The Opioid Crisis in Rural and Small Town America

In this brief, authors Shannon Monnat and Khary Rigg examine rural versus urban differences in opioid mortality and identify challenges for dealing with the opioid crisis in rural areas. They report that, in 2016, opioid mortality rates were higher in urban than in rural counties, particularly in the Midwest, but rates have increased more in rural than in urban counties over the past two decades. Since 2010, the share of drug overdose deaths involving prescription opioids has declined, but the share of deaths involving heroin and synthetic opioids has spiked in both rural and urban areas. The most dramatic increases in opioid deaths were in the rural Midwest, where they were 16 times higher in 2016 than in 1999, and in the rural Northeast, where they were 11.4 times higher. Prescription opioids are involved in a larger share of rural than urban drug overdose deaths, whereas heroin and synthetic opioids (such as fentanyl) account for a larger share of urban deaths. Over half of drug overdose deaths involve multiple drugs. Policy initiatives to date have been largely ineffective at addressing the opioid crisis in many of the hardest-hit rural communities, and the recent surge in fentanyl overdoes in large urban areas may be a precursor of what to expect in at-risk rural communities in the coming years. Existing interventions are unlikely to be effective without addressing the underlying social and economic factors that are plaguing the hardest-hit areas

Rural Adolescents Are More Likely Than Their Urban Peers to Abuse Prescription Painkillers

U.S. media and popular culture historically portrayed drug abuse as an urban problem, but in recent years, there has been more media attention on rural drug issues. Part of this growing attention pertains to the growing epidemic of narcotic painkiller abuse in rural America. Although all areas of the country experienced increases in painkiller prescribing, abuse, and mortality over the past two decades, the increases have been most pronounced in small towns and rural areas. This rural drug epidemic requires immediate attention from policy makers and practitioners

Patterns of Prescription Medication Diversion among Drug Dealers

This research examined the following questions: (1) how do drug dealers acquire their inventories of prescription medications? and (2) which types of prescription medications do dealers most commonly sell? Data are drawn from a National Institute on Drug Abuse-funded research study that examined prescription drug diversion and abuse in South Florida. In-depth semi-structured interviews (n = 50) were conducted with an ethnically diverse sample of prescription drug dealers from a variety of milieus to assess patterns of diversion. Audiotapes of the interviews were transcribed, coded, and thematically analysed using the NVivo 8 software program. Dealers relied on a wide array of diversion methods including visiting multiple pain clinics, working with pharmacy employees to steal medications from pharmacies, and purchasing medications from indigent patients. The type of medication most commonly sold by dealers was prescription opioid analgesics, and to a lesser extent benzodiazepines such as alprazolam. These findings inform public health policy makers, criminal justice officials, the pharmaceutical industry and government regulatory agencies in their efforts to reduce the availability of diverted prescription drugs in the illicit market. Specifically, these data support the need for statewide prescription drug monitoring programs and increased training for healthcare workers who have access to controlled medications

The Stories behind the Struggle: A Closer Look at First Experiences with Opioid Misuse

The opioid crisis is a national public health emergency. Over 47,000 people in the U.S. died of opioid overdoses in 2017. Improving our knowledge about how people first come to misuse opioids can help to inform prevention and treatment interventions. This research brief shows that opioid misuse most often begins before age 25, most people obtain the opioids they misuse from friends and family rather than a health care provider, and experimenting and coping with life stressors are the most common motivations for starting opioid misuse

The Stories behind the Struggle: A Closer Look at First Experiences with Opioid Misuse

The opioid crisis is a national public health emergency. Over 47,000 people in the U.S. died of opioid overdoses in 2017. Improving our knowledge about how people first come to misuse opioids can help to inform prevention and treatment interventions. This research brief shows that opioid misuse most often begins before age 25, most people obtain the opioids they misuse from friends and family rather than a health care provider, and experimenting and coping with life stressors are the most common motivations for starting opioid misuse

Diversion of Benzodiazepines through Healthcare Sources

Background—Benzodiazepines (BZ) are often diverted from legal sources to illicit markets at various points in the distribution process which begins with a pharmaceutical manufacturer, followed by distribution to healthcare providers, and finally, to the intended users. Little is known about the extent of BZ diversion involving distribution points directly related to healthcare sources (e.g., a script doctor) as opposed to points further down the distribution chain (e.g., street dealers). The present study examines the scope of BZ diversion via mechanisms directly related to a healthcare source. It examines the association between BZ dependence and the direct utilization of particular healthcare-related diversion sources among a diverse sample of prescription drug abusers in South Florida. Method—Cross-sectional data were collected from five different groups of drug users: methadone-maintenance clients (n = 247), street drug users (n = 238), public-pay treatment clients (n = 246), private-pay treatment clients (n = 228), and stimulant using men who have sex with men (MSM; n = 248). Results—Findings suggest that those ages 26 to 35 years old, non-Hispanic White participants, private-pay treatment clients, those who are insured, and those with higher incomes had higher odds of utilizing healthcare diversion sources. Participants utilized a pharmacy as a diversion source more than other healthcare sources of diversion, and the highest number of BZs were obtained from doctor shopping compared to other diversion sources. Those who reported BZ dependence also had 2.5 times greater odds of using a healthcare source to obtain BZs than those who did not meet criteria for dependence. Discussion—Prevention of BZ diversion through healthcare sources should include strategies to reduce doctor shopping and diversion from pharmacies

Qualitative evaluation of a deferred consent process in paediatric emergency research: a PREDICT study

Background: A challenge of conducting research in critically ill children is that the therapeutic window for the intervention may be too short to seek informed consent prior to enrolment. In specific circumstances, most international ethical guidelines allow for children to be enrolled in research with informed consent obtained later, termed deferred consent (DC) or retrospective consent. There is a paucity of data on the attitudes of parents to this method of enrolment in paediatric emergency research. Objectives: To explore the attitudes of parents to the concept of DC and to expand the knowledge of the limitations to informed consent and DC in these situations.MethodChildren presenting with uncomplicated febrile seizures or bronchiolitis were identified from three separate hospital emergency department databases. Parents were invited to participate in a semistructured telephone interview exploring themes of limitations of prospective informed consent, acceptability of the DC process and the most appropriate time to seek DC. Transcripts underwent inductive thematic analysis with intercoder agreement, using Nvivo 11 software. Results: A total of 39 interviews were conducted. Participants comprehended the limitations of informed consent under emergency circumstances and were generally supportive of DC. However, they frequently confused concepts of clinical care and research, and support for participation was commonly linked to their belief of personal benefit. Conclusion: Participants acknowledged the requirement for alternatives to prospective informed consent in emergency research, and were supportive of the concept of DC. Our results suggest that current research practice seems to align with community expectations.</jats:sec

The complexities, coordination, culture and capacities that characterise the delivery of oncology services in the common areas of ambulatory settings.

BACKGROUND: Relatively little is understood about real-world provision of oncology care in ambulatory outpatient clinics (OPCs). This study aimed to: 1) develop an understanding of behaviours and practices inherent in the delivery of cancer services in OPC common areas by characterising the organisation and implementation of this care; and 2) identify barriers to, and facilitators of, the delivery of this care in OPC common areas. METHODS: A purpose-designed ethnographic study was employed in four public hospital OPCs. Informal field scoping activities were followed by in-situ observations, key informant interviews and document review. A view of OPCs as complex adaptive systems was used as a scaffold for the data collection and interpretation, with the intent of understanding 'work as done'. Data were analysed using an adapted "Qualitative Rapid Appraisal, Rigorous Analysis" approach. RESULTS: Field observations were conducted over 135 h, interviews over 6.5 h and documents were reviewed. Analysis found six themes. Staff working in OPCs see themselves as part of small local teams and as part of a broader multidisciplinary care team. Professional role boundaries could be unclear in practice, as duties expanded to meet demand or to stop patients "falling through the cracks." Formal care processes in OPCs were supported by relationships, social capital and informal, but invaluable, institutional expertise. Features of the clinic layout, such as the proximity of departments, affected professional interactions. Staff were aware of inter- and intra-service communication difficulties and employed strategies to minimise negative impacts on patients. We found that complexity, coordination, culture and capacity underpin the themes that characterise this care provision. CONCLUSIONS: The study advances understanding of how multidisciplinary care is delivered in ambulatory settings and the factors which promote or inhibit effective care practice. Time pressures, communication challenges and competing priorities can pose barriers to care delivery. OPC care is facilitated by: self-organisation of participants; professional acumen; institutional knowledge; social ties and relationships between and within professional groups; and commitment to patient-centred care. An understanding of the realities of 'work-as-done' may help OPCs to sustain high-quality care in the face of escalating service demand