Peer-Assisted Telemedicine for Hepatitis C (PATHS): Process evaluation results from a State Opioid Response-funded program.

INTRODUCTION: The opioid crisis and the hepatitis C virus epidemic perpetuate and potentiate each other in a syndemic with escalating morbidity. Policy-driven funding can help resolve the syndemic through collaborative solutions that rapidly translate evidence-based interventions into real-world applications. METHODS: We report development and programmatic evaluation of Peer-Assisted Telemedicine for Hepatitis C (PATHS), which utilizes State Opioid Response (SOR) funding to scale-up a positive randomized trial of peer-assisted telemedicine HCV treatment. PATHS employs staff within an academic medical center and partners with people with lived experience of drug use, "peers," to recruit rural-dwelling people who use drugs living with HCV. PATHS staff record patient data by abstracting clinical records or directly communicating with patients and peers. Peers are funded by a separate SOR-supported program administered through the state health authority. Peers support patients through HCV screening, treatment initiation via telemedicine, adherence, and cure. RESULTS: Between March 2021 and June 2024, PATHS expanded to 18 of Oregon's 36 counties. In that time, PATHS diagnosed 198 rural PWUD with HCV. One hundred sixty-seven (84.3 %) linked to telemedicine and of these, 145 (86.8 %) initiated treatment. Of those who initiated treatment, 91 (62.8 %) completed treatment, of which 61 (67.0 %) are cured. CONCLUSIONS: By rapidly translating a clinical innovation in HCV treatment to achieve highly effective real-world results, PATHS models how policy-driven funding can facilitate collaboration between community partners, academic medical centers, and state health departments to end the opioid-HCV syndemic.

Knowledge, attitudes, and behaviors related to the fentanyl-adulterated drug supply among people who use drugs in Oregon.

INTRODUCTION: Nonpharmaceutical fentanyl has reconfigured the U.S. illicit drug market, contributing to a drastic increase in overdose drug deaths. While illicit fentanyl has subsumed the drug supply in the Northeast and Midwest, it has more recently reached the West. For this study, we explored knowledge, attitudes, and behaviors among people who use drugs in Oregon in the context of the emergence of fentanyl in the drug supply. METHODS: We conducted in-depth interviews by phone with 34 people who use drugs in Oregon from May to June 2021. We used thematic analysis to analyze transcripts and construct themes. RESULTS: People who use drugs knew about fentanyl, expressed doubt that fentanyl could be found in methamphetamine; believed those who were younger or less experienced were at higher risk for harm; and received information about fentanyl from drug dealers, syringe service programs, or peers (other people who use drugs). Preference for fentanyl's presence in drugs like heroin or methamphetamine was mixed. Some felt that their preference was irrelevant since fentanyl was unavoidable. Participants reported engaging in harm reduction practices, including communicating about fentanyl with dealers and peers, testing for fentanyl, using smaller quantities of drugs, switching from injecting to smoking, and using naloxone. CONCLUSION: People who use drugs are responding to the rise of fentanyl on the West Coast and are concerned about the increasing uncertainty and hazards of the drug supply. They are willing and motivated to adopt harm reduction behaviors. Harm reduction promotion from syringe service programs and public health agencies is essential to reduce injury and death from nonpharmaceutical fentanyl.

Association of Methamphetamine and Opioid Use With Nonfatal Overdose in Rural Communities.

Importance: Overdoses continue to increase in the US, but the contribution of methamphetamine use is understudied in rural communities. Objective: To estimate the prevalence of methamphetamine use and its correlates among people who use drugs (PWUD) in rural US communities and to determine whether methamphetamine use is associated with increased nonfatal overdoses. Design, Setting, and Participants: From January 2018 through March 2020, the National Rural Opioid Initiative conducted cross-sectional surveys of PWUD in rural communities in 10 states (Illinois, Kentucky, New Hampshire, Massachusetts, North Carolina, Ohio, Oregon, Vermont, West Virginia, and Wisconsin). Participants included rural PWUD who reported any past-30-day injection drug use or noninjection opioid use to get high. A modified chain-referral sampling strategy identified seeds who referred others using drugs. Data analysis was performed from May 2021 to January 2022. Exposures: Use of methamphetamine alone, opioids alone, or both. Main Outcomes and Measures: Unweighted and weighted prevalence of methamphetamine use, any past-180-day nonfatal overdose, and number of lifetime nonfatal overdoses. Results: Among the 3048 participants, 1737 (57%) were male, 2576 (85%) were White, and 225 (7.4%) were American Indian; the mean (SD) age was 36 (10) years. Most participants (1878 of 2970 participants with any opioid or methamphetamine use [63%]) reported co-use of methamphetamine and opioids, followed by opioids alone (702 participants [24%]), and methamphetamine alone (390 participants [13%]). The estimated unweighted prevalence of methamphetamine use was 80% (95% CI, 64%-90%), and the estimated weighted prevalence was 79% (95% CI, 57%-91%). Nonfatal overdose was greatest in people using both methamphetamine and opioids (395 of 2854 participants with nonmissing overdose data [22%]) vs opioids alone (99 participants [14%]) or methamphetamine alone (23 participants [6%]). Co-use of methamphetamine and opioids was associated with greater nonfatal overdose compared with opioid use alone (adjusted odds ratio, 1.45; 95% CI, 1.08-1.94; P = .01) and methamphetamine use alone (adjusted odds ratio, 3.26; 95% CI, 2.06-5.14; P < .001). Those with co-use had a mean (SD) of 2.4 (4.2) (median [IQR], 1 [0-3]) lifetime overdoses compared with 1.7 (3.5) (median [IQR], 0 [0-2]) among those using opioids alone (adjusted rate ratio, 1.20; 95% CI, 1.01-1.43; P = .04), and 1.1 (2.9) (median [IQR], 0 [0-1]) among those using methamphetamine alone (adjusted rate ratio, 1.81; 95% CI, 1.45-2.27; P < .001). Participants with co-use most often reported having tried and failed to access substance use treatment: 827 participants (44%) for both, 117 participants (30%) for methamphetamine alone, and 252 participants (36%) for opioids alone (χ22 = 33.8; P < .001). Only 66 participants (17%) using methamphetamine alone had naloxone. Conclusions and Relevance: These findings suggest that harm reduction and substance use disorder treatment interventions must address both methamphetamine and opioids to decrease overdose in rural communities.

"It wasn't here, and now it is. It's everywhere": fentanyl's rising presence in Oregon's drug supply.

BACKGROUND: Illicit fentanyl has contributed to a drastic increase in overdose drug deaths. While fentanyl has subsumed the drug supply in the Northeastern and Midwestern USA, it has more recently reached the Western USA. For this study, we explored perspectives of people who use drugs (PWUD) on the changing drug supply in Oregon, experiences of and response to fentanyl-involved overdose, and recommendations from PWUD to reduce overdose risk within the context of illicit fentanyl's dramatic increase in the recreational drug supply over the past decade. METHODS: We conducted in-depth interviews by phone with 34 PWUD in Oregon from May to June of 2021. We used thematic analysis to analyze transcripts and construct themes. RESULTS: PWUD knew about fentanyl, expressed concern about fentanyl pills, and were aware of other illicit drugs containing fentanyl. Participants were aware of the increased risk of an overdose but remained reluctant to engage with professional first responders due to fear of arrest. Participants had recommendations for reducing fentanyl overdose risk, including increasing access to information, harm reduction supplies (e.g., naloxone, fentanyl test strips), and medications for opioid use disorder; establishing drug checking services and overdose prevention sites; legalizing and regulating the drug supply; and reducing stigma enacted by healthcare providers. CONCLUSION: PWUD in Oregon are aware of the rise of fentanyl and fentanyl pills and desire access to tools to reduce harm from fentanyl. As states in the Western USA face an inflection point of fentanyl in the drug supply, public health staff, behavioral health providers, and first responders can take action identified by the needs of PWUD.

COVID-19 Vaccination Status and Concerns Among People Who Use Drugs in Oregon.

OBJECTIVES: The objective of this study was to examine COVID-19 vaccination acceptance and explore reasons for COVID-19 vaccine hesitancy among people who use drugs (PWUDs), a population with increased COVID-19 transmission and morbidity. METHODS: We conducted semi-structured in-depth interviews with PWUDs in 7 Oregon counties from May 11 to June 25, 2021. Participants (n = 34) were recruited in partnership with syringe service programs and local community organizations staff, participant-referrals, and flyer advertising. Research staff conducted interviews via telephone to assess participants' acceptance of the COVID-19 vaccine, find knowledge gaps where new educational information about vaccination would be helpful, and identify who would be perceived as a trustworthy source of information. Interviews were transcribed and coded using thematic analysis with a deductive approach. RESULTS: Most participants had not received the COVID-19 vaccine and were not planning on or were unsure about receiving it. Participants were mistrustful of the rapid COVID-19 vaccine development process, the agencies involved in the development, and vaccines in general. Participants shared varied and contrasting responses about who they would trust to provide information about the COVID-19 vaccine, including peer recovery support specialists, doctors, or other health care professionals, and specified federal agencies or media outlets. CONCLUSIONS: As addiction medicine and public health staff continue to respond to the evolving impacts of COVID-19, vaccination planning should be tailored to the unique needs of PWUD to increase COVID-19 vaccine acceptance in this high-risk population.

Simulating the impact of Addiction Consult Services in the context of drug supply contamination, hospitalizations, and drug-related mortality.

BACKGROUND: Illicitly manufactured fentanyl (IMF) is increasing in international drug supply chains, and IMF-related opioid overdose deaths are rising in North America. Hospitalizations among patients with opioid use disorder (OUD) are also rising; and, hospitalized patients are at increased risk of overdose and death following hospital discharge. Hospitalization is a key opportunity to engage patients with OUD. Addiction consult services (ACS) can provide effective treatment for patients hospitalized with OUD. This study aims to estimate the effect of increasing IMF contamination on drug-related death among patients hospitalized with OUD, and simulate the role of ACS expansion to mitigate these effects. METHODS: We used a Markov model to mirror care systems for adult patients hospitalized with OUD in Oregon, from the time of hospital admission through 12-months post-discharge, and simulated patients through modeled care systems to evaluate the expansion of Addiction Consult Services in the context of increasing IMF in the drug supply. RESULTS: In a simulated cohort of 10,000 patients, we estimate that 537 patients would die from drug-related causes within 12-months of hospital discharge. In the context of increased IMF in the drug supply, this estimate increased to 913. ACS referral at baseline was 4%; increasing ACS referral to accommodate 10%, 50%, or 100% of hospitalized OUD patients in the state reduces drug-related deaths to 904, 849, and 780, respectively. The number needed to treat for ACS to avoid one drug-related death in the context of increased IMF was 73. CONCLUSIONS: Hospitals should expand interventions to help reduce IMF-related opioid overdoses, including through implementation of ACS. In the context of rising IMF-related deaths, ACS expansion could help connect patients to treatment, offer harm reduction interventions, or both, which can help reduce the risk of opioid-related death.

Peer Recovery Support Services Across the Continuum: In Community, Hospital, Corrections, and Treatment and Recovery Agency Settings - A Narrative Review.

In this narrative review, we outline the literature describing the history, training, certification, and role of peer recovery support specialists working with people with substance use disorders at different stages of active use and recovery. We explore the impact of peer recovery support specialists serving people in various settings, including the community, hospitals and emergency departments, jails and prisons, and treatment and recovery agencies; and describes considerations for future expansion of peer recovery support services, including supervision needs, compassion fatigue and burnout, and scope of practice. Finally, we make recommendations to support the broad implementation of peer recovery support services as a sustainable, cohesive, and replicable component of harm reduction and addiction services. We also make recommendations for research to continue to evaluate peer recovery support specialist interventions across settings and outcomes.

Predictors of having naloxone in urban and rural Oregon findings from NHBS and the OR-HOPE study.

PURPOSE: Naloxone is an opioid antagonist that can be effectively administered by bystanders to prevent overdose. We determined the proportion of people who had naloxone and identified predictors of naloxone ownership among two samples of people who inject drugs (PWID) who use opioids in Portland and rural Western Oregon. BASIC PROCEDURES: We used data from participants in Portland's National HIV Behavioral Surveillance (NHBS, N = 477) and the Oregon HIV/Hepatitis and Opioid Prevention and Engagement Study (OR-HOPE, N = 133). For each sample, we determined the proportion of participants who had naloxone and estimated unadjusted and adjusted relative risk of having naloxone associated with participant characteristics. MAIN FINDINGS: Sixty one percent of NHBS and 30 % of OR-HOPE participants had naloxone. In adjusted analysis, having naloxone was associated with female gender, injecting goofballs (compared to heroin alone), housing stability, and overdose training in the urban NHBS sample, and having naloxone was associated with drug of choice, frequency of injection, and race in the rural OR-HOPE sample. In both samples, having naloxone was crudely associated with SSP use, but this was attenuated after adjustment. PRINCIPAL CONCLUSIONS: Naloxone ownership was insufficient and highly variable among two samples of PWID who use opioids in Oregon. People who use methamphetamine, males, and people experiencing homelessness may be at increased risk for not having naloxone and SSP may play a key role in improving access.

Harm Reduction and Adaptations Among PWUD in Rural Oregon During COVID-19.

Coronavirus Disease 2019 (COVID-19) may influence HIV/HCV transmission risk behaviors in rural communities. We conducted semi-structured qualitative interviews with people who use drugs (PWUD) in five rural Oregon counties and asked about COVID-19 impact on substance use and harm reduction practices and their advice for improving public health responses. Participants (n = 36) reported using only methamphetamine (52.8%), only heroin (16.7%), or both (30.6%); 75% of participants reported recent injection. Three thematic categories emerged: SSP adaptations and accessibility, PWUD harm reduction practices, and policy suggestions. Participants noted the importance of SSPs to COVID-19 prevention and wellbeing, though some experienced increased barriers, leading to increased risky injection practices. Participants suggested need-based rather than one-for-one exchange, increasing syringe delivery services, encouraging secondary exchange by PWUD, and peers as trusted voices for information exchange. Rapid implementation of policy and practice changes are urgently required to improve SSP access, reinforce safer use, and prevent HIV/HCV and COVID-19 transmission.

"Like Yin and Yang": Perceptions of Methamphetamine Benefits and Consequences Among People Who Use Opioids in Rural Communities.

OBJECTIVES: The objective of this study was to investigate methamphetamine use among people who use opioids in rural Oregon communities to explore reasons for use and perceptions of methamphetamine consequences. METHODS: We conducted interviews and surveys with participants who inject drugs or misuse prescription opioids in 2 rural Oregon counties with high opioid overdose rates. Survey participants were identified through participant-driven sampling initiated in syringe service programs and field outreach (n = 144). Semi-structured interviews with participants were recruited from the same locations (n = 52). RESULTS: Of 144 surveys completed, 112 reported using opioids in the past 30 days; 96% of the 112 also report methamphetamine use. Among the 124 reporting injection drug use, 50% indicated they injected both methamphetamine and heroin in the past 30 days. Interview participants reported early exposure to methamphetamine and indicated that methamphetamine was more widely available, less expensive, and less stigmatized compared to heroin. Participants reported using methamphetamine to improve work-life functioning and because they enjoy the high produced from simultaneous use. Several participants reported a conscious effort to shift to methamphetamine from heroin as a harm reduction strategy.Some participants reported being involuntarily discharged from treatment for opioid use disorder due to methamphetamine use. Several participants perceived methamphetamine as conveying overdose prevention or reversal benefits, while fentanyl contamination in methamphetamine was reported or suspected. CONCLUSION: As rural communities respond to evolving drug supply and demand, there is increasing need for public health efforts to address the emerging issue of concurrent methamphetamine and opioid use.

The Impacts of COVID-19 on Mental Health, Substance Use, and Overdose Concerns of People Who Use Drugs in Rural Communities.

OBJECTIVES: The objective of this study was to investigate the impact of COVID-19 on the mental health, substance use, and overdose concerns among people who use drugs (PWUDs) in rural communities to explore reasons for changes and ways to mitigate COVID-19 impact in the future. METHODS: We conducted semi-structured in-depth interviews with PWUDs in 5 rural Oregon counties with high overdose rates. Participants were identified through participant-driven sampling along with flyer and text advertising (n = 36). Research staff conducted audio-recorded in-depth interviews via telephone, assessing COVID-19 effects on substance use, mental health, and overdose risk. Transcribed interviewers were coded for themes using a semantic approach. RESULTS: Participants reported various mental health symptoms and experiences due to COVID-19, including increased feelings of boredom, loneliness, and depression; increased worry and stress; and increased suicidal ideation. Participants described varying impacts of COVID-19 on substance use. Overall, participants who used only methamphetamine reported decreased use and people who used only heroin or heroin with methamphetamine reported increased use. Most participants reported that they were not concerned about overdose and that COVID-19 did not impact their concerns about overdose, despite increases in risky use and suicidal ideations. CONCLUSIONS: As rural communities respond to the evolving impacts of COVID-19, there is increasing need to identify strategies to address PWUD's mental, physical, and social health needs during COVID-19.

Population-based trends in hospitalizations due to injection drug use-related serious bacterial infections, Oregon, 2008 to 2018.

BACKGROUND: Injection drug use has far-reaching social, economic, and health consequences. Serious bacterial infections, including skin/soft tissue infections, osteomyelitis, bacteremia, and endocarditis, are particularly morbid and mortal consequences of injection drug use. METHODS: We conducted a population-based retrospective cohort analysis of hospitalizations among patients with a diagnosis code for substance use and a serious bacterial infection during the same hospital admission using Oregon Hospital Discharge Data. We examined trends in hospitalizations and costs of hospitalizations attributable to injection drug use-related serious bacterial infections from January 1, 2008 through December 31, 2018. RESULTS: From 2008 to 2018, Oregon hospital discharge data included 4,084,743 hospitalizations among 2,090,359 patients. During the study period, hospitalizations for injection drug use-related serious bacterial infection increased from 980 to 6,265 per year, or from 0.26% to 1.68% of all hospitalizations (P<0.001). The number of unique patients with an injection drug use-related serious bacterial infection increased from 839 to 5,055, or from 2.52% to 8.46% of all patients (P<0.001). While hospitalizations for all injection drug use-related serious bacterial infections increased over the study period, bacteremia/sepsis hospitalizations rose most rapidly with an 18-fold increase. Opioid use diagnoses accounted for the largest percentage of hospitalizations for injection drug use-related serious bacterial infections, but hospitalizations for amphetamine-type stimulant-related serious bacterial infections rose most rapidly with a 15-fold increase. People living with HIV and HCV experienced increases in hospitalizations for injection drug use-related serious bacterial infection during the study period. Overall, the total cost of hospitalizations for injection drug use-related serious bacterial infections increased from $16,305,129 in 2008 to $150,879,237 in 2018 (P<0.001). CONCLUSIONS: In Oregon, hospitalizations for injection drug use-related serious bacterial infections increased dramatically and exacted a substantial cost on the health care system from 2008 to 2018. This increase in hospitalizations represents an opportunity to initiate substance use disorder treatment and harm reduction services to improve outcomes for people who inject drugs.

Challenges with hepatitis B vaccination of high risk adults - A pilot program.

BACKGROUND: Acute hepatitis B virus (HBV) infections in the United States occur predominantly among persons aged 30-59 years. The Centers for Disease Control and Prevention (CDC) recommends vaccination of adults at increased risk for HBV infection. Completing the hepatitis B (HepB) vaccine dose-series is critical for optimal immune response. OBJECTIVES: CDC funded 14 health departments (awardees) from 2012 to 2015 to implement a pilot HepB vaccination program for high-risk adults. We evaluated the pilot program to assess vaccine utilization; vaccine dose-series completion, including by vaccination location type; and implementation challenges. METHODS: Awardees collaborated with sites providing health care to persons at increased risk for HBV infection. Awardees collected information on doses administered, vaccine dose-series completion, and challenges completing and tracking vaccinations, including use of immunization information systems (IIS). Data were reported by each awardee in aggregate to CDC. RESULTS: Six of 14 awardees administered 47,911 doses and were able to report patient-level dose-series completion. Among persons who received dose 1, 40.4% received dose 2, and 22.3% received dose 3. Local health department clinics had the highest 3-dose-series completion, 60.6% (531/876), followed by federally qualified health centers at 38.0% (923/2432). While sexually transmitted diseases (STD) clinics administered the most doses in total (17,173 [35.8% of 47,911 doses]), 3-dose-series completion was low (17.1%). The 14 awardees reported challenges regarding completing and tracking dose-series, including reaching high-risk adults for follow-up and inconsistencies in use of IIS or other tracking systems across sites. CONCLUSIONS: Dose-series completion was low in all settings, but lowest where patients may be less likely to return for follow-up (e.g., STD clinics). Routinely assessing HepB vaccination needs of high-risk adults, including through use of IIS where available, may facilitate HepB vaccine dose-series completion.