Differences by race and ethnicity in drug use patterns, harm reduction practices and barriers to treatment among people who use drugs in Rhode Island.

Background: As in much of the United States, there have been significant increases in overdose deaths among non-Hispanic Black and Hispanic/Latinx populations in Rhode Island over the past decade. Given the shifting dynamics of the overdose epidemic, there is an urgent need for focused interventions that address the specific needs of diverse communities. This study explores differences in drug use patterns, harm reduction behaviors and types and barriers to treatment by race and ethnicity. Methods: This study utilized baseline data from the Rhode Island Prescription and Illicit Drug Study (RAPIDS). We assessed sociodemographic characteristics, drug use patterns, harm reduction practices, treatment type, and barriers to treatment in a cross-sectional analysis of people who use drugs (PWUD), stratified by race and ethnicity (non-Hispanic white, non-Hispanic Black, non-Hispanic other race, and Hispanic). Chi-square tests of independence and ANOVA tests were used to identify statistically significant differences by race and ethnicity. Results: Among 509 participants, the median age was 43, and the majority were men (64%). Non-Hispanic Black participants reported significantly less regular use of unregulated opioids, such as heroin (10%) and fentanyl (12%), as compared to non-Hispanic white participants (39% and 33%, respectively). Non-Hispanic Black participants reported significantly less experience responding to overdoses: only 39% had ever administered naloxone and 34% had ever performed rescue breathing, as compared to 67% and 57% among non-Hispanic white participants, respectively. Despite significant differences in drug use patterns, there were few differences in harm reduction practices by race and ethnicity. Current treatment enrollment was highest among those who were non-Hispanic white (38%) and lowest among those who were non-Hispanic Black (7%). Conclusions: These findings suggest that there are differences in overdose response experience and treatment exposure between non-Hispanic Black PWUD and those belonging to other racial and ethnic groups, indicating a need for enhanced investment in overdose response education, naloxone distribution and treatment access for non-Hispanic Black PWUD.

Preoperative vs Postoperative Opioid Prescriptions and Prolonged Opioid Refills Among US Youths.

Importance: High-risk practices, including dispensing an opioid prescription before surgery when not recommended, remain poorly characterized among US youths and may contribute to new persistent opioid use. Objective: To characterize changes in preoperative, postoperative, and refill opioid prescriptions up to 180 days after surgery. Design, Setting, and Participants: This retrospective cohort study was performed using national claims data to determine opioid prescribing practices among a cohort of opioid-naive youths aged 11 to 20 years undergoing 22 inpatient and outpatient surgical procedures between 2015 and 2020. Statistical analysis was performed from June 2023 to April 2024. Main Outcomes and Measures: The primary outcome was the percentage of initial opioid prescriptions filled up to 14 days prior to vs 7 days after a procedure. Secondary outcomes included the likelihood of a refill up to 180 days after surgery, including refills at 91 to 180 days, as a proxy for new persistent opioid use, and the opioid quantity dispensed in the initial and refill prescriptions in morphine milligram equivalents (MME). Exposures included patient and prescriber characteristics. Multivariable logistic regression models were used to estimate the association between prescription timing and prolonged refills. Results: Among 100 026 opioid-naive youths (median [IQR] age, 16.0 [14.0-18.0] years) undergoing a surgical procedure, 46 951 (46.9%) filled an initial prescription, of which 7587 (16.2%) were dispensed 1 to 14 days before surgery. The mean quantity dispensed was 227 (95% CI, 225-229) MME; 6467 youths (13.8%) filled a second prescription (mean MME, 239 [95% CI, 231-246]) up to 30 days after surgery, and 1216 (3.0%) refilled a prescription 91 to 180 days after surgery. Preoperative prescriptions, increasing age, and procedures not typically associated with severe pain were most strongly associated with new persistent opioid use. Conclusions and Relevance: In this retrospective study of youths undergoing surgical procedures, of which, many are typically not painful enough to require opioid use, opioid dispensing declined, but approximately 1 in 6 prescriptions were filled before surgery, and 1 in 33 adolescents filled prescriptions 91 to 180 days after surgery, consistent with new persistent opioid use. These findings should be addressed by policymakers and communicated by professional societies to clinicians who prescribe opioids.

Standard Versus Family-Based Screening, Brief Intervention, and Referral to Treatment for Adolescent Substance Use in Primary Care: Protocol for a Multisite Randomized Effectiveness Trial.

BACKGROUND: Screening, brief intervention, and referral to treatment for adolescents (SBIRT-A) is widely recommended to promote detection and early intervention for alcohol and other drug (AOD) use in pediatric primary care. Existing SBIRT-A procedures rely almost exclusively on adolescents alone, despite the recognition of caregivers as critical protective factors in adolescent development and AOD use. Moreover, controlled SBIRT-A studies conducted in primary care have yielded inconsistent findings about implementation feasibility and effects on AOD outcomes and overall developmental functioning. There is urgent need to investigate the value of systematically incorporating caregivers in SBIRT-A procedures. OBJECTIVE: This randomized effectiveness trial will advance research and scope on SBIRT-A in primary care by conducting a head-to-head test of 2 conceptually grounded, evidence-informed approaches: a standard adolescent-only approach (SBIRT-A-Standard) versus a more expansive family-based approach (SBIRT-A-Family). The SBIRT-A-Family approach enhances the procedures of the SBIRT-A-Standard approach by screening for AOD risk with both adolescents and caregivers; leveraging multidomain, multireporter AOD risk and protection data to inform case identification and risk categorization; and directly involving caregivers in brief intervention and referral to treatment activities. METHODS: The study will include 2300 adolescents (aged 12-17 y) and their caregivers attending 1 of 3 hospital-affiliated pediatric settings serving diverse patient populations in major urban areas. Study recruitment, screening, randomization, and all SBIRT-A activities will occur during a single pediatric visit. SBIRT-A procedures will be delivered digitally on handheld tablets using patient-facing and provider-facing programming. Primary outcomes (AOD use, co-occurring behavior problems, and parent-adolescent communication about AOD use) and secondary outcomes (adolescent quality of life, adolescent risk factors, and therapy attendance) will be assessed at screening and initial assessment and 3-, 6-, 9-, and 12-month follow-ups. The study is well powered to conduct all planned main and moderator (age, sex, race, ethnicity, and youth AOD risk status) analyses. RESULTS: This study will be conducted over a 5-year period. Provider training was initiated in year 1 (December 2023). Participant recruitment and follow-up data collection began in year 2 (March 2024). We expect the results from this study to be published in early 2027. CONCLUSIONS: SBIRT-A is widely endorsed but currently underused in pediatric primary care settings, and questions remain about optimal approaches and overall effectiveness. In particular, referral to treatment procedures in primary care remains virtually untested among youth. In addition, whereas research strongly supports involving families in interventions for adolescent AOD, SBIRT-A effectiveness trial testing approaches that actively engage family members in primary care are absent. This trial is designed to help fill these research gaps to inform the critical health decision of whether and how to include caregivers in SBIRT-A activities conducted in pediatric primary care. TRIAL REGISTRATION: ClinicalTrials.gov NCT05964010; https://www.clinicaltrials.gov/study/NCT05964010. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/54486.

Trends in Substance-Related Visits Among Youth to US Children's Hospitals, 2016-2021: An Analysis of the Pediatric Health Information System Database.

PURPOSE: This study evaluates recent trends in substance-related visits among youth visiting children's hospitals. METHODS: We conducted a cross-sectional study of substance-related visits to pediatric hospitals within the Pediatric Health Information System database of youth aged 12-21 years from 2016 through 2021. Substance-related visits were defined as acute visits for International Classification of Diseases, 10th Revision Clinical Modification codes related to substance 'use', dependence, or overdoses for alcohol, cannabis, nicotine, opioids, sedatives, stimulants, hallucinogens, or other substances. Cumulative growth rate and stratified substance-related trends were calculated using generalized estimating equations. Predicted number of visits during the COVID-19 pandemic was generated using an auto-regressive time series analysis. RESULTS: There were 106,793 substance-related visits involving 84,632 youth. From 2016 to 2021, substance-related visits increased by 47.9% and increased across all ages, demographics, regions, and payors. Visits of Hispanic youth experienced the greatest percentage growth (63.3%, p < .05) when compared to Non-Hispanic (NH) White (46.2%) or NH Black (49.8%) youth. All substances except sedatives experienced an increase in growth in visits. Cannabis accounted for the largest percentage of visits (52.2%) and experienced the greatest percentage growth during the study period (82.4%, p < .001). During the pandemic, publicly insured, female, NH Black, and Hispanic youth experienced a greater-than-predicted number of substance-related visits. DISCUSSION: Substance-related visits to children's hospitals are increasing for all demographics and nearly all substances. There were substantial increases in visits for most minoritized youth with a disproportionate rise among Hispanic youth. Visits over the pandemic were concentrated among publicly insured, female, NH Black, and Hispanic youth. Equitable large-scale investment is needed to address the rising morbidity of substance use among adolescents.

Treating Adolescent Opioid Use Disorder in Primary Care.

This survey study explores primary care pediatricians' preparedness to counsel and treat adolescents with opioid use disorder (OUD) and perceived barriers to prescribing OUD medications.

Association between willingness to use an overdose prevention center and probation or parole status among people who use drugs in Rhode Island.

BACKGROUND: Overdose prevention centers (OPCs) are being implemented in the United States as a strategy to reduce drug-related mortality and morbidity. Previous studies have suggested that people who use drugs (PWUD) with a history of criminal legal system (CLS) involvement (e.g. current probation/parole) are at greater risk of overdose but may also encounter significant barriers to OPC use. The objective of this study was to explore the association between willingness to use an OPC and probation/parole status in a sample of PWUD in Rhode Island. METHODS: This study utilized data from the Rhode Island Prescription and Illicit Drug Study, which enrolled adult PWUD from August 2020 to February 2023. We used Pearson's chi-square and Wilcoxon rank-sum tests to assess bivariate associations between willingness to use an OPC and probation/parole status (current/previous/never), as well as other sociodemographic and behavioral characteristics. In multivariable Poisson analyses, we examined the association between willingness to use an OPC and probation/parole status, adjusting for key sociodemographic and behavioral characteristics. RESULTS: Among 482 study participants, 67% were male, 56% identified as white, 20% identified as Hispanic/Latine, and the median age was 43 (IQR 35-53). Nearly a quarter (24%) had never been on probation/parole, 44% were not currently on probation/parole but had a lifetime history of probation and parole, and 32% were currently on probation/parole. Most participants (71%) reported willingness to use an OPC, and in both bivariate and multivariable analyses, willingness to use an OPC did not vary by probation/parole status. Crack cocaine use and lifetime non-fatal overdose were associated with greater willingness to use an OPC (all p < 0.05). CONCLUSIONS: These data demonstrate high willingness to use OPC among PWUD in Rhode Island regardless of CLS-involvement. As OPCs begin to be implemented in Rhode Island, it will be imperative to engage people with CLS-involvement and to ensure access to the OPC and protection against re-incarceration due to potential barriers, such as police surveillance of OPCs.

Adolescent Residential Addiction Treatment In The US: Uneven Access, Waitlists, And High Costs.

Drug overdose deaths among adolescents are increasing in the United States. Residential treatment facilities are one treatment option for adolescents with substance use disorders, yet little is known about their accessibility or cost. Using the Substance Abuse and Mental Health Services Administration's treatment locator and search engine advertising data, we identified 160 residential addiction treatment facilities that treated adolescents with opioid use disorder as of December 2022. We called facilities while role-playing as the aunt or uncle of a sixteen-year-old child with a recent nonfatal overdose, to inquire about policies and costs. Eighty-seven facilities (54.4 percent) had a bed immediately available. Among sites with a waitlist, the mean wait time for a bed was 28.4 days. Of facilities providing cost information, the mean cost of treatment per day was $878. Daily costs among for-profit facilities were triple those of nonprofit facilities. Half of facilities required up-front payment by self-pay patients. The mean up-front cost was $28,731. We were unable to identify any facilities for adolescents in ten states or Washington, D.C. Access to adolescent residential addiction treatment centers in the United States is limited and costly.

Medications for Opioid Use Disorder for Youth: Patient, Caregiver, and Clinician Perspectives.

PURPOSE: Clinical trial data support use of medications for opioid use disorder (MOUD) in adolescents and young adults ("youth"), but qualitative data are lacking on the acceptability and importance of MOUD to youth, caregivers, and clinicians. We assessed how these stakeholders viewed the role of MOUD in treatment and recovery. METHODS: We recruited youth aged from 15 to 25 years with opioid use disorder who had received buprenorphine, naltrexone, or methadone and caregivers from a primary care-based youth addiction treatment program. We also recruited clinicians with addiction expertise from social work, nursing, pediatrics, internal medicine, and psychiatry. We conducted semistructured interviews assessing special considerations for MOUD use in youth. Three coders performed inductive and deductive thematic analysis of transcripts. RESULTS: Among 37 participants, including 15 youth (age range, 17-25 years), nine caregivers, and 13 clinicians, we identified three themes. (1) Medications support recovery in the short term: Youth described MOUD as beneficial in managing withdrawal symptoms. Notably, some youth and caregivers preferred to limit MOUD duration. (2) Medication adherence is affected by type of medication, dosing regimen, and route of administration. Participants endorsed long-acting, injectable MOUD for ease of use and youth's ability to continue engagement in "normal activities" without daily medication. (3) Caregiver involvement can support medication decisions and adherence. Youth and some clinicians described the need to assess caregiver involvement before incorporating them into treatment; caregivers and other clinicians described caregivers as critical in supporting accountability. DISCUSSION: MOUD is evidence-based, and its provision should be developmentally responsive and youth- and family-centered, incorporating caregivers when appropriate.

Understanding how primary care providers report discussing substance use with transgender and gender diverse patients.

OBJECTIVES: To explore how primary care providers report discussing substance use with transgender and gender diverse (TGD) adult patients within the context of discussing gender-affirming interventions. METHODS: Between March and April 2022, in-depth, semi-structured qualitative interviews were conducted with 15 primary care providers who care for TGD patients in the Northeastern US. Thematic analysis was used to analyze interview data and identify themes. RESULTS: Two primary themes emerged among providers: 1) placing a focus on harm reduction, emphasizing reducing negative consequences of substance use, and 2) using access to gender-affirming interventions as an incentive for patients to change their substance use patterns. CONCLUSIONS: Focusing on harm reduction can emphasize reducing potential adverse outcomes while working with TGD patients towards their gender-affirmation goals. Future research should explore varying approaches to how substance use is discussed with TGD patients, as well as the interpretation of gender-affirming clinical guidelines. PRACTICE IMPLICATIONS: Findings from this study indicate a need for enhancing provider knowledge around the appropriate application of gender-affirming care guidelines. Investing in training efforts to improve gender-affirming care is critical for encouraging approaches that prioritize harm reduction and do not unnecessarily prevent access to gender-affirming interventions.

A Qualitative Study of Barriers and Facilitators to Integrating Medications for Opioid Use Disorder and HIV Preexposure Prophylaxis for Adolescents and Young Adults.

BACKGROUND: The syndemic of substance use and human immunodeficiency virus (HIV) is a well-recognized global phenomenon that threatens to undermine the priorities outlined by the National Institutes of Health "Ending the HIV Epidemic" initiative. There are few published studies on preexposure prophylaxis (PrEP) for adolescents and young adults (AYAs) with opioid use disorder (OUD) despite increasing availability of biomedical prevention options and Centers for Disease Control and Prevention recommendations to offer PrEP to this group. METHODS: Healthcare providers who previously prescribed medications for OUD (MOUDs) and/or PrEP for AYA were purposively sampled. Audio-recorded in-depth individual interviews were conducted using chart-stimulated recall to explore barriers and facilitators to integrated MOUD and HIV prevention services. Interviews were double-coded, and qualitative analysis was performed using a modified grounded theory. RESULTS: Of 19 providers sampled, most were physicians (63%). All recommended HIV screening at varying intervals; however, few counseled on (19%) or prescribed (11%) PrEP to patients on MOUD. Barriers to PrEP prescriptions included patient-level (ie, stigma surrounding PrEP use, adherence challenges, and competing social or mental healthcare needs), provider (perception of low risk, lack of training/experience), and system-level factors (including restricted visit types). Facilitators of PrEP prescriptions included patient-initiated requests, electronic health record system reminders, and the availability of consistent support staff (ie, navigators, certified recovery specialists). CONCLUSIONS: Our study confirms that discussions about HIV prevention and PrEP prescriptions may be rare for AYA patients receiving MOUD. Further research is needed to develop interventions that increase the integration of PrEP delivery within the context of OUD care among this key AYA population.

Treatments Used Among Adolescent Residential Addiction Treatment Facilities in the US, 2022.

This study surveyed US adolescent residential addiction treatment facilities to assess treatments used for adolescents younger than 18 years seeking treatment for opioid use disorder.

Receipt of Prescription Psychostimulants and Stimulant-Involved Fatal Overdose: A Population-Based Case-Control Study.

Background: Rates of psychostimulant use, misuse, and hospitalization have increased markedly over the past decade. The objective of this study was to estimate the association between receipt of a psychostimulant prescription in the past year and fatal, unintentional psychostimulant-involved overdose. Methods: We conducted a population-based case-control study using linked, state-level databases from the Rhode Island Department of Health. Cases were defined as Rhode Island residents who experienced a fatal, unintentional drug overdose involving a psychostimulant, and controls included non-psychostimulant involved fatal overdoses occurring between May 1, 2017 and May 31, 2020 The primary exposure of interest was receipt of a psychostimulant prescription within 12 months prior to death, ascertained through linkage to the state's prescription drug monitoring program. Conditional logistic regression was used to estimate unadjusted and adjusted odds ratios. Results: Of 894 eligible overdose fatalities, the majority were white/non-Hispanic (72%), mean age was 43 years, and most resided in Providence County (69%). A total of 39 (4%) involved a psychostimulant. After adjusting for year of death and matching by sex, age, and county of residence, cases had 4.1 (95% confidence interval: 1.6, 10.6) times the odds of receiving a prescription stimulant in the past year compared to controls. Conclusions: Our findings suggest that there is a strong, positive association between prescription psychostimulant receipt and psychostimulant-involved fatal overdose. In response to an evolving polysubstance use landscape, current harm reductions measures, including naloxone training, fentanyl test strip distribution, and overdose education, should be expanded to include patients who receive psychostimulant prescriptions.