Cannabis donation as a harm reduction strategy: a case study.

BACKGROUND: The United States (US) continues to experience unprecedented rates of overdose mortality and there is increased need to identify effective harm reduction practices. Research from Canada describes cannabis donation through harm reduction agencies as an adjunctive strategy to mitigate the negative consequences of more harmful drugs. This case study describes the operational logistics, feasibility, and potential benefits of a cannabis donation program that was operated through a harm reduction program in rural Michigan. CASE PRESENTATION: We applied a community driven research approach to gather information from harm reduction program staff about the implementation and evolution of cannabis donation efforts in Michigan. We also examined 20-months (September 2021 through May 2023) of administrative data from a cannabis company to compare the sale and donation of cannabis products. Ten cannabis-experienced harm reduction clients received cannabis donations, with clinical staff determining client interest and appropriateness, and providing weekly pick-up or delivery. To expand product availability and sustainability, we examined administrative data from a commercialcannabis company that volunteered to provide donations. This administrative data suggests that while flower products constitute most of the adult and medical sales, edible, oil, and topical products predominated donations. Further, cost analysis suggests that donations represent only 1% of total gross sales and account for much less than the expected yearly donation amount. CONCLUSIONS: Research suggests there is potential to reduce alcohol and drug use related harms of more dangerous substances through substitution with cannabis. This case study is the first to document cannabis donation as a harm reduction practice in the US and suggests potential for sustainability dependent on state laws. Findings from this case study provide a starting point for inquiry into cannabis donation as a harm reduction strategy in the US; future research is needed to fully understand the individual-level outcomes, public health impacts, necessary legal regulations, and best practices for cannabis donation programs through harm reduction organizations.

Exploring the Lived Experiences of Medication for Opioid use Disorder Treatment: A Qualitative Study among a Crowdsourced Convenience Sample.

Given the effectiveness of medication for opioid use disorder (MOUD) and low engagement of treatment among people who use drugs (PWUD), it is important to better understand how to engage treatment clients with MOUD care. The current study aimed to achieve this goal by using qualitative methodology to characterize the MOUD treatment experiences. Participants (N = 52) were recruited for an online semi-structured interview. Qualitative analysis revealed varied treatment experiences, with the majority expressing irregular and intermittent MOUD treatment engagement. The therapeutic effects of MOUD in curbing withdrawal symptoms in conjunction with counseling services was frequently mentioned, as well as a preference for methadone maintenance treatment (MMT) to buprenorphine or naltrexone. Many participants described barriers to treatment and continuation of care, including failed drug screens for non-opioid drugs, perceived stigma, and physician-initiated discontinuation of treatment. The current study revealed that patients had favorable experiences with MOUD treatment, particularly when supplemented with counseling services.

Spatiotemporal Analysis Exploring the Effect of Law Enforcement Drug Market Disruptions on Overdose, Indianapolis, Indiana, 2020-2021.

Objectives. To test the hypothesis that law enforcement efforts to disrupt local drug markets by seizing opioids or stimulants are associated with increased spatiotemporal clustering of overdose events in the surrounding geographic area. Methods. We performed a retrospective (January 1, 2020 to December 31, 2021), population-based cohort study using administrative data from Marion County, Indiana. We compared frequency and characteristics of drug (i.e., opioids and stimulants) seizures with changes in fatal overdose, emergency medical services nonfatal overdose calls for service, and naloxone administration in the geographic area and time following the seizures. Results. Within 7, 14, and 21 days, opioid-related law enforcement drug seizures were significantly associated with increased spatiotemporal clustering of overdoses within radii of 100, 250, and 500 meters. For example, the observed number of fatal overdoses was two-fold higher than expected under the null distribution within 7 days and 500 meters following opioid-related seizures. To a lesser extent, stimulant-related drug seizures were associated with increased spatiotemporal clustering overdose. Conclusions. Supply-side enforcement interventions and drug policies should be further explored to determine whether they exacerbate an ongoing overdose epidemic and negatively affect the nation's life expectancy. (Am J Public Health. 2023;113(7):750-758. https://doi.org/10.2105/AJPH.2023.307291).

Differences in intent to refer buprenorphine among community correctional and treatment staff: A set of cross-lagged models predicting efficacy beliefs and familiarity with buprenorphine for opioid use disorder.

BACKGROUND AND OBJECTIVES: Despite high rates of individuals with opioid use disorder, community correctional agencies underutilize medications for opioid use disorder (MOUD). Knowledge about the mechanisms which motivate correctional employees to refer buprenorphine remains underdeveloped, and differences in these patterns by employee status are unknown. This study has two objectives: (1) investigate the presence of a reciprocal relationship between familiarity with buprenorphine and efficacy beliefs among community corrections and community treatment staff and (2) identify whether this relationship differs by staff status in referral intentions. METHODS: Data were used from the Criminal Justice Drug Abuse Treatment Studies 2 (CJ-DATS 2) among correctional and treatment employees (N = 873). Four models investigated whether a reciprocal relationship existed between buprenorphine familiarity and efficacy beliefs. Then, the best fitting model was used to test the influence that prior training had on future referral intention through familiarity and efficacy beliefs among the analytic sample (n = 612), by comparing two separate structural equation models (SEMs) among correctional staff and treatment staff, respectively. RESULTS: The fully cross-lagged model provided a significantly better fit to the data than other models ( χ diff 2 ${\chi }_{\mathrm{diff}}^{2}$ (1) = 7.189, p < .01). The results of the multigroup SEM show that training had positive, indirect effects on future referral intentions that significantly differed between treatment and community correction staff. DISCUSSION AND CONCLUSIONS: Findings show that training may influence correctional staff intent to refer individuals to receive buprenorphine through familiarity. SCIENTIFIC SIGNIFICANCE: Tailored training for MOUD treatment for specific staff populations may prove more beneficial than existing approaches.

Substance Use and Violence Victimization Among Women: A Review of Relevant Literature.

A review of the recent scientific literature on the relationship between substance use and violence victimization among women in the United States is presented. Systematic review methodology adhered to the Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines. In total, 15 studies were identified that met inclusion criteria. There is substantial evidence suggesting substance use (e.g., severity of use, types of substances used) is associated with women's violent victimization histories. Evidence suggests that women are uniquely situated in illicit drug markets and other illicit economies in a manner that increases their risk for violent victimization. The strengths and shortcomings of current theoretical explanations of substance use and violence victimization are discussed, as well as considerations for future research and interventions.

Predictors of Safe Prescription Opioid Storage and Participation in Drug Take-Back Events: Results from a Statewide Survey.

Improper storage and disposal of prescribed opioids can lead to diversion or accidental poisonings. Studies of emergency department and cancer patients suggest prescription opioids are rarely stored securely or disposed of when unneeded. Safe storage and disposal practices reduce risks for others living in or visiting a household. The purpose of this study is thus to examine prescription opioid storage and participation in drug take-back events among Michigan adults. Participants (N = 702) were recruited through social media advertisements to complete an online survey in July and August 2018. Logistic regression was used to examine correlates of safe storage and disposal. 8.4% (n = 59) of participants reported always keeping opioids locked; 29.8% (n = 209) reported attending a drug take-back event. Black participants and those who believed that illegal drug use was a serious problem had greater odds of locking opioids; participants with higher levels of education or who knew someone who used heroin or misused prescription opioids had lesser odds of locking opioids. Age and race were associated with take-back event participation. Findings identify factors associated with safe prescription opioid storage/disposal and indicate safe storage/disposal seldom occurs. Education and provision of safe storage equipment should be designed for diverse ages, races/ethnicities, and levels of education. Drug take-back events not hosted by law enforcement may have broader appeal, as may those led by Black or other people of color. Wider use of drug donation boxes may facilitate increased disposal among those who do not wish to or cannot attend take-back events.

Buprenorphine Treatment Intake and Critical Encounters following a Nonfatal Opioid Overdose.

BACKGROUND: Individuals with prior opioid-related overdose events have an increased risk for opioid-related mortality. Buprenorphine is a partial agonist that has shown to be an effective medication for opioid use disorder (MOUD). Yet, few studies have investigated whether buprenorphine reduces the risk of opioid-related mortality following a nonfatal opioid-related overdose. METHODS: A retrospective study was conducted on all overdose cases in Indiana between January 1, 2017 and December 31, 2017. Data were linked from multiple administrative sources. Cases were linked to vital records to assess mortality. Bivariate analyses were conducted to assess group differences between survivors and decedents. A series of multiple logistic regression models were used to determine main and interaction effects of opioid-related mortality. RESULTS: Among the 10,195 nonfatal overdoses, 2.4% (247) resulted in a subsequent fatal overdose. Overdose decedents were on average 36.4 years-old, 66.8% male, 91.1% White, and 83.8% did not receive a buprenorphine dispensation. Incremental increases in the number of buprenorphine dispensations decreased the likelihood of fatal overdose by 94% (95% CI = 0.88-0.98, p = .001). Incremental increases in arrest encounters were found to significantly increase the likelihood of a fatal overdose (AOR = 2.16; 95% CI = 1.13-3.55). Arrest encounters were a significant moderator of the relationship between buprenorphine uptake effectiveness and drug-related mortality. CONCLUSIONS: Analysis of linked data provided details of risk and protective factors of fatal overdose. Buprenorphine reduced the risk of death; however, criminal justice involvement remains an area of attention for diversion and overdose death prevention interventions.

Designing and implementing an intervention for returning citizens living with substance use disorder: discovering the benefits of peer recovery coach involvement in pilot clinical trial decision-making.

Peer-facilitated services in behavioral health care remain underutilized within criminal justice-involved community organizations, and there is little guidance for how to best involve peer workers in behavioral health-focused research activities. This paper described lessons learned regarding implementation of peer recovery coaches (PRCs) as part of development and pilot research on Substance Use Programming for Person-Oriented Recovery and Treatment (SUPPORT), a peer-facilitated substance use disorder (SUD) intervention for returning citizens. Qualitative data were collected from learning meetings with key stakeholders and group interviews with SUPPORT clinical trial participants and PRCs. Transcripts were analyzed to identify key decisions made impacting the development, implementation, and/or revision of the SUPPORT intervention and pilot clinical trial protocols. Analysis demonstrated that PRC involvement drove many of the decisions made regarding modifications to the original intervention and trial protocols, while benefitting client-level interactions and by influencing the non-profit agency and its connection to stakeholders. Moreover, PRCs improved the research design by refining the incentive structure and data collection plans. PRC involvement also contributed to the development of more recovery-oriented resources and catering support services to the unique needs of justice-involved individuals. Discussed were the implications for the role of PRCs in justice-involved behavioral health research and treatment.

Appalachian Women's Use of Substance Abuse Treatment: Examining the Behavioral Model for Vulnerable Populations.

The Gelberg-Andersen Behavioral Model for Vulnerable Populations was applied to understand vulnerable Appalachian women's (N = 400) utilization of addiction treatment. A secondary data analyses included multiple multivariate analyses. Strongest correlates of treatment utilization included ever injecting drugs (OR = 2.77), limited availability of substance abuse treatment facilities (OR = 2.03), and invalidated violence abuse claims (OR = 2.12). This study contributes theory-driven research to the greater social work addiction literature by confirming that vulnerable domains related to substance abuse treatment utilization warrant unique considerations compared to non-vulnerable domains. Findings also highlight the importance of understanding the unique role that cultural factors play in treatment utilization among Appalachian women. Inferences relevant to clinicians and policymakers are discussed.

Incarcerated women's relationship-based strategies to avoid drug use after community re-entry.

While recent research has stressed the supportive role that family and friends play for incarcerated persons as they re-enter the community, drug-using incarcerated women re-entering the community often have to rely on family, community, and intimate relationships that have played a role in their substance abuse and criminalization. In this study the authors conducted qualitative analysis of clinical sessions with rural, drug-using women (N = 20) in a larger prison-based HIV risk reduction intervention in Kentucky during 2012-2014 to examine incarcerated women's perceptions of the role of their family, community, and intimate relationships in their plans to decrease their substance abuse upon community re-entry. Women stressed the obstacles to receiving support in many of their family and drug-using relationships after community re-entry. Nonetheless, they asserted that changes in their relationships could support their desires to end their substance abuse by setting limits on and using their positive relationships, particularly with their children, to motivate them to change. Interventions to promote incarcerated women's health behavior changes-including substance abuse-must acknowledge the complex social environments in which they live.

Use of harm reduction strategies by individuals with a history of incarceration: A short report using baseline data collected from the STAMINA clinical trial.

BACKGROUND: Due to the considerably heightened risk of overdose immediately following jail or prison release, expansion of harm reduction interventions for citizens returning to the community after an incarceration episode should be of utmost concern. However, there are no studies examining the adoption and use of harm reduction among this population. This short report examines the use of individual-level harm reduction strategies (HRS) among people who use drugs, comparing those who have lifetime histories of incarceration with those who do not. METHODS: This study included baseline data (N = 274) from a larger clinical trial, which recruited participants at two syringe service programs. Fisher's exact tests examine correlations between HRS and lifetime incarceration. RESULTS: Significant variation in HRS use were observed by demographic characteristics. Those with lifetime incarceration histories were less likely to report ensuring naloxone was available when using, using when others were present, using fentanyl test strips, using a trusted drug supplier, and using some other HRS compared to those without lifetime incarceration histories. Similarly, those with lifetime incarceration histories were also less likely to report using non-prescribed buprenorphine and methadone, which could potentially reduce overdose risk even if not explicitly used as an HRS. CONCLUSION: The results suggest that one of the populations at highest risk of overdose is least likely to use strategies that may reduce overdose risk. Targeted efforts to increase exposure to HRS learning opportunities and access to these resources could help reduce overdose disparities for people returning to the community after incarceration.

Naloxone vending machines in county jail.

INTRODUCTION: The overdose epidemic in the United States has intensified following the introduction of illicitly manufactured fentanyl to drug markets with recent estimates indicating 110,000 deaths in 2022 and longer-term trends adversely impacting national life expectancy. A period of incarceration has been identified as a critical touchpoint for overdose prevention given its strong association with risk of overdose. In this paper we describe efforts funded by the Centers for Disease Control and Prevention (CDC) Overdose Data to Action (OD2A) grant to design and implement naloxone vending machines that provide free naloxone within county jails to returning citizens and those visiting county jail facilities. METHODS: This study utilized three sources of data. First, we describe the results of a pre-implementation survey administered by technical assistance providers to 18 jails across the state of Michigan. Second, among the 6 jail facilities that accepted a naloxone vending machine we examine administrative data from Michigan Department of Health and Human Services on naloxone orders to look at changes 6-months before and after implementation. Third and lastly, we conducted semi-structured interviews (N = 6) with jail administrators (i.e., County Sheriffs) on the barriers and facilitators to implementing a naloxone vending machine. RESULTS: Six facilities indicated they would accept a vending machine to distribute free naloxone. Overall, the total number of naloxone box orders that were distributed across all jail sites increased by 63.5 % from 4104 boxes pre-naloxone vending machine to 6708 boxes post-naloxone vending machine implementation. Qualitative interviews revealed that prior naloxone distribution efforts and foundational knowledge about opioids, overdose, and naloxone emerged as facilitators for vending machine implementation. CONCLUSION: This study illustrates the utility of policy-driven funding strategies aimed at mitigating accidental overdose deaths among a high-risk population while building community naloxone saturation efforts.

"If everyone knew about this, how many lives could we save?": Do drug suppliers have a role in reducing overdose risk?

Introduction: An unpredictable illicit drug supply is driving high levels of overdose death in North America. Prior research has demonstrated the importance of involving people who use drugs in harm reduction intervention design and implementation. The inclusion of people who supply drugs in these efforts has been scant. We explore this possibility by interviewing persons targeted by a harm reduction educational program designed specifically for people who supply drugs. Methods: In-person interviews with people who use drugs were conducted in 2022 in Indianapolis, Indiana. We conducted a thematic analysis of data from six interviews with people who were either primarily or secondarily trained through this harm reduction training for people who supply drugs. Results: Participants described a diverse array of harm reduction strategies, some gained through the targeted education program, which they regularly practiced as they consumed and/or supplied drugs to others. People who supply drugs were regularly identified as key actors capable of widely reducing risk across drug networks. Participants described being motivated by a moral imperative to protect community members, tying the previous loss of friends and loved ones to overdose to their commitments to the safety of others. Conclusion: This article contributes to the scholarship on the role of people who supply drugs in implementing harm reduction interventions and reducing overdose risk. Better enabling grassroots harm reduction organizations to provide people who supply drugs with harm reduction training and access to harm reduction resources may help to reduce drug-related harms.

Assessing Rural-Urban Differences in Screening for Mental Health Needs Among Individuals in County Jails.

Rural jails are increasingly contributing to the overall jail population and little is known about how they differ from non-rural jails. This study compares demographic, behavioral health and criminal/legal histories of 3,797 individuals who booked into three rural jails and seven non-rural jails. In addition, the study assessed how jails identify mental illness, which was compared to an objective screening instrument (Kessler-6). Individuals in rural jails were more likely to be white, female, have a history of mental health services, misuse substances, and to recidivate. After controlling for these differences, they had 1.5 times greater odds of having a mental illness but lower odds of being identified by the jails. Individuals in rural jails have more behavioral health needs and other criminogenic risk factor and their needs are less likely to be identified by jail staff, which may result in poor connection to diversion or treatment opportunities.

Buprenorphine and opioid analgesics: Dispensation and discontinuity among accidental overdose fatalities in the Indianapolis metropolitan area, 2016-2021.

BACKGROUND: This study describes overall trends and sociodemographic disparities in buprenorphine and opioid analgesic uptake and prescribing patterns prior to fatal overdose events. METHODS: We examined toxicology data from all accidental overdose deaths from 2016 to 2021 (N = 2682) in a large metropolitan area. These data were linked at the individual-level with a prescription drug monitoring program (PDMP). RESULTS: Fewer than half of all deaths had any kind of PDMP record (39.9 %, n = 1070). Among those with a buprenorphine prescription, 10.6 % (n = 35) of decedents had a buprenorphine dispensation within 7 days of their death, while the majority (64.7 %, n = 214) were dispensed buprenorphine more than 30 days prior to death. Evidence existed of racial disparities among those with any buprenorphine uptake, whereby Black individuals (7.3 %, n = 24) had significantly fewer any dispensations compared to White individuals (92.7 %, n = 307). Among those with an opioid analgesic prescription, about 12.2 % (n = 90) were dispensed within 7 days of death, with the majority (68.5 %, n = 506) occurring more than 30 days prior to death. Like buprenorphine dispensations, Black individuals were prescribed a significantly smaller proportion of opioid analgesics (21.9 %, n = 162) versus White individuals (77.7 %, n = 574). Buprenorphine was detected in 78.5 % of deaths where fentanyl was present in the toxicology record, significantly greater when compared to opioid analgesics (57.5 %). CONCLUSION: Consistent with prior research, our findings suggest prescription opioid analgesics may protect against fatal overdoses. Access to buprenorphine treatment did not keep pace with the rising lethality of the overdose crisis, and in recent years, a smaller percentage of the people at risk of fatal overdose availed themselves of MOUD preceding their death.

Community overdose surveillance: Fentanyl involvement in overdose deaths in rural Michigan.

Purpose: Examine fatal overdose toxicology trends to contribute toward understanding the outreach and treatment needs of people who use drugs in rural areas. Methods: We describe toxicology results from overdose deaths that occurred between January 1, 2018, and December 31, 2020, in 11 rural counties in Michigan, a state with relatively high rates of overdose mortality. One-way ANOVA with Tukey's HSD posthoc tests were used to test statistically significant differences in the frequency of substances detected between years. Findings: Decedents (N = 107) were male (72.9%), White (96.3%), non-military (96.3%), unemployed (71.0%), married (73.9%), and had a mean age of 47 years old. The number of observed overdose deaths increased considerably from 2019 to 2020, with an increase of 72.4%. Fentanyl was the most common substance detected and had a 94% increase during the three-year period to present in 70% of all the deaths in these counties in 2020. Among the deaths we examined where cocaine was detected, 69% also contained fentanyl, and in deaths where methamphetamine was detected, 77% also contained fentanyl. Conclusion: Findings could inform rural health and outreach initiatives aimed at reducing overdose risks by providing education on the risks of stimulant and opioid couse but also the widespread saturation of illicit drugs that contain fentanyl. Lowthreshold harm reduction interventions are discussed amid limited prevention and treatment resources in rural communities.

Discriminant Function Analyses: Classifying Drugs/Violence Victimization Typologies Among Incarcerated Rural Women.

This study examined the relationship between drug use and violence victimization among incarcerated women in Appalachian Kentucky. The purpose of this study was to test the utility of Goldstein's tripartite conceptual framework among rural incarcerated women, by examining whether distinct drugs/violence nexus groups could be classified based on psychopharmacological, economic-compulsive, and systemic factors. This study used secondary data from a National Institute on Drug Abuse (NIDA)-funded grant focused on risk reduction among high-risk incarcerated women in Appalachia (N = 400). Predicted drugs/violence groups were developed using a series of discriminant function analyses. The data yielded three statistically significant discriminant models. Findings of the classified groupings indicated support for three distinct drugs/violence victimization subgroups. The psychopharmacological group showed the greatest prevalence (n = 181; Wilks's λ = .389, F = 3.94, p < .001), followed by the economic-compulsive group (n = 77; Wilks's λ = .584, F = 11.86, p < .001) and systemic group (n = 55) significant (Wilks's λ = .994, F = 2.247, p < .035). To date, this is the first study to report a relationship between systemic violence victimization among rural communities. These findings could offer novel considerations for theory development and implications for clinical practice regarding the drug-related risks for violence victimization among rural incarcerated women.

Perception of Resource Allocations to Address the Opioid Epidemic.

OBJECTIVES: Despite billions of dollars spent on opioid policy initiatives, public knowledge of evidence-based policies to reduce opioid-related morbidity remain low. Consequences of this knowledge gap for support of initiatives remains understudied. Our objective was to evaluate how participants with and without lived experience allocate funding for initiatives to address the opioid epidemic. A secondary objective was to collect proof-of-concept data of an informational intervention designed to improve support for evidence-based policies. METHODS: Participants (N = 284; 57.2% female) without lifetime nonmedical opioid use (n = 98) and those with lifetime use (past year [n = 81] or nonpast year [n = 105]) of nonmedical opioids were recruited. All participants reported how they would allocate funds to demand reduction, supply reduction, harm reduction, and treatment policies. Half of all participants were then randomized to a brief informational intervention designed to emphasize evidence-based harm reduction and treatment programs. RESULTS: Funding allocations were highest for policies related to community services and treatment and lowest for those related to harm reduction. Participants with lived experience allocated less to supply reduction policies. Participants (12%) who reallocated funds after information exposure increased funding to supervised consumption sites, dz = 0.77, naloxone distribution, dz = 0.85, syringe exchange programs, dz = 0.63, and medications for opioid use disorder access, dz = 0.70. CONCLUSIONS: This study illustrates how people with and without lived experience prioritize various policies to address the opioid epidemic and emphasize comparably low support for harm reduction policies. Proof-of-concept data suggest that brief informational interventions may increase funding support for harm reduction strategies, at least in a subset of people.

Factors of Recidivism among Individuals with Co-occurring Conditions in Rural Mental Health Jail Interventions.

Estimates indicate that nearly half of rural jail detainees meet the criteria for co-occurring disorders (COD). It is critical to examine factors of recidivism among detainees with COD in rural communities. This exploratory study aimed to examine factors of recidivism among adults in rural jails. Administrative data sources were utilized to assess postyear recidivism among 191 individuals with COD who participated in a jail-based intervention. Results indicated that a greater number of previous jail bookings and not receiving continuity of care were the strongest associations of overall recidivism, and a greater number of previous jail bookings was associated with of multiple recidivism events. The protective effect of receiving continuity of care was diminished in reducing recidivism 4- to 12-months following jail release. Re-entry services should consider developing or further expand specialized psychiatric care parole and connections to evidence-based integrated dual diagnosis treatment with a focus on programs with adaptability for rurality.