"Coke in the Dope": The Underrecognized Complications of a Cocaine-Adulterated Fentanyl Supply.

ABSTRACT: The opioid crisis, particularly the "fourth wave" involving fentanyl and stimulants, has been responsible for an alarming increase in overdose deaths in the United States. Although fentanyl contamination in cocaine has gained significant attention, the converse-cocaine-adulterated fentanyl-has been largely overlooked despite its health implications. The rise in concurrent cocaine and fentanyl overdose deaths could be attributed to various factors, from intentional polysubstance use to unintentional adulterations. Cocaine-related health issues may amplify the problem. Four potential pathways for the increased risk of overdose with cocaine-adulterated opioids include enhanced drug reinforcement, potential overdose risk with switching drug samples, altered metabolism of medications used for opioid use disorder, and increased myocardial demand juxtaposed with opioid-induced respiratory depression. With these risks, the importance of drug testing becomes paramount in the unregulated drug market. As polysubstance use overdoses surge, there is an urgent need to understand how drug supplies are changing in order to effectively identify appropriate harm reduction strategies. Specifically, further research is needed evaluating complications of low-level cocaine exposure with chronic/persistent opioid use. The hazards associated with cocaine-adulterated fentanyl emphasize the significance of understanding not only fentanyl's presence in cocaine but also cocaine's role in the fentanyl supply.

Examining Antimicrobial Stewardship Program Implementation in Carceral Settings.

Antimicrobial resistance is a global threat that inequitably affects minoritized populations, including Black, Latinx, and Indigenous people-especially in carceral settings-and is largely driven by inappropriate antimicrobial prescribing practices. People whose identities are minoritized are more likely to be incarcerated, and people who are incarcerated experience higher disease risk than people who are not incarcerated. This article draws on a case of dental infection suffered by a woman who is incarcerated to consider key ethical and clinical complexities of antimicrobial prescribing in carceral settings.

Locked in and left out: the "prison penalty" for implementation of evidence-based interventions.

BACKGROUND: While the broader medical community grapples with the widely accepted notion that it takes an average of 17 years for research evidence to be incorporated into clinical practice, the implementation of evidence-based interventions in carceral settings (i.e., jails and prisons) faces longer delays, exacerbating health disparities. MAIN BODY: The "prison implementation penalty" describes the significant delay in and limited adoption of evidence-based healthcare practices in carceral settings. We explore the complex challenges of implementing evidence-based interventions in jails and prisons, environments where healthcare often plays a secondary role under security and discipline. We use specific frameworks to highlight the unique barriers within these settings and propose potential implementation strategies. These challenges have broad implications for health equity due to the disproportionate impact on the marginalized groups affected by mass incarceration. Implementation science has potential to mitigate these disparities. CONCLUSION: Bridging the gap between healthcare evidence and practice in carceral settings offers a public health opportunity. Implementation science offers a unique role in improving healthcare standards and reducing health inequities in this environment.

Development and validity evidence for the resident-led large group teaching assessment instrument in the United States: a methodological study.

PURPOSE: Despite educational mandates to assess resident teaching competence, limited instruments with validity evidence exist for this purpose. Existing instruments do not allow faculty to assess resident-led teaching in a large group format or whether teaching was interactive. This study gathers validity evidence on the use of the Resident-led Large Group Teaching Assessment Instrument (Relate), an instrument used by faculty to assess resident teaching competency. Relate comprises 23 behaviors divided into six elements: learning environment, goals and objectives, content of talk, promotion of understanding and retention, session management, and closure. METHODS: Messick's unified validity framework was used for this study. Investigators used video recordings of resident-led teaching from three pediatric residency programs to develop Relate and a rater guidebook. Faculty were trained on instrument use through frame-of-reference training. Resident teaching at all sites was video-recorded during 2018-2019. Two trained faculty raters assessed each video. Descriptive statistics on performance were obtained. Validity evidence sources include: rater training effect (response process), reliability and variability (internal structure), and impact on Milestones assessment (relations to other variables). RESULTS: Forty-eight videos, from 16 residents, were analyzed. Rater training improved inter-rater reliability from 0.04 to 0.64. The Φ-coefficient reliability was 0.50. There was a significant correlation between overall Relate performance and the pediatric teaching Milestone, r = 0.34, P = .019. CONCLUSION: Relate provides validity evidence with sufficient reliability to measure resident-led large-group teaching competence.

Implementing Preexposure Prophylaxis for HIV Prevention in a Statewide Correctional System in the United States.

HIV disproportionately affects populations experiencing incarceration. Preexposure prophylaxis (PrEP) is an effective approach to preventing HIV acquisition among populations at increased risk of acquiring HIV. Yet few, if any, efforts have been made to offer PrEP in correctional settings. Beginning in November 2019, the Rhode Island Department of Corrections (RIDOC) implemented a systemwide PrEP initiation program with linkage to PrEP care in the community upon reentry. Incarcerated individuals identified as being potentially at increased risk of HIV acquisition during standard clinical screenings and medical care were referred to a PrEP care provider for potential PrEP initiation. Of the 309 people who met with a PrEP care provider, 35% (n = 109; 88 men, 21 women) agreed to initiate PrEP while incarcerated. Clinical testing and evaluation were completed for 82% (n = 89; 69 men, 20 women) of those who agreed to initiate PrEP. Of those, 54% (n = 48; 29 men, 19 women) completed the necessary clinical evaluation to initiate PrEP, were determined to be appropriate candidates for PrEP use, and had the medication delivered to a RIDOC facility for initiation. Only 8 people (4 men, 4 women) were successfully linked to a PrEP care provider in the community after release. The RIDOC experience demonstrates notable levels of PrEP interest and moderate levels of PrEP uptake among this population. However, PrEP engagement in care after release and persistence in taking PrEP when in the community were relatively poor, indicating a need to better understand approaches to overcoming barriers to PrEP care in this unique setting.

Buprenorphine Dose and Time to Discontinuation Among Patients With Opioid Use Disorder in the Era of Fentanyl.

Importance: Buprenorphine treatment for opioid use disorder (OUD) has more than doubled since 2009. However, current US Food and Drug Administration buprenorphine dosing guidelines are based on studies among people using heroin, prior to the emergence of fentanyl in the illicit drug supply. Objective: To estimate the association between buprenorphine dose and time to treatment discontinuation during a period of widespread fentanyl availability. Design, Setting, and Participants: This retrospective cohort study used statewide Rhode Island Prescription Drug Monitoring Program data. Participants were Rhode Island residents initiating buprenorphine treatment for OUD between October 1, 2016, and September 30, 2020. Data analysis was performed from December 9, 2022, to August 10, 2023. Exposure: Daily dose of buprenorphine (16 mg and 24 mg) defined starting on the day of initiation based on total quantity and days' supply dispensed. Patients were censored on any dose change. Main Outcomes and Measures: Buprenorphine treatment discontinuation in the 180 days following initiation, defined as a gap in treatment of more than 27 days based on prescription fill dates and days' supply. Kaplan-Meier and Cox regression survival analyses were conducted to estimate the association between buprenorphine dose and time to treatment discontinuation, controlling for potential informative censoring and measured potential confounders. Results: Among 6499 patients initiating buprenorphine treatment for OUD, most were aged 25 to 44 years (57%; n = 3682), were male (61%; n = 3950), and had private (47%; n = 3025) or Medicaid (33%; n = 2153) insurance. More than half of patients were prescribed a daily dose of interest at initiation (16 mg: 50%; n = 3264; 24 mg: 10%; n = 668). In Kaplan-Meier analyses, 58% of patients discontinued buprenorphine treatment within 180 days (16 mg: 59% vs 24 mg: 53%; log-rank test P = .005). In Cox regression analyses, patients prescribed a dose of 16 mg had a greater risk of treatment discontinuation than those prescribed 24 mg (adjusted hazard ratio, 1.20; 95% CI, 1.06-1.37). Conclusions and Relevance: In this cohort study of patients initiating buprenorphine treatment from 2016 to 2020, patients prescribed a 24 mg dose of buprenorphine remained in treatment longer than those prescribed 16 mg. The value of higher buprenorphine doses than currently recommended needs to be considered for improving retention in treatment.

Continuing Education Evaluations of an Internal Medicine and a Pediatric Podcast.

INTRODUCTION: This study aimed to characterize practitioners who use podcasts as a form of continuing education (CE), evaluate attitudes regarding podcasting as a medium for CE, and assess intended practice change after listening to podcasts for CE. METHODS: We examined CE data from a mandatory postpodcast evaluation collected between February 2021 and August 2021 for two free podcasts. We analyzed linked episode data containing podcast downloads. RESULTS: Listeners downloaded 972,691 episodes and claimed 8182 CE credits (less than 1% of total downloads) over 7 months. CE credit was claimed by physicians, physician assistants, nurses, and pharmacists. Most listeners claiming CE credit were not affiliated with an academic institution. Motivation for listening to episodes included a topic of interest, relevance to a patient, and a topic of less comfort. Of individuals obtaining CE, 98% intended to implement change after listening. DISCUSSION: Although only a small number of podcast listeners claim CE credit, those who claim credit represent a diverse and interprofessional audience. Listeners select podcasts to fill self-identified learning needs. Overwhelmingly, listeners report podcast CE changes intended practice. Podcasts may be an effective modality for CE and practice change; further research should focus on facilitators and barriers to CE uptake and on patient health outcomes.

Post-incarceration outcomes of a comprehensive statewide correctional MOUD program: a retrospective cohort study.

Background: As opioid overdoses surge, medications for opioid use disorder (MOUD) remain underutilized. MOUD is rarely offered in correctional facilities although individuals involved in the criminal justice system have higher rates of OUD and mortality relative to the general population. Methods: A retrospective cohort design examined the effect of MOUD while incarcerated on 12 months post-release treatment engagement and retention, overdose mortality, and recidivism. Individuals (N = 1600) who participated in the Rhode Island Department of Corrections (RIDOC) MOUD program (the United States' first statewide program) and were released from incarceration from December 1, 2016, to December 31, 2018, were included. The sample was 72.6% Male (27.4% female) and 80.8% White (5.8% Black, 11.4% Hispanic, 2.0% another race). Findings: 56% were prescribed methadone, 43% buprenorphine, and 1% naltrexone. During incarceration, 61% were continued on MOUD from the community, 30% were inducted onto MOUD upon incarceration, and 9% were inducted pre-release. At 30 days and 12 months post-release, 73% and 86% of participants engaged in MOUD treatment, respectively, and those newly inducted had lower post-release engagement than those who continued from the community. Reincarceration rates (52%) were similar to the general RIDOC population. Twelve overdose deaths occurred during the 12-month follow-up, with only one overdose death during the first two weeks post-release. Interpretations: Implementing MOUD in correctional facilities, with seamless linkage to community care is a needed life-saving strategy. Funding: Rhode Island General Fund, the NIH of Health HEAL Initiative, the NIGMS, and the NIDA.

Anticipated Barriers to Sustained Engagement in Treatment With Medications for Opioid Use Disorder After Release From Incarceration.

BACKGROUND: Although the burden of opioid use disorder is disproportionately high among persons who are incarcerated, medications for opioid use disorder are often unavailable in correctional settings. The Rhode Island Department of Corrections provides all 3 classes of medications for opioid use disorder to clinically eligible persons who are incarcerated. Despite a decrease in fatal overdoses among persons with recent criminal legal system involvement since the program's implementation, barriers to continued engagement in treatment after release from incarceration still exist. METHODS: We conducted 40 semistructured, qualitative interviews with people who were incarcerated and enrolled in the comprehensive medications for opioid use disorder program at the Rhode Island Department of Corrections. Analysis applied a general, inductive approach using NVivo 12. RESULTS: Participants discussed barriers to treatment engagement before incarceration, as well as anticipated barriers to medications to treat opioid use disorder continuation after release from incarceration. Structural factors including housing, health insurance, transportation, and the treatment program structure, as well as social factors such as social support networks were perceived to influence retention in medications to treat opioid use disorder post-release. CONCLUSION: Our findings suggest that people with opioid use disorder who are incarcerated encounter unique challenges upon community reentry. Addressing structural factors that pose barriers to post-release engagement is essential to sustaining retention. We recommend utilization of peer recovery specialists to alleviate some of the stress of navigating the structural barriers identified by participants.

Implementing Gender-Affirming Care in Correctional Settings: A Review of Key Barriers and Action Steps for Change.

Transgender and gender-diverse (TGD) people are disproportionately impacted by incarceration, interpersonal violence, HIV and other sexually transmitted infections, substance use disorders, and suicidality. Little is known about successful approaches to improve health outcomes for TGD individuals impacted by incarceration. We review the barriers to providing gender-affirming clinical care in correctional systems in the United States, identify key knowledge gaps regarding the provision of gender-affirming care to incarcerated TGD populations, and highlight necessary steps to improve the health and safety of this highly vulnerable population. We also describe the components of a gender-affirming care model implemented in a state correctional facility, including support from correctional administrators, identifying a gender-affirming care provider, standardizing clinical care protocols, and adapting clinical services to TGD population needs. Similar models should be employed elsewhere to improve health outcomes for TGD populations during incarceration and on release.

Use of long-acting injectable buprenorphine in the correctional setting.

BACKGROUND: As overdoses due to opioids rise, medications for opioid use disorder (MOUD) continue to be underemployed, resulting in limited access to potentially life-saving treatment. Substance use disorders are prevalent in individuals who are incarcerated, and these individuals are at increased risk for death postrelease due to overdose. Few jails and prisons offer MOUD and most limit access. Extended-release buprenorphine (XR-BUP), a novel monthly injectable MOUD formulation, could be uniquely poised to address treatment access in correctional settings. METHODS: This study linked a retrospective cohort design of statewide datasets to evaluate the real-world use of XR-BUP. The study included individuals (N = 54) who received XR-BUP while incarcerated from January 2019 through February 2022. The study was conducted at the Rhode Island Department of Corrections, with the nation's first comprehensive statewide correctional MOUD program. RESULTS: Fifty-four individuals received a combined total of 162 injections during the study period. The study found no evidence of tampering with the injection site, indicating no attempts by participants to remove, hoard, or divert the medication. Sixty-one percent reported at least one adverse effect after injections were received, with an average of 2.8 side effects. Sixty-one percent of those released on XR-BUP engaged in MOUD after release, 30 % continued with XR-BUP. CONCLUSIONS: XR-BUP is feasible and acceptable in correctional settings. XR-BUP addresses administrative concerns of diversion that obstruct lifesaving MOUD and offers another safe and effective treatment option. Further studies and trials should continue to assess this novel medication's ability to treat opioid addiction in the correctional setting and upon release to the community.

Defining the Pre-exposure Prophylaxis Care Continuum Among Recently Incarcerated Men at High Risk for HIV Infection: Protocol for a Prospective Cohort Study.

BACKGROUND: HIV disproportionately impacts criminal justice-involved individuals, including men who experience incarceration. Men make up the vast majority of those experiencing incarceration as well as those newly diagnosed with HIV infection. Pre-exposure prophylaxis (PrEP) is a highly effective biomedical intervention that significantly reduces the risk of HIV acquisition. However, implementation in criminal justice systems is limited. Little is known about effective PrEP implementation and use in this unique public health context. OBJECTIVE: The aim of this study is to characterize the experience of implementing PrEP clinical care in a criminal justice setting for men vulnerable to HIV acquisition. METHODS: This article describes a PrEP care continuum for men experiencing incarceration who are at increased risk of HIV acquisition, which can help conceptualize approaches to evaluating PrEP implementation. RESULTS: The outlined study will enroll 100 men experiencing incarceration at high risk for HIV acquisition prior to release into the community. The goal is to initiate PrEP prior to release and link individuals to PrEP providers in the community, capturing barriers and facilitators to PrEP use during this uniquely vulnerable time period for HIV acquisition. CONCLUSIONS: Based on the proposed care continuum and what is known about HIV risk and prevention efforts in the criminal justice context, we outline key future research efforts to better understand effective approaches to preventing HIV infection among this vulnerable population. The described approach presents a powerful public health opportunity to help end the HIV epidemic. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/31928.

"It's probably going to save my life;" attitudes towards treatment among people incarcerated in the era of fentanyl.

INTRODUCTION: In recent years, there has been a dramatic increase in overdose deaths involving illicitly manufactured fentanyl. The risk of death due to fentanyl exposure is far higher for people without adequate tolerance, such as those being released from incarceration. However, little is known about knowledge and perceptions of fentanyl among people who are incarcerated. METHODS: We conducted 40 semi-structured qualitative interviews with people who were incarcerated at the Rhode Island Department of Corrections (RIDOC). We explored the impressions of, preferences for and experiences with fentanyl among these people. Analysis employed a general, inductive approach using NVivo 12. RESULTS: We found that a majority of the participants were familiar with fentanyl, sought to avoid it and utilized harm reduction techniques when using drugs and taking treatment with medication for opioid use disorder (MOUD) to reduce their risk of overdose. DISCUSSION: Our findings suggest that broad access to MOUD, especially for incarcerated people, is increasingly necessary in the era of fentanyl, both to aid people seeking recovery due to the increased overdose risk of drug use and to reduce overdose morbidity for people who use drugs.