An evaluation of first responders' intention to refer to post-overdose services following SHIELD training.

BACKGROUND: First responders [law enforcement officers (LEO) and Fire/Emergency Medical Services (EMS)] can play a vital prevention role, connecting overdose survivors to treatment and recovery services. This study was conducted to examine the effect of occupational safety and harm reduction training on first responders' intention to refer overdose survivors to treatment, syringe service, naloxone distribution, social support, and care-coordination services, and whether those intentions differed by first responder profession. METHODS: First responders in Missouri were trained using the Safety and Health Integration in the Enforcement of Laws on Drugs (SHIELD) model. Trainees' intent to refer (ITR) overdose survivors to prevention and supportive services was assessed pre- and post-training (1-5 scale). A mixed model analysis was conducted to assess change in mean ITR scores between pre- and post-training, and between profession type, while adjusting for random effects between individual trainees and baseline characteristics. RESULTS: Between December 2020 and January 2023, 742 first responders completed pre- and post-training surveys. SHIELD training was associated with higher first responders' intentions to refer, with ITR to naloxone distribution (1.83-3.88) and syringe exchange (1.73-3.69) demonstrating the greatest changes, and drug treatment (2.94-3.95) having the least change. There was a significant increase in ITR score from pre- to post-test (ß = 2.15; 95% CI 1.99, 2.30), and LEO-relative to Fire/EMS-had a higher score at pre-test (0.509; 95% CI 0.367, 0.651) but a lower score at post-test (0.148; 95% CI - 0.004, 0.300). CONCLUSION: Training bundling occupational safety with harm reduction content is immediately effective at increasing first responders' intention to connect overdose survivors to community substance use services. When provided with the rationale and instruction to execute referrals, first responders are amenable, and their positive response highlights the opportunity for growth in increasing referral partnerships and collaborations. Further research is necessary to assess the extent to which ITR translates to referral behavior in the field.

Examining Increasing Racial Inequities in Opioid Overdose Deaths: a Spatiotemporal Analysis of Black and White Decedents in St. Louis, Missouri, 2011-2021.

The third wave of the opioid overdose crisis-defined by the proliferation of illicit fentanyl and its analogs-has not only led to record numbers of overdose deaths but also to unprecedented racial inequities in overdose deaths impacting Black Americans. Despite this racialized shift in opioid availability, little research has examined how the spatial epidemiology of opioid overdose death has also shifted. The current study examines the differential geography of OOD by race and time (i.e., pre-fentanyl versus fentanyl era) in St. Louis, Missouri. Data included decedent records from the local medical examiners suspected to involve opioid overdose (N = 4420). Analyses included calculating spatial descriptive analyses and conducting hotspot analyses (i.e., Gettis-Ord Gi*) stratified by race (Black versus White) and time (2011-2015 versus 2016-2021). Results indicated that fentanyl era overdose deaths were more densely clustered than pre-fentanyl era deaths, particularly those among Black decedents. Although hotspots of overdose death were racially distinct pre-fentanyl, they substantially overlapped in the fentanyl era, with both Black and White deaths clustering in predominantly Black neighborhoods. Racial differences were observed in substances involved in cause of death and other overdose characteristics. The third wave of the opioid crisis appears to involve a geographic shift from areas where White individuals live to those where Black individuals live. Findings demonstrate racial differences in the epidemiology of overdose deaths that point to built environment determinants for future examination. Policy interventions targeting high-deprivation communities are needed to reduce the burden of opioid overdose on Black communities.

Identifying drivers of increasing opioid overdose deaths among black individuals: a qualitative model drawing on experience of peers and community health workers.

BACKGROUND: Black individuals in the USA face disproportionate increases in rates of fatal opioid overdose despite federal efforts to mitigate the opioid crisis. The aim of this study was to examine what drives increases in opioid overdose death among Black Americans based on the experience of key stakeholders. METHODS: Focus groups were conducted with stakeholders providing substance use prevention services in Black communities in St. Louis, MO (n = 14). One focus group included peer advocates and volunteers conducting outreach-based services and one included active community health workers. Focus groups were held at community partner organizations familiar to participants. Data collection was facilitated by an interview guide with open-ended prompts. Focus groups were audio recorded and professionally transcribed. Transcripts were analyzed using grounded theory to abstract line-by-line codes into higher order themes and interpret their associations. RESULTS: A core theme was identified from participants' narratives suggesting that opioid overdose death among Black individuals is driven by unmet needs for safety, security, stability, and survival (The 4Ss). A lack of The 4Ss was reflective of structural disinvestment and healthcare and social service barriers perpetuated by systemic racism. Participants unmet 4S needs are associated with health and social consequences that perpetuate overdose and detrimentally impact recovery efforts. Participants identified cultural and relationship-based strategies that may address The 4Ss and mitigate overdose in Black communities. CONCLUSIONS: Key stakeholders working in local communities to address racial inequities in opioid overdose highlighted the importance of upstream interventions that promote basic socioeconomic needs. Local outreach efforts utilizing peer services can provide culturally congruent interventions and promote harm reduction in Black communities traditionally underserved by US health and social systems.

Addressing stimulant use disorder through state opioid response grants from the substance abuse and mental health services administration: Missouri's initial approach.

Background: The alarming growth of stimulant-involved deaths underscores the urgent need for states to expand existing opioid-specific approaches to intentionally reach and serve people who use stimulants. Recent permission from federal agencies has allowed states to spend grant funding that was previously restricted to opioid-related activities on approaches addressing stimulant use.Objectives: This manuscript describes the rationale, methods, and initial results supporting the implementation of Missouri's recent stimulant-focused efforts - including previously-prohibited activities such as Contingency Management and fentanyl test strip distribution.Methods: Missouri's State Opioid Response team facilitated the design and implementation of Contingency Management pilot programming abiding by federal spending limits of no more than $75 of incentives per client, mass distribution of fentanyl test strips, and publicly accessible harm reduction trainings and materials specific to stimulant use. Data sources used for initial evaluations included state-level treatment claims, fentanyl test strip distribution counts by type and region of organizations receiving them, and qualitative feedback from stakeholders.Results: Six substance use treatment agencies developed Contingency Management programs, serving 29 individuals in the first nine months. Over 20,000 fentanyl test strips were distributed using a prioritization system designed to reach those most likely to benefit from their use.Conclusions: Recent federally funded efforts to better address stimulant use in Missouri have increased access to evidence-based treatment and harm reduction resources. Lessons learned from early implementation, especially those regarding time allowed for program development and how best to ensure equitable resource distribution, will inform future stimulant-focused program efforts.

Long-acting reversible contraceptives (LARCs) as harm reduction: a qualitative study exploring views of women with histories of opioid misuse.

BACKGROUND: The sharp rise in opioid use disorder (OUD) among women coupled with disproportionally high rates of unintended pregnancy have led to a four-fold increase in the number of pregnant women with OUD in the United States over the past decade. Supporting intentional family planning can have multiple health benefits and reduce harms related to OUD but requires a comprehensive understanding of women's perspectives of preventing unintended pregnancies. The purpose of this study was to comprehensively evaluate the knowledge, attitudes and experiences as they relate to seeking contraception, particularly LARCs, among women with active or recovered opioid misuse. METHODS: In-depth interviews and focus group discussions with 36 women with current or past opioid misuse were recorded and transcribed. Transcripts were coded by ≥ 2 investigators. Themes related to contraceptive care seeking were identified and contextualized within the Health Belief Model. RESULTS: Our analysis revealed seven interwoven themes that describe individual level factors associated with contraceptive care seeking in women with current or past opioid misuse: relationship with drugs, reproductive experiences and self-perceptions, sexual partner dynamics, access, awareness of options, healthcare attitudes/experiences, and perceptions of contraception efficacy/ side effects. Overall, perceived susceptibility and severity to unintended pregnancy varied, but most women perceived high benefits of contraception, particularly LARC. However, perceived barriers were too high for most to obtain desired contraception to support family planning intentions. CONCLUSIONS: The individual-level factors identified should inform the design of integrated services to promote patient-centered contraceptive counseling as a form of harm reduction. Interventions should reduce barriers to contraceptive access, particularly LARCs, and establish counseling strategies that use open, non-judgmental communication, acknowledge the continuum of reproductive needs, explore perceived susceptibility to pregnancy, and utilize peer educators.

Balancing need and risk, supply and demand: Developing a tool to prioritize naloxone distribution.

Background: Opioid overdose deaths continue to rise nationally. The demand for naloxone, the opioid overdose antidote, is outpacing the supply. With increasing naloxone requests, tools to prioritize distribution are critical to ensure available supplies will reach those at highest risk of overdose. Methods: We developed a standardized "Naloxone Request Form" (NRF) and corresponding weighted prioritization algorithm to serve as decisional aid to better enable grant staff to prioritize naloxone distribution in a data-driven manner. The algorithm computed raw priority scores for each agency, which were then separated into the predetermined quintiles. Historical naloxone distribution decisions were compared with agencies' prioritization quintile. Results: Results demonstrated that the NRF and corresponding algorithm was successful at prioritizing agencies based on potential impact. Although, overall, naloxone was distributed more heavily to the agencies deemed highest priority, our algorithm identified significant shortcomings of the "first come, first served" method of distribution we had initially deployed. Conclusions: This work has laid the foundation to use this tool prospectively to allow for data-driven decision-making for naloxone distribution. Our tool is flexible and can be customized to best fit the needs of a variety of programs and locations to ensure the distribution of limited supplies of naloxone have the greatest impact.

Some law enforcement officers' negative attitudes toward overdose victims are exacerbated following overdose education training.

BACKGROUND: The devastating impact of the current opioid overdose crisis has led to new involvement of law enforcement officers. Training programs have focused on overdose recognition and response without targeting core attitudinal change by covering addiction or harm reduction principles. OBJECTIVES: This study examined the impact of a comprehensive overdose education and naloxone distribution (OEND) training on officers' attitudes toward overdose victims, knowledge of and competence to respond to an opioid overdose, and concerns about using naloxone. The training included the common information about overdose recognition and response, with added components covering broader content about addiction and harm reduction principles and philosophies. METHODS: A total of 787 (83% male) officers were administered surveys before and after attending a 2.5-3 hour comprehensive OEND training. Survey items measured overdose-related knowledge and attitudes, including attitudes about people who use drugs and who overdose. RESULTS: Following the training, participants' overdose-related knowledge and perceived competence to use naloxone improved. However, there were more nuanced changes in attitudes toward overdose victims: though 55.3% of officers reported more positive post-training attitudes, 31% reported more negative attitudes, and 13.7% reported no attitudinal change. Younger officers were most likely to report worsened attitudes. Improvements in attitudes toward overdose victims were associated with reductions in both naloxone-related concerns and risk compensation beliefs. CONCLUSIONS: Despite a comprehensive OEND training that addressed addiction and harm reduction and directly targeted hypothesized drivers of negative attitudes (e.g., risk compensation beliefs), some officers' attitudes worsened after the training. Randomized experiments of different training approaches would elucidate the mediators and moderators underlying these unexpected responses.

Concerns that an opioid antidote could "make things worse": Profiles of risk compensation beliefs using the Naloxone-Related Risk Compensation Beliefs (NaRRC-B) scale.

Background and aims: As opioid overdose death rates reach epidemic proportions in the United States, the widespread distribution of naloxone is imperative to save lives. However, concerns that people who use drugs will engage in riskier drug behaviors if they have access to naloxone remain prevalent, and the measurement scales to assess these risk compensation concerns remain under researched. This study aims to examine the validity of the Naloxone-Related Risk Compensation Beliefs (NaRRC-B) scale and to understand the effect of overdose education and naloxone distribution (OEND) training on risk compensation beliefs across demographic and professional populations. Methods: A total of 1424 participants, 803 police officers, 137 emergency medical services (EMS)/fire personnel, and 484 clinical treatment and social service providers were administered surveys before and after attending an OEND training. Survey items measured the endorsement of opioid overdose knowledge and attitudes, as well as risk compensation beliefs. Results: Police and EMS/fire personnel expressed greater endorsement of risk compensation beliefs than clinical treatment and social service providers at both pre- and post-OEND training. Although endorsement of risk compensation beliefs was significantly reduced in each of the 3 groups after the training, reductions were greatest among EMS/fire personnel, followed by providers, then police. Moreover, younger, male, and black participants endorsed greater beliefs in risk compensatory behaviors as compared with their older, female, and white counterparts. Conclusion: This study validated a novel measure of naloxone-related risk compensation beliefs and suggests participating in OEND trainings decreases beliefs in naloxone-related risk compensation behaviors. OEND trainings should consider addressing concerns about naloxone "enabling" drug use, particularly in law enforcement settings, to continue to reduce stigma surrounding naloxone availability.

The case for a medication first approach to the treatment of opioid use disorder.

Background: The opioid addiction and overdose crisis continues to ravage communities across the U.S. Maintenance pharmacotherapy using buprenorphine or methadone is the most effective intervention for Opioid Use Disorder (OUD), yet few have immediate and sustained access to these medications. Objectives: To address lack of medication access for people with OUD, the Missouri Department of Mental Health began implementing a Medication First (Med First) treatment approach in its publicly-funded system of comprehensive substance use disorder treatment programs. Methods: This Perspective describes the four principles of Med First, which are based on evidence-based guidelines. It draws conceptual comparisons between the Housing First approach to chronic homelessness and the Med First approach to pharmacotherapy for OUD, and compares state certification standards for substance use disorder (SUD) treatment (the traditional approach) to Med First guidelines for OUD treatment. Finally, the Perspective details how Med First principles have been practically implemented. Results: Med First principles emphasize timely access to maintenance pharmacotherapy without requiring psychosocial services or discontinuation for any reason other than harm to the client. Early results regarding medication utilization and treatment retention are promising. Feedback from providers has been largely favorable, though clinical- and system-level obstacles to effective OUD treatment remain. Conclusion: Like the Housing First model, Medication First is designed to decrease human suffering and activate the strengths and capacities of people in need. It draws on decades of research and facilitates partnerships between psychosocial and medical treatment providers to offer effective and life-saving care to persons with OUD.

Medical providers' knowledge and concerns about opioid overdose education and take-home naloxone rescue kits within Veterans Affairs health care medical treatment settings.

BACKGROUND: Overdose from opioids is a serious public health and clinical concern. Veterans are at increased risk for opioid overdose compared with the civilian population, suggesting the need for enhanced efforts to address overdose prevention in Department of Veterans Affairs (VA) health care settings, such as primary care clinics. METHODS: Prescribing providers (N = 45) completed surveys on baseline knowledge and concerns about the VA Overdose Education and Naloxone Distribution (OEND) initiative prior to attending an OEND educational training. RESULTS: Survey items were grouped into 4 OEND-related categories, reflecting (1) lack of knowledge/familiarity/comfort; (2) concerns about iatrogenic effects; (3) concerns about impressions of unsafe opioid prescribing; and (4) concerns about risks of naloxone prescribing. Although certain OEND-related categories were associated with each other, concerns related to iatrogenic effects of OEND (e.g., patients will use more opioids and/or be less likely to see treatment) and lack of knowledge/familiarity/comfort with OEND were endorsed more than concerns related to giving impressions of unsafe opioid prescribing. The majority of providers endorsed the belief that those prescribing opioids to patients should be responsible for providing overdose education to those patients. System-wide naloxone prescription rates and sources increased over 320% following initiation of OEND expansion efforts, although these increases cannot be viewed as a direct result of the in-service trainings. CONCLUSIONS: Findings demonstrate that some providers believe they lack knowledge of opioid overdose prevention techniques and hold concerns about OEND implementation. More training of medical providers outside substance use treatment settings is needed, with particular attention to concerns about harmful consequences resulting from the receipt of naloxone.

The intersection of substance use stigma and anti-Black racial stigma: A scoping review.

BACKGROUND: Substance use stigma poses a barrier to treatment and recovery from substance use disorder. Stigma is amplified when intersecting with other stigmatized identities, particularly Black racial identity. Despite increasing attention to the intersecting roles of racial and substance use stigma, it is unknown how these stigmas interact to impact treatment and health outcomes among Black people who use drugs. This scoping review examines empirical research documenting differential impacts of race and racism on substance use stigma. METHODS: We systematically searched PsychInfo and PubMed databases. Eligible studies were conducted in the U.S.; examined a Black sample, subsample, or experimental condition/variable (i.e., in a vignette); and measured substance use stigma (excluding alcohol or nicotine). Qualitative studies describing a theme related to substance use stigma were also included. RESULTS: Of 1431 unique results, 22 articles met inclusion criteria. The most measured substance use stigma type was interpersonal (e.g., discrimination). Most quantitative findings (n = 15) suggested that Black members of the general public endorse less substance use stigma and Black people who use drugs face less substance use stigma relative to their White counterparts. Qualitative studies (n = 7) suggested stigma was a more common and pernicious substance use treatment barrier for Black people compared to White. Across methods, racial prejudice was associated with substance use stigma, supporting hegemonic ideas that substance use is stereotypically characteristic of Black people. CONCLUSIONS: The interaction between substance use stigma and race is complex and varies by in-group and out-group raters as a function of racial identity and identity as a person who uses drugs. Contradictory findings reflect methodological differences, emphasizing the need for more unified measurement of substance use stigma. More research is needed among Black people who use drugs to improve understanding of the impact of these intersecting stigmas on racial inequities in substance use treatment, morbidity, and mortality.

Naloxone Stigma Among People Who Use Drugs: Characteristics and Associations With Stigma Toward Medication for Opioid Use Disorder.

OBJECTIVES: Widespread naloxone distribution is key to mitigating opioid-related morbidity, but stigma remains a barrier. Naloxone stigma among providers, emergency responders, and the public is well-documented and associated with treatment and policy preferences, but little is known about naloxone stigma among people who use drugs (PWUD), who may be overdose first responders. This study examines naloxone stigma, its correlates, and its association with stigma toward medication for opioid use disorder (MOUD) among PWUD. METHODS: We recruited 293 individuals with a history of substance misuse from facilities that provide substance use and/or health care services (retained n = 195, 54% women, 75% White). Participants completed self-report measures, including the 5-item Naloxone-Related Risk Compensation Beliefs scale. RESULTS: One in 5 respondents agreed with beliefs that access to naloxone leads to more opioid use and less treatment seeking and is "enabling." Those with nonopioid drug misuse, without prior overdose, and with fewer recovery attempts endorsed more naloxone stigma. Opioid misuse, prior overdose, and MOUD utilization were also inversely associated with MOUD stigma. There were no demographic differences in either stigma type. Naloxone stigma was positively associated with MOUD stigma in adjusted models. CONCLUSIONS: This is the first study to quantitatively examine naloxone stigma among PWUD. Findings emphasize the potential role of overdose education and naloxone distribution among those earlier in the substance use disorder course and who use nonopioid drugs. They support integrating MOUD stigma interventions into current overdose education and naloxone distribution targeted at PWUD to increase the acceptance and uptake of both medications.

The association of medical providers' attitudes about naloxone and people with opioid use disorder and their self-reported "low-barrier" treatment practices.

Opioid-involved overdose deaths continue to climb, in part because of suboptimal access to and retention on medications for opioid use disorder (MOUD), including buprenorphine. Low barrier buprenorphine treatment aims to reduce or eliminate the threshold for getting and staying on medication by providing immediate and long-term access to buprenorphine without strict rules or requirements. This study examines associations between medical providers' beliefs about treating people with opioid use disorder (OUD) and naloxone access with their self-reported low-barrier buprenorphine prescribing practices. We surveyed and analyzed responses from providers (N = 86) who completed X-waiver courses in Missouri between March 2017 and September 2019, of which 55% (n = 47) both completed the full survey and endorsed prescribing buprenorphine since the training. The survey included questions about buprenorphine prescribing behaviors as well as the Naloxone-Related Risk Compensation Beliefs (NaRCC-B) scale and the Attitudes toward Patients with OUD scale. Analyses consisted of a series of linear and logistic regressions with the NaRCC-B and OUD Attitudes scales predicting various domains of low-barrier prescribing behaviors. Findings indicate medical providers' beliefs about treating people with OUD are associated with their practice of addiction medicine, with individuals with more favorable views being more likely to endorse low-barrier buprenorphine prescribing practices including offering telemedicine and at-home inductions, prescribing higher doses of buprenorphine, treating larger caseloads, and discussing overdose risk and protective factors with their patients. Providers' beliefs about naloxone being enabling were less related to their buprenorphine practices but strongly related to their likelihood of providing naloxone. Future research may examine which strategies effectively change prescriber attitudes and their adoption of lower-barrier prescribing practices.

Impact of the COVID-19 pandemic on burnout and perceived workplace quality among addiction treatment providers.

BACKGROUND: This study examines the impact of the COVID-19 pandemic on work satisfaction, work-related stress, and perceived work quality among substance use treatment providers to better understand challenges faced among this group during the pandemic. METHODS: Participants of this study were 91 addiction treatment providers (e.g., therapists, physicians, community support specialists, administrative staff) recruited from various treatment facilities (e.g., inpatient and outpatient settings). Mixed method analyses were conducted to assess self-reported burnout, sources of work-related stress, and perceived work quality during the pandemic. Responses from providers reporting COVID-19 related decreases in work quality were compared to responses from providers who reported their quality of work had increased or remained the same. RESULTS: Results demonstrated half of providers (51%) reported their quality of work had decreased. This perceived decrease in quality of work was associated with higher levels of emotional exhaustion (M = 17.41 vs. M = 12.48, p = 0.002), workplace stress (M = 42.80 vs. M = 30.84, p = 0.001), as well as decreased enjoyment of work (83% vs. 51%, p = 0.001) and decreased personal accomplishment (M = 20.64 vs. M = 23.05 p = 0.001). Qualitative investigations further illustrated that increased hours, changes in work schedules, work-life balance challenges, difficulties with client communication, and increased client needs were contributing factors increasing stress/burnout and decreasing perceived work quality. CONCLUSIONS: Addiction treatment providers experience high levels of burnout and workplace stress. Additionally, many individuals perceived a decrease in their quality of work during the COVID-19 pandemic. Addiction treatment facility administration should address these challenges to support the well-being of clinical staff and the clients they serve both during and after the COVID-19 pandemic.

To Prescribe or Not to Prescribe?: Barriers and Motivators for Progressing Along Each Stage of the Buprenorphine Training and Prescribing Path.

This study aimed to identify the strongest barriers and motivators associated with each step toward buprenorphine prescribing (1. obtaining a waiver, 2. beginning to prescribe, and 3. prescribing to more people) among a sample of Missouri-based medical professionals (N = 130). Item weights (number of endorsements times mean rank of the item's importance) were calculated based on their responses. Across groups, lack of access to psychosocial support services, need for higher levels of care, and clinical complexity were strong barriers. Among non-prescribers (n = 57, 46.3%), administrative burden, potential of becoming an addiction clinic, and concern about misuse and diversion were most heavily weighted. Among prescribers (n = 66, 53.7%), patients' inability to afford medications was a barrier across phases. Prominent motivators among all groups were the effectiveness of buprenorphine, improvement in other health outcomes, and a personal interest in treating addiction. Only prescribers reported the presence of institutional support and mentors as significant motivators.

Do people who "mature out" of drinking see themselves as more mature?

BACKGROUND: Self-perceptions of adulthood during the 20s and 30s are influenced by role transitions, age-related norms, and character traits. These factors are also associated with alcohol use disorders (AUDs), which peak and subsequently decrease during this time of life. Previous developmental research has found that alcohol misuse in adolescence predicts lower reported maturity, whereas alcohol misuse in emerging adulthood is not related to maturity. This study examines how self-perceived maturity (SPM) is affected by AUD status, maturity-related personality characteristics, and role transition variables at ages 25, 29, and 35, and how those relationships change over time. METHODS: Data were drawn from a cohort study of 410 college students (N = 489 at baseline). Students were ascertained as first-time freshmen at a large, public midwestern university in the fall of 1987 but were followed up regardless of subsequent enrollment. The data for the current study were drawn from Waves 5 to 7, when participants were, on average, 25, 29, and 35 years of age. Structural equation modeling was used to determine whether the relation between the SPM item "I feel mature for my age" and DSM-III AUD status was moderated by age. RESULTS: Results suggested that individuals with AUDs are more likely to endorse lower SPM levels compared to their nondiagnosing peers at ages 29 and 35 but not at age 25. In contrast, none of the relations between Conscientiousness, concern about Future Consequences, role status variables, and AUD was moderated by time. CONCLUSIONS: These results suggest that alcohol-related problems may be perceived as more "age appropriate" during the mid-20s than at later ages in life and that such developmentally sensitive aspects of self-concept might be useful in cognitive interventions for young adults.

The drunken self: the five-factor model as an organizational framework for characterizing perceptions of one's own drunkenness.

BACKGROUND: Existing literature supports the use of the five-factor model (FFM) personality dimensions (i.e., Neuroticism, Extraversion, Agreeableness, Intellect, and Conscientiousness) as a comprehensive representation of mood, affect, and behavior. This study evaluated the use of the FFM as an organizational framework for understanding self-reported perceptions of drunkenness (i.e., mood, affect, and behavior associated with alcohol intoxication). METHODS: Cross-sectional data were obtained through an online survey of college student drinkers (N = 988; 50% male, 85% white, mean age = 18.2) in an Introductory Psychology course at a large, mid-western university. Participants reported on their perceptions of their sober and drunk "personalities" by rating items from Goldberg's International Personality Item Pool. RESULTS: Confirmatory factor analysis showed that sober and drunk personality structures fit the data equally well. On average, differences between perceived drunken and sober personality were pervasive; each of the 5 factors differed as a function of drunk versus sober state with perceived drunken personality associated with (in order of effect size) less conscientiousness, less intellect, less agreeableness, more extraversion, and less neuroticism. These general patterns varied by sex and drinking pattern. CONCLUSIONS: Findings support the use of the FFM as a framework for organizing self-reported perceptions of global changes in "personality" that occur under intoxication.

Patients With Serious Injection Drug Use-Related Infections who Experience Patient-Directed Discharges on Oral Antibiotics Have High Rates of Antibiotic Adherence but Require Multidisciplinary Outpatient Support for Retention in Care.

BACKGROUND: Persons who inject drugs (PWID) are frequently admitted for serious injection-related infections (SIRIs). Outcomes and adherence to oral antibiotics for PWID with patient-directed discharge (PDD) remain understudied. METHODS: We conducted a prospective multicenter bundled quality improvement project of PWID with SIRI at 3 hospitals in Missouri. All PWID with SIRI were offered multidisciplinary care while inpatient, including the option of addiction medicine consultation and medications for opioid use disorder (MOUD). All patients were offered oral antibiotics in the event of a PDD either at discharge or immediately after discharge through an infectious diseases telemedicine clinic. Additional support services included health coaches, a therapist, a case manager, free clinic follow-up, and medications in an outpatient bridge program. Patient demographics, comorbidities, 90-day readmissions, and substance use disorder clinic follow-up were compared between PWID with PDD on oral antibiotics and those who completed intravenous (IV) antibiotics using an as-treated approach. RESULTS: Of 166 PWID with SIRI, 61 completed IV antibiotics inpatient (37%), while 105 had a PDD on oral antibiotics (63%). There was no significant difference in 90-day readmission rates between groups (P = .819). For PWID with a PDD on oral antibiotics, 7.6% had documented nonadherence to antibiotics, 67% had documented adherence, and 23% were lost to follow-up. Factors protective against readmission included antibiotic and MOUD adherence, engagement with support team, and clinic follow-up. CONCLUSIONS: PWID with SIRI who experience a PDD should be provided with oral antibiotics. Multidisciplinary outpatient support services are needed for PWID with PDD on oral antibiotics.

Acceptance of medications for opioid use disorder in recovery housing programs in Missouri.

BACKGROUND: Recovery housing plays an important role in supporting individuals in their recovery by building recovery capital and providing stable living environments; however, the extent to which medications for opioid use disorder (MOUD), the gold standard for OUD treatment, are accepted in recovery housing settings is unclear. The purpose of this study, as part of a larger statewide evaluation of Missouri recovery homes, was to identify the extent to which Missouri recovery houses were accepting of methadone, buprenorphine, and naltrexone as well as the extent to which the acceptance of each medication was linked to whether the recovery home encouraged tapering off MOUDs. METHODS: Sixty-four recovery housing managers and/or staff, out of 66 eligible recovery homes in Missouri completed the survey. RESULTS: Results indicated that methadone was the least accepted medication for long-term use followed by buprenorphine and then naltrexone. Recovery houses that had significantly lower overall acceptance of methadone encouraged tapering; however, the overall acceptance for buprenorphine and naltrexone was not significantly related to the encouragement of tapering off MOUDs. CONCLUSION: This work highlights the need to develop reliable instruments to measure and assess MOUD-capable recovery homes and to increase knowledge and acceptance of MOUD within recovery home settings.