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1.  Feeling Good in Your Own Skin: The Influence of Complimentary Sexual Stereotypes on Risky Sexual Attitudes and Behaviors in a Community Sample of African American Women 
Women & health  2013;53(1):1-19.
Although negative racial stereotypes may affect the mental and physical health of African Americans, little research has examined the influence of positive or complimentary racial stereotypes on such outcomes. More specifically, this study explored the relationship between African American women’s endorsement of complimentary stereotypes about their sexuality (CSS) and attitudes/behaviors that have been associated with sexual risk. Data were gathered from 206 African American women as part of the Black Women in the Study of Epidemics project (B-WISE). Multivariate regression models were used to examine associations between women’s endorsement of CSS and selected sex-related attitudes and behaviors. Participants’ endorsement of CSS was significantly positively associated with beliefs that having sex without protection would strengthen their relationship (B = .28, SE = .10, p < .01) and that they could use drugs and always make healthy choices about using protection (B = .31, SE = .09, p < .01). Significant positive associations were also found between CSS and the number of casual sexual partners women reported in the past year (B = .29, SE = .15, p = .05) and their willingness to have sex in exchange for money or drugs during that time (B = .78, OR = 2.18, p < .05). These findings suggest that endorsement of CSS by African American women can lead to increased risk behavior, particularly relating to possible infection with HIV or other sexually transmitted infections (STI).
doi:10.1080/03630242.2012.750260
PMCID: PMC3579527  PMID: 23421336
2.  Prevalence of HIV and Risky Sexual Behaviors Among Rural Drug Users: Does Age Matter? 
Annals of epidemiology  2012;22(11):778-782.
Objectives
To determine the seroprevalence of HIV among a representative sample of rural drug using adults. Also, to determine whether young rural drug users engage in greater levels of sexual risk behavior than their older counterparts.
Methods
Cross-sectional study of 503 adult drug users. Rapid tests for antibodies to HIV were used and self-reported data was collected via computer.
Results
None of the participants tested positive for antibodies to HIV. In bivariate tests only two differences were observed between young and older participants. Young males were more likely to engage in unprotected vaginal sex (P=.018) and young females were more likely to engage in unprotected sex with persons injecting drugs (P=.016). In controlled multivariate analyses, age had a modest but significant association with an 8-item index of sexual risk behavior (b= −.15) and a reduced 6-item index of risk (b= −.18).
Conclusion
Despite a fairly dense and interactive sexual network and relatively high-levels of sexual risk behaviors, this rural population has not yet been affected by the HIV epidemic. In the event an outbreak of HIV in this population the observed levels of sexual behavior suggest that rapid sexual transmission could occur among drug-using populations and may include persons of all ages.
doi:10.1016/j.annepidem.2012.07.006
PMCID: PMC3490025  PMID: 22902042
HIV; rural; sexual networks; drug use
3.  Feasibility of a computerized intervention for offenders with substance use disorders: a research note 
Objectives
Despite evidence that treatment is effective in reducing recidivism among inmates with substance use problems, scarce resources mean that few of those in need of treatment actually receive it. Computerized substance abuse interventions could be used to expand access to treatment in prisons without placing an undue burden on resources. The major aim of the study was to compare treatment conditions in terms of their service utilization, skills acquisition, and treatment satisfaction.
Methods
The study recruited men and women with substance use disorders from 10 prisons in 4 states. In an open label clinical trial, 494 subjects were randomly assigned either to the Experimental condition, a computerized drug treatment intervention, the Therapeutic Education System (TES; n = 249), or to the Control condition, Standard Care (n = 245). Chi-square tests compared groups on categorical variables and independent samples t tests were used for interval level continuous variables.
Results
Initial evidence demonstrated: (1) comparable group rates of session attendance and high rates of TES module completion for experimental subjects; (2) comparable group gains in the development of coping skills; and (3) a more favorable view of TES than of Standard Care.
Conclusions
Collectively, these results show that a computerized intervention, such as TES, can be implemented successfully in prison. Given the barriers to the delivery of substance abuse treatment typically encountered in correctional settings, computerized interventions have the potential to fill a significant treatment gap and are particularly well suited to inmates with mild to moderate substance use disorders who often are not treated.
doi:10.1007/s11292-013-9187-y
PMCID: PMC3945711  PMID: 24634641
Computerized intervention; Correctional settings; Offenders; Substance abuse treatment; Substance use
4.  Characteristics of Rural Crack and Powder Cocaine Users: Gender and Other Correlates 
Background
Little is known about the relationship of gender with cocaine use in rural areas. This study describes these relationships among stimulant users residing in rural areas of Arkansas, Kentucky and Ohio.
Objectives
Understanding characteristics of crack and powder cocaine users in rural areas may help inform prevention, education and treatment efforts to address rural stimulant use.
Methods
Participants were 690 stimulant users, including 274 (38.6%) females, residing in 9 rural counties. Cocaine use was measured by self-report of cocaine use, frequency of use, age of first use, and cocaine abuse/dependence. Powder cocaine use was reported by 49% of this sample of stimulant users and 59% reported using crack cocaine.
Findings
Differing use patterns emerged for female and male cocaine users in this rural sample; females began using alcohol, marijuana, and cocaine at later ages than males but there were no gender differences in current powder cocaine use. Females reported more frequent use of crack cocaine and more cocaine abuse/dependence than males, and in regression analyses, female crack cocaine users had 1.8 times greater odds of reporting frequent crack use than male crack users.
Conclusions and Scientific Significance
These findings suggest differing profiles and patterns of cocaine use for male and female users in rural areas, supporting previous findings in urban areas of gender-based vulnerability to negative consequences of cocaine use. Further research on cocain use in rural areas can provide insights into gender differences that can inform development and refinement of effective interventions in rural communities.
doi:10.3109/00952990.2011.600380
PMCID: PMC3756482  PMID: 21851207
cocaine; rural; substance abuse; gender
5.  Examining Factorial Structure and Measurement Invariance of the Brief Symptom Inventory (BSI)-18 among Drug Users 
Addictive behaviors  2009;35(1):23-29.
The purpose of this study is to examine the factorial structure of the Brief Symptom Inventory 18 (BSI-18) and test its measurement invariance among different drug using populations. A total sample of 710 drug users was recruited using respondent-drive sampling (RDS) from three states: Ohio (n=248), Arkansas (n=237), and Kentucky (n=225). The results of confirmatory factor analysis (CFA) show: 1) the BSI-18 has a three-factor structure (somatization, depression, and anxiety) with an underlying second-order factor (global severity index of distress); and 2) its factorial structure and metric (factor loadings) are invariant across populations under study. However, the scalars (intercepts) of the BSI-18 items are not invariant, and the means of the latent factors also varied across populations. Our findings provide evidence of a valid factorial structure of the BSI-18 that can be readily applied to studying drug using populations.
doi:10.1016/j.addbeh.2009.08.003
PMCID: PMC3718020  PMID: 19733442
BSI-18; psychological distress; CFA model; measurement invariance; drug users
6.  “Tweaking and Geeking, Just Having Some Fun”: An Analysis of Methamphetamine Poems 
Journal of psychoactive drugs  2010;42(3):377-383.
There is a body of methamphetamine-themed poetry that speaks regretfully of the highly negative experiences of those in recovery from methamphetamine (MA) addiction or who feel trapped in an MA-using lifestyle. During ethnographic research in western Kentucky, the author collected two MA-themed poems from active MA users that differ from other MA poetry. They describe misadventures that occur during MA “binges.” However, the text and tone of the poems are comically ironic and represent optimism rather than regret toward MA use. Analyzing these poems provide valuable insights into local patterns of MA use, related terminology, and attitudes toward MA use.
PMCID: PMC3713610  PMID: 21053760
Methamphetamine; oral narratives; drug slang; United States
7.  Prescription opiate misuse among rural stimulant users in a multi-state community-based study 
Objectives
The purpose of the current analysis was to examine the factors associated with prescription opiate misuse among stimulant users from rural counties in Arkansas, Kentucky, and Ohio (N=714).
Methods
Multiple logistic regression was utilized to determine the independent correlates of recent (prior 6 months) prescription opiate misuse.
Results
More than half of participants (53.2%) reported prescription opiate misuse in the previous 6 months. Other drug use (heroin, cocaine, methamphetamine and marijuana) and anxiety (Adjusted Odds Ratio: 2.04, 95% Confidence Interval: 1.60, 2.59) were independently associated with prescription opiate misuse. Chronic pain and other health indicators were not associated with prescription opiate misuse after adjustment for covariates.
Conclusions
Results indicate that illicit drug involvement and psychiatric symptoms may be driving the high rates of prescription opiate misuse among rural stimulant users. These findings have implications for the provision of treatment in resource-deprived rural areas.
doi:10.1080/00952990802326298
PMCID: PMC3692559  PMID: 19152201
prescription opiates; methamphetamine; cocaine; stimulants; rural
8.  OxyContin® as Currency: OxyContin® Use and Increased Social Capital among Rural Appalachian Drug Users 
Social science & medicine (1982)  2012;74(10):1602-1609.
Studies have shown that position within networks of social relations can have direct implications on the health behaviors of individuals. The present study examines connections between drug use and individual social capital within social networks of drug users (n=503) from rural Appalachian Kentucky, U.S.A. Respondent driven sampling was used to recruit individuals age 18 and older who had used one of the following drugs to get high: cocaine, crack, heroin, methamphetamine, or prescription opioids. Substance use was measured via self-report and social network analysis of participants’ drug use network was used to compute effective size, a measure of social capital. Drug network ties were based on sociometric data on recent (past 6 month) drug co-usage. Multivariate multi-level ordinal regression was used to model the independent effect of sociodemographic and drug use characteristics on social capital. Adjusting for gender, income, and education, daily OxyContin® use was found to be significantly associated with greater social capital, and daily marijuana use was associated with less social capital. These results suggest that in regions with marked economic disparities such as rural Appalachia, OxyContin® may serve as a form of currency that is associated with increased social capital among drug users. Interventions focusing on increasing alternate pathways to acquiring social capital may be one way in which to alleviate the burden of drug use in this high-risk population.
doi:10.1016/j.socscimed.2011.12.053
PMCID: PMC3331592  PMID: 22465379
U.S.A.; social capital; Appalachia; OxyContin; nonmedical prescription drug use; marijuana; social networks
9.  Hepatitis C Viremia and Genotype Distribution among a sample of HCV-exposed Nonmedical Prescription Drug Users in Rural Appalachia 
Journal of medical virology  2012;84(9):1376-1387.
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.
doi:10.1002/jmv.23252
PMCID: PMC3571688  PMID: 22825816
genotype; hepatitis C virus; injection drug use; rural
10.  Correlates of Participation in Peer Recovery Support Groups as well as Voluntary and Mandated Substance Abuse Treatment among Rural and Urban Probationers 
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.
doi:10.1016/j.jsat.2011.07.004
PMCID: PMC3218255  PMID: 21839606
Rural; Probationers; Peer Recovery Support Groups; Treatment; Mandated Treatment
11.  Individual and Network Factors Associated With Prevalent Hepatitis C Infection Among Rural Appalachian Injection Drug Users 
American journal of public health  2012;103(1):e44-e52.
Objectives
We determined the factors associated with hepatitis C (HCV) infection among rural Appalachian drug users.
Methods
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.
Results
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.
Conclusions
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.
doi:10.2105/AJPH.2012.300874
PMCID: PMC3518360  PMID: 23153148
12.  RISKY RELATIONSHIPS: TARGETING HIV PREVENTION FOR WOMEN OFFENDERS 
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.
doi:10.1521/aeap.2012.24.4.339
PMCID: PMC3490206  PMID: 22827903
13.  An Ethnographic Exploration of Self-Reported Violence Among Rural Methamphetamine Users 
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.
doi:10.1080/15332640802683409
PMCID: PMC3375908  PMID: 19266373
Methamphetamine; violence; rural drug use; southern United States
14.  Rural Drug Users: Factors Associated with Substance Abuse Treatment Utilization 
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.
doi:10.1177/0306624X10366012
PMCID: PMC2923294  PMID: 20463206
15.  Physical Victimization of Rural Methamphetamine and Cocaine Users 
Violence and Victims  2012;27(1):109-124.
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.
PMCID: PMC3343718  PMID: 22455188
Violence; substance use; cocaine; methamphetamine; alcohol; rural
16.  Individual and Network Factors Associated with Non-fatal Overdose among Rural Appalachian Drug Users 
Drug and alcohol dependence  2010;115(1-2):107-112.
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1016/j.drugalcdep.2010.11.003
PMCID: PMC3056907  PMID: 21126831
non-fatal overdose; witnessed overdose; rural; prescription drug use; social networks
17.  Injection risk behaviors among rural drug users: Implications for HIV prevention 
AIDS care  2011;23(5):638-645.
Objective
The purpose of this study was to examine injection drug use (IDU) among a cohort of felony probationers from rural Appalachian Kentucky.
Methods
An interviewer administered questionnaire given to 800 rural felony probationers ascertained data regarding demographics, drug use, criminal behavior, psychological distress, and HIV risk behaviors.
Results
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).
Discussion
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.
doi:10.1080/09540121.2010.516346
PMCID: PMC3078960  PMID: 21293995
18.  Relationship influence and health risk behavior among re-entering women offenders 
Background
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.
Methods
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.
Findings
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.
Conclusions
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.
doi:10.1016/j.whi.2010.10.006
PMCID: PMC3085849  PMID: 21315617
19.  Social support and crack/cocaine use among incarcerated mothers and non-mothers 
Substance use & misuse  2012;47(6):686-694.
doi:10.3109/10826084.2012.659367
PMCID: PMC3328654  PMID: 22468988
female; cocaine; incarceration; social support; criminal justice; motherhood
20.  Predictors of Depressive Symptomatology Among Rural Stimulant Users† 
Journal of Psychoactive Drugs  2010;42(4):435-445.
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.
PMCID: PMC3320035  PMID: 21305908
depression; cocaine HCl; crack cocaine; methamphetamine; PHQ-9; rural; substance abuse
21.  Gender Differences in Provider’s Use of a Standardized Screening Tool for Prenatal Substance Use 
Journal of addiction medicine  2011;5(1):36-42.
Objectives
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1097/ADM.0b013e3181ccec2e
PMCID: PMC3045208  PMID: 21359106
Prenatal Substance Use; Standardized Screening Tools; Physician Gender Differences
22.  Examining gender differences in substance use and age of first use among rural, Appalachian drug users in Kentucky 
Background/Objective
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.
Methods
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.
Results
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.
Conclusion/Scientific Significance
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.
doi:10.3109/00952990.2010.540282
PMCID: PMC3164779  PMID: 21142705
gender; substance use; rural; Appalachia
23.  Substance Use, Criminal Activity, and Mental Health Among Violent and Nonviolent Rural Probationers 
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.
PMCID: PMC3162314  PMID: 21874101
24.  Criminality Among Rural Stimulant Users in the United States 
Crime and delinquency  2011;57(4):600-621.
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.
doi:10.1177/0011128708325048
PMCID: PMC3115620  PMID: 21686091
rural; stimulants; crack cocaine; methamphetamine; arrest
25.  Health, mental health, substance use, and service utilization among rural and urban incarcerated women 
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.
doi:10.1016/j.whi.2007.02.004
PMCID: PMC3073072  PMID: 17560124
health; mental health; substance use; service utilization

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