Background Despite the recognition of substance use and sex work as public health issues, the intersection of these areas, especially within the rural US, is an area of special importance.Methods The Rural Opioid Initiative comprises of eight research cohorts spanning 10 states and 65 rural US counties. Between 1/2018-3/2020, individuals who reported past 30-day substance injection or opioid misuse were recruited. Analyses were restricted to people who use drugs (PWUD) who reported trading "vaginal or anal sex for drugs, money, housing, or other things you need" in the past 30 days. We analyzed cross-sectional associations between injection drug use and sexual behaviors associated with hepatitis C virus (HCV)/HIV infection transmission, access to harm reduction, and HCV status among PWUD and engaged in sex work in rural US areas.Results Of the 2045 participants, 9% (n=180) reported engagement with sex work, with just over half being women (58% [n=104]). In adjusted models, people who engaged in sex work, compared to PWUD who did not, had higher prevalence ratios of past 30-day receptive syringe sharing (adjusted prevalence ratio [aPR]=1.69, 95% Confidence Interval [95%CI]=1.44-1.98), practice of multiple injections per injection episode (aPR = 1.28, 95% CI = 1.15-1.43), practice of syringe mediated drug sharing (aPR=1.50, 95% CI=1.32-1.71), condomless sex (aPR=1.62, 95% CI=1.48-1.77) and condomless sex with someone who injects drugs (aPR=2.05, 95% CI=1.76-2.39). PWUD engaged in sex work were less likely to report easy condom access (aPR=0.88, 95% CI=0.80-0.96), while no significant differences were observed for most other harm reduction access measures.Conclusion PWUD engaged in sex work in the rural US had higher likelihood of injection drug use and sexual behaviors associated with HCV/HIV infection transmission, while having lower use of and access to condoms. This study emphasizes the importance of ensuring affordable access to condoms within the context of harm reduction services, especially given the limited access to health care and supportive services, particularly in rural communities.

Importance:Persons who inject drugs in the rural US have high rates of chronic hepatitis C virus (HCV) infection and poor access to HCV testing, direct-acting antiviral (DAA) treatment, and syringe services. Effective approaches to test and treat this population are needed to achieve national HCV elimination goals. Objective:To test whether a mobile telemedicine-based HCV treatment intervention increases HCV treatment initiation and viral clearance and decreases sharing of injection equipment among rural persons who inject drugs. Design, Setting, and Participants:This open-label, randomized, parallel-group clinical trial compared mobile telemedicine care (MTC) for HCV treatment with enhanced usual care (EUC), both integrated with van-based syringe services, from April 21, 2022, to September 13, 2024. Participants were persons aged 18 years or older with a history of drug injection and chronic HCV infection from 3 rural counties in New Hampshire and Vermont. Intervention:MTC consisted of DAA treatment for HCV via telemedicine along with on-demand syringe services, all on a mobile van. EUC consisted of treatment referral by van staff, with care navigation to a local or regional clinician. Main Outcomes and Measures:Primary outcomes were the proportion of participants who (1) initiated DAA treatment for HCV, (2) achieved viral clearance at the 12-week follow-up, and (3) reported no injection equipment sharing at any point after the expected treatment completion visit. Results:Of 503 prescreened individuals, 169 were eligible and 150 were randomized to MTC (n = 75) or EUC (n = 75). Participants had a mean (SD) age of 38.1 (8.1) years, 103 (68.7%) were male, 105 (70.0%) experienced homelessness, and 97 (64.7%) reported drug injection in the past 30 days. MTC participants were more likely than EUC participants to initiate DAA treatment (43 [57.3%] vs 20 [26.7%]; relative risk [RR], 2.15 [95% CI, 1.41-3.28]) and to achieve viral clearance (28 [37.3%] vs 14 [18.7%]; RR, 2.00 [95% CI, 1.15-3.49]). No effect was detected on abstention from sharing of syringes or other injection equipment at follow-up (RR, 0.95; 95% CI, 0.68-1.32). Conclusions and Relevance:In this randomized clinical trial, telemedicine for chronic HCV treatment integrated with syringe services on a mobile van was associated with improved access to HCV treatment initiation and cure for people with a history of drug injection in rural communities where HCV treatment services are scarce, suggesting optimal strategies in rural areas should include convenient, low-threshold telemedicine treatment. Trial Registration:ClinicalTrials.gov Identifier: NCT05466331.

Background Effective working relationships between drug courts and community providers are critical to improving access to medications for opioid use disorder (MOUD), but collaboration is often inadequate. We adapted and piloted a package of implementation strategies (Clinical Organizations and Legal Agency Alliance Building; COLAAB) designed to enhance collaboration between recovery courts and MOUD agencies. COLAAB activities included structured interagency meetings, agency tours, academic liaison, and development of local resource guides. Methods After the implementation of COLAAB in three courts, we conducted semi-structured interviews (n = 24) with drug court and MOUD staff to assess the impact of COLAAB on collaboration, communication, and referrals. Data were analyzed using a modified iterative categorization approach. Results Drug court and MOUD agency staff perceived COLAAB as facilitating interagency relationships and referrals to MOUD, increasing MOUD agencies’ understanding of drug courts, improving communication quality, strengthening understanding and trust in MOUD providers and drug courts, and reducing time to referrals to MOUD. COLAAB also increased the MOUD agency staff’s awareness of other community providers and helped build their potential referral networks. COLAAB may have also enhanced drug court staff’s willingness to speak with clients about MOUD and MOUD provider staff’s willingness to discuss clients’ criminal legal involvement. Discussion Our pilot study provides preliminary evidence that court-MOUD agency collaborations can be enhanced through active learning about one another’s practices and services, participation in regularly scheduled meetings or activities, and the identification and use of resources that support efficient interagency referral processes.

OBJECTIVES:Injection drug use is associated with increased risk of blood-borne infectious disease transmission. People with opioid use disorder (OUD) may be less likely to receive health care services, including human immunodeficiency virus (HIV screening), especially in rural areas. Addiction treatment settings may provide additional opportunities to screen for HIV in this population. METHODS:The rural opioid initiative (ROI) conducted a survey of people who use drugs (PWUD) on substance use, health care access, and utilization. From January 2018 to March 2020, PWUD were enrolled across 65 rural counties in 10 US states. Eligible participants either used opioids or reported injecting any drug "to get high" in the past 30 days. We evaluated the association between reporting past 30-day medication for OUD (MOUD) receipt and past-year HIV testing using relative risk regression. RESULTS:Participants (N = 2649, mean age = 36 y) were predominantly male (57%), reporting White race (85%) and non-Hispanic ethnicity (96%). Among participants receiving MOUD (methadone or buprenorphine) in the past year, 42% (179/431) were HIV-tested in the past year compared with 29% (636/2,218) among those not receiving MOUD. The prevalence of HIV testing in the past year was 1.42 times greater when comparing those who received MOUD in the past 30 days compared with those who did not (95% CI: 1.25-1.62). CONCLUSIONS:Recent HIV testing prevalence among this rural population of PWUD was low, given testing guidelines. Future research should explore ways to increase testing in rural drug treatment settings and whether there are differences by treatment setting type.

Background Medication for opioid use disorder (MOUD) treatment is increasingly available within jails, but little is known about patient experiences regarding treatment continuity post-release. Methods Between 2021 and 2022, we interviewed 38 recently-released people who received MOUD in Massachusetts county jails. We asked participants about their experiences with reentry and MOUD continuity post-release. Thematic analyses were framed by the social-ecological model. Results At the individual-interpersonal level, participants reported the importance of self-advocacy during incarceration to plan for post-release MOUD treatment continuity. They cited increasing awareness of diminished opioid tolerance as a risk factor for post-release overdose. Participants reported hopelessness about recovery when returning to communities saturated with substance use-related triggers. Participants recognized social support systems as crucial. At the organizational level, participants reported variation by facility in reentry assistance. Detail-oriented reentry teams, active outreach, follow through, clear communication, caring attitudes, and early initiation of reentry planning were key to filling gaps in treatment post-release. Community-level themes emphasized the importance of communication between jail staff and community providers to schedule appointments and provide transportation. At the policy level, advanced reentry planning is needed to avoid treatment lapses, including assistance with health insurance reactivation and bridge prescriptions during the transition from jail-based to community-based MOUD. Conclusion Participants recognized the high risk of MOUD treatment lapses during transitions from jail to community reentry, and valued MOUD continuity services initiated during incarceration and continued post-release. Variation in patient-reported quality of reentry planning services underscored the need for more standardized investment in re-entry and treatment continuity services.

This randomized clinical trial investigates whether a mobile telemedicine-based intervention for chronic hepatitis C virus infection among rural people who inject drugs increases treatment initiation and viral clearance and reduces sharing of injection equipment. QuestionIs a mobile telemedicine-based intervention for hepatitis C virus (HCV) infection associated with increased HCV treatment initiation and viral clearance and reduced injection equipment sharing among rural persons who inject drugs?FindingsIn this randomized clinical trial of 150 rural persons with chronic HCV infection and a history of drug injection, a mobile telemedicine-based HCV intervention, compared with enhanced usual care, was associated with significantly greater initiation of HCV treatment (57% vs 27%) and viral clearance (37% vs 19%) but not reduced equipment sharing.MeaningMobile telemedicine may be a reasonable approach to increase uptake of HCV treatment among rural persons who inject drugs. ImportancePersons who inject drugs in the rural US have high rates of chronic hepatitis C virus (HCV) infection and poor access to HCV testing, direct-acting antiviral (DAA) treatment, and syringe services. Effective approaches to test and treat this population are needed to achieve national HCV elimination goals.ObjectiveTo test whether a mobile telemedicine-based HCV treatment intervention increases HCV treatment initiation and viral clearance and decreases sharing of injection equipment among rural persons who inject drugs.Design, Setting, and ParticipantsThis open-label, randomized, parallel-group clinical trial compared mobile telemedicine care (MTC) for HCV treatment with enhanced usual care (EUC), both integrated with van-based syringe services, from April 21, 2022, to September 13, 2024. Participants were persons aged 18 years or older with a history of drug injection and chronic HCV infection from 3 rural counties in New Hampshire and Vermont.InterventionMTC consisted of DAA treatment for HCV via telemedicine along with on-demand syringe services, all on a mobile van. EUC consisted of treatment referral by van staff, with care navigation to a local or regional clinician.Main Outcomes and MeasuresPrimary outcomes were the proportion of participants who (1) initiated DAA treatment for HCV, (2) achieved viral clearance at the 12-week follow-up, and (3) reported no injection equipment sharing at any point after the expected treatment completion visit.ResultsOf 503 prescreened individuals, 169 were eligible and 150 were randomized to MTC (n = 75) or EUC (n = 75). Participants had a mean (SD) age of 38.1 (8.1) years, 103 (68.7%) were male, 105 (70.0%) experienced homelessness, and 97 (64.7%) reported drug injection in the past 30 days. MTC participants were more likely than EUC participants to initiate DAA treatment (43 [57.3%] vs 20 [26.7%]; relative risk [RR], 2.15 [95% CI, 1.41-3.28]) and to achieve viral clearance (28 [37.3%] vs 14 [18.7%]; RR, 2.00 [95% CI, 1.15-3.49]). No effect was detected on abstention from sharing of syringes or other injection equipment at follow-up (RR, 0.95; 95% CI, 0.68-1.32).Conclusions and RelevanceIn this randomized clinical trial, telemedicine for chronic HCV treatment integrated with syringe services on a mobile van was associated with improved access to HCV treatment initiation and cure for people with a history of drug injection in rural communities where HCV treatment services are scarce, suggesting optimal strategies in rural areas should include convenient, low-threshold telemedicine treatment.Trial RegistrationClinicalTrials.gov Identifier: NCT05466331

Background Geospatial analyses of opioid involved overdose deaths can inform community harm reduction efforts. Differences in overdose deaths by time of day are important, as overdose events may be more likely to go unrecognized at night when fewer community resources are available. Methods Using Massachusetts Registry of Vital Records and Statistics data (2019-2023), we utilized regression analyses to evaluate demographics, residence, and toxicology differences associated with the recorded time of opioid involved overdose deaths, stratified by day (6AM-5:59PM) and night (6PM-5:59AM). Kernel density estimates and hotspot clusters assessed location differences and proximity to opioid treatment resources. Results Of 9,539 opioid-involved overdose deaths, 6,255 (65.6%) occurred during daytime hours and 3,284 (34.4%) at night. Non-Hispanic Black individuals (OR 1.14; 95%CI 1.01-1.28) and married individuals (OR 1.19; 95%CI 1.04-1.35) were more likely to have a recorded time of overdose death at night. Alcohol was more likely to be present among people who experienced an opioid involved overdose death at night (OR 1.23; 95%CI 1.11-1.37). Decedents were more likely to have the hospital as their location of death at night (OR 2.24, 95%CI 2.01-2.48). Proximity to treatment and harm reduction resources did not differ by time of day (OR 1.02, 95%CI 0.88-1.13). Conclusions While time of day was not associated with differences in proximity to opioid treatment resources, several demographic and toxicology characteristics were associated with opioid-involved overdose deaths at night. Harm reduction strategies must evolve beyond “where” services are located to address when and how harm reduction is delivered.

OBJECTIVES:More than 3.7 million individuals are currently under community correctional supervision (eg, probation, parole) in the United States, and approximately 46% of them use illicit substances. Although high rates of substance use and the need for high-quality treatment for this population have been acknowledged, additional research is needed to characterize treatment needs among this population, especially those residing in rural or underserved communities. METHODS:Data were drawn from the Rural Opioid Initiative, a study focused on substance use in rural communities across 10 states in the United States. Our analyses examined past 6-month substance use disorder (SUD) treatment receipt among 978 participants under community supervision in the past 6 months. RESULTS:More than 55 percent had engaged in some type of treatment for substance use in the past 6 months; among those, nearly half (46%) had enrolled in inpatient or residential treatment. The odds of receiving treatment were greater among women than men (odds ratio [OR] 1.49, 95% confidence interval [CI] [1.15-1.94]), those with health insurance coverage (OR 3.10, 95% CI: [2.24-4.31]) and those with access to transportation (OR 1.54, 95% CI: [1.08-2.20]). Treatment receipt was lower among participants who used methamphetamine/amphetamine as their primary drug of choice compared with other substances. CONCLUSIONS:Initiatives to increase SUD treatment engagement among rural people who use drugs under community correctional supervision should address gaps in insurance coverage, transportation access, and treatment modalities that target stimulant use disorders. Gender-specific needs should also be considered when creating substance use interventions for this population.

To understand circumstances surrounding transitions between initial drug use, non-prescribed opioid use, and injection drug use (IDU) among people who use non-prescribed opioids in the rural U.S. We interviewed adults who use non-prescribed opioids in 10 states. We coded transcript data regarding age, drug, modality, circumstances for each “first use” event and transitions to illicit opioid use/IDU. Transition-related themes were categorized using the Social Ecological Model (SEM) through iterative qualitative memoing. We calculated frequencies and measures of central tendency. Participants (n = 304, mean age [MA] = 36 years, 56

PURPOSE:Naloxone administration by laypersons is proven to reduce opioid overdose mortality. Despite legislative advances, people who use drugs (PWUD) in rural settings face unique barriers to naloxone possession. This study aims to examine naloxone possession and identify its correlates among a large, geographically diverse sample of people who either use opioids or inject drugs in rural areas. METHODS:We performed a cross-sectional analysis using Rural Opioid Initiative (ROI) data from rural counties of ten US states. Study sites administered a harmonized survey instrument of 3048 PWUD recruited from January 2018 to March 2020. The primary outcome was current naloxone possession. Potential correlates were identified through review of the literature. Data were collected on demographics, drug use behaviors, overdose experiences, access to care, and addiction treatment. Data were analyzed using descriptive statistics, bivariate associations, and multivariable prevalence ratios. FINDINGS:Among 3008 participants included in the analysis, 36.4% reported possessing naloxone. Naloxone possession was associated with younger age, illegal income sources, past 30-day opioid use, personal history of overdose, witnessing an overdose, knowing someone who died from an overdose, current injection drug use, and receiving syringes from syringe service programs (SSPs). No association was found between access to care and naloxone possession. CONCLUSIONS:Only 36% of high-risk rural PWUD possessed naloxone. Factors such as injection drug use, overdose history, and SSP access increased the likelihood of naloxone possession. These findings highlight the need for targeted naloxone distribution strategies in rural areas, considering the unique barriers faced by rural PWUD.

The high prevalence of opioid use among jailed adults offers an unmatched opportunity to identify and treat those with opioid use disorder (OUD), a population that is at a substantial risk for post-release overdose. From a public health perspective, jails are critical touchpoints, as these facilities typically admit more than 7 million adults per year. One clinical consideration is whether pre-trial detainees with OUD would benefit from early induction onto extended-release buprenorphine (XRB). In this 3-year randomized controlled trial, we will identify and recruit 200 incarcerated adults with OUD who are receiving sublingual buprenorphine (SLB) or tolerate a SLB test dose and randomize them to receive extended release buprenorphine (XRB) (n = 100) or to remain on SLB (n = 100) while in custody. Study participation will continue through their pre-trial time in jail (up to 6 months) or until they are sentenced or released. Community treatment will then be tracked for 90 days following release. In addition to collecting data on XRB uptake in jail, we will assess (1) the percentage of XRB and SLB study participants leaving jail with a clinically active dose of buprenorphine in their system, (2) 90- day post-release MOUD continuation, (3) levels of buprenorphine diversion while in custody, and (4) recidivism and death (90 days). “Clinically active” is defined as receiving XRB within the past 28 days or SLB in the past 24 h. Findings from this study will demonstrate the feasibility and outcomes of inducting pre-trial adults with OUD onto XRB, as well as offer practical clinical and policy guidelines for best practices for treating this high risk and understudied population.

Importance:Medications for opioid use disorder (MOUD) are effective, but hospitalized people with opioid use disorder (OUD) seldom receive MOUD while in the hospital or link with treatment after. Objective:To test whether an addiction-focused consultation service, the Substance Use Treatment and Recovery Team (START), increases MOUD initiation during hospitalization and linkage to follow-up care after discharge. Design, Setting, and Participants:This 1:1 randomized clinical trial grouped participants into the START intervention or usual care. The study was conducted between November 2021 and September 2023 at 3 hospitals in the following cities: Los Angeles, California; Albuquerque, New Mexico; and Springfield, Massachusetts. The last follow-up was in December 2023. Eligible individuals were 18 years and older and met criteria for OUD. Intervention:START consists of an addiction medicine specialist and a care manager delivering a motivational and addiction-focused discharge planning intervention and follow-up calls. Main Outcomes and Measures:Primary outcomes were the proportions of patients (1) initiating MOUD (naltrexone, buprenorphine, or methadone) during hospitalization (per electronic medical record data) and (2) successfully linking to OUD treatment within 30 days after discharge (per patient self-report). Results:A total of 325 were consented and randomized to START (n = 164) or usual care (n = 161). Median (IQR) age was 41.0 (32.0-50.0) years. A total of 213 participants (65.5%) were male at birth, 28 (8.6%) were American Indian or Alaska Native, 21 (6.5%) were Black, 156 (48.0%) were Hispanic, and 125 (38.5%) were White. More than half, 175 (53.8%), were unhoused in the past year, and 163 (50.2%) were unemployed. START participants were more likely than usual care participants to initiate MOUD during hospitalization (94/164 [57.3%] vs 43/161 [26.7%], respectively; adjusted risk ratio [aRR], 2.10 [97.5% CI, 1.51-2.91]) and to link to OUD care after discharge (90/125 [72.0%] vs 50/104 [48.1%], respectively; aRR, 1.49 [97.5% CI, 1.15-1.93]). Conclusions and Relevance:By addressing gaps in inpatient care, the hospital-based addiction-focused consultation service presented in this randomized clinical trial improved receipt of evidence-based treatment for people with OUD in the hospital and linkage to treatment after discharge. Trial registration:ClinicalTrials.gov Identifier: NCT05086796.

BACKGROUND:Individuals with opioid use disorder living in rural areas face barriers to accessing medications for treatment (MOUD), including finding prescribing clinicians and difficulties with transportation. This study sought to describe self-reported barriers to MOUD access in rural areas and associations between desired MOUD type and barriers encountered or perceived. METHODS:We performed a cross-sectional study of Rural Opioid Initiative participants who ever used opioids and sought MOUD treatment, who were surveyed from 2018 to 2020 about access to MOUD. Multivariable logistic regressions explored the association between MOUD type and barriers while controlling for age, gender, race, and study site. RESULTS:Of 2906 participants who used opioids and sought MOUD, 826 (28.4 %) were unable to access MOUD. In logistic regression models, lack of transportation was a more common barrier for those seeking methadone versus sublingual buprenorphine (adjusted odds radio [aOR] 1.87, 95 % confidence interval (CI) 1.24-2.81). A long wait list was more common for those seeking injectable naltrexone than sublingual buprenorphine (aOR 1.68, 95 % CI 1.05-2.69). Lack of doctors or programs and affordability were more common for those seeking injectable versus sublingual buprenorphine (aOR 7.84, 95 % CI 4.87-12.63 and aOR 1.89, 95 % CI 1.26-2.83, respectively). CONCLUSIONS:Access barriers vary by MOUD type for rural individuals with OUD. Compared to sublingual buprenorphine, methadone access was hindered more by transportation difficulties, while injectable long-acting buprenorphine was hindered more by affordability and finding a doctor or program. These barriers highlight the need to de-regulate and expand locations for methadone access and prescribing, and to improve affordability and prescriber uptake of newer MOUDs, such as injectable buprenorphine.

Hepatitis C virus (HCV) remains a public health concern in the United States, particularly in rural communities where the opioid epidemic accelerates transmission among people who use drugs (PWUD). Despite this growing burden, the genetic features and transmission dynamics of HCV in these settings are poorly understood. We analyze 692 HCV antibody-positive specimens collected from rural communities in ten U.S. states using amplicon-based deep sequencing and the Global Hepatitis Outbreak and Surveillance Technology (GHOST) platform to reconstruct transmission networks. Among sequenced individuals, 29.5% are linked within clusters. Cluster structure varies by region from sparse networks in Ohio to dense clusters in New England and phylogenetic analyses show that some networks persist for over a decade, indicating sustained transmission. Nearly half of all clusters involve individuals connected through social recruitment, suggesting peer-referral strategies effectively identify transmission chains. Penalized regression retains only a few individual factors including younger age, peer or partner recruitment, illegal income, methamphetamine use, each with modest effects. These findings suggest that clustering is shaped primarily by social and structural contexts rather than individual characteristics and underscore the importance of integrating genomic surveillance with social-network insights to detect emerging HCV clusters and guide targeted interventions in underserved rural communities.

BACKGROUND:Stigma is a barrier to help-seeking in rural-dwelling people who use drugs. However, little is known about whether stigma is experienced in patterned ways, and what characteristics are associated with these patterns. METHODS:Data came from a cohort of people who use drugs at eight geographically diverse Rural Opioid Initiative sites (n = 3048). We used three-step latent class analysis to classify participants by patterns of felt substance use stigma, then used multinomial logistic regression to explore demographic, health, and substance-related covariates associated with class membership. RESULTS:Based on fit statistics and interpretability, we selected a five-class solution. Four classes were patterned by severity: Low Stigma (23.7%), Medium-Low Stigma (12.5%), Medium-High Stigma (34.9%), and High Stigma (24.7%). The fifth class ("High Fearers/Low Perceivers," 4.3%) reported high shame and fear of rejection but low perceived stigma from others. Members of higher stigma classes were more likely to have criminal-legal system involvement, inject drugs, and avoid healthcare and drug treatment. In contrast analyses, "High Fearers/Low Perceivers" were more likely to be younger and women, and less likely to have criminal-legal system involvement, experience homelessness, or inject drugs compared with other classes. CONCLUSION:Rural people who use drugs experience substance use stigma in distinct severity-based patterns, with four classes ranging from low to high stigma across all dimensions. A fifth, smaller class reports high internalized stigma despite low perceived stigma from others, potentially suggesting non-disclosure of substance use. These distinct profiles and their correlates offer targets for tailored stigma interventions.

Opioid-related overdose is the leading cause of mortality among individuals recently released from incarceration in the U.S. Naloxone is an FDA-approved opioid antagonist medication designed to rapidly reverse opioid overdose. Despite evidence of its acceptability and effectiveness at reducing the risk of opioid overdose death after release from incarceration, only an estimated 25

Background: The United States’ (US) opioid overdose epidemic has evolved into a combined stimulant/opioid epidemic, a pattern driven in part by mitigating opioid overdose risk, variable substance availability, and personal preferences. This study aimed to investigate the association between self-reported substance preference (heroin or methamphetamine) and behavioral/health outcomes among individuals who used both heroin and methamphetamine in the rural US. Methods: The Rural Opioid Initiative is a consortium of 8 research cohorts from 10 states and 65 rural counties that recruited individuals reporting past 30-day injection of any substance or opioid substance use by any route from 1/2018 to 3/2020. Analyses were restricted to participants ⩾18 years, who self-reported either heroin or methamphetamine as their preferred substance and past 30-day use of both heroin and methamphetamine. We examined cross-sectional associations between preferred substance (heroin versus methamphetamine) and behavioral and health outcomes using random effects meta-analysis with adjusted regression models. Results: Among 1239 participants, 61% (n = 752) reported heroin as their preferred substance. Adjusting for age, sex, and race/ethnicity, methamphetamine preference was associated with lower prevalence ratios for current naloxone possession (adjusted prevalence ratio [aPR] = 0.68; 95% Confidence Interval [95% CI] = 0.59-0.78; P-value ⩽ .001), of ever being told they had the hepatitis C virus (HCV; aPR = 0.72; 95% CI: 0.61-0.85; P-value ⩽ .001) and a personal history of overdose (aPR = 0.81; 95% CI = 0.73-0.90; P-value ⩽ .001). Conclusion: In our study analyzing associations between preferred substance and various behavioral and health outcomes amongst people who use both heroin and methamphetamine, a majority of participants preferred heroin. Methamphetamine preference was associated with lower prevalence of naloxone possession, ever being told they had HCV, and prior history of an overdose. This study underscores the need for targeted harm reduction services for people who prefer methamphetamine in rural areas.

Although research on Medications for Opioid Use Disorder (MOUD) in carceral settings has grown, it has largely focused on the implementation of medication delivery or on substance use outcomes in the community. However, the introduction of new programs or the expansion of treatment services in criminal legal settings can have both direct and indirect consequences on other treatment programs and correctional operations within jails. Mental health and substance use disorders frequently co-occur, and their psychosocial treatment components often overlap. We examined how the implementation of MOUD in all jails across Massachusetts impacted the mental health services operating within the jails and the requirements for substance use counseling alongside MOUD. We conducted semi-structured interviews (n = 47) and focus groups (n = 42) with staff from 13 county jails as part of an implementation of MOUD in jails study. Using deductive and inductive coding, all transcripts were double-coded and analyzed using a modified framework method. We identified five key themes about the perceived impact of MOUD on mental health and substance use counseling services. First, MOUD implementation was perceived to reduce acute mental health crises, such as risk for suicide, and the demand on mental health services at intake to the facility. Second, staff perceptions about the effectiveness of MOUD as a stand-alone treatment influenced their decisions about the need for and interpretation of substance use counseling requirements. Third, the required components of substance use counseling created a need for additional staff, which exacerbated the existing shortage of mental health staff. Fourth, infrastructure limitations and privacy needs made the delivery of substance use counseling logistically challenging in jail settings. Finally, MOUD implementation increased interdisciplinary collaboration in some jails by requiring medical, mental health, and substance use providers to work together to resolve the needs of incarcerated individuals. As jails aim to meet regulatory requirements for MOUD, they will need to manage potential staffing shortages, infrastructure constraints, and shifts in the mental health and substance use counseling services. Guidelines for implementing MOUD in carceral settings should also consider the unintended consequences of MOUD on other behavioral health services.

Importance:Many of the approximately 2 million people being held in US correctional facilities are experiencing an opioid use disorder (OUD). Providing medications for OUD (MOUD) to this population is, therefore, essential to curb the opioid crisis. Objective:To examine the types of MOUD jails are making available, factors associated with availability, and additional supports needed for jails to address implementation challenges. Design, Setting, and Participants:This survey study used a cross-sectional survey of jails conducted between February 2 and July 1, 2023, to explore how they administer MOUD. Publicly available county-level data were connected with the survey responses to assess how variables in the surrounding community were associated with MOUD availability. The survey was administered to jails via mail, telephone, and online survey link. Participants included jails with MOUD available that completed the survey. Exposures:Urbanization, average daily population, availability of a health care professional to administer MOUD, whether the state expanded Medicaid, average drive time to MOUD in the county, county overdose rate, and county social vulnerability were assessed. Main Outcomes and Measures:The primary outcome was the type of MOUD available in the jail, including buprenorphine, methadone, or naltrexone, or all 3 medications. Binary logistic regressions were conducted to identify the characteristics of jails and county-level factors associated with offering the medications. Results:A total of 462 jails were invited to complete the survey based on responses to a previous nationally representative survey of jails, in which they indicated that MOUD was available to individuals in their facility. A total of 265 US jails with MOUD available were included in the analysis, representative of 1243 jails nationwide with MOUD available after weighting (812 jails [65.3%] provided buprenorphine, 646 jails [52.0%] provided naltrexone, 560 jails [45.0%] provided methadone, and 343 jails [27.6%] provided all 3 medications). Availability was associated with urbanicity, location in a Medicaid expansion state, county opioid overdose rate, and county social vulnerability. Common challenges included jail policies and procedures and the logistical accessibility of the medication. Conclusions and Relevance:The findings of this survey study of US jails demonstrate that jails with MOUD available still experience challenges with making all 3 types of medication available to anyone held within their facility. Policy, regulatory, financing, staffing, and educational solutions are needed to ensure that all detainees with OUD have access to treatment while incarcerated.

BACKGROUND:Benzodiazepines and opioids are among the most frequently misused psychoactive substances, but their patterns of co-use (polysubstance use) in rural areas are unclear. As resources to address substance use are disproportionally scarce in rural areas, a better understanding of this polysubstance use is critical to allocate and direct interventions. METHODS:The Rural Opioid Initiative comprises 8 research cohorts spanning 10 states and 65 rural counties. Participants were recruited from January 2018 to March 2020 and eligibility included past 30-day opioid use by any route or past 30-day injection of any substance. Analyses were restricted to participants reporting past 30-day opioid use and either benzodiazepine or stimulant use. We described bivariate cross-sectional associations between benzodiazepine+opioid use, compared with stimulant+opioid use, and substance use behaviors, health outcomes, injection drug use, addiction treatment, and criminal legal system involvement. RESULTS:Of the 1107 ROI participants that met inclusion criteria, 10% (n = 107) reported benzodiazepine+opioid use, and 90% (n = 1000) reported stimulant+opioid use. The benzodiazepine+opioid group, compared with the stimulant+opioid group, had a higher use of opioid pain medication (73% vs 55%), gabapentin (43% vs 23%), and clonidine (12% vs 4%) to get high and used these substances more frequently; they also reported more frequent heavy episodic drinking (6.1 days per 30 days, SD = 9.4 vs 4.1 days, SD 7.5). The benzodiazepine+opioid group reported a lower prevalence in the past 6 months of law enforcement stop-and-search incidents (29% vs 48%), arrests (11% vs 28%), probation (22% vs 34%), jail/prison (18% vs 41%), and fewer days in jail/prison (4.7, SD = 19.1 days vs 15.9, SD = 35.7 days). CONCLUSION:We found that benzodiazepines+opioids use was associated with more heavy episodic drinking and gabapentin use, and lower prevalence of criminal legal system involvement. These data suggest that individuals reporting benzodiazepines+opioids use have distinct behavioral patterns and outcomes that require targeted interventions for rural populations.