Overdose Experiences Among a Sample of Women in Jail with Opioid Use Disorder.

Background:  Previous non-fatal overdose may increase risk of overdose fatality for women reentering the community following incarceration, but pre-incarceration overdose experiences are understudied. This study describes the prevalence and correlates of non-fatal overdose prior to jail among women with opioid use disorder (OUD). Methods: Women (N = 700) were randomly selected from eight Kentucky jails, screened for OUD, and interviewed as part of the NIDA-funded Kentucky Justice Community Opioid Innovation Network (JCOIN) trial. Descriptive statistics were used to examine women's prior overdose experiences, while bivariate analyses and logistic regression were used to identify correlates of overdose in the 90 days prior to jail. Results: Analyses found that 55.4% of women had overdosed in their lifetime, and 21.4% overdosed in the 90 days prior to jail. Of those who overdosed in the 90 days prior to jail, heroin (80.7%) was the most-commonly used drug prior to overdose, 35.2% received emergency, medically-attended services post-overdose, and 92.4% were administered naloxone - primarily by acquaintances. Overdosing in the 90 days prior to jail was positively correlated with identifying as a sexual minority, being from an urban community, childhood victimization, as well as recent heroin, fentanyl, and injection drug use. Conclusions: Findings indicate that prior overdose is common among jailed women with OUD, and although naloxone was often administered, few women received medically-attended services post-overdose. Results highlight the importance of distributing naloxone to community members and women reentering the community from jail, and suggest additional research is needed to understand factors inhibiting medical care following an overdose.

Maltreatment, resilience, and sexual relationship power in a sample of justice-involved women with opioid use disorder.

Justice-involved women frequently report maltreatment and intimate relationships characterized by violence and abuse throughout adulthood. The present study aimed to (a) investigate the association between victimization and sexual relationship power (SRP) among justice-involved women with opioid use disorder (OUD) and (b) explore resilience as a potential moderating factor of the association between victimization and SRP. Under the ongoing Kentucky Justice Community Opioid Innovation Network (JCOIN) cooperative, justice-involved women (N = 700) were randomly selected from eight jails in Kentucky, screened for OUD, consented to participate, and interviewed by research staff. SRP was examined using the Sexual Relationship Power Scale, a validated instrument with two distinct subscales measuring decision-making dominance (DMD) and relationship control (RC); prior maltreatment was measured using the Global Appraisal of Individual Needs General Victimization Scale, and resilience was assessed using the Brief Resilience Scale. Linear regression was used to examine the association between maltreatment and SRP, with three models constructed to account for SRP, DMD, and RC, controlled for demographic characteristics. Finally, we examined whether the association between victimization and SRP varied as a function of resilience. Significant negative associations between maltreatment and the SRP were observed, ps < .001. Resilience moderated the association between maltreatment and DMD, p = .005; however, resilience did not moderate the associations between maltreatment and SRP, p = .141, or RC, p = .735. These findings highlight the importance of increasing resilience in justice-involved women with OUD to reduce the impact of maltreatment on SRP. Prioritizing resilience may offer significant benefits for preventing and addressing maltreatment.

Scales for participant Alliance with Recovery Coach (SPARC): initial development and pilot test.

Recovery coaches are individuals with lived experience with recovery from substance use disorder who typically engender a greater sense of trust than found with other types of healthcare providers. However, there currently are no validated tools that measure the connection between recovery coaches and their participants. The purpose of this study was to describe the initial development of the Scales for Participant Alliance with Recovery Coach (SPARC) to measure recovery coach connection or alliance, including initial psychometric analyses. Measurement development began with five scales of the Client Evaluation of Self Treatment (treatment participation, treatment satisfaction, rapport, peer support, and social support). Adapted items were pre-tested with focus groups (n = 8) to ensure they were meaningful and accurately reflected the domains (Study 1). After modifications, the SPARC has six scales (engagement, satisfaction, rapport, motivation and encouragement, role model and community linkage). The survey was piloted with 100 individuals (Study 2) age 18 or over who had met with a recovery coach within the last six months. Most study participants were male (60%) and white (87%) with less than two years in recovery. After removing two low performing items, the items for five of the domains had acceptable internal consistency. The items for the engagement domain had a slightly lower reliability. Findings suggest that items cover relevant recovery coach roles, are internally consistent within domains, and can be easily administered to individuals engaging in recovery coaching services. Additional research is needed with a larger, more heterogenous sample to further refine items.

Adverse childhood experiences and mental health among incarcerated women: Self-esteem as a mediating mechanism.

BACKGROUND: Adverse childhood experiences (ACEs) and mental health problems are interrelated. However, less is known about this relationship in incarcerated women and how self-esteem impacts this relationship. OBJECTIVE: To investigate the relationship between ACEs and mental health problems (traumatic stress, depression, and anxiety) in incarcerated women with opioid use disorder (OUD) and, the possible role of self-esteem as a mediator of the relationship. PARTICIPANTS AND SETTING: Incarcerated women (N = 500) were randomly selected from eight Kentucky jails, screened for OUD, and interviewed by research staff. METHODS: Regression analyses and mediation models were used to examine the relationship between ACEs, mental health, and self-esteem. RESULTS: ACEs were positively correlated with present mental health problems (traumatic stress, r = 0.407, p < .001; depression, r = 0.177, p < .001; and anxiety, r = 0.213, p < .001) and negatively correlated with current self-esteem (r = -0.241, p < .001). Linear regression analyses established that ACEs and self-esteem were significantly related to all three mental health variables of interest. Additionally, self-esteem mediated the relationship between ACEs and mental health. CONCLUSION: This study shows that incarcerated women's experiences with ACEs are significantly related to poor mental health. Self-esteem plays a critical role in this relationship.

Impaired driving and other risky drug use and sex behaviors: a cross-sectional examination of high-risk rural women incarcerated in jail.

Background: Despite women accounting for an increasing proportion of impaired drivers and higher rates of impaired driving and road fatalities in rural areas, little is known about rural women who drive impaired and their other risky behavior.Objective: The present study assessed the association between impaired driving history, risky substance use, and other drug- and sex-related risk behaviors in a sample of high-risk rural women incarcerated in jail.Methods: Four hundred women from three rural jails provided information about their impaired driving, drug use, injection drug use practices, and sex risk behaviors. Groups were stratified on whether they self-reported impaired driving in the year prior to incarceration. Impaired drivers (n = 260, M = 31.90 years old) were compared to women who did not drive impaired (n = 131, M = 34.42 years old) using MANCOVA and logistic regression analyses.Results: Impaired drivers had significantly (p < .05) higher substance use severity scores for cannabis, sedatives, and prescription opioids. Furthermore, impaired drivers were significantly (p < .05) more likely to have been the passenger of an impaired driver (78.08% vs. 53.44%), been an injection drug user (69.62% vs. 41.98%), had a casual sex partner (47.31% vs. 25.95%), and traded sex for drugs or money (31.15% vs. 15.27%) in the year prior to incarceration.Conclusions: This study found a consistent association between past year impaired driving and a range of drug- and sex-related risk behaviors in a sample of high-risk rural women incarcerated in jail. These findings highlight an opportunity to intervene in criminal justice settings to reduce multiple health risk behaviors.

Community relationship quality and reincarceration following rural drug-using women's reentry from jail.

Interpersonal relationships and social support are important factors in women's successful reentry from incarceration, but limited research has explored the role of women's relationships to their communities during the reentry process. In the current study, women were recruited from three rural Appalachian jails, screened for high-risk behaviors (including drug use and unprotected sex), and interviewed at 12 months postrelease (N = 339). Interviews included the Relational Health Indices-Community scale, a validated measure of women's relationships in community contexts, with subscales for empowerment/zest, engagement, and authenticity. Women who were reincarcerated during the 12-month postrelease period (43.4%) were younger, less employed, more likely to have used illicit drugs, and reported lower-quality community relationships at 12-month follow-up. Multivariate logistic regression models indicated that the effect of community relationships may be driven by the engagement and empowerment/zest constructs. Results suggest that community connectedness may relate to more successful reentry outcomes for rural women.

Kentucky Women's Justice Community Opioid Innovation Network (JCOIN): A type 1 effectiveness-implementation hybrid trial to increase utilization of medications for opioid use disorder among justice-involved women.

The opioid crisis has disproportionately affected women, but research on approaches to increase initiation of medications for opioid use disorder (MOUD) among women is limited. The Kentucky Justice Community Opioid Innovation Network (JCOIN) will implement a type 1 hybrid effectiveness and implementation trial to examine an innovative MOUD pretreatment model using telehealth (alone and in combination with peer navigators) for justice-involved women in transition from jail to the community. The overall goal of the project is to increase initiation and maintenance of MOUD among high-risk justice-involved women during community reentry to reduce opioid relapse and overdose. This project and other studies through the JCOIN network have the potential to significantly impact the OUD treatment field by contributing empirical evidence about the effectiveness and implementation of innovative technologies to increase initiation and maintenance of MOUD during a critical, high-risk time of community reentry among vulnerable, justice-involved individuals in both urban and nonurban communities.

The role of law enforcement officers in responding to the opioid epidemic: A qualitative assessment.

Background: Opioid-related overdose deaths continue to rise with the ongoing opioid epidemic. In response, changes in the role of law enforcement officers have included being trained to administer naloxone to reverse overdoses and offering navigation and referrals to substance use treatment. Methods: This secondary data analysis includes qualitative data from law enforcement officers collected as part of a mixed-methods needs assessment from one Kentucky county. Law enforcement officers (n = 151) responded to a confidential, online survey using Qualtrics and a subsample also completed a qualitative interview (n = 6). Open-ended questions in the online survey and interviews included how the opioid epidemic has affected the individual's profession, specifically their role in reversing overdoses and providing referrals to individuals who misuse opioids. Results: Law enforcement officers surveyed indicated that they have expanded their professional roles to include providing naloxone to reverse opioid overdoses and referrals. While their specific roles and duties have changed to include naloxone administration to reverse opioid overdoses and providing referrals, officers felt that this was just part of their job in responding to the needs of the community. Officers reported that they have learned how to use (99%) and carry naloxone (87%) to reverse opioid related overdoses. The majority (92%) reported providing referrals (e.g., treatment and harm reduction resources) to individuals who misuse opioids. Conclusions: The opioid epidemic has changed the roles of law enforcement officers, including providing naloxone to reverse overdoses and referrals for treatment. Future research should continue to explore how substance misuse in the community changes the roles of law enforcement officers and how to best train and support officers as their roles evolve in response to these changes.

A Description of COVID-19 Lifestyle Restrictions Among a Sample of Rural Appalachian Women.

Background: COVID-19 has led to swift federal and state response to control virus transmission, which has resulted in unprecedented lifestyle changes for U.S. citizens including social distancing and isolation. Understanding the impact of COVID-19 lifestyle restrictions and related behavioral risks is important, particularly among individuals who may be more vulnerable (such as rural women with a history of substance use living in Appalachia). Purpose: The overall purpose of this study was to better understand the perceptions of lifestyle changes due to COVID-19 restrictions among this vulnerable group. Methods: The study included a mixed methods survey with a convenience sample of rural women (n=33) recruited through a closed, private Facebook group. Results: Study findings indicated that COVID-19 restrictions related to limited social activities and interactions with family and friends had a significant impact on women. Implications: Findings suggest that social isolation may have a number of unintended consequences for rural women, and implications for rural health practitioners are discussed.

Impaired driving among rural female drug-involved offenders.

OBJECTIVE: Very little is known about rural female impaired drivers despite disproportionate rates of impaired driving arrests and associated traffic fatalities in rural areas. The present study examined past-year impaired driving histories and impaired driving correlates in a sample of rural female drug-involved offenders. METHODS: Female drug-involved offenders (N = 400) from 3 rural jails completed a confidential interview focused on substance use and related risk behaviors. After removing cases with missing data (n = 23), participants self-reporting past-year impaired driving (n = 254) were compared to those who did not (n = 123) on demographic characteristics, substance use, mental health, and criminal histories. Impaired drivers also reported the substances involved in their past-year impaired driving episodes. RESULTS: A significantly higher percentage of impaired drivers reported past-year use of 8 of the 11 substances (including alcohol) examined when compared to other drug-involved offenders. Though symptoms of major depressive and posttraumatic stress disorders were similar, significantly more impaired drivers (49.6%) reported symptoms of generalized anxiety disorder than did other drug-involved offenders (35.0%). No differences in criminal histories were found. Nearly all (94.9%) impaired drivers reported driving under the influence of drugs in the past year; less than one-fourth reported driving under the influence of alcohol. Prescription opioids were the most prevalent substance type involved in impaired driving episodes (84.6%), followed by anti-anxiety medications (40.9%). Approximately one-third of impaired drivers reported driving under the influence of methamphetamine (33.9%), marijuana (31.5%), and alcohol (30.7%) in the past year. CONCLUSIONS: Findings indicate that rural female impaired drivers may have more extensive substance use and mental health problems than other rural female drug-involved offenders. In addition, study results suggest that a recent history of impaired driving may serve as a marker for a more extensive substance use history. Other implications include that early identification of impaired drivers in at-risk groups may be an important opportunity to prevent future traffic injuries and fatalities.

Rural-Urban Differences in Breast Reconstruction Utilization Following Oncologic Resection.

BACKGROUND: Breast reconstruction (BR) is the reconstructive surgical technique that focuses on restoring normal form and function to the breast following oncologic resection. The goal of this study was to determine if BR disparities exist among rural female patients in Kentucky. METHODS: A retrospective (2006-2015), population-based cohort study was conducted on breast cancer patients (stages I-III) treated with mastectomy with or without BR. We used 2013 Beale codes to stratify patients according to geographic status. Chi-square tests were used to examine the association of BR along the rural-urban continuum. A multivariate logistic regression model controlling for patient, disease, and treatment factors was used to predict BR. The likelihood of BR was reported in odds ratios (OR) using a 95% confidence interval (CI). RESULTS: Overall, 10,032 patients met study criteria. Of those, 2,159 (21.5%) underwent BR. The rate of BR among urban, near-metro, and rural patients was 31.1%, 20.4%, and 13.4%, respectively (P < .001). Multivariate analysis revealed that women from near metro (OR 0.54, CI: 0.47-0.61; P < .001) and rural areas (OR 0.36, CI: 0.31-0.41; P < .001) were less likely to undergo BR than women from urban areas. CONCLUSION: Although BR benefits are well documented, women from rural Kentucky undergo BR at lower rates and are less likely to receive BR than their urban counterparts. Efforts should seek to promote equitable access to BR for all patients, including those from rural areas.

A preliminary examination of substance use risk among metropolitan and non-metropolitan girls involved in the juvenile justice system.

Research is limited on geographic differences in substance use risk factors among juvenile justice-involved girls. This secondary data analysis from one state juvenile justice system, collected as part of the NIH/NIDA funded JJTRIALS cooperative agreement, assessed criminogenic needs at intake for 160 girls from metropolitan and non-metropolitan counties. Although girls from different geographic areas did not differ significantly on key variables of interest, including substance use risk and related criminality variables, findings suggest that substance use risk is related to criminal history, substance-related offenses, and relationship problems among justice-involved girls. Implications include gender-specific juvenile justice programming and research.

A mixed-methods assessment of the impact of the opioid epidemic on first responder burnout.

BACKGROUND: First responders have demanding jobs and report experiencing burnout. The opioid epidemic has added to first responder workloads, which could contribute to increased burnout. This mixed-methods study examined burnout among first responders by: 1) describing burnout among first responders specifically related to workload demands associated with the opioid epidemic; 2) exploring first responder perspectives on how the opioid epidemic has affected their profession; and 3) conducting exploratory analyses to examine how burnout and perspectives on the effect of the opioid epidemic differ across first responder professions. METHODS: First responders completed an online survey (n = 196), including a burnout questionnaire, as part of a county-wide opioid misuse resource and needs assessment. A subset completed qualitative interviews (n = 12). In both the survey and interviews, participants were asked their perspectives on how the opioid epidemic impacted their profession. RESULTS: One-third (33%; n = 179) of survey respondents reported high burnout scores. The majority saw community opioid misuse as a significant problem (98%; n = 188) that has affected their profession (95%; n = 188). Qualitative analyses supported survey findings with participants expressing increased workloads and emotional effects related to the opioid epidemic. CONCLUSIONS: First responders reported experiencing burnout, increased workloads, and negative emotional effects related to their role in responding to the opioid epidemic. Despite this, first responders view responding to community opioid misuse as part of their professional role for which they have received specialized training. Future research should continue to explore the impact of the opioid epidemic on first responders, including how to prevent or address burnout.

Appalachian Status Is a Negative Predictor of Breast Reconstruction Following Breast Cancer Resection.

BACKGROUND: Health care disparities in Appalachia are well documented. However, no previous studies have examined possible differences in the utilization of breast reconstruction (BR) in Appalachia. This study aims to determine if a disparity in BR utilization exists in women from Appalachia Kentucky. METHODS: A retrospective, population-based cohort study was conducted from January 1, 2006, to December 31, 2015. The Kentucky Cancer Registry was queried to identify population-level data for female patients diagnosed with breast cancer and treated with mastectomy. A multivariate logistic regression model controlling for patient, disease, and treatment characteristics was constructed to predict the likelihood of BR. RESULTS: Bivariate testing showed differences (P < 0.0001) in BR utilization between Appalachian and non-Appalachian women in Kentucky (15.0% and 26.3%, respectively). Multivariate analysis showed that women from Appalachia (odds ratio, 0.54; confidence interval (95), 0.48-0.61; P < 0.0001) were less likely to undergo BR than non-Appalachian women. Interestingly, the rate of BR increased over time in both Appalachian (r = 0.115; P < 0.0001) and non-Appalachian women (r = 0.148; P < 0.0001). CONCLUSIONS: Despite the benefits of BR, women from Appalachia undergo BR at lower rates and are less likely to receive BR than non-Appalachian Kentuckians. Although the rates of BR increased over time in both populations, access to comprehensive breast cancer care remains a challenge for women from Kentucky's Appalachian region.

Brief Report: Sex Differences in Substance Use, Mental Health, and Impaired Driving Among Rural DUI Offenders.

BACKGROUND AND OBJECTIVES: Studies have documented sex differences among driving under the influence (DUI) offenders, but none have examined rural DUI offenders. METHODS: Rural DUI offenders (83 males and 34 females) self-reported past year and lifetime substance use, mental health problems, and impaired driving history. RESULTS: Substance use and impaired driving histories were similar, but significant disparities in mental health problems for female DUI offenders were found. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: This initial examination of sex differences among rural DUI offenders suggests additional research is needed to better understand their substance use and mental health problems and whether different treatment approaches are needed. (Am J Addict 2019;28:405-408).

A Comparison of Appalachian and Non-Appalachian Kentucky DUI Offenders.

Purpose: To help fill this void in the literature, the current study uses a statewide sample to examine how Appalachian DUI offenders differ from non-Appalachian DUI offenders in a predominantly rural state. Methods: Assessment records for 11,640 Kentucky DUI offenders who completed an intervention in 2017 were examined. Appalachian DUI offenders were compared to non-Appalachian metro and non-metro DUI offenders. Demographic information, DUI violation details, DSM-5 substance use disorder criteria, and referral information were compared using ANCOVAs and logistic regression models. Results: More than one-fourth of the sample was convicted in an Appalachian county. Compared to non-Appalachian DUI offenders, Appalachian offenders were significantly older and more likely to have a prior DUI conviction, to meet DSM-5 criteria for a drug use disorder, and to drive drug-impaired. Referral and intervention compliance also varied across groups. Implications: Results suggest that Appalachian DUI offenders are more drug-involved and have increased risk of recidivism. Findings indicate a need for practitioners to consider the distinct needs of Appalachian DUI offenders during service delivery. Future research should explore alternative intervention methods for preventing continued impaired driving in Appalachia given limited treatment availability in the region.

Patterns of buprenorphine use and risk for re-arrest among highly vulnerable opioid-involved women released from jails in rural Appalachia.

Aims: Opioid use is common among correctional populations, yet few inmates receive treatment during incarceration or post-release, particularly in rural areas. This article examines associations of buprenorphine use, licit and illicit, health services use, and risk for re-arrest within 3 months of jail release among rural opioid-involved women. Methods: Women were randomly selected from three rural Appalachian jails. Those with moderate to severe opioid-involvement on the NM-ASSIST, and data on patterns of buprenorphine use (N = 188), were included in this analysis. Logistic regression analyses examined predictors of re-arrest within 3 months of release. Results: Median age was 32, all were White. At follow-up, 39 (22.7%) had been rearrested; 9 (5.2%) reported receiving MAT, all with buprenorphine. Significant risk factors for re-arrest included: number of days high, injection use, number of illicit buprenorphine days, and withdrawal symptoms in the follow-up period. The sole protective factor was having a regular source of healthcare at follow-up. Conclusions: Rural opioid-involved women released from jail are highly vulnerable to re-arrest, and lack access to supportive care systems for substance treatment. Innovations to integrate MAT into reentry to improve access is recommended.

Characteristics of Prescription-Opioid-Impaired and Other Substance-Impaired Drivers in Rural Appalachian Kentucky.

Previous studies have highlighted the prescription opioid epidemic in rural Appalachia and its associated risk behaviors; however, no studies have examined prescription-opioid-impaired driving as a consequence of this epidemic. The purpose of the present study was to describe prescription-opioid-impaired drivers in rural Appalachian Kentucky and examine how they are similar to and different from other substance-impaired drivers from the region. A sample of convicted DUI offenders from rural Appalachian Kentucky completed a confidential research interview focused on their substance use, mental health, and criminal activity. Prescription-opioid-impaired drivers (n = 33) were compared to other drug-impaired drivers (n = 29) and to alcohol-only-impaired drivers (n = 44). Overall, prescription-opioid-impaired drivers had a similar prevalence of illicit substance use and criminal activity, including impaired driving frequency, to other drug-impaired drivers, but had a higher prevalence of illicit substance use and more frequent impaired driving when compared to alcohol-only-impaired drivers. Study implications include the importance of comprehensive substance abuse assessment and treatment for DUI offenders and the need for tailored interventions for prescription-opioid-impaired and other drug-impaired drivers.

The Affordable Care Act and Changes in Insurance Coverage and Source of Health Care among High-risk Rural, Substance-using, Female Offenders Transitioning to the Community.

PURPOSE: This study examines health care coverage and health care among rural, drug-involved female offenders under the Affordable Care Act (ACA) compared with pre-ACA and whether being insured is associated with having a usual source of care. METHODS: This study involved random selection, screening, and face-to-face interviews with drug-using women in three rural Appalachian jails. Analyses focused on participants who had completed a three-month follow-up interview after release from jail (N=371). RESULTS: Analyses indicated that women released after ACA implementation were more likely than those released pre-implementation to be insured. A multivariate logistic regression model showed that being insured was significantly related to having a usual health care source during community re-entry. CONCLUSIONS: Results demonstrate the benefits of the ACA, signaling important implications for public health in rural communities and the criminal justice system, including targeting underserved groups during incarceration and providing information about and resources for health care enrollment.

HIV Prevention in Rural Appalachian Jails: Implications for Re-entry Risk Reduction Among Women Who Use Drugs.

Rural women are at risk for health consequences (such as HIV) associated with substance misuse, but targeted interventions are limited for this population. Jails provide an underutilized opportunity for outreach to high-risk women in rural Appalachian communities. Rural women were randomized to either the NIDA Standard education intervention (n = 201) or the NIDA Standard plus motivational interviewing (MI-HIV; n = 199) while in jail. Outcomes focused on HIV risk behaviors 3 months post-release from jail. Decreases in HIV risk behaviors were observed at follow-up across conditions. Although participants in the MI-HIV group showed reductions in outcomes compared to the NIDA Standard group (OR = 0.82-0.93), these estimates did not reach significance (p values > .57). HIV education interventions can be associated with risk-reduction behaviors. These findings support the need for increased access to prevention education in criminal justice venues, particularly in rural communities.