responses to varied methadone distribution policies. METHODS: Fifty-nine substance use disorder treatment professionals were interviewed between 2017 and 2020 in-person or over video call. An inductive iterative coding process was used to analyze the data. Constructivist grounded theory guided the collection and analysis of in-depth interviews. RESULTS: Treatment professionals expressed mixed views toward methadone take-home regulations. Participants justified regulation using several arguments: 1) patient care benefitting from supervision, 2) attributing improved patient safety to take-home regulation, 3) fearing liability for methadone-related harms, and 4) relying on buprenorphine as an "escape hatch" for patients who cannot manage MMT policies. Other professionals suggested partial deregulation, while others strongly opposed pre-pandemic take-home regulation, explaining such regulations impede medication access and hinder patient-centered care. Some professionals supported the COVID-19 policy changes and saw these as a test run for broader deregulation, while others framed the changes as temporary and cautiously applied deregulation to their services, at times revoking looser rules for patients they perceived as nonadherent. CONCLUSION: Treatment professionals working in a range of modalities, including opioid treatment programs, expressed hesitation toward expanded take-home methadone access. While some participants also supported forms of deregulation, post-pandemic efforts to extend looser methadone distribution policies will have to address apprehensive professionals if such policy changes are to be meaningfully adopted in community services.

Individual and county-level variation in outcomes following non-fatal opioid-involved overdose.

BACKGROUND: A lack of large-scale, individually linked data often has impeded efforts to disentangle individual-level variability in outcomes from area-level variability in studies of many diseases and conditions. This study investigated individual and county-level variability in outcomes following non-fatal overdose in a state-wide cohort of opioid overdose patients. METHODS: Participants were 24 031 patients treated by emergency medical services or an emergency department for opioid-involved overdose in Indiana between 2014 and 2017. Outcomes included repeat non-fatal overdose, fatal overdose and death. County-level predictors included sociodemographic, socioeconomic and treatment availability indicators. Individual-level predictors included age, race, sex and repeat non-fatal opioid-involved overdose. Multilevel models examined outcomes following non-fatal overdose as a function of patient and county characteristics. RESULTS: 10.9% (n=2612) of patients had a repeat non-fatal overdose, 2.4% (n=580) died of drug overdose and 9.2% (n=2217) died overall. Patients with a repeat overdose were over three times more likely to die of drug-related causes (OR=3.68, 99.9% CI 2.62 to 5.17, p<0.001). County-level effects were limited primarily to treatment availability indicators. Higher rates of buprenorphine treatment providers were associated with lower rates of mortality (OR=0.82, 95% CI 0.68 to 0.97, p=0.024), but the opposite trend was found for naltrexone treatment providers (OR=1.20, 95% CI 1.03 to 1.39, p=0.021). Cross-level interactions showed higher rates of Black deaths relative to White deaths in counties with high rates of naltrexone providers (OR=1.73, 95% CI 1.09 to 2.73, p=0.019). CONCLUSION: Although patient-level differences account for most variability in opioid-related outcomes, treatment availability may contribute to county-level differences, necessitating multifaceted approaches for the treatment and prevention of opioid abuse.

Validating Imputation Procedures to Calculate Corrected Opioid-Involved Overdose Deaths, Marion County, Indiana, 2011-2016.

OBJECTIVES: Understanding the scope of the current opioid epidemic requires accurate counts of the number of opioid-involved drug overdose deaths. Given known errors and limitations in the reporting of these deaths, several studies have used statistical methods to develop estimates of the true number of opioid-involved overdose deaths. This study validates these procedures using a detailed county-level database of linked toxicology and vital records data. METHODS: We extracted and linked toxicology and vital records data from Marion County, Indiana (Indianapolis), during a 6-year period (2011-2016). Using toxicology data as a criterion measure, we tested the validity of multiple imputation procedures, including the Ruhm regression-based imputation approach for correcting the number of opioid-involved overdose deaths. RESULTS: Estimates deviated from true opioid-involved overdose deaths by 3% and increased in accuracy during the study period (2011-2016). For example, in 2016, 231 opioid-involved overdose deaths were noted in the toxicology data, whereas the corresponding imputed estimate was 233 opioid-involved overdose deaths. A simple imputation approach, based on the share of opioid-involved overdose deaths among all drug overdose deaths for which the death certificate specified ≥1 drug, deviated from true opioid-involved overdose deaths by ±5%. CONCLUSIONS: Commonly used imputation procedures produced estimates of the number of opioid-involved overdose deaths that are similar to the true number of opioid-involved overdose deaths obtained from toxicology data. Although future studies should examine whether these results extend beyond the geographic area covered in our data set, our findings support the continued use of these imputation procedures to quantify the extent of the opioid epidemic.

Firearm Ownership and Domestic Versus Nondomestic Homicide in the U.S.

INTRODUCTION: Gun ownership is associated with firearm mortality, although this association differs across victim-offender relationships. This study examines the relationship between gun ownership and domestic versus nondomestic homicide rates by victim sex. METHODS: Several sources of state-level panel data from 1990 through 2016 were merged from each of the 50 states to model domestic (i.e., family and intimate partners) and nondomestic firearm homicide as a function of state-level household firearm ownership. Firearm ownership was examined using a validated proxy measure and homicide rates came from the Supplemental Homicide Reports of the Federal Bureau of Investigation's Uniform Crime Reports. Negative binomial regression with fixed effects was used to model the outcomes and employed generalized estimating equations to account for clustering within states. Statistical analyses were completed in 2018. RESULTS: State-level firearm ownership was uniquely associated with domestic (incidence rate ratio=1.013, 95% CI=1.008, 1.018) but not nondomestic (incidence rate ratio=1.002, 95% CI=0.996, 1.008) firearm homicide rates, and this pattern held for both male and female victims. States in the top quartile of firearm ownership had a 64.6% (p<0.001) higher incidence rate of domestic firearm homicide than states in the lowest quartile; however, states in the top quartile did not differ significantly from states in the lowest quartile of firearm ownership in observed incidence rates of nondomestic firearm homicide. CONCLUSIONS: State-level firearm ownership rates are related to rates of domestic but not nondomestic firearm homicide.

Criminal Justice Professionals' Attitudes Toward Mental Illness and Substance Use.

Despite the high prevalence of behavioral health disorders in justice settings and prior research on the importance of attitudes in successful treatment outcomes for behavioral health populations, few studies have examined criminal justice professionals' attitudes toward mental illness and substance use. We conducted a state-wide survey of 610 criminal justice professionals using items adapted from the Drug and Drug Problems Perceptions Questionnaire (Albery et al. 2003) to examine attitudes toward mental illness and substance use as a function of criminal justice position and personal contact. For attitudes toward both mental illness and substance use, defense attorneys and community corrections officers reported more positive attitudes relative to jail correctional staff and prosecutors. For attitudes toward substance use, personal contact moderated the effect of position on attitudes. Findings underscore the importance of targeted training and other contact-based interventions to improve criminal justice professionals' attitudes toward behavioral health populations.

Barriers and facilitators to implementing an urban co-responding police-mental health team.

BACKGROUND: In an effort to reduce the increasing number of persons with mental illness (PMI) experiencing incarceration, co-responding police-mental health teams are being utilized as a way to divert PMI from the criminal justice system. Co-response teams are typically an inter-agency collaboration between police and mental health professionals, and in some cases include emergency medical personnel. These teams are intended to facilitate emergency response by linking patients to mental health resources rather than the criminal justice system, thus reducing burdens on both the criminal justice systems as well as local healthcare systems. The current study examines the barriers and facilitators of successfully implementing the Mobile Crisis Assistance Team model, a first-responder co-response team consisting of police officers, mental health professionals, and paramedics. Through content analysis of qualitative focus groups with team members and interviews with program stakeholders, this study expands previous findings by identifying additional professional cultural barriers and facilitators to program implementation while also exploring the role of clear, systematic policies and guidelines in program success. RESULTS: Findings demonstrate the value of having both flexible and formal policies and procedures to help guide program implementation; ample community resources and treatment services in order to successfully refer clients to needed services; and streamlined communication among participating agencies and the local healthcare community. A significant barrier to successful program implementation is that of role conflict and stigma. Indeed, members of the co-response teams experienced difficulty transitioning into their new roles and reported negative feedback from other first responders as well as from within their own agency. Initial agency collaboration, information sharing between agencies, and team building were also identified as facilitators to program implementation. CONCLUSION: The current study provides a critical foundation for the implementation of first-responder police-mental health co-response teams. Cultural and systematic barriers to co-response team success should be understood prior to program creation and used to guide implementation. Furthermore, attention must be directed to cultivating community and professional support for co-response teams. Findings from this study can be used to guide future efforts to implement first-response co-response teams in order to positively engage PMI and divert PMI from the criminal justice system.

Identifying Unreported Opioid Deaths Through Toxicology Data and Vital Records Linkage: Case Study in Marion County, Indiana, 2011-2016.

OBJECTIVES: To demonstrate the severity of undercounting opioid-involved deaths in a local jurisdiction with a high proportion of unspecified accidental poisoning deaths. METHODS: We matched toxicology data to vital records for all accidental poisoning deaths (n = 1238) in Marion County, Indiana, from January 2011 to December 2016. From vital records, we coded cases as opioid involved, specified other substance, or unspecified. We extracted toxicology data on opioid substances for unspecified cases, and we have reported corrected estimates of opioid-involved deaths after accounting for toxicology findings. RESULTS: Over a 6-year period, 57.7% of accidental overdose deaths were unspecified and 34.2% involved opioids. Toxicology data showed that 86.8% of unspecified cases tested positive for an opioid. Inclusion of toxicology results more than doubled the proportion of opioid-involved deaths, from 34.2% to 86.0%. CONCLUSIONS: Local jurisdictions may be undercounting opioid-involved overdose deaths to a considerable degree. Toxicology data can improve accuracy in identifying opioid-involved overdose deaths. Public Health Implications. Mandatory toxicology testing and enhanced training for local coroners on standards for death certificate reporting are needed to improve the accuracy of local monitoring of opioid-involved accidental overdose deaths.

EMS naloxone administration as non-fatal opioid overdose surveillance: 6-year outcomes in Marion County, Indiana.

BACKGROUND AND AIMS: Despite rising rates of opioid overdose in the United States, few studies have examined the frequency of non-fatal overdose events or mortality outcomes following resuscitation. Given the widespread use of naloxone to respond to overdose-related deaths, naloxone administration may provide a useful marker of overdose events to identify high-risk users at heightened risk of mortality. We used naloxone administration by emergency medical services as a proxy measure of non-fatal overdose to examine repeat events and mortality outcomes during a 6-year period. METHODS: We conducted a retrospective investigation of all cases in Marion County, Indiana between January 2011 and December 2016 where emergency medical services used naloxone to resuscitate a patient. Cases were linked to vital records to assess mortality and cause of death during the same time-period. We used Cox regression survival analysis to assess whether repeat non-fatal overdose events during the study period were associated with the hazard of mortality, both overall and by cause of death. RESULTS: Of 4726 patients administered naloxone, 9.4% (n = 444) died an average of 354 days [standard deviation (SD) = 412.09, range = 1-1980] following resuscitation. Decedents who died of drug-related causes (34.7%, n = 154) were younger and more likely to have had repeat non-fatal overdose events. Patients with repeat non-fatal overdose events (13.4%, n = 632) had a ×2.07 [95% confidence interval (CI) = 1.59, 2.71] higher hazard of all-cause mortality and a ×3.06 (95% CI = 2.13, 4.40) higher hazard of drug-related mortality. CONCLUSIONS: Among US emergency medical service patients administered naloxone for opioid overdose, those with repeat non-fatal opioid overdose events are at a much higher risk of mortality, particularly drug-related mortality, than those without repeat events.