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BACKGROUND: Although the burden of opioid use disorder is disproportionately high among persons who are incarcerated, medications for opioid use disorder are often unavailable in correctional settings. The Rhode Island Department of Corrections provides all 3 classes of medications for opioid use disorder to clinically eligible persons who are incarcerated. Despite a decrease in fatal overdoses among persons with recent criminal legal system involvement since the program’s implementation, barriers to continued engagement in treatment after release from incarceration still exist. METHODS: We conducted 40 semistructured, qualitative interviews with people who were incarcerated and enrolled in the comprehensive medications for opioid use disorder program at the Rhode Island Department of Corrections. Analysis applied a general, inductive approach using NVivo 12. RESULTS: Participants discussed barriers to treatment engagement before incarceration, as well as anticipated barriers to medications to treat opioid use disorder continuation after release from incarceration. Structural factors including housing, health insurance, transportation, and the treatment program structure, as well as social factors such as social support networks were perceived to influence retention in medications to treat opioid use disorder post-release. CONCLUSION: Our findings suggest that people with opioid use disorder who are incarcerated encounter unique challenges upon community reentry. Addressing structural factors that pose barriers to post-release engagement is essential to sustaining retention. We recommend utilization of peer recovery specialists to alleviate some of the stress of navigating the structural barriers identified by participants.

Background Fentanyl and related compounds have recently saturated the illicit drug supply in the United States, leading to unprecedented rates of fatal overdose. Individuals who are incarcerated are particularly vulnerable, as the burden of opioid use disorder is disproportionately higher in this population, and tolerance generally decreases during incarceration. Methods We conduct a systematic search for publications about fentanyl overdoses during incarceration in PubMed and PsycINFO, as well as lay press articles in Google, from January 1, 2013 through March 30th, 2021. Results Not a single fentanyl overdose was identified in the medical literature, but 90 overdose events, comprising of 76 fatal and 103 nonfatal fentanyl overdoses, were identified in the lay press. Among the 179 overdoses, 138 occurred in jails and 41 occurred in prisons, across the country. Conclusions Fentanyl-related overdoses are occurring in correctional facilities with unknown but likely increasing frequency. In addition to the need for improved detection and reporting, immediate efforts to 1) increase understanding of the risks of fentanyl and how to prevent and treat overdose among correctional staff and residents, 2) ensure widespread prompt availability of naloxone and 3) expand the availability of medications to treat opioid use disorder for people who are incarcerated will save lives.

ImportanceMost prisons and jails in the US discontinue medications for opioid use disorder (MOUD) upon incarceration and do not initiate MOUD prior to release.ObjectiveTo model the association of MOUD access during incarceration and at release with population-level overdose mortality and OUD-related treatment costs in Massachusetts.Design, Setting, and ParticipantsThis economic evaluation used simulation modeling and cost-effectiveness with costs and quality-adjusted life-years (QALYs) discounted at 3% to compare MOUD treatment strategies in a corrections cohort and an open cohort representing individuals with OUD in Massachusetts. Data were analyzed between July 1, 2021, and September 30, 2022.ExposuresThree strategies were compared: (1) no MOUD provided during incarceration or at release, (2) extended-release (XR) naltrexone offered only at release from incarceration, and (3) all 3 MOUDs (naltrexone, buprenorphine, and methadone) offered at intake.Main Outcomes and MeasuresTreatment starts and retention, fatal overdoses, life-years and QALYs, costs, and incremental cost-effectiveness ratios (ICERs).ResultsAmong 30 000 simulated incarcerated individuals with OUD, offering no MOUD was associated with 40 927 (95% uncertainty interval [UI], 39 001-42 082) MOUD treatment starts over a 5-year period and 1259 (95% UI, 1130-1323) overdose deaths after 5 years. Over 5 years, offering XR-naltrexone at release led to 10 466 (95% UI, 8515-12 201) additional treatment starts, 40 (95% UI, 16-50) fewer overdose deaths, and 0.08 (95% UI, 0.05-0.11) QALYs gained per person, at an incremental cost of $2723 (95% UI, $141-$5244) per person. In comparison, offering all 3 MOUDs at intake led to 11 923 (95% UI, 10 861-12 911) additional treatment starts, compared with offering no MOUD, 83 (95% UI, 72-91) fewer overdose deaths, and 0.12 (95% UI, 0.10-0.17) QALYs per person gained, at an incremental cost of $852 (95% UI, $14-$1703) per person. Thus, XR-naltrexone only was a dominated strategy (both less effective and more costly) and the ICER of all 3 MOUDs compared with no MOUD was $7252 (95% UI, $140-$10 018) per QALY. Among everyone with OUD in Massachusetts, XR-naltrexone only averted 95 overdose deaths over 5 years (95% UI, 85-169)—a 0.9% decrease in state-level overdose mortality—while the all-MOUD strategy averted 192 overdose deaths (95% UI, 156-200)—a 1.8% decrease.Conclusions and RelevanceThe findings of this simulation-modeling economic study suggest that offering any MOUD to incarcerated individuals with OUD would prevent overdose deaths and that offering all 3 MOUDs would prevent more deaths and save money compared with an XR-naltrexone–only strategy.

Purpose The purpose of this paper is to describe the course, “Designing Education for Better Prisoner and Community Health,” which provided students with the knowledge, skills and resources needed to build real-world health education materials for persons who are criminal justice involved. Design/methodology/approach A multiphase engaged scholarship course was designed and implemented through the Brown University School of Public Health in Rhode Island, USA. Findings Students collaborated closely with instructors, subject matter experts and affected community members to develop highly tailored health education projects across six topic areas. The structure and outcomes of the paper are described with the hope that other instructors and institutions might replicate components of the model. Originality/value Engaged scholarship in public health can provide students with rich, collaborative learning experiences, and when executed effectively, these endeavors can provide underserved communities with robust and informed health education interventions and programs.

Background: The association between cannabis use and HIV-1 RNA (viral load) among people with HIV (PWH) engaged in care is unclear. Methods: We used data collected from 2002 to 2018 on PWH receiving antiretroviral therapy (ART) enrolled in the Veterans Aging Cohort Study. Generalized estimating equations were used to estimate associations between self-reported past-year cannabis use and detectable viral load (≥500 copies/mL), with and without adjustment for demographics, other substance use, and adherence. Results: Among 2515 participants, 97% were male, 66% were Black, the mean age was 50 years, and 33% had detectable HIV viral load at the first study visit. In unadjusted analyses, PWH with any past-year cannabis use had 21% higher odds of a detectable viral load than those with no past-year use (OR = 1.21; 95% CI, 1.07–1.37). However, there was no significant association between cannabis use and viral load after adjustment. Conclusions: Among PWH engaged in care and receiving ART, cannabis use is associated with decreased adherence in unadjusted analyses but does not appear to directly impact viral control. Future studies are needed to understand other potential risks and benefits of cannabis use among PWH.

Scant research has examined the influence of overdoses occurring in social networks (i.e., knowing someone who has overdosed) on individual overdose risk. We sought to characterize drug use behaviors of individuals following the overdose of someone in their social network.We conducted semi-structured interviews with 25 people who use drugs and knew someone who overdosed in the prior 90 days. All interviews were conducted in person in Rhode Island from July to October 2021. Data were stratified by drug use behaviors following the overdose of a network member (i.e., risk behaviors, protective behaviors, no change; selected a priori) and analyzed using a thematic analysis variation to identify salient themes.We identified variation in the effect of knowing someone who overdosed on subsequent drug use behaviors and emotional affect. Several participants described increasing their drug use or using more types of drugs than usual to manage feelings of bereavement and trauma, and a subset of these participants described increased drug use with suicidal intention and increased suicidal ideations following the overdose event. Other participants described reducing their drug use and engaging in protective behaviors in response to heightened perceived overdose risk, protection motivation (i.e., increased motivation to protect oneself), and concern for others. Additionally, some participants reported no change in drug use behaviors, and these participants described already engaging in harm reduction practices, feeling desensitized due to frequent or repeated exposure to overdose, and ambivalence about living.Findings suggest a need for enhanced investment in network-based overdose prevention interventions, as well as more robust integration of bereavement support and mental health services in settings that serve people who use drugs. The findings also suggest a need for future research to identify mediators of the effect of overdose occurring in social networks on individual overdose risk.

Background: Prior evidence suggests that plasma HIV viral load is elevated during periods of crack cocaine use independent of antiretroviral therapy (ART) exposure. We sought to evaluate the effect of crack cocaine use frequency on HIV disease severity among HIV-positive people who use unregulated drugs (PWUD). Methods: We analyzed data from the ACCESS study, an open prospective cohort of HIV-positive PWUD including comprehensive HIV clinical monitoring in a setting with no-cost healthcare, including ART. Multivariable generalized linear mixed-effects models were used to estimate the independent effect of time-updated crack cocaine use frequency on HIV disease severity, adjusting for ART exposure and relevant confounders. HIV disease severity was measured using the Veterans Aging Cohort Study (VACS) Index, which is a validated prognostic index. Findings: Between 2005 and 2018, 806 individuals were recruited and contributed 8,537 observations. At baseline, the frequencies of crack cocaine use in the previous 180 days were: none (187, 23%), less than weekly (150, 19%), weekly (229, 28%), and daily or greater (240, 30%). In multivariable models adjusted for ART exposure and other confounders, daily or greater frequency of crack cocaine use was significantly associated with higher VACS Index scores (β = 0.9, 95% confidence interval: 0.2, 1.6) as compared to none. Interpretation: Daily or greater frequency of crack cocaine use may exacerbate HIV disease severity among HIV-positive PWUD. Although the observed effect was small, it was also independent of ART exposure. As this finding has been supported by previous evidence, the observed difference may reflect an underlying biological mechanism or other factors linked with crack cocaine use although further investigation is warranted. Funding Information: US National Institutes of Health. Declaration of Interests: We declare no competing interests. Ethics Approval Statement: The ACCESS study was approved by the University of British Columbia/Providence Healthcare Research Ethics Board.

Objective: Despite research demonstrating increased need for healthcare services among people who use drugs, few studies have investigated barriers to general healthcare in this population. We explored the most common barriers to general healthcare faced by clients utilizing syringe access services. Methods: Clients of Project Safe Point- a syringe access service serving Albany, NY and surrounding regions-were surveyed on their general health practices and specific health care barriers. Descriptive analyses were used to identify which barriers were most prevalent. Results: Of the clients surveyed (n = 59), the most common specific barriers were deprioritization of medical care (i.e., procrastination [80%], finding it easier to ignore the problem [63%]), cost (i.e., not having insurance [59%], not being able to afford the cost of care [58%]), transportation (53%), and judgement by clinicians (53%). When participants were asked to choose which was their biggest barrier to healthcare, judgement by clinicians was chosen more than twice as often as any other barrier. Conclusion: While people who inject drugs at a syringe access program often experience traditional barriers to healthcare (i.e., logistical barriers, procrastination), nearly a quarter of the clients reported feeling judged by clinicians as their most significant barrier. Future work in this field should explore interventions that motivate clients to seek care and that reduce stigma in healthcare interactions.

Background Opioid-related overdose deaths have accelerated in recent years. In response, overdose education and naloxone distribution (OEND) programs have been implemented across the United States, although many rural Appalachians continue to lack access. Despite the growing number of OEND programs, risk factors for inappropriate overdose response among persons who are training-naïve are currently unknown. Methods We used respondent-driven sampling to recruit and enroll 169 adults who use prescription opioids non-medically from three rural counties in West Virginia. Participants were interviewed to ascertain experience with witnessed overdose (lifetime and prior-year), characteristics of the most recent witnessed overdose, responses to the witnessed overdose, and OEND acceptability. Logistic regression was used to assess factors associated with inappropriate response to opioid-related overdose. Results Among the 73 (43% of the total sample) participants who witnessed an opioid-related overdose, the majority (n = 53, 73%) reported any inappropriate response. Participants were significantly more likely to report an inappropriate overdose response when the overdose victim was unresponsive (OR = 3.36; 95% CI = 1.07, 10.58). The most common appropriate responses were staying with the victim until recovery or help arrived (n = 66, 90%) and calling 911 (n = 63, 86%), while the most common inappropriate responses were hitting or slapping the victim (n = 37, 51%) and rubbing the victim with ice or placing them in a cold shower or bath (n = 14, 19%). While most (n = 60, 82%) had never heard of overdose prevention training, the vast majority (n = 69, 95%) were willing to participate in training, particularly those who had responded inappropriately (n = 52, 98%). Conclusions These findings underscore the urgent need for expanded access to OEND programs in at-risk rural communities that lacked coverage. Indeed, information generated by this study informed the development of a statewide naloxone distribution program in WV. These findings also indicate OEND programs are highly acceptable to training-naïve people who use opioids in rural Appalachia. Additional approaches to expand access to harm reduction services in the region, including mobile services and mail-based naloxone distribution should be aggressively pursued.

People who are incarcerated are at increased risk for HIV (human immunodeficiency virus) acquisition upon release, and one possible intervention for prevention is the use of pre-exposure prophylaxis (PrEP) upon release. The present study assessed HIV risk perceptions as well as PrEP awareness and interest among 39 people who were incarcerated and enrolled in a structured Medication for Addiction Treatment (MAT) program at the Rhode Island Department of Corrections using semi-structured, qualitative interviews. Analysis was conducted using a generalized, inductive method in NVivo 12. While PrEP awareness was low across the study sample, some participants were interested in PrEP uptake or learning more about PrEP after they were provided with an overview of it. PrEP interest strongly related to current perceived HIV risk. Potential barriers included side effects, adherence, and reluctance to take medications in general. MAT programs for people who are criminal justice (CJ) involved may serve as useful linkage spaces to PrEP information, access, and retention.

Background As overdose deaths have increased in the United States, some lawmakers have explored punitive, “supply-side” interventions aimed at reducing the supply of fentanyl. While a rationale of seeking to protect people who use drugs is often given to justify harsh sentences for fentanyl distribution, there is no research to our knowledge on perceptions of the effect of drug-induced homicide laws among people who use drugs. Methods We conducted semi-structured, qualitative interviews with 40 people with opioid use disorder (OUD) who were enrolled in a medication for addiction treatment (MAT) program in a unified jail and prison system in Rhode Island on attitudes surrounding increased sentences for distribution of fentanyl, including recently enacted drug-induced homicide laws. Codes were developed using a generalized, inductive method and interviews analyzed in NVivo 12 after being coded by two coders. Results Most participants stated that drug-induced homicide laws would not be an effective strategy to stem the overdose crisis. We identified key themes, including discussions surrounding the autonomy of people who use drugs, widespread fentanyl prevalence as a barrier to implementation of drug-induced homicide laws, discussions of mass incarceration as ineffective for addressing substance use disorders, feelings that further criminalization could lead to violence, criminalization as a justification for interpersonal loss, and intention as meaningful to categorizing an act as homicide. Conclusions Findings highlight the importance of centering the experiences of people with OUD in creating policies surrounding the overdose epidemic, potential unintended health consequences of drug-induced homicides laws such as deterrence from calling 911 and increased violence, and how drug-induced homicide laws may undermine advances made in expanding access to OUD treatment for people who are criminal justice-involved.

Background Rates of fatal opioid overdose in Massachusetts (MA) and Rhode Island (RI) far exceed the national average. Community-based opioid education and naloxone distribution (OEND) programs are effective public health interventions to prevent overdose deaths. We compared naloxone distribution and opioid overdose death rates in MA and RI to identify priority communities for expanded OEND. Methods We compared spatial patterns of opioid overdose fatalities and naloxone distribution through OEND programs in MA and RI during 2016 to 2019 using public health department data. The county-level ratio of naloxone kits distributed through OEND programs per opioid overdose death was estimated and mapped to identify potential gaps in naloxone availability across geographic regions and over time. Results From 2016 to 2019, the statewide community-based naloxone distribution to opioid overdose death ratio improved in both states, although more rapidly in RI (from 11.8 in 2016 to 35.6 in 2019) than in MA (from 12.3 to 17.2), driven primarily by elevated and increasing rates of naloxone distribution in RI. We identified some urban/non-urban differences, with higher naloxone distribution relative to opioid overdose deaths in more urban counties, and we observed some counties with high rates of overdose deaths but low rates of naloxone kits distributed through OEND programs. Conclusions We identified variations in spatial patterns of opioid overdose fatalities and naloxone availability, and these disparities appeared to be widening in some areas over time. Data on the spatial distribution of naloxone distribution and opioid overdose deaths can inform targeted, community-based naloxone distribution strategies that optimize resources to prevent opioid overdose fatalities.

BACKGROUND AND AIMS: Income assistance is critical to the health and well-being of socioeconomically marginalized people who use illicit drugs (PWUD). However, past literature paradoxically identifies unintended increases in drug-related harm coinciding with synchronized payments that may magnify signals for drug use. The scope of such harm has not been fully characterized among non-institutionalized populations. This study examined sociodemographic, health and drug use-related correlates of payment-coincident drug-related harm. DESIGN: This observational study using data from prospective community-based longitudinal cohorts of PWUD between December 2013 and May 2018. SETTING: Vancouver, British Columbia, Canada. PARTICIPANTS: A total of 1604 PWUD receiving monthly income assistance. Our sample included 586 (36.5%) women, 861 (53.7%) non-white participants, and 685 (42.7%) people living with HIV. MEASUREMENTS: Primary outcome was a self-reported composite measure of drug-related harm in the past 6 months coinciding with income assistance, including higher frequency substance use, non-fatal overdose, and service barriers or interruptions. Subanalyses disaggregated this outcome. FINDINGS: Payment-coincident drug-related harm was reported among 77.7% of participants during the study period. In multivariable models, key correlates positively and significantly associated with payment-coincident harm included: street-based income generation (Adjusted Odds Ratio [AOR]=1.48, 95% Confidence Interval [CI]=1.26–1.74, P

Background We examined the impact of expanded access to medications for opioid use disorder (MOUD) in a unified prison and jail system on post-release, opioid-related overdose mortality. Methods We developed a microsimulation model to simulate a population of 55,000 persons at risk of opioid-related overdose mortality in Rhode Island. The effect of an extended-release (XR) naltrexone only intervention and the effect of providing access to all three MOUD (i.e., methadone, buprenorphine, and XR-naltrexone) at release from incarceration on cumulative overdose death over eight years (2017–2024) were compared to the standard of care (i.e., limited access to MOUD). Results In the standard of care scenario, the model predicted 2385 opioid-related overdose deaths between 2017 and 2024. An XR-naltrexone intervention averted 103 deaths (4.3% reduction), and access to all three MOUD averted 139 deaths (5.8% reduction). Among those with prior year incarceration, an XR-naltrexone only intervention and access to all three MOUD reduced overdose deaths by 22.8% and 31.6%, respectively. Conclusions Expanded access to MOUD in prison and jail settings can reduce overdose mortality in a general, at-risk population. However, the real-world impact of this approach will vary by levels of incarceration, treatment enrollment, and post-release retention.

BACKGROUND: The endocannabinoid system has been implicated in physiological processes fundamental to pain, giving plausibility to the hypothesis that cannabis may be used as a substitute or complement to prescription opioids in the management of chronic pain. We examined the association of medical cannabis licensure with likelihood of prescription opioid receipt using administrative records. METHODS: This study linked registry information for medical cannabis licensure with records from the prescription drug monitoring program from April 1, 2016 to March 31, 2019 to create a population-based, retrospective cohort in Rhode Island. We examined within-person changes in receipt of any opioid prescription and receipt of an opioid prescription with a morphine equivalent dose of 50 milligrams or more, and of 90 milligrams or more. RESULTS: The sample included 5,296 participants with medical cannabis license. Medical cannabis licensure was not associated with the odds of filling any opioid prescription (OR: 0.99; 95% CI: 0.94–0.1.05) or the odds of filling a prescription with a morphine equivalent dose of 50 milligrams or more (OR: 0.93; 95% CI: 0.84–1.04) and 90 milligrams or more (OR: 0.99; 95% CI: 0.86–1.15). CONCLUSION: Medical cannabis licensure was not associated with subsequent cessation and reduction in prescription opioid use. Re-scheduling of cannabis will allow for the conduct of randomized controlled trials to determine the efficacy of medical cannabis alternative to prescription opioid use or complement the use of lower doses of prescription opioids in patients with chronic pain.

Recently incarcerated individuals are at increased risk of opioid overdose. Methadone maintenance treatment (MMT) is an effective way to address opioid use disorder and prevent overdose, however, few jails and prisons in the United States initiate or continue people who are incarcerated on MMT. In the current study, the 12 month outcomes of a randomized control trial in which individuals were provided MMT while incarcerated at the Rhode Island Department of Corrections (RIDOC) are assessed. An as-treated analysis included a total of 179 participants—128 who were, and 51 who were not, dosed with methadone the day before they were released from the RIDOC. The results of this study demonstrate that 12 months post-release individuals who received continued access to MMT while incarcerated were less likely to report using heroin and engaging in injection drug use in the past 30 days. In addition, they reported fewer non-fatal overdoses and were more likely to be continuously engaged in treatment in the 12-month follow-up period compared to individuals who were not receiving methadone immediately prior to release. These findings indicate that providing incarcerated individuals continued access to MMT has a sustained, long-term impact on many opioid-related outcomes post-release.

Key Points Question Were there changes in the rate and characteristics of deaths from drug overdose before vs during the COVID-19 pandemic in Rhode Island? Findings In this population-based cohort study of 470 adults who died of drug overdose in Rhode Island from January 1 to August 31 in 2019 and 2020, rates of death from overdose among men, deaths involving synthetic opioids, and deaths occurring in personal residences increased significantly in 2020 compared with 2019. Deaths due to overdose also increased among people experiencing job loss and in subgroups with mental health diagnoses. Meaning These findings suggest that policy and service delivery interventions that are responsive to emerging characteristics of deaths from drug overdose are needed to curtail these deaths., This cohort study compares the rates and characteristics of deaths from drug overdose before vs during the COVID-19 pandemic in Rhode Island., Importance The rate of deaths from overdose has increased during the COVID-19 pandemic, and recent US overdose mortality rates have been markedly high. However, scant data are available on the causes of this increase or subpopulations at elevated risk. Objective To evaluate the rates and characteristics of deaths from drug overdose before vs during the COVID-19 pandemic. Design, Setting, and Participants This retrospective, population-based cohort study used data from 4 statewide databases linked at the person level via the Rhode Island Data Ecosystem on adults with deaths due to overdose in Rhode Island from January 1 to August 31, 2019, and January 1 to August 31, 2020. Main Outcomes and Measures The rates of unintentional deaths from drug-related overdose during the 2019 and 2020 observation periods overall and by sociodemographic characteristics, drugs contributing to the cause of death, location of death, and socioeconomic factors were evaluated. In subgroup analyses restricted to Medicaid beneficiaries (n = 271), the proportions of deaths from overdose by behavioral health treatment and diagnosis claims in the year before death were also examined. Results A total of 470 adults who died of drug overdose were included in the analysis (353 men [75%]; mean [SD] age, 43.5 [12.1] years). The rate of deaths from overdose in Rhode Island increased 28.1%, from 29.2 per 100 000 person-years in 2019 to 37.4 per 100 000 person-years in 2020 (P = .009). Compared with 2019, rates of deaths due to overdose during 2020 were higher among men (43.2 vs 59.2 per 100 000 person-years; P = .003), non-Hispanic White individuals (31.0 vs 42.0 per 100 000 person-years; P = .005), single individuals (54.8 vs 70.4 per 100 000 person-years; P = .04), deaths involving synthetic opioids (20.8 vs 28.3 per 100 000 person-years; P = .005), and deaths occurring in a personal residence (13.2 vs 19.7 per 100 000 person-years; P = .003). A decrease in the proportion of deaths from overdose involving heroin (11 of 206 [5%] vs

The rate of overdose deaths caused by fentanyl-contaminated heroin (FCH) use is increasing rapidly in the United States. We examined risk factors for exposure to FCH and experiences with FCH use among young adult non-medical prescription opioids (NMPO) users.We analyzed data from the Rhode Island Young Adult Prescription Drug Study (RAPiDS), which enrolled young adults aged 18 to 29 reporting prior 30day NMPO use between January 2015 and February 2016. Participants completed questionnaires ascertaining drug use patterns and risk behaviors, including FCH exposure. Logistic regression was used to assess factors associated with known or suspected FCH exposure.Of 199 participants, the median age was 25 (IQR: 22, 27), 130 (65.3%) were male, and 122 (61.3%) were of White, non-Hispanic race/ethnicity. In total, 22 (11%) reported known or suspected FCH exposure in the prior six months. Several drug use patterns and risk behaviors were associated with FCH exposure, including: regular heroin and cocaine use; diverted pharmaceutical fentanyl use in the prior six months; NMPO use to avoid withdrawal symptoms; longer duration of NMPO use; regular injection drug use; and prior overdose (all p0.001). Among participants who reported FCH exposure, 59% were unaware that their heroin was contaminated with fentanyl prior to last use, 59% reported that FCH provides a better high, and all recognized that fentanyl increases overdose risk.Exposure to fentanyl-contaminated heroin is an emerging trend among young adult NMPO users in Rhode Island. Overdose prevention programs addressing FCH use are urgently needed.

As of September 23, 2020, the USA had both the highest number of COVID-19 cases and the largest incarcerated population in the world. Approximately 2·3 million people are currently incarcerated in prisons and jails in the USA. More than 6·5 million individuals are under daily correctional supervision, which includes probation and parole, representing 2·6% of the entire US adult population.

OBJECTIVES: Medications for opioid use disorder (MOUD) in the criminal justice setting is an effective way to address opioid use disorder and prevent associated deaths in the community. The Rhode Island Department of Corrections (RIDOC) is the first statewide correctional system in the United States to offer comprehensive MOUD services to incarcerated individuals; however, due to stigma, eligible individuals may be reluctant to engage with MOUD. This study aims to 1) evaluate the efficacy of an educational video intervention and 2) characterize MOUD-related attitudes in a general incarcerated population. METHODS: Participants were recruited from eight elective classes offered to soon-to-be-released incarcerated individuals at the RIDOC. Participants viewed an eight-minute video featuring incarcerated individuals speaking about their experiences using MOUD, designed to reduce MOUD-related stigma. Participants were administered surveys prior to and after watching the video to assess changes in MOUD knowledge (MOUD-K) and MOUD attitudes (MOUD-A). RESULTS: This evaluation of the intervention included 80 incarcerated participants (median age = 35), 93% male, 36% non-Hispanic White, and 26% non-Hispanic Black). Forty percent indicated non-medical opioid use within six months prior to incarceration; 13% had previously used MOUD. Significant improvements in MOUD-K scores (t(65) = −7.0, p < 0.0001) and MOUD-A scores (t(69) = −5.8, p < 0.0001) were detected after participants viewed the video. The intervention yielded greater Δ MOUD-A scores among those identifying as non-Hispanic Black, compared to non-Hispanic Whites (β = 2.6, CI = 0.4, 4.8). CONCLUSION: The educational video improved both knowledge and positive attitudes towards MOUD, with changes in MOUD attitudes being influenced by race. These findings may inform future MOUD educational programs, thereby helping to reduce opioid use disorder-related morbidity and mortality.

Background Medicaid recipients have a high burden of opioid overdose and opioid use disorder (OUD). Opioid agonist therapies are an effective treatment for OUD, but there is a wide and persisting gap between those who are indicated and those who receive treatment. The objective of this study was to identify the predictors of enrollment in opioid agonist therapy within 6 months of an opioid overdose or OUD diagnosis in a cohort of Medicaid recipients. Methods Using multiple linked, state-level databases, we conducted a retrospective cohort study of 17,449 Medicaid recipients in Rhode Island who had an opioid overdose or an OUD diagnosis between July 2013 and June 2018. Results The majority (58 %) of Medicaid recipients did not enroll in opioid agonist therapy within 6 months. In adjusted models, having one or more prior overdose (adjusted risk ratio [ARR] = 0.33, 95 % CI: 0.28, 0.38), alcohol use disorder (ARR = 0.56, 95 % CI: 0.52, 0.60), or back problems (ARR = 0.58, 95 % CI: 0.55, 0.61) were strong predictors of non-enrollment. Conversely, emergency department (ARR = 1.31, 95 % CI: 1.28–1.34) and primary care provider (ARR = 1.03, 95 % CI: 1.01–1.34) visit frequency above the 75th percentile were associated with timely enrollment in opioid agonist therapy. Conclusions Our findings underscore the need to enhance pathways to treatment for OUD through varied nodes of engagement with healthcare systems. Interventions to improve screening for OUD and referrals to opioid agonist therapies should include high-impact settings, such as treatment programs for alcohol and substance use disorders, pain clinics, and outpatient behavioral care settings.

Summary The burden of HIV/AIDS and other transmissible diseases is higher in prison and jail settings than in the non-incarcerated communities that surround them. In this comprehensive review, we discuss available literature on the topic of clinical management of people infected with HIV, hepatitis B and C viruses, and tuberculosis in incarcerated settings in addition to co-occurrence of one or more of these infections. Methods such as screening practices and provision of treatment during detainment periods are reviewed to identify the effect of community-based treatment when returning inmates into the general population. Where data are available, we describe differences in the provision of medical care in the prison and jail settings of low-income and middle-income countries compared with high-income countries. Structural barriers impede the optimal delivery of clinical care for prisoners, and substance use, mental illness, and infectious disease further complicate the delivery of care. For prison health care to reach the standards of community-based health care, political will and financial investment are required from governmental, medical, and humanitarian organisations worldwide. In this review, we highlight challenges, gaps in knowledge, and priorities for future research to improve health-care in institutions for prisoners.

Background Medications for opioid use disorder (OUD) are the most effective treatment for OUD, but uptake of these life-saving medications has been extremely limited in US prisons and jail settings, and limited data are available to guide policy decisions. The objective of this study was to estimate the impact of screening and treatment with medications for OUD in US prisons and jails on post-release opioid-related mortality. Methods We used data from the National Center for Vital Statistics, the Bureau of Justice Statistics, and relevant literature to construct Monte Carlo simulations of a counterfactual scenario in which wide scale uptake of screening and treatment with medications for OUD occurred in US prisons and jails in 2016. Results Our model predicted that 1840 (95% Simulation Interval [SI]: -2757 – 4959) lives would have been saved nationally if all persons who were clinically indicated had received medications for OUD while incarcerated. The model also predicted that approximately 4400 (95% SI: 2675 – 5557) lives would have been saved nationally if all persons who were clinically indicated had received medications for OUD while incarcerated and were retained in treatment post-release. These estimates correspond to 668 (95% SI: -1008 – 1812) and 1609 (95% SI: 972 – 2037) lives saved per 10,000 persons incarcerated, respectively. Conclusions Prison and jail-based programs that comprehensively screen and provide treatment with medications for OUD have the potential to produce substantial reductions in opioid-related overdose deaths in a high-risk population; however, retention on treatment post-release is a key driver of population level impact.

The review details recent literature reports regarding Hepatitis B Virus (HBV) and, in particular, Hepatitis B prevalence/incidence in incarcerated populations around the world. Furthermore, the review will summarize the national/international guidelines regarding HBV and look at diagnosis, vaccination, treatment, and linkage to care after release. HBV affects prisoners at a much higher rate than the general populations. Many who are at increased risk for HBV infection are also at increased risk for incarceration. Incarcerated settings also have higher rates of HBV transmission. Incarcerated individuals should be immunized if they are not already immune to HBV. Increased access to safe injecting and tattoo paraphernalia, condoms, and personal hygiene equipment could reduce the spread of HBV and other blood-borne and sexually transmitted infections. Future research should focus on ways to prevent the spread of HBV and similar viruses in incarcerated settings in order to protect incarcerated individuals and the general public. Research on effective linkage to community HBV care following release is needed.

Overdose is the leading cause of unintentional injury-related death. Rhode Island (RI) has the highest rate of illicit drug use nationally and the 5th highest overdose mortality rate. RI has experienced an outbreak of fentanyl-related overdoses. In incarcerated populations, risk of overdose is greatly elevated. However, little is known about fentanyl-related overdose post-release. In the current analyses, we identify changes in fentanyl-related fatal overdose among those who died in 2014 and 2015 who were incarcerated in the year before death. We linked data from the RI Office of the Medical Examiner with records from the RI Department of Corrections. We calculated risk ratios and 95% confidence intervals using log-binomial regression to compare risk of fentanyl-involved overdose death. We also compared median time to death since release, median sentence length, and median number of incarcerations in 2014 and 2015. Results indicate that the risk of dying of a fentanyl-related overdose increased (RR: 1.99 (95% CI: 1.11-3.57, p = 0.014)) from 2014 to 2015 among those with past year incarceration. This study is one of the first to describe fentanyl-related fatal overdose among those with past year incarceration. In 2015 the median sentence was longer among those with a fentanyl-related overdose death and the median time from release to death among all who had past year incarceration extended past 90 days. Access to medications for addiction treatment, overdose education, and naloxone should be available during community re-entry and extended beyond the early post-release period.

The level of disease and illness among prison populations worldwide tends to be much higher than in the general population. In particular, the resurgence of communicable diseases poses enormous challenges for prison systems internationally. Reducing disease transmission in prisons is an integral part of reducing the spread of diseases in the community. States have an obligation to implement policies consistent with good public health and human rights practice and to ensure that prisoners are provided with a standard of health care equivalent to that in the broader society. Based on empirical evidence, this article examines key medical and penal policy issues raised by the transmission of infectious diseases in prisons. It analyzes the policy directions and alliances that are effective in improving the health of prisoners in light of their practical applications.

Objectives To assess initial change in knowledge, self-efficacy, and anticipated behaviors among Rhode Island law enforcement officers on drug overdose response and prevention. Methods Law enforcement officers (N = 316) voluntarily completed a pre-post evaluation immediately before and after taking part in overdose prevention and response trainings. Assessment items included measures of knowledge (Brief Overdose Recognition and Response Assessment (BORRA)), self-efficacy, attitudes toward drugs and overdose prevention, awareness of the Good Samaritan Law, and open-ended items pertaining to overdose knowledge and response behaviors. Non-parametric tests measured within-group and between-group differences. Wilcoxon Signed Rank tests and Kruskal-Wallis tests evaluated changes in BORRA scores and self-efficacy items. McNemar’s tests assessed changes regarding the Good Samaritan law and open-ended items. Wilcoxon Signed Rank tests measured post-training change in attitudes. Results Law enforcement officers demonstrated statistically significant improvements in self-efficacy (identifying signs of opioid overdose, naloxone indication, counseling witnesses in overdose prevention, and referring witnesses for more information), overdose identification knowledge (BORRA mean increased from 7.00 to 10.39), naloxone administration knowledge (BORRA mean increased from 10.15 to 12.59), Good Samaritan Law awareness (17.9% increase after training), and anticipated behaviors in response to future observed overdose (65.7% changed from passive to active response post training). Conclusions Harm reduction programs can provide law enforcement officers with the knowledge and skills necessary to intervene and reduce overdose mortality. Given the statistically significant improvements in self-efficacy, attitudinal changes, and Good Samaritan law awareness, law enforcement officers are more prepared to actively interact with drug users during a drug-involved emergency.

Statement of purpose Though traditionally concentrated in urban areas, deaths due to drug overdose have increased to epidemic levels in rural areas, and opioids including prescription drugs and heroin play an important role nationwide. To our knowledge, no opioid overdose prevention programs (OOPPs) with take-home naloxone presently exist in several high-risk Appalachian states including West Virginia (WV). In partnership with substance abuse prevention community members, we sought to assess the feasibility of translating and implementing such an OOPP in WV. Methods Local substance abuse prevention professionals screened, enrolled, and interviewed community members who endorsed prescription drug misuse in the previous 90 days. Interviews were conducted face-to-face in semi-private areas mutually agreed upon by the participant and interviewer. Participants were asked about drug overdoses they had witnessed or experienced, their knowledge of naloxone, their willingness to participate in an overdose prevention program, and socio-demographic characteristics. Results Based on preliminary analyses of 170 participants, over half (n = 87) witnessed at least one drug overdose, and over a fifth (n = 36) experienced an overdose themselves. Though fewer than half ofparticipants (n = 79) reported hearing of Narcan ® or naloxone, the majority were moderately or very interested in receiving a prescription for a rescue medication (n = 159) and/or participating in a prevention program (i.e. undergoing training) (n = 146). Conclusions Significant numbers of community members misusing opioids have witnessed and/or experienced a drug overdose. Though less than half were aware of naloxone, most expressed a willingness to participate in a prevention program, suggesting that a fatal overdose prevention program with take-home naloxone is acceptable to potential program participants. Significance and contributions Given these findings and the magnitude of the opioid epidemic in rural areas such as WV, fatal opioid overdose prevention with peer-distributed naloxone has the potential to significantly decrease fatal opioid overdose.