Psychometric evaluation of two indices assessing stigma toward opioid misuse and treatment among health care providers.

Background: Stigma is described as highly relevant to the treatment context for opioid use disorder (OUD) partly because it is known to influence clinicians' treatment decisions and care provision. However, appropriate measures are needed to test the salience of stigmatizing views held by clinicians directly.Objective: This study assessed dimensionality, reliability, and validity evidence for two measures - of public stigma toward opioid misuse and clinician stigma associated with medication for opioid use disorder (MOUD), respectively.Methods: Psychometric tests were conducted based on survey data collected from a sample of 144 clinicians participating in a buprenorphine waiver training program (30% female).Results: Factor analysis indicated that the indices of stigma associated with opioid misuse and MOUD stigma are best represented as separate measures. Spearman-Brown Prophesy estimates (opioid misuse stigma = .88; MOUD stigma = .93) and Cronbach's alpha coefficients (opioid misuse stigma = .93; MOUD stigma = .91) supported the reliability of both measures. Construct validity evidence was additionally found in correlation tests based on provider background characteristics, and discriminant validity evidence is supported by the between-factor correlation coefficient (r = .44, p = .04) for the opioid misuse stigma and MOUD stigma indices.Conclusions: Both indices examined in this report are psychometrically acceptable measures for assessing general bias among health care providers toward persons who misuse opioids and toward those seeking MOUD treatment. Further consideration of these forms of bias are recommended in future research to improve clinical practice and increase the implementation of MOUD treatment.

Factors that influence enrollment in syringe services programs in rural areas: a qualitative study among program clients in Appalachian Kentucky.

BACKGROUND: Enrolling sufficient number of people who inject drugs (PWID) into syringe services programs (SSP) is important to curtail outbreaks of drug-related harms. Still, little is known about barriers and facilitators to SSP enrollment in rural areas with no history of such programs. This study's purpose was to develop a grounded theory of the role of the risk environment and individual characteristics of PWID in shaping SSP enrollment in rural Kentucky. METHODS: We conducted one-on-one semi-structured interviews with 41 clients of 5 SSPs that were established in rural counties in Appalachian Kentucky in 2017-2018. Interviews covered PWID needs, the process of becoming aware of SSPs, and barriers and facilitators to SSP enrollment. Applying constructivist grounded theory methods and guided by the Intersectional Risk Environment Framework (IREF), we applied open, axial and selective coding to develop the grounded theory. RESULTS: Stigma, a feature of IREF's meso-level social domain, is the main factor hampering SSP enrollment. PWID hesitated to visit SSPs because of internalized stigma and because of anticipated stigma from police, friends, family and healthcare providers. Fear of stigma was often mitigated or amplified by a constellation of meso-level environmental factors related to healthcare (e.g., SSPs) and social (PWID networks) domains and by PWID's individual characteristics. SSPs mitigated stigma as a barrier to enrollment by providing low threshold services in a friendly atmosphere, and by offering their clients program IDs to protect them from paraphernalia charges. SSP clients spread positive information about the program within PWID networks and helped their hesitant peers to enroll by accompanying them to SSPs. Individual characteristics, including child custody, employment or high social status, made certain PWID more susceptible to drug-related stigma and hence more likely to delay SSP enrollment. CONCLUSIONS: Features of the social and healthcare environments operating at the meso-level, as well as PWID's individual characteristics, appear to enhance or mitigate the effect of stigma as a barrier to SSP enrollment. SSPs opening in locations with high stigma against PWID need to ensure low threshold and friendly services, protect their clients from police and mobilize PWID networks to promote enrollment.

Rural and urban clinician views on COVID-19's impact on substance use treatment for individuals on community supervision in Kentucky.

BACKGROUND: The COVID-19 pandemic produced system-level changes within the criminal legal system and community-based substance use disorder (SUD) treatment system with impacts on recovery efforts. This study examines rural and urban clinicians' perspectives of COVID-19 on SUD treatment delivery for people on community supervision. METHODS: Virtual qualitative interviews were conducted between April and October 2020 with 25 community supervision clinicians employed by Kentucky's Department of Corrections (DOC), who conduct assessments and facilitate community-based treatment linkages for individuals on probation or parole. Transcripts were analyzed in NVivo using directed content analysis methods. RESULTS: Clinicians were predominantly white (92%) and female (88%) with an average of over 9 years working in the SUD treatment field and 4.6 years in their current job. Four COVID-19 themes were identified by both rural and urban clinicians including: (1) telehealth increases the modes of communication, but (2) also creates paperwork and technological challenges, (3) telehealth requires more effort for inter/intra-agency collaboration, and (4) it limits client information (e.g., no urine drug screens). Two additional rural-specific themes emerged related to COVID-19: (5) increasing telehealth options removes SUD treatment transportation barriers and (6) requires flexibility with programmatic requirements for rural clients. CONCLUSIONS: Findings indicate the need for community-based SUD treatment providers approved or contracted by DOC to support and train clients to access technology and improve information-sharing with community supervision officers. A positive lesson learned from COVID-19 transitions was a reduction in costly travel for rural clients, allowing for greater engagement and treatment adherence. Telehealth should continue to be included within the SUD continuum of care, especially to promote equitable services for individuals from rural areas.

Opioid use-related stigma and health care decision-making.

OBJECTIVE: Stigma is described as highly relevant to the treatment context for opioid use disorder (OUD) partly because it is known to influence providers' treatment decisions and care provision. However, further study is needed to directly test the salience of stigmatizing views for healthcare decision-making among providers, and particularly those including medication for opioid use disorder (MOUD). This study assessed whether stigma toward illicit opioid use was associated with a willingness to provide or refer patients for MOUD treatment among a sample of healthcare providers. It also evaluated variation in stigmatizing views as a function of familiarity with OUD and MOUD and provider type. METHOD: Structural equation modeling was utilized to evaluate the antecedents and healthcare decision-making consequences associated with stigma based on survey data from a sample of 144 clinicians participating in a buprenorphine waiver training program (30% female). RESULTS: Providers who have less familiarity with OUD and MOUD and those who are medical students or residents are significantly more likely to endorse stigmatizing views of illicit opioid use. In turn, greater stigma is significantly associated with a lesser willingness to provide treatment or refer patients to MOUD treatment. CONCLUSIONS: Further consideration of stigma is recommended in future research to improve clinical practice and increase the implementation of MOUD treatment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Barriers and facilitators to the use of medication for opioid use disorder within the criminal justice system: Perspectives from clinicians.

INTRODUCTION: This study examines social service clinicians' (SSCs) perspectives of factors within the criminal justice system that impact justice-involved individuals' use of medications for opioid use disorder (MOUD). Opioid use disorder (OUD) rates are high among justice-involved individuals, and overdose risk is heightened upon release from incarceration. This study is innovative, as it specifically focuses on criminal justice contexts that influence the MOUD continuum of care from the perspective of clinicians working within the criminal justice system. Understanding criminal justice-related facilitators and barriers to MOUD treatment will guide tailored policy intervention to increase MOUD use and promote recovery and remission among justice-involved individuals. METHODS: The study completed qualitative interviews with 25 SSCs who are employed by a state department of corrections to provide assessment and referrals to substance use treatment to individuals on community supervision. The study used NVivo software to code the major themes found within each transcribed interview; two research assistants participated in consensus coding to ensure consistency in coding across transcripts. This study focused on the secondary codes that fell under the "Criminal Justice System" primary code, as well as codes that indicated barriers and facilitators to MOUD treatment. RESULTS: SSCs cited sentencing time credits as structural facilitators of MOUD treatment; clients sought more information about extended-release naltrexone since time off of their sentence was available if initiated. Support for extended-release naltrexone by officers and judges was often mentioned as an attitudinal facilitator of initiation. Poor intra-agency collaboration among department of corrections agents was an institutional barrier to MOUD. Also, probation and parole officers' stigma surrounding other types of MOUD, specifically buprenorphine and methadone, was an attitudinal barrier to MOUD within the criminal justice system. CONCLUSIONS: Future research should examine the effect that time credits have on extended-release naltrexone initiation, considering the wide consensus among SSCs that their clients were motivated to initiate this type of MOUD because of the resulting time off their sentences. Stigma among probation and parole officers and lack of communication within the criminal justice system need to be addressed so that more individuals with OUD may be exposed to life-saving treatments.

Social ecological factors and medication treatment for opioid use disorder among justice-involved rural and urban persons: the Geographic variation in Addiction Treatment Experiences (GATE) longitudinal cohort study protocol.

INTRODUCTION: Three medications are Food and Drug Administration approved for the treatment of opioid use disorder (OUD); however, these medications are underused within prisons, which elevates the risk of relapse and overdose when persons with opioid use disorder (POUD) are released. Research is scant regarding the multilevel factors associated with POUDs' willingness to initiate medication treatment for opioid use disorder (MOUD) while in prison and their continued engagement in treatment after release. Furthermore, rural and urban populations have not been compared. The Geographic variation in Addiction Treatment Experiences (GATE) study seeks to identify multilevel factors (ie, individual, personal network, and structural factors) influencing prison-based extended-release injectable naltrexone (XR-NTX) and buprenorphine initiation and will examine predictors of postrelease MOUD use and adverse outcomes (ie, relapse, overdose, recidivism) among both rural and urban POUDs. METHODS AND ANALYSIS: This mixed methods study employs a social ecological framework. A prospective observational longitudinal cohort study is being conducted with 450 POUDs using survey and social network data collected in prison, immediately postrelease, 6 months postrelease and 12 months postrelease to identify multilevel rural-urban variation in key outcomes. In-depth qualitative interviews are being conducted with POUDs, prison-based treatment staff and social service clinicians. To maximise rigour and reproducibility, we employ a concurrent triangulation strategy, whereby qualitative and quantitative data contribute equally to the analysis and are used for cross-validation when examining scientific aims. ETHICS AND DISSEMINATION: The GATE study was reviewed and approved by the University of Kentucky's Institutional Review Board prior to implementation. Findings will be disseminated through presentations at scientific and professional association conferences, peer-reviewed journal publications and a summary aggregate report submitted to the Kentucky Department of Corrections.

Retention strategies among those on community supervision in the South: Lessons learned during the COVID-19 pandemic.

OBJECTIVES: Cohort studies must implement effective retention strategies to produce internally valid and generalizable results. Ensuring all study participants are retained, particularly those involved in the criminal legal system, ensures study findings and future interventions will be relevant to this group, who are often lost to follow-up: critical to achieving health equity. Our objective was to characterize retention strategies and describe overall retention among an 18-month longitudinal cohort study of persons on community supervision prior to and during the COVID-19 pandemic. METHODS: We implemented various retention strategy best-practices (e.g., multiple forms of locator information, training study staff on rapport building, study-branded items). During the COVID-19 pandemic, we developed and describe new retention strategies. We calculated overall retention and analyzed differences between those retained and lost to follow-up by demographic characteristics. RESULTS: Prior to the start of the COVID-19 pandemic, 227 participants enrolled across three sites (N = 46 North Carolina; N = 99 Kentucky; N = 82 Florida). Of these, 180 completed the final 18-month visit, 15 were lost to follow-up, and 32 were ineligible. This resulted in an overall retention of 92.3% (180/195). While most participant characteristics did not differ by retention status, a greater proportion of those experiencing unstable housing were lost to follow-up. CONCLUSION: Our findings highlight that when retention strategies are flexible, particularly during a pandemic, high retention is still achievable. In addition to retention best-practices (e.g., frequent requests for updated locator information) we suggest other studies consider retention strategies beyond the study participant (e.g., paying participant contacts) and incentivize on-time study visit completion (e.g., providing a bonus when completed the study visit on time).

Embedding Big Qual and Team Science into Qualitative Research: Lessons from a Large-scale, Cross-site Research Study.

Background: A major part of the HEALing Communities Study (HCS), launched in 2019 to address the growing opioid epidemic, is evaluating the study's intervention implementation process through an implementation science (IS) approach. One component of the IS approach involves teams with more than 20 researchers collaborating across four research sites to conduct in-depth qualitative interviews with over 300 participants at four time points. After completion of the first two rounds of data collection, we reflect upon our qualitative data collection and analysis approach. We aim to share our lessons learned about designing and applying qualitative methods within an implementation science framework. Methods: The HCS evaluation is based on the RE-AIM/PRISM framework and incorporates interviews at four timepoints. At each timepoint, the core qualitative team of the Intervention Work Group drafts an interview guide based on the framework and insights from previous round(s) of data collection. Researchers then conduct interviews with key informants and coalition members within their respective states. Data analysis involves drafting, iteratively refining, and finalizing a codebook in a cross-site and within-site consensus processes. Interview transcripts are then individually coded by researchers within their respective states. Results: Successes in the evaluation process includes having structured procedures for communication, data collection, and analysis, all of which are critical for ensuring consistent data collection and for achieving consensus during data analysis. Challenges include recognizing and accommodating the diversity of training and knowledge between researchers, and establishing reliable ways to securely store, manage, and share the large volumes of data. Conclusion: Qualitative methods using a team science approach have been limited in their application in large, multi-site randomized controlled trials of health interventions. Our experience provides practical guidance for future studies with large, experientially and disciplinarily diverse teams, and teams seeking to incorporate qualitative or mixed-methods components for their evaluations.

The rural identity scale: Development and validation.

PURPOSE: The purpose of this study was to conduct a psychometric evaluation of a new 35-item survey developed in the United States to measure rural identity. METHODS: Factor structure, reliability, convergent validity, and incremental validity of the Rural Identity Scale (RIS) were examined using two datasets. Study 1 examined RIS psychometric properties using survey data collected from substance use treatment counselors in a southeastern state (n = 145), while Study 2 used data collected from women incarcerated in rural jails (n = 400). FINDINGS: A one-factor structure containing 15 items was identified in the RIS, with acceptable internal reliability (α = .72-.83). In Study 1, participants from rural counties had significantly higher RIS scores than their urban counterparts. In both studies, convergent validity was evaluated and the RIS scores were significantly associated with other measures relevant to identity and rurality at the bivariate level. Incremental validity was supported in multivariable models as the RIS scores were significantly and uniquely associated with primary rural place variables in each sample. CONCLUSIONS: This study is an initial step toward a reliable, valid scale measuring rural identity. RIS may be especially beneficial to health research as a methodological tool that can contextualize health behaviors among rural populations and highlight potential interventions to promote health equity.

Capacity for sustainment of recently established syringe service programs in Appalachian Kentucky: The central role of staff champions.

INTRODUCTION: Ensuring adequate harm reduction infrastructure in rural areas is imperative, as drug-related epidemics expand into them. Here, we explore the capacity for sustainment of syringe service programs (SSP) in Appalachian Kentucky. METHODS: We interviewed all staff (n = 16) of all SSPs (n = 7) in two Kentucky health districts in 2018-2019 using semi-structured one-on-one qualitative interviews; local departments of health (DOH) operated the SSPs. Interview domains encompassed: (i) SSP establishment; (ii) day-to-day operations, participation and health impacts; (iii) perceived prospects for sustainment; and (iv) perceived influences on #i-#iii. We analysed verbatim transcripts using thematic analytic methods; Schell's 'capacity for sustainment' constructs were treated as sensitising concepts during the analysis. RESULTS: Most community members, law enforcement and DOH staff opposed SSPs before they opened, because of stigma and concerns about enabling and needlestick injuries; DOH staff also opposed SSPs because they believed they lacked the capacity to operate them. Training, technical assistance, visible evidence of the programs' public health impact and contact with SSP participants transformed DOH staff into program champions. As champions, SSP staff developed programs that had strong capacity for sustainment, as defined by Schell (e.g. visible public health impact, stable funding, political support). Staff reported that the SSPs had high prospects for sustainment. DISCUSSION AND CONCLUSION: As in SSPs that opened in cities decades ago, staff in emerging SSPs in these rural areas appear to have become crucial champions for these controversial programs, and may serve as vital resources for expanding harm reduction programming more broadly in these underserved areas.

Community coalition and key stakeholder perceptions of the community opioid epidemic before an intensive community-level intervention.

INTRODUCTION: Opioid overdoses are a major public health emergency in the United States. Despite effective treatments that can save lives, access to and utilization of such treatments are limited. Community context plays an important role in addressing treatment barriers and increasing access. The HEALing Communities Study (HCS) is a multisite community-level cluster-randomized trial that will study implementation and outcomes of a community coalition-based intervention (Communities that HEAL [CTH]) that implements evidence-based practices (EBPs) to reduce opioid overdose deaths in four states. To examine contextual factors critical to understanding implementation, we assessed the perspectives of community members about their communities, current substance use-related services, and other important issues that could impact intervention implementation. METHODS: Researchers conducted 382 semi-structured qualitative interviews in the HCS communities. Interviews were audio-recorded and transcribed; researchers subsequently analyzed data using directed content analysis based on the constructs of the RE-AIM/PRISM implementation science framework to identify key themes within the external community context. RESULTS: Despite the diversity in states and communities, four similar themes related to the external community context emerged across communities: These themes included the importance of understanding: 1) community risk perceptions, 2) levels of stigma, 3) the health services environment and the availability of substance use services, and 4) funding for substance use services. CONCLUSION: Understanding and addressing the external community context in which the CTH intervention and EBPs are implemented are crucial for successful health services-related and community engaged interventions. While implementing EBPs is a challenging undertaking, doing so will help us to understand if and how a community-based intervention can successfully reduce opioid overdose deaths and influence both community beliefs and the community treatment landscape.

Psychosocial resources and strains and health services use among adult illicit drug users from the Miami-Dade community.

This study builds on previous research concerning the associations of positive and negative dimensions of the self-concept and social relationships, respectively, with medical treatment seeking actions by modeling potentially positive and negative effects simultaneously. Using data from the first wave of a large community study including adult (20-93) drug users (n = 318), multivariate linear regression analysis presents the effects of psychosocial resources on drug users' medical treatment seeking in six progressive models. Social resources such as family support, family conflict, and friend support account for variation in medical treatment seeking actions in adult drug users. Dimensions of the self-concept, including perception of powerlessness and self-esteem also influence medical treatment seeking actions in adult drug users. Moderation tests reveal that the presence of family problems related to drug use is associated with a lower likelihood of taking treatment-seeking action in the context of greater family support. This study assessed how positive and negative dimensions of social relationships and the self-concept can jointly influence medical treatment seeking actions. Implications for medical treatment seeking action research are discussed.