Research has demonstrated that hepatitis C (HCV) genotype distribution varies geographically and demographically. This exploratory study examines HCV viremia, viral concentration, and genotype distribution among anti-HCV positive, rural Appalachian nonmedical prescription drug users. The study population was randomly selected from a pool of 200 anti-HCV positive participants in a longitudinal study. Those randomly chosen were representative of the overall pool in terms of demographics, drug use, and other risk behaviors. Participants were tested serologically for HCV RNA, viral concentration, and genotype, and interview-administered questionnaires examined behavioral and demographic characteristics. Of the 81 participants, 69% tested RNA positive, 59% of which had viral loads exceeding 800,000 IU/mL. Approximately 66% of the RNA positive sample had genotype 1a; types 2b (16%) and 3a (13%) were less common. RNA positive participants were not significantly different than RNA negative participants demographically or behaviorally. Likewise, with the exception of education, genotype 1 participants were not significantly different than those with genotype 2 or 3. The prevalence of active HCV infection highlights a need for prevention and treatment in this population. However, the predominance of genotype 1 may present challenges due to its association with decreased responsiveness to drug treatment, although the novel class of direct-acting antivirals such as telaprevir and boceprevir offer new hope in this regard. The prevalence of genotype 1 may also foreshadow heightened burden of hepatocellular carcinoma and elevated healthcare expenditures. More research is needed to characterize HCV infection and genotype in this population.
genotype; hepatitis C virus; injection drug use; rural
This study explores the correlates of probationers’ participation in 12-step programs, voluntary treatment, and mandated treatment, with respect to the geographic location of where the services are being provided as the primary covariate of interest. Data were derived from face-to-face interviews with rural and urban probationers (n=1464). Results of the three logistic regression models suggested that even when all the covariates are taken into account, urban probationers were significantly more likely to have been involved in 12-step programs, voluntary treatment, and mandated treatment over their lifespan. Despite high levels of self-reported substance use among all participants, treatment services were underutilized by rural probationers. These data suggest that individuals residing in rural communities may face additional barriers to receiving treatment services and that criminal involvement is associated with participation in peer recovery support groups and treatment. Future studies can investigate criminal involvement as an avenue to enhance recovery as well as how to overcome treatment barriers in rural areas.
Rural; Probationers; Peer Recovery Support Groups; Treatment; Mandated Treatment
We determined the factors associated with hepatitis C (HCV) infection among rural Appalachian drug users.
This study included 394 injection drug users (IDUs) participating in a study of social networks and infectious disease risk in Appalachian Kentucky. Trained staff conducted HCV, HIV, and herpes simplex-2 virus (HSV-2) testing, and an interviewer-administered questionnaire measured self-reported risk behaviors and sociometric network characteristics.
The prevalence of HCV infection was 54.6% among rural IDUs. Lifetime factors independently associated with HCV infection included HSV-2, injecting for 5 or more years, posttraumatic stress disorder, injection of cocaine, and injection of prescription opioids. Recent (past-6-month) correlates of HCV infection included sharing of syringes (adjusted odds ratio = 2.24; 95% confidence interval = 1.32, 3.82) and greater levels of eigenvector centrality in the drug network.
One factor emerged that was potentially unique to rural IDUs: the association between injection of prescription opioids and HCV infection. Therefore, preventing transition to injection, especially among prescription opioid users, may curb transmission, as will increased access to opioid maintenance treatment, novel treatments for cocaine dependence, and syringe exchange.
HIV is a health issue for women offenders who are at particularly high risk. Women's prisons can be opportune settings for HIV prevention interventions. How women perceive partner relationships could be central to targeting HIV interventions. Consequently, this study examines changes in women offenders' risky relationships. Baseline and follow-up data are presented from 344 women offenders. Intent-to-treat analysis is used as well as analysis of covariance to control for baseline values. Findings indicate that women released to the community from prison who were randomized into the prevention intervention were significantly more likely to report changes in five of seven risky relationship thinking myths. Findings suggest that a relationship theory–based prevention intervention for reducing HIV risk could be promising for women offenders reentering the community after prison. Additional research is suggested.
Baseline and follow-up qualitative interviews with methamphetamine (MA) users in rural Kentucky and Arkansas examined their involvement in drug-related violence. Twelve baseline participants reported MA-related violence, while 20 reported violence linked to other substances. In follow-up interviews conducted 12 to 24 months later, four participants reported MA-related violence and 3 reported violence associated with other substances. Violence was rarely connected to MA’s psychoactive effects. Rather, causes of violence included disputes over MA or its use, as well as paranoia, ill-tempers, and hallucinations during MA “binges.” Implications of the findings for informing additional research and interventions are discussed.
Methamphetamine; violence; rural drug use; southern United States
The purpose of this study is to use a modified version of Andersen’s (1968, 1995) Behavioral Model of Health Services Use to identify the correlates of the number of substance abuse treatment episodes received by rural drug users. Data were collected from face-to-face interviews with 711 drug users in rural areas of Ohio, Arkansas, and Kentucky. Descriptive analyses examine rural drug users’ substance use histories and retrospective substance abuse treatment service utilization patterns. A negative binomial regression model indicated that selected predisposing, historical health, and enabling factors were significantly associated with the utilization of substance abuse treatment among rural drug users. Despite high levels of recent and lifetime self-reported substance use among these rural drug users, treatment services were underutilized. Future studies are needed to examine the impact of the health care system and characteristics of the external environment associated with rural substance abuse treatment in order to increase utilization among drug users.
Substance use and physical violence often co-occur, but little has been published on the correlates associated with receipt of partner versus non-partner physical violence for rural users of methamphetamine and/or cocaine. In this study, participants’ substance use, depression and past-year physical victimization were assessed. In separate logistic regression models, received partner violence in females was associated with age; alcohol, cocaine and methamphetamine abuse/dependence; and number of drugs used in the past six months. In males, received non-partner violence was associated with age, cocaine abuse/dependence and being Caucasian. Findings suggest a relationship between stimulant use and received violence among rural substance users and a need for victimization screenings in settings where such individuals seek health care.
Violence; substance use; cocaine; methamphetamine; alcohol; rural
Fatal overdoses involving prescription opioids have increased significantly in recent years in the United States – especially in rural areas. However, there are scant data about non-fatal overdose among rural drug users. The purpose of this study is to examine the prevalence and correlates of non-fatal overdose and witnessed overdose among rural Appalachian drug users.
Rural drug users were participants in a longitudinal study of social networks and HIV transmission. An interviewer-administered questionnaire elicited information in the following domains: sociodemographic characteristics, drug use (including lifetime overdose and witnessed overdose), psychiatric disorders, HIV risk behaviors and social networks (support, drug and sex networks). Negative binomial regression was used to model the number of lifetime overdoses and witnessed overdoses.
Of the 400 participants, 28% had ever experienced a non-fatal overdose, while 58.2% had ever witnessed an overdose (fatal or non-fatal). Factors independently associated with a greater number of overdoses included having ever been in drug treatment, past 30-day injection of prescription opioids, meeting the criteria for post-traumatic stress disorder and/or antisocial personality disorder and having more members in one's support network.
Rural drug users with history of overdose were more likely to have injected with prescription opioids – which is different from urban heroin users. However, the remaining correlates of non-fatal overdose among this cohort of rural drug users were similar to those of urban heroin users, which suggests current overdose prevention strategies employed in urban settings may be effective in preventing fatal overdose in this population.
non-fatal overdose; witnessed overdose; rural; prescription drug use; social networks
The purpose of this study was to examine injection drug use (IDU) among a cohort of felony probationers from rural Appalachian Kentucky.
An interviewer administered questionnaire given to 800 rural felony probationers ascertained data regarding demographics, drug use, criminal behavior, psychological distress, and HIV risk behaviors.
The sample was primarily white (95.1%), male (66.5%) and the median age was 32.3 years (interquartile range [IQR]: 25.2, 40.5). There were no cases of HIV in the sample. Of the 800 rural probationers, 179 (22.4%) reported lifetime IDU. Receptive and distributive syringe sharing (RSS and DSS) were reported by 34.5% and 97.1% of the IDUs, respectively. Independent correlates of risky injection behaviors included cocaine injection (AOR: 14.9, 95% CI: 8.0, 27.7) and prescription opioid injection (AOR: 14.7, 95% CI: 7.7, 28.1).
Although HIV was not prevalent, data suggest that the rural felony probationers in this sample were engaging in risky injection practices that could facilitate transmission of HIV. This is especially problematic since those involved in the criminal justice system may be more likely to be exposed to HIV. Therefore, prevention aimed at reducing HIV risk behaviors among rural, criminally-involved individuals is warranted.
Studies have shown that relationships can influence health risk behaviors such as drug use among women offenders. This study takes an exploratory look at the positive and negative influences of parents, peers, and partners for women prisoners to better understand their health risk behavior for HIV, including risky sex and drug use.
The current study includes secondary analysis of cross-sectional data from women offenders enrolled in three protocols of the National Institute on Drug Abuse (NIDA) funded Criminal Justice Drug Abuse Treatment Studies (CJDATS) cooperative agreement. Baseline interviews were completed with incarcerated women preparing for community re-entry and focused on behaviors during the 6 months prior to incarceration. Relationship influences during the 6 months before prison were categorized as “positive” or “negative” for the women offenders.
Multivariate regression models suggested that positive parental influence was significantly associated with reduced HIV risk and reduced drug use in the 6 months prior to incarceration. However, negative peer influence increased drug use including both risky needle behavior and any drug use in the 6 months prior to incarceration.
These data suggest that, while relationships are generally important to women, particular types of relationship influences may be related to risky behavior. Implications for targeting re-entry interventions for women offenders are discussed.
female; cocaine; incarceration; social support; criminal justice; motherhood
This study examined sociodemographic and drug-related predictors of depressive symptoms among a rural, multistate sample of not-in-treatment stimulant drug users (n = 710). Participants were recruited using respondent-driven sampling in Ohio, Arkansas, and Kentucky. The Patient Health Questionnaire (PHQ-9) was used to measure symptoms of depression. Moderate to severe depressive symptomatology was reported by 43.0% of the sample. Cumulative logistic regression analysis showed that daily and nondaily crack use as well as the daily use of cocaine HCl increased the odds of depressive symptoms. Methamphetamine use had no significant association with depression. The daily use of marijuana, the illicit use of tranquilizers, light/moderate cigarette smoking, and injection drug use also increased the risk of depressive symptoms. Living in Kentucky or Ohio (compared to Arkansas), having unstable living arrangements, and being White, female, and older were related to higher odds of depressive symptoms. These results suggest that a host of drug and nondrug factors need to be considered when addressing depressive symptoms in stimulant users.
depression; cocaine HCl; crack cocaine; methamphetamine; PHQ-9; rural; substance abuse
Prenatal substance use contributes birth defects, prematurity, and infant mortality in the U.S. As such, it is critical that medical professionals receive appropriate education and actively engage in screening patients; however, a physician’s gender may influence differences in screening practices. The purpose of this study is to examine male and female Ob/Gyn physician’s beliefs and practices related to perinatal substance use screening and to identify the significant correlates of using a standardized screening tool.
Data were collected from 131 Ob/Gyn physician’s in Kentucky using a web-based survey. Chi-square and t-tests were used to distinguish differences between male (n=84) and female (n=47) providers. Binary logistic regression was also used to assess the independent correlates of the use of a standardized screening tool.
Female Ob/Gyn physician’s were more likely to “believe in” the effectiveness of screening, to discuss sensitive topics with patients, and were motivated to screen as a part of comprehensive care or because screening could produce a behavioral change. Female providers were also more likely to use a screening tool in a multivariate model; however, being female was no longer significant after additional variables were included in the model. Specifically, younger Ob/Gyn physicians who frequently discussed mental health issues with female patients of childbearing age, and were motivated to screen because it is part of comprehensive care were significantly more likely to use a standardized substance use screening tool.
In summary, less than half of Ob/Gyn physicians were using a standardized screening tool and the majority of physicians were using the CAGE. This suggests additional training is needed to increase their use of substance use screening tools, especially those geared towards pregnant women.
Prenatal Substance Use; Standardized Screening Tools; Physician Gender Differences
Past research suggests gender differences exist in types of substances used and age of first use. Recent studies exploring contextual differences in substance use between rural Appalachian and urban environments show different patterns of substance use in rural environments. This study explores whether previously established differences in gender and age of first use exist within a rural Appalachian environment.
Data are from a community-based study of drug users in rural Appalachia (N=400). Self-reported substance use was recorded via an interviewer-administered questionnaire with questions from the Addiction Severity Index.
On average, participants were 32 years old (X̄ = 32.33; median = 31.00; IQR = 12) and the majority were male (59%). Examining past 30 day use, more males reported alcohol (AOR: 2.11, 95% CI: 1.36, 3.23; p = .001) and any illegal drug use (AOR: 1.85, 95% CI: 1.16, 2.95; p=.010) which included heroin, cocaine, crack cocaine, methamphetamine, marijuana, and hallucinogens, after controlling for socio-demographic characteristics. ANCOVA analyses showed that males reported use of alcohol (p=.000), marijuana (p=.007), and hallucinogens (p=.009) at a significantly younger age than females.
Findings suggest more men report use of alcohol and “street” drugs including: heroin, crack cocaine, methamphetamine, marijuana, and hallucinogens. Further, males report the use of alcohol, marijuana, and hallucinogens at a significantly younger age. Understanding gender differences in substance use as well as other differences among individuals living in rural, Appalachia presents important opportunities to incorporate this knowledge into substance abuse early intervention, prevention and treatment efforts.
gender; substance use; rural; Appalachia
Differences between violent and nonviolent probationers were examined in the growing, yet understudied, rural probation population. Violent rural probationers had higher rates of substance use, criminal activity, and mental health symptoms than did nonviolent rural probationers. Implications for practitioners are discussed.
Despite the increase in media attention on “meth cooking” in rural areas of the United States, little is known about rural stimulant use, particularly the criminality associated with stimulant use. Data were collected from community stimulant users in rural Ohio, Arkansas, and Kentucky (N=709). Findings from three logistic regression models indicate that younger stimulant users (x =32.55, SD = 10.35), those with more convictions, and those who used crack frequently were significantly more likely to have been arrested for committing a substance-related crime, a property crime, or another crime in the 6-months before entering the study. Implications include the need for longitudinal studies to further understand rural stimulant use as well as increasing community and corrections-based drug abuse prevention and treatment interventions for stimulant users who live in rural areas.
rural; stimulants; crack cocaine; methamphetamine; arrest
Incarcerated women commonly report health, mental health, and substance use problems, yet there is limited research on service utilization before incarceration, particularly among women from urban and rural areas. This study includes a stratified random sample of 100 rural and urban incarcerated women to profile the health, mental health, substance use, and service utilization, to examine the relationship between the number of self-reported problems and service utilization, and to examine self-reported health and mental health problems in prison as associated with pre-incarceration health-related problems and community service utilization. Study findings suggest that health and mental health problems and substance use do not differ significantly among rural and urban women prisoners. However, there are differences in service utilization – particularly behavioral health services including mental health and substance abuse services with urban women reporting more service utilization. In addition, rural women who reported using needed community services before prison also reported fewer health problems in prison. Implications for correctional and community treatment opportunities in rural and urban areas are discussed.
health; mental health; substance use; service utilization
Illicit drug use in the rural United States is increasingly common, yet little is known about drug users’ treatment-seeking behaviors. This study identifies predictors of substance abuse treatment entry over 24 months among 710 illicit stimulant users in rural areas of Ohio, Arkansas, and Kentucky. Active users of powdered cocaine, crack cocaine, and/or methamphetamine (MA) were recruited using respondent-driven sampling. Participants completed structured interviews at baseline and follow-up questionnaires every 6 months for 24 months. Data were analyzed using the Cox proportional hazards model. The paper is informed by the Anderson-Newman Model. Overall, 18.7% of the sample entered treatment. Ohio or Kentucky residence, perceived need for substance abuse treatment, higher ASI legal problem composite scores, prior substance abuse treatment, and tranquilizer use were positively associated with treatment entry. Non-daily crack cocaine users and marijuana users were less likely to enter treatment. The findings can help inform rural substance abuse treatment program development and outreach.
Substance abuse; drug abuse treatment; rural; cocaine; crack; methamphetamine
The primary objective of this study was to investigate whether drug use severity is associated with physical health-related quality of life (HRQL) over time. Data are from a longitudinal, multi-state, natural history community study of users of cocaine and/or methamphetamine who were interviewed at 6-month intervals over 2 years with a 79% follow-up participation rate. Physical HRQL was assessed with the physical component summary (PCS) of the SF-8™ Health Survey and drug, alcohol, and psychiatric severity were all assessed with the Addiction Severity Index (ASI). Random coefficient regression analyses were conducted to test for longitudinal associations between the independent variables and SF-8 PCS scores. Reductions in drug use severity over time were accompanied by only minor improvements in SF-8 PCS scores, underscoring the potential long-term harm of illicit drug use on physical health. Greater psychiatric severity was strongly associated with lower SF-8 PCS scores, suggesting that clinical attention to mental health issues could potentially lead to improvements in perceived physical health as well among stimulant users.
health-related quality of life; methamphetamine; cocaine; rural; natural history; SF-8
The purpose of this study is to use the Criminal Justice Drug Abuse Treatment Studies’ (CJ-DATS) Inmate Pre-Release Assessment (IPASS), which recommends either intensive or non-intensive treatment after release, to predict rural offenders’12-step attendance and treatment entry within 6 months of release from prison. IPASS scores indicated that 52% of rural offenders needed intensive treatment upon community re-entry. In bivariate analyses, rural offenders with an intensive aftercare placement recommendation were significantly younger, more likely to have been employed more months in the year prior to incarceration, to have ever injected drugs, and to have ever received outpatient substance abuse treatment. The variables which were significant at the bivariate level were entered into two logistic multivariate models predicting 12-step attendance and treatment entry within 6 months of being released from prison. Age and having ever injected drugs were positive predictors of having attended a 12-step meeting, while the number of months legally employed was negatively related to 12-step attendance. In the treatment entry model, age increased the odds of entering formal treatment while having ever injected a drug decreased the odds. IPASS aftercare placement recommendation was not significant in either of the multivariate models. Findings from this study suggest that offenders re-entering rural communities may receive limited community-based continued care and future studies should explore geographic-specific treatment barriers. Implications for rural substance abuse treatment are provided.
Rural; Inmates; Re-entry; Assessment; 12-Step Programs; Substance Abuse Treatment
Nonmedical prescription opioid use has emerged as a major public health concern in recent years, particularly in rural Appalachia. Little is known about the routes of administration (ROA) involved in nonmedical prescription opioid use among rural and urban drug users. The purpose of this study was to describe rural-urban differences in ROA for nonmedical prescription opioid use.
A purposive sample of 212 prescription drug users was recruited from a rural Appalachian county (n = 101) and a major metropolitan area (n = 111) in Kentucky. Consenting participants were given an interviewer-administered questionnaire examining sociodemographics, psychiatric disorders, and self-reported nonmedical use and ROA (swallowing, snorting, injecting) for the following prescription drugs: buprenorphine, fentanyl, hydrocodone, hydromorphone, methadone, morphine, OxyContin® and other oxycodone.
Among urban participants, swallowing was the most common ROA, contrasting sharply with substance-specific variation in ROA among rural participants. Among rural participants, snorting was the most frequent ROA for hydrocodone, methadone, OxyContin®, and oxycodone, while injection was most common for hydromorphone and morphine. In age-, gender-, and race-adjusted analyses, rural participants had significantly higher odds of snorting hydrocodone, OxyContin®, and oxycodone than urban participants. Urban participants had significantly higher odds of swallowing hydrocodone and oxycodone than did rural participants. Notably, among rural participants, 67% of hydromorphone users and 63% of morphine users had injected the drugs.
Alternative ROA are common among rural drug users. This finding has implications for rural substance abuse treatment and harm reduction, in which interventions should incorporate methods to prevent and reduce route-specific health complications of drug use.
The purpose of this study was to examine the implementation, adherence and protocol fidelity for the Reducing Risky Relationships for HIV (RRR-HIV) study. The RRR-HIV study is a phase III trial of a randomized intervention to reduce human immunodeficiency virus (HIV) risk behaviors among incarcerated women in four US states: Connecticut, Delaware, Kentucky and Rhode Island. The intervention consists of five interventionist-led prison-based group sessions and a sixth individual community-based session. Data on adherence, implementation, acceptability and fidelity of the intervention were obtained from forms completed after the five prison-based sessions by both the interventionist and participant. Data from the sixth session were collected by the interventionist. Of the 363 women recruited to date, 173 (47.6%) have been randomly allocated to the experimental RRR intervention, of which implementation measures were available for 162 (93.6%). Almost three-quarters of women attended all five sessions, each of which lasted a median of 90 minutes, indicating successful implementation of the protocol across multiple study sites. Interventionists and participants alike reported that all of the topics for each session were discussed, suggesting adherence to the protocol. In addition, protocol interventionists indicated that more than 95% of the women were engaged/involved, interested, and understood the materials presented, indicating high levels of acceptability among the participants and fidelity to the intervention protocols. The majority of participants also answered all of the post-test questions correctly, which is another strong indicator of the fidelity to the intervention. Results suggest that the RRR-HIV study has been successfully implemented across multiple study sites. Adherence to the protocol, as well as protocol fidelity and acceptability, were also strong, which is essential to establish prior to examining outcome data.
HIV; Intervention; Women offenders
The HIV infection rate is increasing among women in general and for female inmates specifically (Maruschak 2004), which makes understanding the correlates of risky sexual behaviors critical for this population. Partner relationships, particularly the extent to which women perceive they have power within the relationship, may be important in modeling risk behaviors. Few studies have considered the association between relationship power and HIV risk behaviors among women offenders. This study examines women’s perceptions of their relationships using the Sexual Relationship Power Scale (Pulerwitz, Gortmaker, & DeJong 2000) and NIDA’s HIV Risk Behavior Assessment (NIDA 1995). Data were collected from female inmates in four prisons as part of the Reducing Risky Relationships for HIV protocol being conducted through the NIDA’s Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) cooperative agreement. Women reported whether they had engaged in five types of unprotected sex in the month prior to incarceration. Logistic regression models of the associations between relationship power and five types of unprotected sex revealed some support for the importance of power as a protective factor in reducing the odds of unprotected sexual behaviors. Implications and findings are presented to add to understanding of partner relationships and HIV risk behaviors.
HIV risk behaviors; women offenders; relationship power; relational model
Women’s substance abuse treatment outcomes are improved when women-specific needs are addressed through wraparound services, such as the provision of child care, employment assistance, or mental health counseling. Despite a higher prevalence of pre-incarceration drug use, women in prison report receiving fewer services than their male counterparts, suggesting they likely have greater service needs upon release. It is unknown whether community-based treatment organizations with a women-specific program offer more wraparound services than programs without a focus on women. This study uses data from the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) research cooperative’s National Criminal Justice Treatment Practices Survey (NCJTPS), a nationally representative sample of community-based treatment programs serving predominantly criminal offenders (n = 217). First, bivariate analyses identified differences between organizations with and without a women-specific program on the number of wraparound services adopted as well as organizational-level characteristics (i.e., organizational structure, personnel characteristics, culture, sources of information, and systems integration) related to their adoption. Second, Poisson regression was used to identify the organizational characteristics associated with the number of adopted wraparound services, with having a women-specific program being the primary covariate of interest. Results indicate larger organizations that utilized a greater number of treatment approaches and believed that treatment could reduce crime were more likely to offer a greater assortment of wraparound services. In an effort to improve behavioral treatment outcomes, it is imperative to examine organizational-level contextual factors that shape the availability of wraparound services for female offenders in community-based substance abuse treatment settings.
wraparound services; organizations; women-specific programs; criminal offenders