Missouri's overdose field report: descriptive analysis, survival trends, and naloxone dosing patterns from a community-based survey tool, 2018-2022.

Background: Missouri's Overdose Field Report (ODFR) is a community-based reporting system which intends to capture overdoses which may not be otherwise recorded.Objectives: Describe the factors related to non-fatal overdoses reported to Missouri's ODFR.Methods: This study used a descriptive epidemiological approach to examine the demographics and circumstances of overdoses reported to the ODFR. We used binary logistic regression to evaluate factors associated with survival and ordinal logistic regression to evaluate factors associated with number of doses used. Factors were chosen based on their relevance to overdose education and survival, and naloxone distribution.Results: Between 2018 and 2022, 12,225 overdoses (67% male; 78% White) were reported through the ODFR, with a 96% (n = 11,225) survival rate. Overdose survival (ps < .02) was associated with younger age (OR = .58), no opioid and stimulant co-involvement (OR = .61), and private location (OR = .48). Intramuscular naloxone in particular was associated with a significantly higher odds of survival compared to nasal naloxone (OR = 2.11). An average of 1.6 doses of naloxone per incident were administered. Additional doses were associated (ps < .02) with being older (OR = .45), female (OR = .90), nasal naloxone (versus intravenous) (OR = .65), and the belief fentanyl was present (OR = 1.49).Conclusion: Our reporting form provides a comprehensive picture of the events surrounding reported overdoses, including factors associated with survival, how much naloxone was used, and the effects of respondents believing fentanyl was involved. Missouri's report can provide support for current naloxone dosing, contextualize refusing post-overdose transport, and can be used to improve overdose response by community and first responders.

Prevalence and Characteristics of Alcohol Use in Substance-Involved Deaths in St. Louis, Missouri from 2011-2022.

OBJECTIVE: Alcohol contributes to a large number of deaths annually, both in terms of deaths fully attributed to alcohol (e.g., alcohol poisoning) and deaths where alcohol is a contributing cause (e.g., motor-vehicle accidents). Nationally, alcohol-involved deaths are increasing. This study examines alcohol's role in substance-involved deaths and factors that are associated with alcohol-involvement in the St. Louis, Missouri region. METHOD: The present study examines 7,641 substance-involved deaths that occurred in the St. Louis, Missouri region. Data were provided by city and county medical examiner offices and comprise all substance-involved deaths between 2011 and 2022. We examined the prevalence of alcohol stratified by manner of death, sex, and race. We conducted logistic regression predicting odds of alcohol involvement based demographic factors, presence of medical conditions, involvement of other substances, and year of death. RESULTS: Overall, 26.29% (2,009/7,671) of substance-involved deaths involved alcohol, and annual alcohol-involved deaths increased 54.33% from 2011 to 2022. Most substance-involved deaths were overdose deaths (82.54%, 6,307/7,641). Alcohol-involved overdose deaths increased 60.76% from 2011 to 2022. Prevalence of alcohol was higher for overdose deaths involving opioids and benzodiazepines (18-24%) than for other drug classes (7-16%). Odds of alcohol involvement in overdose deaths increased with age (OR=1.02, 95% CI:[ 1.01, 1.02]) and were higher for males (OR=1.67, 95% CI: [1.43-1.96]). CONCLUSIONS: The St. Louis metropolitan area saw increases in alcohol-involved fatalities for all manner of deaths, particularly overdose deaths and deaths among Black men. To improve prevention strategies for alcohol fatalities, further research is needed to investigate the role of alcohol in polysubstance overdose deaths.

Methadone's Resurgence in Bridging the Treatment Gap in the Overdose Crisis: Position Statement of AMERSA, Inc (Association for Multidisciplinary Education, Research, Substance Use, and Addiction).

BACKGROUND: The United States is grappling with an unprecedented overdose crisis, exacerbated by the proliferation of potent synthetic opioids like illicitly manufactured fentanyl. Despite the efficacy of methadone treatment in managing opioid use disorder, regulatory barriers hinder its widespread utilization. This article examines the complex landscape of methadone regulation across federal, state, and local levels, highlighting disparities and opportunities for reform. ISSUE: The COVID-19 public health emergency prompted temporary flexibility in methadone regulations, including expanded take-home doses and telehealth counseling, leading to improved treatment experiences and retention. Permanent revisions to federal guidelines have since been introduced by the Substance Abuse and Mental Health Services Administration, reflecting a progressive shift toward patient-centered care and streamlined access. State regulations, managed by Single State Agencies and State Opioid Treatment Authorities, vary widely, often imposing additional restrictions that impede access to methadone treatment. Local OTP clinics further exacerbate barriers through stringent policies, despite federal and state guidelines advocating for flexibility. RECOMMENDATIONS: Coordinated efforts among policymakers, healthcare providers, and communities are needed to promote the development of accountability measures, incentives, and community involvement to ensure equitable access and quality of care. To truly meet the demand needed to end the existing overdose crisis and enhance accessibility and comprehensive healthcare services, methadone treatment expansion beyond traditional OTP settings into primary care offices and community pharmacies should take place.

Longitudinal Assessment of Emergency Responders' Attitudes Toward People Who Overdose and Naloxone Following an Overdose Education Training.

BACKGROUND: In addition to teaching overdose recognition and response, overdose education and naloxone distribution (OEND) trainings for emergency responders aim to improve trainee attitudes toward people who use drugs and toward naloxone. This study examines the training effectiveness long term, as well as the extent to which improvements are dependent on profession type or recent experience administering naloxone. METHODS: A total of 774 emergency responders, consisting of law enforcement officers (LEOs) (n = 624, 81%) and emergency medical service (EMS) personnel (n = 150, 19%), attended OEND trainings and completed surveys immediately prior to ("pre") and following ("post") the training, as well as 6 months later ("follow-up"). Survey items assessed attitudes toward people who have overdosed, naloxone-related risk compensation (ie, "enabling") beliefs, and whether participants had administered naloxone since attending the training. Multiple regression and estimated marginal means were used to evaluate changes in scores. RESULTS: Emergency responders showed improved attitudes (pre = 2.60, follow-up = 2.45, P < .001) and risk compensation beliefs (pre = 2.97, follow-up = 2.67, P < .001) 6 months following the training. Follow-up scores differed by profession, with LEOs endorsing worse attitudes (difference = 0.55, P = .013) and more risk compensation beliefs (difference = 0.67, P = .014) than EMS. In addition, having recently administered naloxone predicted more negative attitudes (EMS: difference = 0.55, P = .01; LEO: difference = 0.54, P = .004) and risk compensation beliefs (EMS = 0.73, P = .006; LEO = 0.69, P = .002) at follow-up. CONCLUSION: Six months after an OEND training, emergency responders' attitudes toward people who overdose, and their risk compensation beliefs remained improved. However, LEOs had more negative follow-up attitudes and beliefs compared to EMS. Emergency responders who had administered naloxone had worse attitudes and beliefs at follow-up than those who had not. Of note, our sample evidenced sizable attrition between pre and follow-up assessments, leaving room for selection bias. Future studies should investigate how to mitigate negative effects of administering naloxone on attitudes toward those who overdose, and belief that naloxone is "enabling."

An evaluation of first responders' intention to refer to post-overdose services following SHIELD training.

BACKGROUND: First responders [law enforcement officers (LEO) and Fire/Emergency Medical Services (EMS)] can play a vital prevention role, connecting overdose survivors to treatment and recovery services. This study was conducted to examine the effect of occupational safety and harm reduction training on first responders' intention to refer overdose survivors to treatment, syringe service, naloxone distribution, social support, and care-coordination services, and whether those intentions differed by first responder profession. METHODS: First responders in Missouri were trained using the Safety and Health Integration in the Enforcement of Laws on Drugs (SHIELD) model. Trainees' intent to refer (ITR) overdose survivors to prevention and supportive services was assessed pre- and post-training (1-5 scale). A mixed model analysis was conducted to assess change in mean ITR scores between pre- and post-training, and between profession type, while adjusting for random effects between individual trainees and baseline characteristics. RESULTS: Between December 2020 and January 2023, 742 first responders completed pre- and post-training surveys. SHIELD training was associated with higher first responders' intentions to refer, with ITR to naloxone distribution (1.83-3.88) and syringe exchange (1.73-3.69) demonstrating the greatest changes, and drug treatment (2.94-3.95) having the least change. There was a significant increase in ITR score from pre- to post-test (ß = 2.15; 95% CI 1.99, 2.30), and LEO-relative to Fire/EMS-had a higher score at pre-test (0.509; 95% CI 0.367, 0.651) but a lower score at post-test (0.148; 95% CI - 0.004, 0.300). CONCLUSION: Training bundling occupational safety with harm reduction content is immediately effective at increasing first responders' intention to connect overdose survivors to community substance use services. When provided with the rationale and instruction to execute referrals, first responders are amenable, and their positive response highlights the opportunity for growth in increasing referral partnerships and collaborations. Further research is necessary to assess the extent to which ITR translates to referral behavior in the field.

Outcomes of State Targeted/Opioid Response Grants and the Medication First Approach: Evidence of Racial Inequities in Improved Treatment Access and Retention.

BACKGROUND: Since 2017, Missouri has increased access to medication for opioid use disorder (OUD) within the State's publicly-funded substance use specialty treatment system through a "Medication First" approach. Results from a statewide assessment of the first year of State Targeted Response implementation showed increases and improvements in overall treatment admissions, medication utilization, and treatment retention. The current study, which focuses on the St. Louis region, the epicenter of Missouri's overdose crisis, examines whether improvements were experienced equally among Black and White clients. METHODS: This study is a retrospective analysis using state-level billing records for individuals with OUD receiving services through publicly-funded substance use treatment programs between July 1, 2016, and June 30, 2019, with claimed services updated through November 1, 2020. Comparisons across time periods, treatment groups, and Black and White clients were assessed using chi-square tests of independence and multivariate negative binomial regressions. RESULTS: White individuals in St. Louis experienced larger increases in treatment admissions and utilization of medications for OUD than Black individuals, and Black clients were retained in treatment for shorter lengths of time than White clients. CONCLUSION: In Missouri, rates of drug overdose deaths are more than three times higher for Black people than White people. Racial inequities in OUD treatment utilization and retention must be intentionally targeted and corrected as one component of reducing this sizable disparity in fatalities.

The association of medical providers' attitudes about naloxone and people with opioid use disorder and their self-reported "low-barrier" treatment practices.

Opioid-involved overdose deaths continue to climb, in part because of suboptimal access to and retention on medications for opioid use disorder (MOUD), including buprenorphine. Low barrier buprenorphine treatment aims to reduce or eliminate the threshold for getting and staying on medication by providing immediate and long-term access to buprenorphine without strict rules or requirements. This study examines associations between medical providers' beliefs about treating people with opioid use disorder (OUD) and naloxone access with their self-reported low-barrier buprenorphine prescribing practices. We surveyed and analyzed responses from providers (N = 86) who completed X-waiver courses in Missouri between March 2017 and September 2019, of which 55% (n = 47) both completed the full survey and endorsed prescribing buprenorphine since the training. The survey included questions about buprenorphine prescribing behaviors as well as the Naloxone-Related Risk Compensation Beliefs (NaRCC-B) scale and the Attitudes toward Patients with OUD scale. Analyses consisted of a series of linear and logistic regressions with the NaRCC-B and OUD Attitudes scales predicting various domains of low-barrier prescribing behaviors. Findings indicate medical providers' beliefs about treating people with OUD are associated with their practice of addiction medicine, with individuals with more favorable views being more likely to endorse low-barrier buprenorphine prescribing practices including offering telemedicine and at-home inductions, prescribing higher doses of buprenorphine, treating larger caseloads, and discussing overdose risk and protective factors with their patients. Providers' beliefs about naloxone being enabling were less related to their buprenorphine practices but strongly related to their likelihood of providing naloxone. Future research may examine which strategies effectively change prescriber attitudes and their adoption of lower-barrier prescribing practices.

Examining Increasing Racial Inequities in Opioid Overdose Deaths: a Spatiotemporal Analysis of Black and White Decedents in St. Louis, Missouri, 2011-2021.

The third wave of the opioid overdose crisis-defined by the proliferation of illicit fentanyl and its analogs-has not only led to record numbers of overdose deaths but also to unprecedented racial inequities in overdose deaths impacting Black Americans. Despite this racialized shift in opioid availability, little research has examined how the spatial epidemiology of opioid overdose death has also shifted. The current study examines the differential geography of OOD by race and time (i.e., pre-fentanyl versus fentanyl era) in St. Louis, Missouri. Data included decedent records from the local medical examiners suspected to involve opioid overdose (N = 4420). Analyses included calculating spatial descriptive analyses and conducting hotspot analyses (i.e., Gettis-Ord Gi*) stratified by race (Black versus White) and time (2011-2015 versus 2016-2021). Results indicated that fentanyl era overdose deaths were more densely clustered than pre-fentanyl era deaths, particularly those among Black decedents. Although hotspots of overdose death were racially distinct pre-fentanyl, they substantially overlapped in the fentanyl era, with both Black and White deaths clustering in predominantly Black neighborhoods. Racial differences were observed in substances involved in cause of death and other overdose characteristics. The third wave of the opioid crisis appears to involve a geographic shift from areas where White individuals live to those where Black individuals live. Findings demonstrate racial differences in the epidemiology of overdose deaths that point to built environment determinants for future examination. Policy interventions targeting high-deprivation communities are needed to reduce the burden of opioid overdose on Black communities.

Implementing an EMA burst design in community-engaged research: participant and researcher perspectives and recommendations.

Background: Implementing ecological momentary assessment (EMA) methodology to evaluate the substance use disorder (SUD) treatment pipeline has clear advantages, including learning about participants' day-to-day experiences to aid in the improvement of services and accessibility for those seeking treatment. Given that the SUD treatment pipeline spans long periods of time, EMA burst designs (deployment of multiple short EMA periods spread over time) can be advantageous for evaluating the treatment pipeline over time while keeping participant burden low.Objectives: This feasibility study describes (1) the process and study design of implementing EMA burst methodology to evaluate the SUD treatment pipeline experience; (2) study implementation from the perspective of researchers, including discussion of collaboration with community partners; and (3) participant feedback on the experience of engaging with this type of research.Method: EMA metrics, feasibility ratings, and general experience ratings in the study are presented from 22 participants (64% women) who participated in a parent EMA study evaluating the SUD treatment pipeline and 8 who provided feedback in a follow-up survey.Results: Participants found the EMA burst design to be acceptable and not burdensome, although technology issues were present for some participants. Steps to partnering with community treatment programs and implementation of a burst design are outlined.Conclusions: Strategies and recommendations for implementation of an EMA burst study with community partners are provided, including aspects of study design, technology issues, retention, and funding.

Identifying drivers of increasing opioid overdose deaths among black individuals: a qualitative model drawing on experience of peers and community health workers.

BACKGROUND: Black individuals in the USA face disproportionate increases in rates of fatal opioid overdose despite federal efforts to mitigate the opioid crisis. The aim of this study was to examine what drives increases in opioid overdose death among Black Americans based on the experience of key stakeholders. METHODS: Focus groups were conducted with stakeholders providing substance use prevention services in Black communities in St. Louis, MO (n = 14). One focus group included peer advocates and volunteers conducting outreach-based services and one included active community health workers. Focus groups were held at community partner organizations familiar to participants. Data collection was facilitated by an interview guide with open-ended prompts. Focus groups were audio recorded and professionally transcribed. Transcripts were analyzed using grounded theory to abstract line-by-line codes into higher order themes and interpret their associations. RESULTS: A core theme was identified from participants' narratives suggesting that opioid overdose death among Black individuals is driven by unmet needs for safety, security, stability, and survival (The 4Ss). A lack of The 4Ss was reflective of structural disinvestment and healthcare and social service barriers perpetuated by systemic racism. Participants unmet 4S needs are associated with health and social consequences that perpetuate overdose and detrimentally impact recovery efforts. Participants identified cultural and relationship-based strategies that may address The 4Ss and mitigate overdose in Black communities. CONCLUSIONS: Key stakeholders working in local communities to address racial inequities in opioid overdose highlighted the importance of upstream interventions that promote basic socioeconomic needs. Local outreach efforts utilizing peer services can provide culturally congruent interventions and promote harm reduction in Black communities traditionally underserved by US health and social systems.

Impact of the COVID-19 pandemic on burnout and perceived workplace quality among addiction treatment providers.

BACKGROUND: This study examines the impact of the COVID-19 pandemic on work satisfaction, work-related stress, and perceived work quality among substance use treatment providers to better understand challenges faced among this group during the pandemic. METHODS: Participants of this study were 91 addiction treatment providers (e.g., therapists, physicians, community support specialists, administrative staff) recruited from various treatment facilities (e.g., inpatient and outpatient settings). Mixed method analyses were conducted to assess self-reported burnout, sources of work-related stress, and perceived work quality during the pandemic. Responses from providers reporting COVID-19 related decreases in work quality were compared to responses from providers who reported their quality of work had increased or remained the same. RESULTS: Results demonstrated half of providers (51%) reported their quality of work had decreased. This perceived decrease in quality of work was associated with higher levels of emotional exhaustion (M = 17.41 vs. M = 12.48, p = 0.002), workplace stress (M = 42.80 vs. M = 30.84, p = 0.001), as well as decreased enjoyment of work (83% vs. 51%, p = 0.001) and decreased personal accomplishment (M = 20.64 vs. M = 23.05 p = 0.001). Qualitative investigations further illustrated that increased hours, changes in work schedules, work-life balance challenges, difficulties with client communication, and increased client needs were contributing factors increasing stress/burnout and decreasing perceived work quality. CONCLUSIONS: Addiction treatment providers experience high levels of burnout and workplace stress. Additionally, many individuals perceived a decrease in their quality of work during the COVID-19 pandemic. Addiction treatment facility administration should address these challenges to support the well-being of clinical staff and the clients they serve both during and after the COVID-19 pandemic.

To Prescribe or Not to Prescribe?: Barriers and Motivators for Progressing Along Each Stage of the Buprenorphine Training and Prescribing Path.

This study aimed to identify the strongest barriers and motivators associated with each step toward buprenorphine prescribing (1. obtaining a waiver, 2. beginning to prescribe, and 3. prescribing to more people) among a sample of Missouri-based medical professionals (N = 130). Item weights (number of endorsements times mean rank of the item's importance) were calculated based on their responses. Across groups, lack of access to psychosocial support services, need for higher levels of care, and clinical complexity were strong barriers. Among non-prescribers (n = 57, 46.3%), administrative burden, potential of becoming an addiction clinic, and concern about misuse and diversion were most heavily weighted. Among prescribers (n = 66, 53.7%), patients' inability to afford medications was a barrier across phases. Prominent motivators among all groups were the effectiveness of buprenorphine, improvement in other health outcomes, and a personal interest in treating addiction. Only prescribers reported the presence of institutional support and mentors as significant motivators.

Addressing stimulant use disorder through state opioid response grants from the substance abuse and mental health services administration: Missouri's initial approach.

Background: The alarming growth of stimulant-involved deaths underscores the urgent need for states to expand existing opioid-specific approaches to intentionally reach and serve people who use stimulants. Recent permission from federal agencies has allowed states to spend grant funding that was previously restricted to opioid-related activities on approaches addressing stimulant use.Objectives: This manuscript describes the rationale, methods, and initial results supporting the implementation of Missouri's recent stimulant-focused efforts - including previously-prohibited activities such as Contingency Management and fentanyl test strip distribution.Methods: Missouri's State Opioid Response team facilitated the design and implementation of Contingency Management pilot programming abiding by federal spending limits of no more than $75 of incentives per client, mass distribution of fentanyl test strips, and publicly accessible harm reduction trainings and materials specific to stimulant use. Data sources used for initial evaluations included state-level treatment claims, fentanyl test strip distribution counts by type and region of organizations receiving them, and qualitative feedback from stakeholders.Results: Six substance use treatment agencies developed Contingency Management programs, serving 29 individuals in the first nine months. Over 20,000 fentanyl test strips were distributed using a prioritization system designed to reach those most likely to benefit from their use.Conclusions: Recent federally funded efforts to better address stimulant use in Missouri have increased access to evidence-based treatment and harm reduction resources. Lessons learned from early implementation, especially those regarding time allowed for program development and how best to ensure equitable resource distribution, will inform future stimulant-focused program efforts.

Acceptance of medications for opioid use disorder in recovery housing programs in Missouri.

BACKGROUND: Recovery housing plays an important role in supporting individuals in their recovery by building recovery capital and providing stable living environments; however, the extent to which medications for opioid use disorder (MOUD), the gold standard for OUD treatment, are accepted in recovery housing settings is unclear. The purpose of this study, as part of a larger statewide evaluation of Missouri recovery homes, was to identify the extent to which Missouri recovery houses were accepting of methadone, buprenorphine, and naltrexone as well as the extent to which the acceptance of each medication was linked to whether the recovery home encouraged tapering off MOUDs. METHODS: Sixty-four recovery housing managers and/or staff, out of 66 eligible recovery homes in Missouri completed the survey. RESULTS: Results indicated that methadone was the least accepted medication for long-term use followed by buprenorphine and then naltrexone. Recovery houses that had significantly lower overall acceptance of methadone encouraged tapering; however, the overall acceptance for buprenorphine and naltrexone was not significantly related to the encouragement of tapering off MOUDs. CONCLUSION: This work highlights the need to develop reliable instruments to measure and assess MOUD-capable recovery homes and to increase knowledge and acceptance of MOUD within recovery home settings.

Patients With Serious Injection Drug Use-Related Infections who Experience Patient-Directed Discharges on Oral Antibiotics Have High Rates of Antibiotic Adherence but Require Multidisciplinary Outpatient Support for Retention in Care.

BACKGROUND: Persons who inject drugs (PWID) are frequently admitted for serious injection-related infections (SIRIs). Outcomes and adherence to oral antibiotics for PWID with patient-directed discharge (PDD) remain understudied. METHODS: We conducted a prospective multicenter bundled quality improvement project of PWID with SIRI at 3 hospitals in Missouri. All PWID with SIRI were offered multidisciplinary care while inpatient, including the option of addiction medicine consultation and medications for opioid use disorder (MOUD). All patients were offered oral antibiotics in the event of a PDD either at discharge or immediately after discharge through an infectious diseases telemedicine clinic. Additional support services included health coaches, a therapist, a case manager, free clinic follow-up, and medications in an outpatient bridge program. Patient demographics, comorbidities, 90-day readmissions, and substance use disorder clinic follow-up were compared between PWID with PDD on oral antibiotics and those who completed intravenous (IV) antibiotics using an as-treated approach. RESULTS: Of 166 PWID with SIRI, 61 completed IV antibiotics inpatient (37%), while 105 had a PDD on oral antibiotics (63%). There was no significant difference in 90-day readmission rates between groups (P = .819). For PWID with a PDD on oral antibiotics, 7.6% had documented nonadherence to antibiotics, 67% had documented adherence, and 23% were lost to follow-up. Factors protective against readmission included antibiotic and MOUD adherence, engagement with support team, and clinic follow-up. CONCLUSIONS: PWID with SIRI who experience a PDD should be provided with oral antibiotics. Multidisciplinary outpatient support services are needed for PWID with PDD on oral antibiotics.

Long-acting reversible contraceptives (LARCs) as harm reduction: a qualitative study exploring views of women with histories of opioid misuse.

BACKGROUND: The sharp rise in opioid use disorder (OUD) among women coupled with disproportionally high rates of unintended pregnancy have led to a four-fold increase in the number of pregnant women with OUD in the United States over the past decade. Supporting intentional family planning can have multiple health benefits and reduce harms related to OUD but requires a comprehensive understanding of women's perspectives of preventing unintended pregnancies. The purpose of this study was to comprehensively evaluate the knowledge, attitudes and experiences as they relate to seeking contraception, particularly LARCs, among women with active or recovered opioid misuse. METHODS: In-depth interviews and focus group discussions with 36 women with current or past opioid misuse were recorded and transcribed. Transcripts were coded by ≥ 2 investigators. Themes related to contraceptive care seeking were identified and contextualized within the Health Belief Model. RESULTS: Our analysis revealed seven interwoven themes that describe individual level factors associated with contraceptive care seeking in women with current or past opioid misuse: relationship with drugs, reproductive experiences and self-perceptions, sexual partner dynamics, access, awareness of options, healthcare attitudes/experiences, and perceptions of contraception efficacy/ side effects. Overall, perceived susceptibility and severity to unintended pregnancy varied, but most women perceived high benefits of contraception, particularly LARC. However, perceived barriers were too high for most to obtain desired contraception to support family planning intentions. CONCLUSIONS: The individual-level factors identified should inform the design of integrated services to promote patient-centered contraceptive counseling as a form of harm reduction. Interventions should reduce barriers to contraceptive access, particularly LARCs, and establish counseling strategies that use open, non-judgmental communication, acknowledge the continuum of reproductive needs, explore perceived susceptibility to pregnancy, and utilize peer educators.

Balancing need and risk, supply and demand: Developing a tool to prioritize naloxone distribution.

Background: Opioid overdose deaths continue to rise nationally. The demand for naloxone, the opioid overdose antidote, is outpacing the supply. With increasing naloxone requests, tools to prioritize distribution are critical to ensure available supplies will reach those at highest risk of overdose. Methods: We developed a standardized "Naloxone Request Form" (NRF) and corresponding weighted prioritization algorithm to serve as decisional aid to better enable grant staff to prioritize naloxone distribution in a data-driven manner. The algorithm computed raw priority scores for each agency, which were then separated into the predetermined quintiles. Historical naloxone distribution decisions were compared with agencies' prioritization quintile. Results: Results demonstrated that the NRF and corresponding algorithm was successful at prioritizing agencies based on potential impact. Although, overall, naloxone was distributed more heavily to the agencies deemed highest priority, our algorithm identified significant shortcomings of the "first come, first served" method of distribution we had initially deployed. Conclusions: This work has laid the foundation to use this tool prospectively to allow for data-driven decision-making for naloxone distribution. Our tool is flexible and can be customized to best fit the needs of a variety of programs and locations to ensure the distribution of limited supplies of naloxone have the greatest impact.

Understanding barriers to treatment among individuals not engaged in treatment who misuse opioids: A structural equation modeling approach.

Background: Many individuals misusing opioids do not enter into treatment. The question of who enters into treatment for their opioid abuse and under what circumstances is complex and shaped by multiple factors. The objective of the current study is to explore the risk factors for wide-ranging and numerous barriers to treatment among social media users. Method: Opioid-related forums within a popular social media platform were used to recruit non-treatment engaged individuals (≥15 years) who had misused opioids in the past month (n = 144; 66% male; median age 28). Four treatment barrier factors were identified utilizing principle component analysis: (1) stigma, (2) awareness, (3) attitudinal, and (4) denial. A structural equation model (SEM) was then created to explore the risk factors for different types of barriers to OUD treatment. Results: The most common barriers among participants not engaged in treatment for their opioid misuse were the belief that one should be able to help themselves with their condition (66%), treatment was too expensive (63%), and worries about being labeled or judged (57%). Additionally, SEM results demonstrate stigma barriers, awareness, and attitudinal barriers were associated with mental health comorbidities, opioid abuse and dependence severity, and treatment history. Denial barriers, however, were only associated with treatment history, and structural/financial barriers were only associated with opioid abuse and dependence severity. Conclusions: Our research findings are relevant for underscoring the wide-ranging and numerous barriers to treatment faced by individuals misusing opioids that are especially concentrated among those who also struggle with comorbid mental illness.

Dismantling racism against Black, Indigenous, and people of color across the substance use continuum: A position statement of the association for multidisciplinary education and research in substance use and addiction.

The Association for Multidisciplinary Education and Research in Substance Use and Addiction (AMERSA) acknowledges that racism profoundly affects persons who use alcohol and other drugs. Racism's deadly effects compounded with other social determinants of health result in a cascade of negative impacts. The AMERSA Board of Directors (BOD) proposes an initial set of strategies to promote diversity, equity, and inclusion using a framework that speaks to four key AMERSA experiences: engagement, education, mentorship, and leadership. Through these strategies, AMERSA commits to promoting equity and inclusion to dismantle the individual, institutional, and structural racism that has permeated the United States for centuries.