Patterns and contexts of polysubstance use among young and older adults who are involved in the criminal legal system and use opioids: A mixed methods study.

INTRODUCTION: Opioid prevention and treatment programs tailored to young adults involved in the criminal legal system are rare. We examined profiles of polysubstance use among younger and older adults involved in the criminal legal system who use opioids, and explored their experiences and motivations related to substance use. Information gleaned can inform the adaptation of existing programs and the development of novel approaches for young adults in the criminal legal system. METHODS: Using a sequential mixed methods design we 1) quantitatively identified typologies of polysubstance users among adults aged 18-24 (n = 92) and those age 25 and over (n = 27) involved in the criminal legal system who use opioids, using latent class analysis and 2) qualitatively explored differences in personal motivations, cultural influences, and psychosocial contexts of substance use by class. RESULTS: Our quantitative results supported a three-class typology: the majority of participants were in Class I (73 %, n = 87) and reported using primarily alcohol and marijuana. Participants in Classes II (15 %, n = 18) and III (12 %, n = 14) endorsed distinct and complicated polysubstance use profiles. Further, participants in Classes I and III were significantly younger than those in Class II. Qualitative analysis allowed us to understand associations between patterns of use, motivations, and contexts among young and older adults, comparing across classes. CONCLUSIONS: Our results highlight the importance of attending to the needs of subpopulations based on age and use patterns to adapt and develop targeted treatment and prevention programs for high-risk adults involved in the criminal legal system.

Access to Primary and Specialty Health Care in the California State Prison Population During the COVID-19 Pandemic.

This cross-sectional study examines trends in referrals for and timely delivery of primary and specialty health care among individuals incarcerated in California state prisons during the COVID-19 pandemic.

Attitudes and Perceived Barriers to Sexually Transmitted Infection Screening Among Graduate Medical Trainees.

ABSTRACT: Graduate medical training is an opportune time to improve provider delivery of sexually transmitted infection (STI) screening. A survey of trainees found that the majority feel STI screening is their job but identified barriers to successful screening. Training that intentionally address service-specific barriers will be valuable in ending the STI epidemic.

Attitudes and Perceived Barriers to Routine HIV Screening and Provision and Linkage of Postexposure Prophylaxis and Pre-Exposure Prophylaxis Among Graduate Medical Trainees.

New York City is the metropolitan area in the United States with the highest number of new HIV diagnoses nationwide. The End-The-Epidemic (EtE) initiative calls for identifying persons with HIV who remain undiagnosed, linking and retaining persons living with HIV to maximize viral suppression, and facilitate access to pre-exposure prophylaxis (PrEP) for patients at increased risk of HIV. HIV screening represents the first step to both the primary and secondary HIV prevention cascades. We conducted an online, anonymous, cross-sectional survey of residents at all stages of training within four residency programs at one institution in Northern Manhattan between August 2017 and August 2018. All internal medicine, emergency medicine, obstetrics and gynecology trainees, and pediatrics were invited to complete the survey via email. Of 298 eligible trainees, 142 (48%) completed the survey. Most trainees were aware of the HIV testing law and agreed that HIV testing was their responsibility, but few successfully screened most of their patients. Most trainees were not knowledgeable about non-occupational post-exposure prophylaxis (nPEP) or PrEP, but felt that it was important to provide these services across settings. Barriers to HIV, nPEP, and PrEP varied across specialties. Ending the HIV epidemic will require efforts across clinical specialties. In this survey from an EtE jurisdiction, most trainees felt that it is important to provide HIV prevention services in most settings; however, their knowledge and comfort with HIV prevention services other than testing were low. Barriers varied across specialties, and developing specialty-specific materials for trainees may be beneficial.

Psychosocial Factors and the Care Cascade for Hepatitis C Treatment Colocated at a Syringe Service Program.

BACKGROUND: Direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) is highly effective. However, people who inject drugs face significant barriers to DAA access. METHODS: We describe a program that colocates HCV management within a syringe service program in New York City. We performed a retrospective chart review of all patients with confirmed HCV viremia. RESULTS: From 2015 to 2018, 102 patients with viremia completed intake. Fifty-eight patients started DAAs. Nine patients discontinued treatment or were lost to follow-up before completion; 1 is continuing DAA treatment. Of 48 patients who completed therapy, sustained virologic response (SVR) was achieved in 43 (89.6%). Age and established mental health treatment at intake were associated with SVR. Regular cocaine use was negatively associated with SVR in univariate analysis, but this association was not significant after adjustment for age. Of 30 patients completing DAA therapy with active illicit opioid use at intake, 14 (46.4%) engaged in opioid use disorder (OUD) treatment during therapy, and 9 remained in OUD treatment after completion of DAA treatment. CONCLUSIONS: Loss to follow-up is a challenge for people who inject drugs, but among those who completed treatment, SVR was achieved at a high rate. Mental health treatment may facilitate HCV cure. Conversely, HCV therapy may facilitate engagement in OUD treatment and other services.

Treating Opioid Use Disorder and Related Infectious Diseases in the Criminal Justice System.

This article provides an overview of the diagnosis and management of opioid use disorder and its infectious complications among populations with criminal justice involvement. Opioid use disorder and chronic infections such as human immunodeficiency virus and hepatitis C virus are highly prevalent among incarcerated individuals and some of the unique features of correctional facilities present challenges for their appropriate medical management. We outline evidence-based strategies for integrated, patient-centered treatment during incarceration and the potentially hazardous transition back to the community upon release.

Attitudes, practices and perceived barriers to hepatitis C screening among medical residents at a large urban academic medical center.

Infections with hepatitis C virus (HCV) are increasing among adolescents and adults born after 1965. Screening strategies may need to be adapted for this changing population. We surveyed trainees in different specialties about attitudes and practices related to HCV screening and identified specific barriers to screening across various healthcare settings. Constraints related to health system resources and the provider's role were among the most common barriers cited across specialties, but paediatrics residents also cited barriers specific to their population, which can likely be addressed with targeted education.

Preliminary Screening Results Outside the 1945-1965 Birth Cohort: A Forgotten Population for Hepatitis C?

In December 2017, our academic medical center implemented universal hepatitis C virus screening among adult hospitalized patients. We reviewed charts of patients screening positive outside the birth cohort (1945-1965) in the first 6 months after implementation. Documented risk factors were common in younger patients but rare in patients born before 1945.

Expanding Treatment Opportunities for Hospitalized Patients with Opioid Use Disorders.

The prevalence of opioid use disorders (OUDs) is rising across the United States. Patients with OUDs are often hospitalized for medical conditions other than addiction, such as infection, injury, or pregnancy. These hospital admissions provide an opportunity for healthcare providers to initiate opioid agonist therapy with methadone or buprenorphine. Randomized trials have demonstrated the superior effectiveness of this treatment strategy, but its adoption by hospital providers has been slow. A number of barriers have impeded its implementation, including misperceptions about the regulation of opioid prescribing, limited resources for the transition to community- based treatment, and a lack of familiarity among clinicians about the appropriate initiation and dose adjustment of these opioid agonists for maintenance therapy. We discuss changes in policy and practice to expand opportunities to engage patients with OUDs in opioid agonist treatment during their inpatient hospitalizations.

Cost analysis of tuberculin skin test and the QuantiFERON-TB Gold In-tube test for tuberculosis screening in a correctional setting in Dallas, Texas, USA.

BACKGROUND: Tuberculosis (TB) disproportionately affects immigrants, HIV-infected individuals, and those living in crowded settings such as homeless shelters and correctional facilities. Although the majority of jails and prisons use a tuberculin skin test (TST) for latent tuberculosis infection (LTBI) screening, limited data exist on the clinical performance and costs of the TST compared to interferon gamma release assays (IGRAs) in this setting. METHODS: A prospective pilot study comparing cost between TST and an IGRA (QuantiFERON Gold In-tube, QFT-GIT) for the detection of LTBI in a convenience sample of inmates entering the Dallas County Jail (DCJ) was conducted June-October 2014. Participants completed a risk questionnaire, TST placement, QFT-GIT testing, and were offered opt-out HIV-Ab testing. LTBI prevalence based on TST and QFT-GIT results, an evaluation of discordant results and a cost analysis are presented. RESULTS: A total of 529 subjects were enrolled. The majority were male (75 %), and 46 % were Black, 29 % White, and 24 % Hispanic. Most (85 %) had been previously incarcerated. Over 28 % of participants were released prior to TST reading, with paired QFT-GIT and TST results available for 351 subjects. Of these, nine (2.6 %) tested positive by TST and 47 (13.4 %) tested positive by QFT-GIT. It costs $23.27 more per inmate per year to screen with QFT-GIT than TST in this population, though the cost per LTBI case detected was nearly three times higher for TST than QFT-GIT ($1247 v $460). CONCLUSIONS: We found a substantially higher rate of QFT-GIT positivity compared to TST in this sample of individuals entering the Dallas County Jail. Although no gold standard exists, this finding may indicate under-recognized LTBI in this setting. QFT-GIT as an initial screening tool was more time-efficient, had four-fold fewer labor costs and provided results on more individuals when compared with the TST. The overall cost of QFT-GIT was $23.27 more per inmate per year, though the cost per LTBI case detected was nearly three times higher for TST than QFT-GIT. Further research is needed to determine the long-term performance of IGRA testing in the correctional setting and the public health implications of pairing QFT-GIT screening with other tests for communicable diseases.

Prevalence, risk factors and social context of active pulmonary tuberculosis among prison inmates in Tajikistan.

SETTING: Tuberculosis (TB) is highly prevalent in prisons of the former Soviet Union. OBJECTIVE: To understand the behavioral, demographic and biological factors placing inmates in Tajikistan at risk for active TB. DESIGN: We administered a behavioral and demographic survey to 1317 inmates in two prison facilities in Sughd province, Tajikistan along with radiographic screening for pulmonary TB. Suspected cases were confirmed bacteriologically. Inmates undergoing TB treatment were also surveyed. In-depth interviews were conducted with former prisoners to elicit relevant social and behavioral characteristics. RESULTS: We identified 59 cases of active pulmonary TB (prevalence 4.5%). Factors independently associated with increased prevalence of active TB were: HIV-infection by self-report (PR 7.88; 95%CI 3.40-18.28), history of previous TB (PR 10.21; 95%CI 6.27-16.63) and infrequent supplemental nutrition beyond scheduled meals (PR 3.00; 95%CI 1.67-5.62). Access to supplemental nutrition was associated with frequency of visits from friends and family and ability to rely on other inmates for help. CONCLUSION: In prison facilities of Tajikistan, HIV-infection, injection drug use and low access to supplemental nutrition were associated with prevalent cases of active pulmonary TB. Policies that reduce HIV transmission among injection drug users and improve the nutritional status of socially isolated inmates may alleviate the TB burden in Tajikistan's prisons.

Screening and rapid molecular diagnosis of tuberculosis in prisons in Russia and Eastern Europe: a cost-effectiveness analysis.

BACKGROUND: Prisons of the former Soviet Union (FSU) have high rates of multidrug-resistant tuberculosis (MDR-TB) and are thought to drive general population tuberculosis (TB) epidemics. Effective prison case detection, though employing more expensive technologies, may reduce long-term treatment costs and slow MDR-TB transmission. METHODS AND FINDINGS: We developed a dynamic transmission model of TB and drug resistance matched to the epidemiology and costs in FSU prisons. We evaluated eight strategies for TB screening and diagnosis involving, alone or in combination, self-referral, symptom screening, mass miniature radiography (MMR), and sputum PCR with probes for rifampin resistance (Xpert MTB/RIF). Over a 10-y horizon, we projected costs, quality-adjusted life years (QALYs), and TB and MDR-TB prevalence. Using sputum PCR as an annual primary screening tool among the general prison population most effectively reduced overall TB prevalence (from 2.78% to 2.31%) and MDR-TB prevalence (from 0.74% to 0.63%), and cost US$543/QALY for additional QALYs gained compared to MMR screening with sputum PCR reserved for rapid detection of MDR-TB. Adding sputum PCR to the currently used strategy of annual MMR screening was cost-saving over 10 y compared to MMR screening alone, but produced only a modest reduction in MDR-TB prevalence (from 0.74% to 0.69%) and had minimal effect on overall TB prevalence (from 2.78% to 2.74%). Strategies based on symptom screening alone were less effective and more expensive than MMR-based strategies. Study limitations included scarce primary TB time-series data in FSU prisons and uncertainties regarding screening test characteristics. CONCLUSIONS: In prisons of the FSU, annual screening of the general inmate population with sputum PCR most effectively reduces TB and MDR-TB prevalence, doing so cost-effectively. If this approach is not feasible, the current strategy of annual MMR is both more effective and less expensive than strategies using self-referral or symptom screening alone, and the addition of sputum PCR for rapid MDR-TB detection may be cost-saving over time.