Levels of engagement among office-based opioid treatment (OBOT) patients with concurrent methamphetamine use.

BACKGROUND AND OBJECTIVES: Recent increases in methamphetamine use among people seeking treatment for opioid use disorder (OUD) has created significant demand for effective approaches to support this clinical population. This study assessed the extent to which office-based opioid treatment (OBOT) patients, who were diagnosed with methamphetamine use disorder (MUD), engaged with providers. METHODS: A retrospective analysis was conducted of adult patients (n = 470) seeking treatment for OUD who attended at least one visit between March 2020 and March 2023 at a rural regional OBOT provider. Approximately one quarter (28.7%) of patients were diagnosed with MUD in addition to receiving an OUD diagnosis. Bivariate methods and multivariate negative binomial regression models were estimated to examine the associations between clinical measures and the numbers of office visits, peer visits, and telehealth visits. RESULTS: Regression results indicated patients who met criteria for MUD in addition to OUD attended a higher rate of peer visits (incidence rate ratio [IRR] = 2.63, p = .036) when compared to patients who did not meet criteria for MUD. In contrast, patients with MUD and OUD diagnoses displayed significantly lower (IRR = 0.68, p < .001) engagement rates through fewer office visits relative to those who did not meet MUD criteria. DISCUSSION AND CONCLUSIONS: Patients seeking treatment for OUD who meet criteria for MUD are more likely to engage through peer support specialists rather than office visits. SCIENTIFIC SIGNIFICANCE: This study demonstrates the ways patients who meet criteria for OUD and MUD engage with providers to receive treatment.

Detecting DSM-5 Opioid and Methamphetamine Use Disorders With the UNCOPE Screen.

BACKGROUND: The most recent wave of the opioid epidemic has contributed to record number of drug overdoses. Most fatal outcomes are associated with opioids and methamphetamine; two substances that tend to be used at high rates among criminal justice populations. Despite the steady rise in the number of overdoses in local detention centers, many correctional facilities do not conduct routine screens for opioid and methamphetamine use disorders. This study examines the utility of the UNCOPE, a 6-item brief screen, to detect probable Diagnostic and Statistical Manual for Mental Disorders, fifth edition (DSM-5) diagnoses for these 2 specific substance use disorders (SUDs). The study also examines key indicators of these specific SUDs. METHODS: Data were collected from comprehensive substance use assessments conducted with 717 adults who were recently admitted to 4 county jails. RESULTS: Findings indicate that 3 positive UNCOPE responses accurately detected 99.8% of opioid use disorder diagnoses and 98.7% of methamphetamine use disorder diagnoses. Receiver operating characteristic curve results generate an area under the curve at 0.99 for severe opioid use cases and 0.98 for severe methamphetamine use cases. Subsequent analyses indicate 2 of the 6 items on the UNCOPE function to accurately identify 100% of cases classified with opioid use disorder and 99.6% of cases classified with methamphetamine use disorder. CONCLUSIONS: Evidence suggests that UNCOPE is a practical and efficient approach to identifying opioid and methamphetamine use disorders. In addition, 2 items can serve as an ultra-brief method to detecting these conditions at the time of admission to detention centers.

Building bridges to outpatient treatment services for post-overdose care via paramedic buprenorphine field initiation.

INTRODUCTION: Despite sustained efforts to reduce opioid-related overdose fatalities, rates have continued to rise. In many areas, overdose response involves emergency medical service (EMS) personnel administering naloxone and transporting patients to the emergency department (ED). However, a substantial number of patients decline transport, and many EDs do not provide medication for opioid use disorder (MOUD). One approach to filling this gap involves delivering MOUD to overdose patients in the field with trained post-overdose EMS teams who can initiate buprenorphine. In this MOUD field initiation pilot program, a trained EMS Community Paramedicine team initiates buprenorphine in the field and links patients to care. The program includes three pathways to treatment with the first designed for EMS to initiate buprenorphine after overdose reversal when the patient is in withdrawal from naloxone; a second pathway initiates buprenorphine after overdose when the patient is not in withdrawal; and a third enables self-referral via a connection to the community EMS team not necessarily related to a recent overdose. METHODS: We conducted a retrospective cohort study of the MOUD field initiation pilot program. Data are from 28 patients who entered care immediately post-overdose initiation of buprenorphine, 21 patients who initiated on buprenorphine while not in naloxone withdrawal, and 37 patients who self-referred to treatment following outreach efforts by paramedicine and peer support professionals. RESULTS: A total of 118 patients initiated buprenorphine during the 12-month study period and 104 (83 %) visited the clinic for their first appointment. Over two thirds (68 %, n = 80) remained engaged in care after 30 days. Retained patients tended to be male, white, uninsured, food insecure, have unstable housing, lack reliable transportation, and report prior involvement with the criminal legal system. CONCLUSION: The initial 12-month period of the pilot program demonstrated the feasibility of initiating buprenorphine at the site of overdose without requiring transport to the ED and offer self-referral pathways for people experiencing barriers to treatment. Specialized EMS can play a critical role in expanding access to MOUD treatment by bridging the gap between overdose and comprehensive community-based care.

Jail Characteristics and Availability of Opioid Treatment Services: Results from a Nationally Representative Survey.

The current wave of the opioid epidemic has contributed to a record number of drug-related overdoses and a significant proportion of people who experience opioid use disorder are admitted to local jails. These correctional facilities serve as the principal entry point to the criminal justice system as nearly every person who is taken into custody is admitted to a local detention center. Although jails are recognized as primary intervention points for people who may require treatment for opioid use disorder, services in these facilities remain deficient. The absence of jail-based treatment has become a pressing concern as the number of drug-related deaths in custody continues to rise and the risk of post-release overdose also remains high. The present study draws on the opioid-related module of the 2019 Bureau of Justice Statistics' Census of Jails to assess the relationships between the characteristics of 2588 local detention centers and the availability of treatment services. These specific approaches included screening for opioid use disorder, providing medication to manage withdrawal symptoms, administering medication for opioid use disorder (MOUD), providing overdose reversal medication at the time of release, and linking people with community-based care following release from the detention center. The results demonstrate facilities located in the Northeast, larger jails, those in urban areas, and detention centers with higher turnover rates are significantly more likely to provide a wider variety of opioid treatment services. These findings have important implications for the prioritization of policies and the allocation of resources to support the adoption of opioid treatment services in local jails.

Mental Health Conditions, Substance Use Disorders, and Jail Readmission in Four Rural Counties.

Most jails are in rural areas, and many adults who pass through these facilities experience behavioral health needs. Evidence suggests mental health conditions (MHCs) and substance use disorders (SUDs) may be linked to an increased risk for jail readmission, but most work documenting this relationship uses vague measures, outdated diagnostic information, has been conducted in large metropolitan jails, or has demonstrated significant variability between facilities. This multisite study examined the associations between specific MHCs, SUDs, and jail readmission among 675 adults from four rural jails. Descriptive statistics and multivariate analyses indicated rural jail populations are likely to present MHCs, especially major depression and PTSD, at higher rates than those found in national estimates. SUDs were also observed at rates higher than those typical of national surveys, and particular SUDs were significantly more prevalent in some facilities relative to others. MHCs were not associated with prior jail admission, but SUDs were linked to a greater probability of a previous jail stay. These results highlight the importance of increasing the availability of jail-based, substance-specific treatment programs that cater to individual facilities' most pressing needs to ultimately reduce jail readmission.

Naloxone Plus, Plus Some: Examining Ohio's Quick Response Teams Through the Lens of Deflection.

There were nearly 50 000 opioid-related deaths in 2019 in the United States.* The dramatic frequency of opioid overdoses and fatalities has led to strained community resources, especially among hospitals and first responders (law enforcement, fire, and emergency medical services). In response to rising overdose rates, many first responders have implemented programs that align public health and public safety responses to overdoses. Often called "Quick Response Teams" (QRTs), these programs leverage a collaborative team to respond to those at risk of overdose, or who have survived an overdose. The initial QRT was implemented in Colerain Township, Ohio, in 2015.† Today, QRTs are a widely accepted "model" overdose response program.‡ Despite the popularity of QRTs, research on the model is limited. In this article, the authors use existing qualitative and quantitative data from QRTs across the state of Ohio to examine QRTs. Using the lens of the Police, Treatment and Community Collaborative's 5 deflection pathways, the authors answer four key questions: (1) What is the scale of QRTs in Ohio, and how are QRTs in our sample structured? (2) Whom are the QRTs serving? (3) How many pathways of deflection are reflected in Ohio's QRTs? (4) What can these data teach us about the context of the QRT work and (more generally) collaborative overdose response? After examining the QRTs and their data, the authors provide suggestions to help researchers, practitioners, and funders better understand QRTs and similar public health/public safety partnerships.

An Ultra-Brief 2-Item Depression Screening Tool for Correctional Populations.

Although a number of depression screening instruments exist for use primarily in community mental health and medical settings, few have been validated on correctional populations. This study sought to examine the clinical utility of six different 2-item pairs in identifying risk for DSM-5 major depressive episode among a sample of county jail inmates. Data for the current report were derived from routine clinical assessments of 283 inmates recently admitted to a county jail. All inmates were administered the depression screening items as part of a structured diagnostic assessment interview to identify mental health needs. Results revealed that the best performing 2-item screen involved the combination of "difficulty concentrating" and "lack of energy," which represented the best balance of sensitivity (85.5%) and specificity (76.6%). Screening for major depression using as few as two items can be a valid and efficient strategy in identifying risk for major depressive episode among jail inmates.

Behavioral health indicators and time-to-rearrest in an adult pre-arrest diversion program.

Several states have recently adopted legislation in support of pre-arrest diversion programs that give police the authority to refer adults with behavioral health needs to treatment providers instead of placing them under arrest and booking them into local jails. The Adult Civil Citation program has been operating since 2013 to divert adults accused for the first time of a misdemeanor offense to a community behavioral health provider with the primary goal of addressing underlying needs that are likely to be associated with future criminal justice contact. The current study analyzed data from a sample of 1,071 adults who participated in the program to assess the impact of behavioral health indicators on time-to-rearrest. Adults who presented greater behavioral health needs were more likely to come into subsequent contact with police, but these indications did not influence the amount of time that lapsed between program participation and rearrest events.

Exposure to Violence and Posttreatment Substance Use Among Patients With Opioid Use Disorder.

Exposure to violence can lead to a dramatic increase in the likelihood of the development of a substance use disorder (SUD). Given the overlap between the two, substance use for survivors of violence, then, can be a coping mechanism to manage the traumatic effects of abuse and persistent use can evolve into a diagnosable SUD. This study was designed to examine the posttreatment substance use among adults who have a history of exposure to violence and sought treatment for opioid use disorder. Data for this study were drawn from the Comprehensive Addiction Treatment Outcome Research system. Among the 13,105 patients included in the study, 444 (3.4%) received a formal diagnosis for opioid use disorder. Female victims of violence are at a greater risk of suffering injuries related to violence, resulting in increased levels of medical care utilization, which may prompt the initiation and prolonged use of prescription pain relief medication. Related to this important finding is another indicating that exposure to violence at multiple points in the past was associated with more severe indicators of substance use. These data show that there is a relationship between exposure to violence, SUDs, and relapse among patients seeking treatment. Not only must patients and treatment providers address these past violent experiences as important psychological factors in recovery, but in the context of opioid use disorder, physical injuries contributing to chronic pain may also trigger persistent substance use.

Posttraumatic stress, panic disorder, violence, and recidivism among local jail detainees.

PURPOSE: Most research on posttraumatic stress disorder (PTSD) and offending has been conducted with special populations (e.g. veterans and female inmates) and generally overlooks the additive effect of panic disorder (PD) in offending patterns. The purpose of this paper is to assess the prevalence of PTSD and PD among jail inmates, while simultaneously examining the relationships between these disorders, offending types and frequency. DESIGN/METHODOLOGY/APPROACH: A random sample of adults recently booked into a local county jail participated in the Comprehensive Addictions and Psychological Evaluation-5 (CAAPE-5), a structured psychological assessment. The study sample was comprised of 200 male and 83 female inmates. FINDINGS: Indications of PTSD were observed among 44.0 percent of male inmates and 57.8 percent of female inmates. Most male inmates (78.4 percent) with positive PTSD indications also met criteria for PD, with a similar proportion (78.1 percent) of female inmates also meeting criteria for both. The combination of PTSD and PD was not associated with offending frequency, but inmates presenting indications of both PTSD and PD were more likely to be charged with a violent offense relative to those with only PTSD. PRACTICAL IMPLICATIONS: Inmates with PTSD who also have panic attacks may have a more severe condition with possible implications for other risks. Observations of these conditions among adults recently booked into local jails should coincide with each other. ORIGINALITY/VALUE: Few studies have examined mental health conditions among local jail detainees, despite the ever-present need to address them. The current study considers this important population and investigates the prevalence of co-occurring conditions.

A prospective study of behavioral health indicators and repeat jail admissions among rural inmates.

BACKGROUND: Approximately three quarters of a million adults are detained in US jails, and rural detention centers are responsible for the largest recent increases in this population. It is estimated that two thirds of jail inmates meet criteria for a substance use disorder (SUD), nearly half present symptoms consistent with a mental health condition (MHC), and the vast majority of adults in jails have been arrested and booked into these facilities in the past. It is critical to examine the link between SUDs, MHCs, and readmissions to help inform better approaches. METHODS: This prospective study examined the associations between SUDs, MHCs, and jail readmissions in a random sample of 224 adults collected from a rural correctional facility in North Carolina. The Comprehensive Addiction and Psychological Evaluation-5 (CAAPE-5) was administered to participants within 24 to 96 h of admission to the jail. Information consistent with DSM-5 designations for SUDs and several MHCs was evaluated in conjunction with 12-month jail readmission data. RESULTS: Bivariate analyses demonstrated the disproportionality of SUDs and several MHCs (including depressive episode, posttraumatic stress, and antisocial personality) among adults who were readmitted to the jail. Binary multivariate logistic regression analyses showed SUDs nor MHCs to be associated with any jail readmissions, but multinomial regression results indicated SUDs were the most robust indicator of multiple 12-month jail readmissions. CONCLUSIONS: Local jails need to implement systems capable of conducting behavioral health assessments, with a special focus on SUDs as one of the strongest indicators of readmission. This information will allow jail administrators to better manage detainees while they are incarcerated, but it can also enhance the ability to connect adults with appropriate programming options to address the condition and reduce the likelihood of reentering the detention center.

Substance Use Risk Indicators and Offending Patterns Among Local Jail Inmates.

This study examined clinical indicators of adult jail inmates' substance use severity and offending patterns. Clinical assessment and booking data were gathered from a random sample of 283 adult inmates using the Comprehensive Addiction and Psychological Evaluation-5, which is consistent with diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Greater substance use risk was associated with increased likelihood of detention for property-related offenses, nonviolent offenses, and multiple jail admissions. Inmates with greater substance use risk were also significantly less likely to be detained for violent offenses. The assessment and coordination of care for jail inmates in local detention centers is paramount to reducing jail bookings, especially for nonviolent offenses.

Exposure to Violence and Substance Use Treatment Outcomes Among Female Patients.

BACKGROUND: Many female substance use patients have experienced violence in the past, with most estimates showing the majority of patients reporting violent experiences at some point. Prior experience with violence has been linked to increased severity of substance use, and this may contribute to more challenges in the path to recovery. OBJECTIVES: Existing research has confounded the timing at which violence has occurred with the type of violence to which patients have been exposed. The current study was conducted to specify the extent to which the timing of exposure and the type of violence were associated with substance use after discharge from treatment. METHODS: Data were collected from 3,439 female patients included in the Comprehensive Assessment and Treatment Outcome Research (CATOR) system. RESULTS: With regard to the type of exposure, findings indicated female patients who were exposed to multiple forms of violence (i.e. physical and sexual) displayed the greatest severity of substance use upon treatment initiation, as well as the greatest likelihood for use following discharge from treatment. In terms of the timing, female patients who experienced violence at various time points (i.e. before and after 18 years of age) displayed the greatest severity of substance use, but patients who experienced violence after 18 years of age had the highest probability of substance use following discharge from treatment. Conclusions/Importance: Clinicians should collect information related to these important details as treatment protocols are developed, and as patients are connected to aftercare services to minimize post-treatment substance use.

An Initial Assessment of Leon County Florida's Pre-Arrest Adult Civil Citation Program.

Momentum is building behind law enforcement-assisted diversion programs. Some of these programs have been designed specifically for drug-involved offenders, while others focus on adults who have no prior involvement in the criminal justice system. The Leon County Pre-Arrest Diversion program, which has been operating since March 2013, offers first-time arrestees the opportunity to participate in an alternative to arrest-as-usual. Successful completion of the program results in avoidance of a formal criminal arrest record. This paper provides an initial assessment of participants involved in the program during the first 3 years of operation. Results indicate male participants, those who submitted a positive drug test at program initiation, and those who presented significantly greater behavioral health needs were more likely to fail to complete the program and become rearrested. These findings are discussed with regard to practices among pre-arrest diversion programs.

The Role of Patient Payment Method in Premature Discharge from Methadone Maintenance Treatment.

BACKGROUND: Premature discharge is a pervasive problem in methadone maintenance treatment (MMT), and is associated with numerous adverse outcomes. Although a number of demographic variables have consistently been found to impact MMT retention, method of payment has received considerably less attention. A notable limitation of prior work is that most studies classify all patients who leave treatment early, irrespective of reason, as treatment dropouts and fail to account for specific reasons. OBJECTIVE: This study sought to determine whether method of payment for MMT services was associated with differential reasons for premature discharge. METHODS: The sample was comprised of 4158 patients prematurely discharged from 33 MMT facilities located throughout the U.S. from 2009 to 2012. Patients were classified into two groups based on their method of payment: self-pay and insurance (largely Medicaid). Patients were studied through retrospective electronic chart review. RESULTS: Binary logistic regression indicated that insurance patients who were prematurely discharged were significantly more likely to be discharged due to a program-initiated reason (administrative), while self-pay patients were more likely to be discharged due to a patient-initiated reason (against medical advice) after controlling for significant intake demographic and clinical covariates. CONCLUSIONS: Further research is needed to determine whether insurance patients may require different supports in place compared to self-pay patients in order to improve compliance with program guidelines (e.g. behavioral contracts providing a detailed description of rules both at admission and throughout treatment with an emphasis on the potential consequences of noncompliance), and whether self-pay patients may benefit from motivational incentives and interventions to remain engaged in treatment.

A PTSD Screen for Forensic Populations.

Posttraumatic stress disorder (PTSD) has been observed in a sizable proportion of the U.S. adult correctional population. Jail administrators must pay particularly close attention to inmates with PTSD symptoms, considering these facilities serve as the gateway to the criminal justice system and inmates with PTSD may pose a risk to themselves, other inmates, and staff. The reality of conducting behavioral health assessments in a jail environment is wrought with significant challenges, including limited time. The current study examined prior research on PTSD screening tools to establish an empirical basis for a practical screen to be used among adults recently booked into local jails. Data from a random sample of 283 adults assessed specificity and sensitivity rates of different combinations of criteria. Results indicated a two-item screen achieved an 86.4% sensitivity rate as well as an 80.4% specificity rate. This evidence demonstrates a practical and clinically relevant approach to conducting PTSD screens among adult jail inmates.

AiRCare: A naturalistic evaluation of the effectiveness of a protracted telephone-based recovery assistance program on continuing care outcomes.

BACKGROUND & OBJECTIVE: Substance use disorder treatments are increasingly being contextualized within a disease management framework. Within this context, there is an identified need to maintain patients in treatment for longer periods of time in order to help them learn how to manage their disease. One way to meet this need is through telephone-based interventions that engage patients, and include more active outreach attempts and involvement of the patient's family. This study sought to evaluate the effectiveness of three formats of an intensive 12-month post-discharge telephone-based case management approach (AiRCare) on adherence to continuing care plans and substance use outcomes. METHODS: Data were abstracted from electronic medical records for 379 patients (59.9% male) discharged from a residential treatment program located in the southwestern U.S. from 2013 to 2015. Patients were categorized into one of three groups and received telephone contacts based on their self-selection upon admission to residential treatment (i.e., patient only, family only, and both patient and family). Outcome variables included re-engagement and re-admission rates, quality of life, abstinence rates at 6 and 12 months, and compliance with continuing care plans. RESULTS & CONCLUSIONS: Favorable short- and long-term outcomes were found for the majority of patients, irrespective of case management group. There appeared to be some value in the addition of family contacts to patient contacts with respect to reducing risk for 12-month re-admission to residential care. These positive but preliminary indications of the effectiveness of AiRCare require replication in a well-powered, randomized controlled trial.

The entanglement between relapse and posttreatment criminal justice involvement.

BACKGROUND: Research has established a connection between substance use and criminal activity, but much less is known about the association between posttreatment relapse and related contact with the criminal justice system. OBJECTIVE: The current study was designed to elucidate this relationship by examining the long-term effects of relapse on arrest. The study also investigated the probability of relapse into substance use as it followed an arrest. METHOD: Data from 5,822 adults who participated in the Comprehensive Assessment and Treatment Outcome Research (CATOR) system were analyzed. This prospective longitudinal research design included 0-6, 6-12, 12-18, and 18-24 month follow-up data. RESULTS: A series of logistic regression analyses indicated that relapse was associated with posttreatment arrest within the observed follow-up period, but did not significantly influence the likelihood of arrest in future follow-up periods. In comparison, posttreatment arrest in the 6-12 month follow-up period had lasting effects for relapse to substance use in the 12-18 and 18-24 month periods. Arrest in the 0-6 month posttreatment period was also associated with increased risk for relapse in the 18-24 month period. CONCLUSIONS: Given the evidence that demonstrated within follow-up period associations between relapse and arrest, relapse prevention is critical to preventing contact with the criminal justice system. In addition, the lasting impact of an arrest must be mitigated to maintain posttreatment recovery from substance use for adults who come into contact with the criminal justice system.

Diagnostic Concordance between DSM-5 and ICD-10 Cannabis Use Disorders.

OBJECTIVES: With the recent federal mandate that all U.S. health care settings transition to ICD-10 billing codes, empirical evidence is necessary to determine if the DSM-5 designations map to their respective ICD-10 diagnostic categories/billing codes. The present study examined the concordance between DSM-5 and ICD-10 cannabis use disorder diagnoses. METHOD: Data were derived from routine clinical assessments of 6871 male and 801 female inmates recently admitted to a state prison system from 2000 to 2003. DSM-5 and ICD-10 diagnostic determinations were made from algorithms corresponding to the respective diagnostic formulations. RESULTS: Past 12-month prevalence rates of cannabis use disorders were comparable across classification systems. The vast majority of inmates with no DSM-5 diagnosis continued to have no diagnosis per the ICD-10, and a similar proportion with a DSM-5 severe diagnosis received an ICD-10 dependence diagnosis. Most of the variation in diagnostic classifications was accounted for by those with a DSM-5 moderate diagnosis in that approximately half of these cases received an ICD-10 dependence diagnosis while the remaining cases received a harmful use diagnosis. CONCLUSIONS: Although there appears to be a generally high level of agreement between diagnostic classification systems for those with no diagnosis or those evincing symptoms of a more severe condition, concordance between DSM-5 moderate and ICD-10 dependence diagnoses was poor. Additional research is warranted to determine the appropriateness and implications of the current DSM-5 coding guidelines regarding the assignment of an ICD-10 dependence code for those with a DSM-5 moderate diagnosis.

Pathways to rearrest among court mandated female substance use treatment patients.

BACKGROUND AND OBJECTIVES: Many women who experience substance dependence come into contact with the criminal justice system and are mandated by the court to enter treatment. Treatment is a viable option and can have many positive outcomes, but there remains significant room for improvement. This study was designed to identify key risk factors that can be addressed to improve substance use treatment outcomes for this population. METHODS: The study sample consisted of (n) 381 women who were court mandated to enter substance use treatment. Multivariate path analyses were conducted to assess the associations between correlates of substance use treatment outcomes, risk for relapse, and rearrest. RESULTS: Women who displayed certain demographic risk factors (i.e., less educated and unmarried) and had greater levels of substance use severity prior to entering treatment experienced elevated risk for relapse. Consequently, women who relapsed were nearly three times (OR = 2.50, 95% CI = 1.26-4.93) as likely to be rearrested within 12 months of discharge from treatment compared to those who did not relapse. DISCUSSION AND CONCLUSIONS: Certain risk factors contribute to relapse, which increases risk for rearrest. SCIENTIFIC SIGNIFICANCE: Services specifically tailored to women who were court mandated to enter treatment need to consider certain demographic risk factors, clinical substance use severity, and relapse prevention as key elements to minimize subsequent criminal offending.