Understanding Geographic and Neighborhood Variations in Overdose Death Rates.

The current opioid epidemic continues to challenge us in new and potentially troubling ways. For example, research today finds more overdose deaths occurring in rural, rather than urban, geographic areas. Yet, studies have often ignored heterogeneities within these spaces and the neighborhood variations therein. Using geodemographic classification, we investigate neighborhood differences in overdose death rates by geographical areas to further understand where and among what groups the problem might be most concentrated. For deaths between 2013 and 2016, we find significant variation in rates among neighborhoods, defined by their socio-economic and demographic characteristics. For example, overdose death rates vary up to 13-fold among neighborhoods within geographic areas. Our results overall show that while the rural or urban classification of a geographic area is important in understanding the current overdose problem, a more segmented analysis by neighborhood's socio-economic and demographic makeup is also necessary.

Sentinel Events Preceding Youth Firearm Violence: An Investigation of Administrative Data in Delaware.

INTRODUCTION: Accurately identifying youth at highest risk of firearm violence involvement could permit delivery of focused, comprehensive prevention services. This study explored whether readily available city and state administrative data covering life events before youth firearm violence could elucidate patterns preceding such violence. METHODS: Four hundred twenty-one individuals arrested for homicide, attempted homicide, aggravated assault, or robbery with a firearm committed in Wilmington, Delaware, from January 1, 2009 to May 21, 2014, were matched 1:3 to 1,259 Wilmington resident controls on birth year and sex. In 2015, descriptive statistics and a conditional logistic regression model using Delaware healthcare, child welfare, juvenile services, labor, and education administrative data examined associations between preceding life events and subsequent firearm violence. RESULTS: In a multivariable adjusted model, experiencing a prior gunshot wound injury (AOR=11.4, 95% CI=2.7, 48.1) and being subject to community probation (AOR=13.2, 95% CI=5.7, 30.3) were associated with the highest risk of subsequent firearm violence perpetration, though multiple other sentinel events were informative. The mean number of sentinel events experienced by youth committing firearm violence was 13.0 versus 1.9 among controls (p<0.0001). Within the sample, 84.1% of youth experiencing a sentinel event in all five studied domains ultimately committed firearm violence. CONCLUSIONS: Youth who commit firearm violence have preceding patterns of life events that markedly differ from youth not involved in firearm violence. This information is readily available from administrative data, demonstrating the potential of data sharing across city and state institutions to focus prevention strategies on those at greatest risk.

Improvements in Correctional HIV Services: A Case Study in Delaware.

This article describes the experience and outcomes of the National Institute on Drug Abuse-funded Criminal Justice Drug Abuse Treatment Studies HIV Services and Treatment Implementation in Corrections protocol in the state of Delaware. The protocol was designed to test the effectiveness of a change team model in improving HIV services in correctional settings. In Delaware, a team was created with representatives from correctional and community agencies to work on improving linkage to HIV care for individuals released from incarceration. The team made improvements in the entire HIV service continuum: linkage to HIV care, HIV education, and HIV testing. The experiences in Delaware and the findings from this study suggest that the use of a change team model is a viable method for making organizational change in correctional settings.

Condom use preferences among Latinos in Miami-Dade: emerging themes concerning men's and women's culturally-ascribed attitudes and behaviours.

Among Latinos, cultural values such as machismo and marianismo may promote inconsistent condom use representing a significant risk factor for HIV infection. Yet there continues to be a need for additional research to explore the influence these cultural values have on Latino men and women's condom use attitudes and behaviours given increasing HIV rates of HIV infection among Latinos. The purpose of this study was to explore further Latino traditional culturally-ascribed attitudes and behaviour for emerging themes toward condom use among a diverse group of adult Latino men and women living in Miami-Dade County, Florida, USA. The study used a qualitative study-design and collected data from 16 focus groups with a total of 67 Latino men and women. Findings from the focus groups described attitudes and behaviours that counter traditional gender roles towards sex and expected sexual behaviours informed by machismo and marianismo. Common attitudes noted in the study include men's classification of women as dirty-clean to determine condom use and women's assertiveness during sexual encounters negotiating condom use--in favour and against it. As the findings of this study suggest, the process differ greatly between Latino men and women, having an impact on the risk behaviours in which each engage.

Teen mothers, unintended pregnancies, and costs across Delaware.

The present study used data from several sources to 1) present information on mothers and births in a single state (Delaware); 2) present cost data to estimate health-related birth real costs; and 3) use the data to estimate the costs and impact on mothers, health care providers, and taxpayers. In addition, this study explicitly examined costs of births through the lens of unplanned/unintended teen and young adult births. Concomitantly, the medical cost of these pregnancies for most of these young mothers who had not wanted to be pregnant at the time, was paid for through the state's Medicaid program. The percentage of Medicaid funded births was much higher for young mothers than for older mothers. Ultimately, it was estimated that young teen (age 17 and under) births cost about $4.0 million each year, older teens (18-20) births $14.0 million, and young adults (21-24) over $26 million. The State funded almost 75 percent of the health care costs of young teen pregnancy prenatal care, deliveries, and newborn care, through Medicaid. And over 75 percent of these Medicaid costs are for births that were unintended at the time. The cost of unintended teen and young adult births funded through Medicaid in Delaware was approximately $25 million annually.

Parole officer-parolee relationships and HIV risk behaviors during community supervision.

We tested if good parole officer (PO)-parolee relationships reduce HIV risk behaviors during parole, as they do for risk of rearrest. Analyses used data from 374 parolees enrolled in a randomized clinical trial. Past month HIV risk behaviors were assessed by interview at baseline, 3- and 9-months after parole initiation. The Working Alliance Inventory and the Dual-Role Relationships Inventory measured PO relationship. Gender-stratified multivariate regressions tested associations of PO-parolee relationship with sex with multiple partners, unprotected sex with risky partner(s), and drug injection. Women parolees (n = 65) who reported better PO relationship characteristics were less likely to report having multiple sex partners [adjusted odds ratio: 0.82 (0.69, 0.98) at 3-months, 0.89 (0.80, 0.99) at 9-months], and, among those reporting multiple sex partners, had fewer partners on average [adjusted relative risk 0.98 (0.96, 0.99)]. These effects were not found among men. PO-parolee relationship quality can influence sexual risk behaviors among women parolees.

Limiting options: sex ratios, incarceration rates, and sexual risk behavior among people on probation and parole.

BACKGROUND: To investigate how incarceration may affect risk of acquiring HIV and other sexually transmitted infections, we tested associations of ex-offenders' sexual risk behavior with the male-female sex ratio and the male incarceration rate. METHODS: Longitudinal data from 1287 drug-involved persons on probation and parole as part of the Criminal Justice Drug Abuse Treatment Studies were matched by county of residence with population factors, and stratified by race/ethnicity and gender. Generalized estimating equations assessed associations of having unprotected sex with a partner who had HIV risk factors, and having >1 sex partner in the past month. RESULTS: Among non-Hispanic black men and women, low sex ratios were associated with greater risk of having unprotected sex with a risky partner (adjusted relative risk [ARR] = 1.76, 95% confidence interval [CI] = 1.29, 2.42; ARR = 2.48, 95% CI = 1.31, 4.73, respectively). Among non-Hispanic black and non-Hispanic white (NHW) women, low sex ratios were associated with having >1 sex partner (ARR = 2.00, 95% CI = 1.02, 3.94; ARR = 1.71, 95% CI = 1.06, 2.75, respectively). High incarceration rates were associated with greater risk of having a risky partner for all men (non-Hispanic black: ARR = 2.14, 95% CI = 1.39, 3.30; NHW: ARR = 1.39, 95% CI: 1.05, 1.85; Hispanic: ARR = 3.99, 95% CI = 1.55, 10.26) and having >1 partner among NHW men (ARR = 1.92, 95% CI = 1.40, 2.64). CONCLUSIONS: Low sex ratios and high incarceration rates may influence the number and risk characteristics of sex partners of ex-offenders. HIV-prevention policies and programs for ex-offenders could be improved by addressing structural barriers to safer sexual behavior.

Collaborative behavioral management among parolees: drug use, crime and re-arrest in the Step'n Out randomized trial.

AIMS: To determine whether collaborative behavioral management (CBM) reduces substance use, crime and re-arrest among drug-involved parolees. DESIGN: Step'n Out was a randomized behavioral trial of CBM versus standard parole (SP) during 2004-08. CBM adapted evidence-based role induction, behavioral contracting and contingent reinforcement to provide parole officer/treatment counselor dyads with positive tools in addition to sanctions to manage parolees' behavior over 12 weeks. SETTING: Six parole offices in five states in the USA. PARTICIPANTS: Parolee volunteers with a mandate for addiction treatment and a minimum of 3 months of parole (n = 476). Follow-up was 94% at 3 months and 86% at 9 months. MEASUREMENTS: Drug use and crime in a given month from calendar interviews 3 and 9 months after parole initiation, and re-arrests from criminal justice administrative data. FINDINGS: The CBM group had fewer months in which they used their primary drug [adjusted risk ratio (ARR) 0.20, 95% confidence interval (CI): 0.05, 0.78, P = 0.02] and alcohol (ARR 0.38, 95% CI: 0.22, 0.66, P = 0.006) over follow-up. CBM had its greatest effects among parolees who reported marijuana or another 'non-hard' drug as their primary drug; parolees who preferred stimulants or opiates did not benefit. No differences were seen in total crime, re-arrests or parole revocations. CONCLUSIONS: Collaborative behavioral management may reduce substance use among primary marijuana or other 'non-hard' drug-using parolees without increasing revocations. Because the majority of drug violation arrests in the United States are for marijuana, these findings have important implications for the management of a substantial proportion of the US community correctional population.

The "black box" of prescription drug diversion.

A variety of surveys and studies are examined in an effort to better understand the scope of prescription drug diversion and to determine whether there are consistent patterns of diversion among various populations of prescription drug abusers. Data are drawn from the RADARS System, the National Survey of Drug Use and Health, the Delaware School Survey, and a series of quantitative and qualitative studies conducted in Miami, Florida. The data suggest that the major sources of diversion include drug dealers, friends and relatives, smugglers, pain patients, and the elderly, but these vary by the population being targeted. In all of the studies examined, the use of the Internet as a source for prescription drugs is insignificant. Little is known about where drug dealers are obtaining their supplies, and as such, prescription drug diversion is a "black box" requiring concentrated, systematic study.

Collaborative Behavioral Management for Drug-Involved Parolees: Rationale and Design of the Step'n Out Study.

This article describes the rationale, study design, and implementation for the Step'n Out study of the Criminal Justice Drug Abuse Treatment Studies. Step'n Out tests the relative effectiveness of collaborative behavioral management of drug-involved parolees. Collaborative behavioral management integrates the roles of parole officers and treatment counselors to provide role induction counseling, contract for pro-social behavior, and deliver contingent reinforcement of behaviors consistent with treatment objectives. The Step'n Out study will randomize 450 drug-involved parolees to collaborative behavioral management or usual parole. Follow-up at 3-and 9-months will assess primary outcomes of rearrest, crime and drug use. If collaborative behavioral management is effective, its wider adoption could improve the outcomes of community reentry of drug-involved ex-offenders.

Integrating an HIV/HCV brief intervention in prisoner reentry: results of a multisite prospective study.

Brief interventions to reduce harmful or problem behaviors have become increasingly popular in a variety of health fields, including HIV and hepatitis risk reduction. A central issue in intervention research involves the evaluation of what constitutes an effective "dose" of an intervention. This research examines the relative effectiveness of three alternative brief interventions of varying intensity designed to change the risk behaviors of inmates who are reentering society: a DVD-based, peer delivered intervention; the NIDA Standard HIV Intervention; and a standard practice condition (HIV educational video). All participants randomly received one of the interventions and were tested for HIV and HCV prior to release from custody. Thirty and ninety-day follow-ups examined changes in high-risk behaviors. Results reported here for 343 subjects who have completed the 90-day follow up indicate significant reductions in reported sexual risk behaviors for those participating the DVD intervention, compared to the other two brief interventions. This study is among the first to report any positive impacts on sexual behaviors among a population of inmates returning to the community.

Using thought mapping and structured stories to decrease HIV risk behaviors among cocaine injectors and crack smokers in the South of Brazil

OBJECTIVES: To compare changes in AIDS knowledge and risk behaviors among Brazilian cocaine users in an intervention trial. METHOD: 119 participants were randomly assigned to either a standard or a standard plus "thought mapping" intervention, and re-interviewed 2 and 8 weeks after intake using standardized data collection instruments. Intervention effects were examined using generalized estimated equation model. RESULTS: Significant increases in AIDS knowledge and condom use were observed in the experimental group, as well as significant changes in the subscores for sexual and drug risks. The experimental intervention was less successful in decreasing mean days of cocaine use when compared to the standard. CONCLUSION: Although not robust, the findings nevertheless suggest that components of the experimental thought-mapping model might be useful in combination with other approaches.

OBJETIVOS: Comparar as mudanças em conhecimento sobre AIDS e comportamentos de risco em usuários de cocaína brasileiros submetidos a uma intervenção experimental. MÉTODO: 119 sujeitos foram aleatoriamente designados para uma intervenção padrão ou uma intervenção padrão adicionada a um "mapa cognitivo", e re-entrevistados duas e oito semanas após admissão no estudo, utilizando-se instrumentos de coleta padronizados. Os efeitos da intervenção foram examinados utilizando modelo de equações de estimação generalizadas. RESULTADOS: Foram observados aumentos significativos no conhecimento sobre AIDS e uso de preservativos no grupo experimental, bem como modificações significativas nos subescores para risco sexual e uso de drogas. A intervenção experimental teve menos sucesso em diminuir dias de uso de cocaína quando comparada com a intervenção padrão. CONCLUSÃO: Apesar de não serem robustos, os achados sugerem que os componentes do modelo de mapa cognitivo experimentados poderiam ser úteis em combinação com outras abordagens.

Working toward recovery: the interplay of past treatment and economic status in long-term outcomes for drug-involved offenders.

Research on the relationship between employment and substance use tends to focus on employment lowering use. It is also potentially the case, however, that lowered substance use among addicts may lead to better employment and thus to greater long-term abstinence. In this article, we utilize complementary elements of three mainstream criminological approaches to suggest how therapeutic community-based treatment of drug user(s) during the transition from prison to community may lower clients' levels of substance use and thus increase their likelihood of better economic outcomes. We then use structural equations modeling to demonstrate how this process might play out. The data for this study were collected from 1992 through 1998 from the Delaware Department of Corrections. The study's limitations are noted.

Using thought mapping and structured stories to decrease HIV risk behaviors among cocaine injectors and crack smokers in the South of Brazil.

OBJECTIVES: To compare changes in AIDS knowledge and risk behaviors among Brazilian cocaine users in an intervention trial. METHOD: 119 participants were randomly assigned to either a standard or a standard plus "thought mapping" intervention, and re-interviewed 2 and 8 weeks after intake using standardized data collection instruments. Intervention effects were examined using generalized estimated equation model. RESULTS: Significant increases in AIDS knowledge and condom use were observed in the experimental group, as well as significant changes in the subscores for sexual and drug risks. The experimental intervention was less successful in decreasing mean days of cocaine use when compared to the standard. CONCLUSION: Although not robust, the findings nevertheless suggest that components of the experimental thought-mapping model might be useful in combination with other approaches.

Differences in prevalence of prescription opiate misuse among rural and urban probationers.

We compared the prevalence of prescription opiate misuse among 2 cohorts of felony probationers (N = 1525). Multiple logistic regression was utilized to determine the independent correlates of prescription opiate misuse among rural (n = 782) and urban (n = 743) probationers participating in an HIV-intervention study. After adjustment for differences in demographic and drug use characteristics, rural participants were almost five times more likely than their urban counterparts to have misused prescription opiates. The prevalence of prescription opiate misuse was significantly higher among the rural probationers; however, given the paucity of illicit opiates and relatively recent emergence of prescription opiates in rural areas, rural substance abuse treatment may be ill-prepared to treat prescription opiate misuse.

Changing patterns of cocaine use and hiv risks in the south of Brazil.

For well over a decade, researchers in Porto Alegre, Brazil, have been documenting the extent of the AIDS epidemic in the region, with a specific focus on the linkages between drug use and HIV seropositivity. Virtually all of the studies conducted during those years found injection drug use (IDU) to be the major vector for HIV seropositivity in this population. However, recent research found that the number of IDUs had declined significantly. Qualitative interviews and focus groups suggested many reasons for this decline: (1) many had died, because they had never heard of AIDS or HIV, and were unaware of how HIV is transmitted. As a result, they had become infected through the sharing of injection paraphernalia. (2) The quality of street cocaine had declined, making injection difficult. (3) Because of a fear of AIDS, some shifted to the smoking of crack, which had become a newly availability commodity in the street culture. Within this context, this article describes the qualitative data describing the decline of cocaine injecting and the corresponding emergence of crack use in Porto Alegre, Brazil, and related HIV risks.

A prospective examination of high-cost health services utilization among drug using prisoners reentering the community.

The use of health services by prisoners during their incarceration and after their return to the community impacts the U.S. health care system and health care costs associated with this system. These health care costs are expected to increase over the next decade as more prisoners return to their communities. The current study prospectively examines the use of high-cost health care services-emergency room visits and hospitalizations-among 565 male drug-abusing prisoners about 1 year after prison release. A series of structural equation models were used to examine predisposing factors, including health status and drug use, and to estimate the frequency of high-cost health service utilization. As expected, health status was the most robust predictor of high-cost health services. However, the finding that drug abuse had nonsignificant relationships with high-cost health services utilization was not expected. Discussion focuses on health care service issues and health problems as prisoners' transition from prison to the community.

Treatment during transition from prison to community and subsequent illicit drug use.

This study examined the effects of postrelease transitional therapeutic community treatment on the drug use and employment rates of drug involved prisoners in the Delaware corrections system followed for up to 5 years after release. A comparison group received standard postrelease supervision. Abstinence rates were 32.2% in the treatment group and 9.9% in the no-treatment group, and the treatment group had a higher overall proportion of time free of drug use. Time to relapse was a mean of 28.8 months in the treatment group versus 13.2 months in the no-treatment group. Relapse was defined as any use of any drug and was confirmed by urinalysis. Positive effects were seen even for those who did not complete treatment. The treatment group had a significantly higher rate of employment after leaving work release (54.6%) than did the no-treatment group (45.4%). Treatment during the transitional period between prison and community showed substantial and persistent benefits even for a cohort marked with extensive criminal history, low rates of marital bonds, and substantial unemployment.