Literature Collection

BACKGROUND: Rural areas have high rates of opioid and stimulant involved polysubstance use which are known to contribute to overdose. Justice-involved women are likely to have multiple substance use disorders and are particularly vulnerable in rural areas where treatment is limited. OBJECTIVES: The research had three aims to (1) identify the patterns of polysubstance use of rural Appalachian justice-involved women, (2) examine how women's engagement in polysubstance use changed in the 12-months following initial release from jail, and (3) determine if women's changes in substance use patterns were associated with re-incarceration during the 12-months of post-release follow-up. METHODS: A total of 339 women with recent substance use histories were randomly recruited from three rural jails. Latent transition analysis of women's substance use from baseline (in jail) to 6 and 12-months was examined, including the effect of re-incarceration on transitions (changes in substance use patterns). RESULTS: Three latent classes were found: High Polysubstance/injection drug use (IDU) (36.3% baseline), Opioid/Benzo (Benzodiazepine) Involved Polysubstance Use (57.3% baseline), and Low Use (6.4% baseline). Polysubstance use classes were characterized by use of opioids and benzodiazepines; the High Polysubstance/IDU class was distinct in co-use and injection use of methamphetamine. Post-release, women transitioned to latent classes of reduced substance use and/or reduced injection drug use, particularly in the first six months. Women who were re-incarcerated during follow-up were likely to remain engaged in, or transition to, the High Polysubstance/IDU class (ORs: 3.14-46.56). CONCLUSION: Justice-involved women in Appalachia reported risky polysubstance use. The first six-months post-release were a critical period for changes in substance use.

INTRODUCTION: Patients with opioid use disorder (OUD) have a heightened need for quality health care, including access to evidence-based medications to reduce cravings and prevent overdose. However, primary care providers (PCPs) are reluctant to work with patients with OUD and implement medication prescribing into primary care practice. Previous studies have sought to identify potential ways to overcome these barriers, but often utilize interventions that facilitate both positive contact with as well as empathy for patients with OUD. In this study, we jointly assess positive contact and empathy to determine their unique impact on treatment attitudes and behaviors among PCPs, after controlling for other known predictors. METHODS: We surveyed 409 PCPs currently practicing in Ohio in 2022. Our primary dependent variables were willingness to work with patients with OUD, receipt of an X-waiver to prescribe buprenorphine, and interest in receiving an X-waiver. Our primary independent variables were positive contact and empathy toward patients with OUD. We computed bivariate correlations and multivariable linear regression (for continuous dependent variables) and logistic regression (for binary dependent variables) to understand the relationship between positive contact, empathy, and our outcome variables while accounting for other known predictors and relevant participant demographics. RESULTS: Positive contact was positively correlated with willingness to work with patients with OUD, receipt of the X-waiver, an interest in receiving the X-waiver, more frequent checking with patients about the need for naloxone, and higher odds of naloxone prescribing. These relationships held after accounting for PCP demographics, explicit bias toward patients with OUD, and overall levels of contact with patients with OUD. Empathy, conversely, was not a significant predictor of any treatment outcomes in the fully adjusted models. CONCLUSION: Interventions and medical education programs aimed at improving treatment outcomes for patients with OUD should facilitate positive contact between PCPs and patients with OUD.

A 25-year-old woman, gravida 3 para 2 at 12 weeks of gestation, with two prior cesarean deliveries, presents for prenatal care. She is in treatment for opioid use disorder on extended-release naltrexone injection, with a history of opioid overdose, relapse, and poor treatment adherence on methadone and buprenorphine. She asks, "Is it safe for my baby if I continue on this medication? How will you manage my postoperative pain?"

IMPORTANCE: The incidence of opioid use during pregnancy is increasing, and drug overdoses are a leading cause of postpartum mortality. Most women who are pregnant do not receive medications for treatment of opioid use disorder, despite the mortality benefit that these agents confer. Furthermore, buprenorphine is associated with milder symptoms of neonatal abstinence syndrome (NAS) compared with methadone. OBJECTIVE: To describe the prevalence and geographic distribution across the US of obstetrician-gynecologists who can prescribe buprenorphine (henceforth described as X-waivered) in 2019. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional, nationwide study linking physician-specific data to county- and state-level data was conducted from September 1, 2019, to March 31, 2020. Data were obtained on 31 211 obstetrician-gynecologists who accept Medicaid insurance through the Centers for Medicare & Medicaid Services Physician Compare data set and linked to the Drug Addiction Treatment Act buprenorphine-waived clinician list. EXPOSURES: State-level NAS incidence and county-level uninsured rates and rurality. MAIN OUTCOMES AND MEASURES: Prevalence and geographic distribution of obstetrician-gynecologists who are trained to prescribe buprenorphine. RESULTS: Among the 31 211 identified obstetrician-gynecologists, 18 710 (59.9%) were women. Most had hospital privileges (23 236 [74.4%]) and worked in metropolitan counties (28 613 [91.7%]). Only 560 of the identified obstetrician-gynecologists (1.8%) were X-waivered. Obstetrician-gynecologists in counties with fewer than 5% uninsured residents had nearly twice the odds of being X-waivered (adjusted odds ratio [aOR], 1.59; 95% CI, 1.04-2.44; P = .04) compared with those in counties with greater than 15% uninsured residents. Compared with those located in metropolitan counties, obstetrician-gynecologists in suburban counties (eg, urban population of ≥20 000 and adjacent to a metropolitan area) were more likely to be X-waivered (aOR, 1.85; 95% CI, 1.26-2.71; P = .002). Compared with states with an NAS rate of 5 per 1000 births or less, obstetrician-gynecologists in states with an NAS rate of 15 per 1000 births or greater had nearly 5 times the odds of being X-waivered (aOR, 4.94; 95% CI, 3.60-6.77; P < .001). Obstetrician-gynecologists without hospital privileges were more likely to be X-waivered (aOR, 1.32; 95% CI, 1.08-1.61; P = .007). CONCLUSIONS AND RELEVANCE: Fewer than 2% of obstetrician-gynecologists who accept Medicaid are able to prescribe buprenorphine, and their geographic distribution appears to be skewed in favor of suburban counties. This finding suggests that there is an opportunity for health systems and professional societies to incentivize X-waiver trainings among obstetrician-gynecologists to increase patients' access to buprenorphine, especially during pregnancy.