Barriers to retention in inpatient and residential drug treatment among persons who use opioids and/or injection drugs living in the rural U.S.

AIM: Barriers to retention in inpatient and residential care for persons who use drugs are understudied in the rural context. We sought to better understand barriers to retention in inpatient and residential drug treatment in a large, multi-site, geographically diverse sample of persons who use opioids and/or injection drugs in the rural U.S. METHODS: We conducted semi-structured individual interviews with persons currently using opioids and/or injection drugs in 9 U.S. states, including Illinois, Kentucky, Massachusetts, North Carolina, New Hampshire, Ohio, Oregon, Vermont, and Wisconsin. Content areas included substance use history and experiences with all modalities of drug treatment. We performed initial structural coding followed by an iterative "open-coding" process of itemizing and categorizing content within each code, and a multi-coder memoing process to summarize themes. We identified themes using three levels of the Social-Ecological Model (SEM): individual, interpersonal, and facility-level (organizational) barriers. RESULTS: Among 304 interviewed, over half (n = 166, 54 %) reported having experienced inpatient and residential treatment. Lack of treatment retention was driven by interrelated factors at all levels of the SEM. Person-level factors inhibiting retention included lack of readiness to stop using, which was particularly true for court-ordered treatment, and dislike of "freedom limitations". The sole interpersonal-level factor was the influence of other patients on re-initiation of drug use. Facility-level barriers included unaddressed withdrawal symptoms and lack of access to MOUD, staff relatability, inadequate staff training, and, particularly in residential treatment, lack of structure and supervision. Lack of preparation for coping with real-world triggers was seen as a barrier to engagement in ongoing treatment. CONCLUSION: Barriers to retention in inpatient and residential substance use treatment were present at three levels of the SEM. Interviews suggest much room for improvement in inpatient and residential drug treatment programs with respect to improving access to MOUD, tailoring content to better address social challenges in the rural context, and improving quality control measures with respect to staff and resident supervision.

Motivation and context of concurrent stimulant and opioid use among persons who use drugs in the rural United States: a multi-site qualitative inquiry.

BACKGROUND: In recent years, stimulant use has increased among persons who use opioids in the rural U.S., leading to high rates of overdose and death. We sought to understand motivations and contexts for stimulant use among persons who use opioids in a large, geographically diverse sample of persons who use drugs (PWUD) in the rural settings. METHODS: We conducted semi-structured individual interviews with PWUD at 8 U.S. sites spanning 10 states and 65 counties. Content areas included general substance use, injection drug use, changes in drug use, and harm reduction practices. We used an iterative open-coding process to comprehensively itemize and categorize content shared by participants related to concurrent use. RESULTS: We interviewed 349 PWUD (64% male, mean age 36). Of those discussing current use of stimulants in the context of opioid use (n = 137, 39%), the stimulant most used was methamphetamine (78%) followed by cocaine/crack (26%). Motivations for co-use included: 1) change in drug markets and cost considerations; 2) recreational goals, e.g., seeking stronger effects after heightened opioid tolerance; 3) practical goals, such as a desire to balance or alleviate the effects of the other drug, including the use of stimulants to avoid/reverse opioid overdose, and/or control symptoms of opioid withdrawal; and 4) functional goals, such as being simultaneously energized and pain-free in order to remain productive for employment. CONCLUSION: In a rural U.S. cohort of PWUD, use of both stimulants and opioids was highly prevalent. Reasons for dual use found in the rural context compared to urban studies included changes in drug availability, functional/productivity goals, and the use of methamphetamine to offset opioid overdose. Education efforts and harm reduction services and treatment, such as access to naloxone, fentanyl test strips, and accessible drug treatment for combined opioid and stimulant use, are urgently needed in the rural U.S. to reduce overdose and other adverse outcomes.

Barriers to opioid use disorder treatment among people who use drugs in the rural United States: A qualitative, multi-site study.

BACKGROUND: In 2020, 2.8 million people required substance use disorder (SUD) treatment in nonmetropolitan or 'rural' areas in the U.S. Among this population, only 10% received SUD treatment from a specialty facility, and 1 in 500 received medication for opioid use disorder (MOUD). We explored the context surrounding barriers to SUD treatment in the rural United States. METHODS: We conducted semi-structured, in-depth interviews from 2018 to 2019 to assess barriers to SUD treatment among people who use drugs (PWUD) across seven rural U.S. study sites. Using the social-ecological model (SEM), we examined individual, interpersonal, organizational, community, and policy factors contributing to perceived barriers to SUD treatment. We employed deductive and inductive coding and analytical approaches to identify themes. We also calculated descriptive statistics for participant characteristics and salient themes. RESULTS: Among 304 participants (55% male, mean age 36 years), we identified barriers to SUD treatment in rural areas across SEM levels. At the individual/interpersonal level, relevant themes included: fear of withdrawal, the need to "get things in order" before entering treatment, close-knit communities and limited confidentiality, networks and settings that perpetuated drug use, and stigma. Organizational-level barriers included: strict facility rules, treatment programs managed like corrections facilities, lack of gender-specific treatment programs, and concerns about jeopardizing employment. Community-level barriers included: limited availability of treatment in local rural communities, long distances and limited transportation, waitlists, and a lack of information about treatment options. Policy-level themes included insurance challenges and system-imposed barriers such as arrest and incarceration. CONCLUSION: Our findings highlight multi-level barriers to SUD treatment in rural U.S. communities. Salient barriers included the need to travel long distances to treatment, challenges to confidentiality due to small, close-knit communities where people are highly familiar with one another, and high-threshold treatment program practices. Our findings point to the need to facilitate the elimination of treatment barriers at each level of the SEM in rural America.

Factors predicting entry of injecting drug users into substance abuse treatment.

A prospective study of 823 injecting drug users (IDUs) was made to identify baseline variables differentiating those who entered treatment during the study from those who did not enter. Variables independently associated with entering treatment in a multiple logistic regression model included (a) expressed desire for treatment, (b) being eligible for methadone maintenance, (c) two or more previous treatment admissions, (d) frequency of injection, (e) heroin use in the past 30 days, (e) being human immunodeficiency virus (HIV) positive, (f) giving money or drugs for sex, and (g) level of injection-related risk for HIV infection.

Predicting treatment-seeking behavior: psychometric properties of a brief self-report scale.

Development of a brief instrument to assess attitudes toward treatment and predict treatment-seeking behavior among out-of-treatment substance misusers is described. Exploratory factor analysis of an initial pool of 41 items identified four subscales: Perceived need for treatment: perceived drug problem severity; motivation to quit; and negative attitudes toward treatment. Psychometric analyses of data from 535 substance misusers participating in an outreach intervention project provided substantial support for the reliability and construct validity of the first three subscales, and marginal support for the fourth. Evidence of predictive validity was provided by further analyses indicating significant relationships between the three primary scales and both treatment admissions and treatment-seeking during a 3-month follow-up period. The final instrument, the Treatment Attitude Profile (TAP), contains 25 items in a self-report format suitable for use with limited literacy populations in field or office settings.

Histories of childhood trauma and the effects on risky HIV behaviors in a sample of women drug users.

A cross-sectional study was conducted to examine the association between childhood trauma and current human immunodeficiency virus (HIV) risk behaviors of 181 active illicit-drug-using women in San Antonio, Texas. We found very few statistically significant associations, which could he explained by (a) childhood trauma subtypes not being mutually exclusive, (b) clustering of mild-to-severe forms of abuse. and (c) childhood trauma having an indirect, rather than direct, effect on HIV risk behavior. Public health implications from this study are that prevention programs need to consider past and current individual and environmental factors that influence HIV sexual risk behaviors in women drug users.

Prevalence of childhood trauma in a community sample of substance-abusing women.

The purpose of this study was to estimate the prevalence of positive trauma histories in a community sample of intravenous drug using (IVDU) women for five subsets of childhood trauma (emotional abuse or neglect, physical abuse or neglect, and sexual abuse) and to compare demographic variables between the abused versus nonabused groups. Of the 181 women who completed the Childhood Trauma Questionnaire (CTQ), 109 (60.2%) were sexually abused, 100 (55.2%) were physically abused, 83 (45.9%) were emotionally abused, 151 (83.4%) were emotionally neglected, and 108 (59.7%) were physically neglected. There were no statistically significant findings for age, ethnicity, and educational level. Those subjects that were physically neglected were more likely not to be in a current relationship compared to those subjects that were not abused (p = .036). The findings suggest that the prevalence of all five childhood traumas was higher than what has been reported in the general population, and that physical neglect of individuals may predict lack of current significant relationships.

Reaching and enrolling drug users for HIV prevention: a multi-site analysis.

Since 1994, several sites have participated in a NIDA Cooperative Agreement for AIDS Community-based Outreach/Intervention Research Program to examine rates of HIV risk behaviors and evaluate HIV risk reduction interventions among out-of-treatment drug injection and crack cocaine and heroin smokers. We studied the process and outcome of community outreach for recruitment of drug users in AIDS research and education projects in three metropolitan areas: St. Louis, MO; San Antonio, TX, and Durham and Wake Counties, NC. There were two primary areas of focus: (1) the level of accuracy among community health outreach workers (CHOWs) in identifying potentially eligible persons for HIV prevention, and (2) overall effectiveness in recruiting and enrolling persons in formal assessment and intervention studies. We found cross-site and within-site differences in levels of accuracy and in recruitment and enrollment yields. Drug users who had never been in treatment and drug users who had never been tested for HIV infection were underrepresented at all sites. We discuss the factors which may have contributed to cross-site and within-site differences. The findings suggest a need for continued study, refinement, and evaluation of community outreach strategies in order to enroll a broad spectrum of vulnerable groups in HIV prevention activities.

An ethnographic comparison of HIV risk behaviors among heroin and methamphetamine injectors.

Drug injection and other practices affecting the risk of human immunodeficiency virus (HIV) infection were studied among 154 heroin users and 45 methamphetamine users in San Antonio, Texas. Amphetamine users were younger, mostly white, and had less-severe drug dependence. Heroin users had significantly higher levels of needle risk, as indicated by frequency of injection, number of persons sharing equipment, and place of injection. Methamphetamine users tended to buy syringes in lots of 10 or more from pharmacies and to use a syringe less than 5 times before discarding it. Heroin users tended to buy 1 needle at a time from an illicit source and to use it more than 20 times. Of methamphetamine users, 71% had more than one sex partner, compared to 39% of heroin users. Partners of methamphetamine users were more likely to be drug injectors than were partners of heroin users. Fewer methamphetamine users reported a behavior change in response to the acquired immunodeficiency syndrome (AIDS) epidemic, and fewer had been contacted by AIDS Education/Outreach. We suggest that efforts to promote risk reduction among methamphetamine users be stepped up because this population has been underserved and because less-sweeping behavior changes are needed to reduce needle-related risks to acceptable levels.

Attitudes toward methadone maintenance: implications for HIV prevention.

Attitudes of opioid users toward methadone maintenance were studied using semi-structured field interviews. One hundred and sixty-one heroin and speedball users in San Antonio, Texas, were interviewed between 1989 and 1992. Users were classified according to whether or not they had ever been on methadone maintenance. Opioid users who had never been on methadone maintenance were more likely to express a negative attitude toward methadone maintenance than users who had been on it (50% versus 30%). Sources of negative attitudes fell into the following categories: (1) general societal disapproval of addictive drugs, including methadone; (2) prior experience with 12 Step groups or abstinence-based treatment programs; (3) previous forced rapid detoxification from methadone in jail; and (4) observation of methadone maintained peers who continued to use drugs. Very few respondents reported adverse effects from methadone itself as a source of negative attitudes. Sources of positive attitudes included: (1) prior successful treatment with methadone; and (2) observation of methadone patients who stopped using drugs.

Injecting drug users who want treatment.

This study examined characteristics of injecting drug users (IDUs) who want treatment and the features that differentiate them from IDUs who do not want treatment. Data were collected as part of a community-based HIV prevention project in San Antonio, Texas. Interviews were administered to 1,100 IDUs between February 1993 and May 1995. Interview topics included sociodemographics, drug use history, current drug use, treatment history, injection-related HIV risk behavior, sexual behavior, and previous contact related to HIV prevention. Multiple logistic regression analysis identified four factors independently associated with wanting treatment in the multivariate model. These were: (1) 30 or more injections per month; (2) being eligible for methadone maintenance; (3) 2 or more previous treatment admissions; and (4) being recruited after the first year of the project. Implications of these findings are discussed.

The intravenous injection of illicit drugs and needle sharing: an historical perspective.

This study reviewed the literature on the history of needle sharing and intravenous drug abuse. Reports suggest that needle sharing was practiced by drug abusers as early as 1902 in China and 1914 in the United States. Intravenous drug abuse was first mentioned in the literature in 1925. However other references suggest that some opioid users were injecting intravenously prior to 1920. Outbreaks of malaria in Egypt, the United States, and China between 1929 and 1937 were attributed to needle sharing and intravenous injection of opioids. These reports suggest that both needle sharing and intravenous drug use were common by 1937. Factors such as medical use of intravenous injections, enactment and zealous enforcement of antinarcotic laws, and interactions among drug users in institutional settings such as regional hospitals and prisons may have contributed to the spread of both needle sharing and the intravenous technique among drug abusers.

Risk and reciprocity: HIV and the injection drug user.

Injecting practices of illicit drug users in San Antonio, Texas, were studied by means of informal field interviews and participant observation. The methods injection drug users (IDUs) employed to obtain drugs seemed to affect their HIV risk behaviors. Many of the methods involve reciprocal exchanges between a person who has drugs and a person who wants drugs. The exchanges frequently occur in the context of asymmetrical social interactions. The person with the drugs usually occupies the dominant role in the interaction and determines the needle hygiene for both parties. Analysis of the decision-making process of IDUs indicates that the party in the dominant role may choose not to disinfect a syringe for a variety of reasons. An understanding of the subcultural rules that govern these interactions may provide valuable clues to researchers or educators who are designing interventions aimed at reducing HIV risk behaviors among IDUs. This research suggests that for IDUs in subordinate roles, education alone may be insufficient to produce behavior changes necessary to eliminate risk of HIV infection.