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Introduction An ED visit for opioid overdose may be a person's only contact with the medical and behavioral health care systems and is an important opportunity to reduce risk of subsequent overdose and death. While ED initiatives to engage people with opioid use disorder (OUD) are being increasingly implemented, there are significant gaps in the receipt of services at the time of the ED encounter. Methods This is a retrospective cohort study of an outreach pilot project providing real-time telehealth delivered buprenorphine initiation and referral to community harm reduction and addiction treatment services via a follow up telephone call to patients after an ED visit for an opioid overdose. Results From January 2020 to April 2021 there were 606 patients with an ED visit for an opioid overdose eligible for a callback. Of the 606 eligible patients, 254/645 (42%) patients could be contacted and accepted service and/or treatment referrals. Fifteen patients were connected same-day to a buprenorphine prescriber for a telehealth encounter and, of connected patients, nine received a buprenorphine prescription. Conclusion A post-ED follow up telephone call protocol is an opportunity to improve treatment engagement and access to buprenorphine for patients at high risk for opioid overdose and death.

HIV clinicians are uniquely positioned to treat their patients with opioid use disorder using buprenorphine to prevent overdose death. The Prescribe to Save Lives (PtSL) study aimed to increase HIV clinicians' buprenorphine prescribing via an overdose prevention intervention.The quasi-experimental stepped-wedge study enrolled 22 Ryan White-funded HIV clinics and delivered a peer-to-peer training to clinicians with follow-up academic detailing that included overdose prevention education and introduced buprenorphine prescribing. Site-aggregated electronic medical record (EMR) data measured with the change in X-waivered clinicians and patients prescribed buprenorphine. Clinicians completed surveys preintervention and at 6- and 12-month postintervention that assessed buprenorphine training, prescribing, and attitudes. Analyses applied generalized estimating equation models, adjusting for time and clustering of repeated measures among individuals and sites.Nineteen sites provided EMR prescribing data, and 122 clinicians returned surveys. Of the total patients with HIV across all sites, EMR data showed 0.38% were prescribed buprenorphine pre-intervention and 0.52% were prescribed buprenorphine postintervention. The intervention increased completion of a buprenorphine training course (adjusted odds ratio 2.54, 95% confidence interval: 1.38 to 4.68, P = 0.003) and obtaining an X-waiver (adjusted odds ratio 2.11, 95% confidence interval: 1.12 to 3.95, P = 0.02). There were nonsignificant increases at the clinic level, as well.Although the PtSL intervention resulted in increases in buprenorphine training and prescriber certification, there was no meaningful increase in buprenorphine prescribing. Engaging and teaching HIV clinicians about overdose and naloxone rescue may facilitate training in buprenorphine prescribing but will not result in more treatment with buprenorphine without additional interventions.

Safe consumption spaces (SCS) are evidence-based interventions that reduce drug-related morbidity and mortality operating in many countries. However, SCS are yet to be widely implemented in the USA despite the escalating overdose epidemic. The aim of this multi-city study was to identify the factors associated with willingness to use a SCS among people who use drugs (PWUD) in Baltimore, Providence, and Boston, stratified by injection drug use status. Our secondary aim was to characterize the anticipated barriers to accessing SCS if they were to be implemented in these cities. PWUD were invited to complete a cross-sectional survey in 2017. The analysis was restricted to 326 opioid users (i.e., heroin, fentanyl, and non-medical opioid pill use). The majority (77%) of participants expressed willingness to use a SCS (Baltimore, 78%; Providence, 68%; Boston. 84%). Most respondents were male (59%), older than 35 years (76%), non-white (64%), relied on public/semi-public settings to inject (60%), had a history of overdose (64%), and recently suspected fentanyl contamination of their drugs (73%). A quarter (26%) preferred drugs containing fentanyl. Among injectors, female gender, racial minority status, suspicion of drugs containing fentanyl, and drug use in public/semi-public settings were associated with higher willingness to use a SCS; prior arrest was associated with lower willingness. Among non-injectors, racial minority status, preference for fentanyl, and drug use in public/semi-public settings were associated with higher willingness, whereas recent overdose held a negative association. The most commonly anticipated barriers to accessing a SCS in the future were concerns around arrest (38%), privacy (34%), confidentiality/trust/safety (25%), and cost/time/transportation (16%). These data provide evidence of high SCS acceptability among high-risk PWUD in the USA, including those who prefer street fentanyl. As SCS are implemented in the USA, targeted engagement efforts may be required to reach individuals exposed to the criminal justice system.

Background The opioid epidemic is one of the greatest public health crises of our times, driven increasingly by synthetic opioids such as fentanyl in the heroin supply. The implementation of drug checking in community settings has the potential to reduce the burden of fatal overdose, provide harm reduction education around safer drug consumption, and increase health access among people who use drugs (PWUD). To inform program development, we explored stakeholder opinions on drug checking technologies and implementation considerations. Methods This study, from the larger FORECAST study, utilized semi-structured in-depth interviews (n = 32) with a range of stakeholders in Baltimore, Boston, and Providence, many of whom were service providers. Stakeholders represented various roles and levels in organization types including harm reduction, public health, peer groups, and advocates. Interviews were audio recorded and transcribed. Data were coded using a priori codes; the coded text was analyzed for key themes. Results Stakeholders responded positively to drug checking technology, though they shared apprehensions regarding service implementation. Primary topics requiring consideration included: utility in fentanyl endemic areas, trust and rapport between providers and PWUD, legality and policy concerns. Additional considerations included: technology accuracy, cost, ease of distribution, and service delivery setting. Conclusions Stakeholders overwhelmingly supported the concept of drug checking with the goals of providing needed risk reduction information and resources to PWUD and serving as a point for greater engagement in services. Programs need to be tailored to local circumstances. Law enforcement buy-in and policy change will be critical aspects of providing drug checking services.

BACKGROUND Evidence-based interventions that engage community-dwelling, justice-involved, people living with HIV (PLWH) in care are urgently needed. Project Bridge, an intensive case management intervention, has demonstrated efficacy for linking PLWH to care transitioning from prison to the community. We assessed whether a modified Project Bridge model was effective for increasing rates of HIV treatment engagement, antiretroviral therapy receipt, and adherence for community-dwelling individuals supervised on probation and parole. SETTING Baltimore, Maryland. METHODS In this study, the 18-month outcomes of a randomized controlled trial in which PLWH were also on probation or parole received either Project Bridge (n = 50) or treatment as usual (n = 50) were assessed. HIV treatment engagement (primary outcome), antiretroviral therapy prescription, and adherence (secondary outcomes) are evaluated using the intent-to-treat approach. RESULTS There were no statistically significant differences in rates of HIV treatment engagement, antiretroviral therapy prescription receipt, or adherence between groups over the 18-month study period. Across groups, participants were 5.6 times more likely to receive HIV care, 5.8 times more likely to receive an antiretroviral therapy prescription, and 4 times more likely to report antiretroviral therapy adherence at each follow-up period. CONCLUSIONS Future research is needed to identify potentially less-intensive interventions that target the unique needs of PLWH under community supervision.

BACKGROUND: People with a history of incarceration are at high risk for opioid overdose. A variety of factors contribute to this elevated risk though our understanding of these factors is deficient. Research to identify risk and protective factors for overdose is often conducted using administrative data or researcher-derived surveys and without explicit input from people with lived experience. We aimed to understand the scope of U.S. research on factors associated with opioid overdose among previously incarcerated people. We did this by conducting a narrative review of the literature and convening expert panels of people with lived experience. We then categorized these factors using a social determinants of health framework to help contextualize our findings. METHODS: We first conducted a narrative review of the published literature. A search was performed using PubMed and APA PsycInfo. We then convened two expert panels consisting of people with lived experience and people who work with people who were previously incarcerated. Experts were asked to evaluate the literature derived factors for completeness and add factors that were not identified. Finally, we categorized factors as either intermediary or structural according to the World Health Organization’s Social Determinants of Health (SDOH) Framework. RESULTS: We identified 13 papers that met our inclusion criteria for the narrative review. Within these 13 papers, we identified 22 relevant factors for their role in the relationship between overdose and people with a history of incarceration, 16 were risk factors and six were protective factors. Five of these were structural factors (three risk and two protective) and 17 were intermediary factors (13 risk and four protective). The expert panels identified 21 additional factors, 10 of which were structural (six risk and four protective) and 11 of which were intermediary (eight risk and three protective). CONCLUSION: This narrative review along with expert panels demonstrates a gap in the published literature regarding factors associated with overdose among people who were previously incarcerated. Additionally, this review highlights a substantial gap with regard to the types of factors that are typically identified. Incorporating voices of people with lived experience is crucial to our understanding of overdose in this at-risk population.

We survey research using neural sequence-to-sequence models as compu-tational models of morphological learning and learnability. We discusstheir use in determining the predictability of inflectional exponents, inmaking predictions about language acquisition and in modeling languagechange. Finally, we make some proposals for future work in these areas.

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.

The U.S. government declared the opioid epidemic as a national public health emergency in 2017, but regulatory frameworks that govern the treatment of opioid use disorder (OUD) through pharmaceutical interventions have remained inflexible. The emergence of the COVID-19 pandemic has effectively removed regulatory restrictions that experts in the field of medications for opioid use disorder (MOUD) have been proposing for decades and has expanded access to care. The regulatory flexibilities implemented to avoid unnecessary COVID-related death must be made permanent to ensure that improved access to evidence-based treatment remains available to vulnerable individuals with OUD who otherwise face formidable barriers to MOUD. We must seize this moment of COVOD-19 regulatory flexibilities to demonstrate the feasibility, acceptability, and safety of delivering treatment for OUD through a low-threshold approach.

Despite the strong correlation between HIV and corrections, testing and prevention efforts have largely been ignored among community corrections populations. The current study is a secondary analysis to compare characteristics of individuals under community corrections supervision who completed rapid HIV testing with those who refused such testing (N = 2,382) in Baltimore, Maryland, and Providence, Rhode Island. Results indicate that the following variables were significantly associated with the receipt of rapid HIV testing: being female (p = .024), Black race (p = .004), homeless (p = .016), early age of crime onset (p = .001), more drug use during the past 90 days (p = .033), and previously tested for hepatitis C virus/hepatitis B virus (p = .024). Such findings make it especially important that individuals under community supervision be linked with services in the community to ensure that HIV testing and health care planning occur simultaneously.

Background In lower to middle income countries (LMIC), the influences of environmental stress on neurobiological processes involved in the development of schizophrenia is of great importance. High levels of stress may contribute to an increased burden of schizophrenia, including profound functional impairment and disability, decreased productivity, and even elevated mortality. Stress in Schizophrenia has been associated with behavioral disturbances such as maladaptive coping styles as well as well-established physiological abnormalities in sensorimotor gating in the form of abnormal startle responses. In turn, childhood trauma exposure is known to affect physiological stress responses. Indeed, we have found childhood trauma to be associated with both white matter and hippocampal changes in schizophrenia. Few studies, however, have explored the relationship between Childhood trauma and stress responses in schizophrenia. In recent years Virtual Reality (VR) has undergone a resurgence as a viable method for studying fear related physiological stress responses in an ecologically valid manner. Here we aim to investigate the potential relationship between abnormal physiological stress responses in schizophrenia with early life adversity. Methods Physiological response data were collected while participants completed a VR paradigm based on the Trier stress test, a well-established social stressor that reliably elicits a stress response in participants in VR and HPA axis attenuation in schizophrenia. Data were also collected in a fear of heights environment, not associated with abnormalities in schizophrenia. Childhood trauma was assessed with the Childhood Trauma Questionnaire (CTQ). HPA axis stress responses during the course of the task were assessed using saliva cortisol samples collected at key points during the paradigms. Results Preliminary data of both the social anxiety and fear of heights scenario will be presented. We will focus specifically on the viability of using VR in a LMIC context. Discussion VR could prove to be a cost-effective tool to explore the relationship between childhood trauma, stress sensitivity and schizophrenia.

Background An established Clinical skills (CS) assessment tool had been used to assess competence in a range of clinical skills in an acute trust since 2009 and a local mental health trust since 2013. Simultaneously it became clear to clinical skills facilitators from both organisations a review of the existing tool was required due to feedback and anecdotal evidence of shortfalls in the tool’s adaptability as well as the licensing cost of the tool. The motivation for change remained to ensure use of an assessment tool which is structured, robust and reliable, and, ensures patient and staff safety is maintained when procedural skills are being performed. Summary Literature searches were performed, many existing tools were considered. The facilitator from the mental health trust shared her work with the acute trust and concluded working together on one tool would be an efficient approach and aid cross agency working. Following on from project work across Doncaster, personnel from primary and social care joined the collaboration to produce CCAST (Care and Clinical skills ASsessment Tool) suitable for use by all health and social care settings across the Doncaster footprint with the first meeting of all agencies in November 2017. Results Preliminary data from the roll out across the Mental Health Trust suggested an increased compliance with competence assessment and positive feedback regarding the ease of use of the tool. Following this pilot, changes were made in collaboration with all agencies. Discussion The pilot results revealed themes such as increased flexibility due to a broader scoring system; reduced subjectivity on the part of the assessor and the tool clearly shows achieved competence and areas for further growth Recommendation To implement CCAST across the Doncaster locality gathering data from the start. User feedback will be obtained via 1:1 interviews using purposive sampling of the assessments performed across all care settings. Findings will be reported at conference. Formal publication of this project work showing how one tool can be developed to be suitable for use in the assessment of competence in any skill in any health and social care setting enabling movement of staff between organisations with the assurance of level of competence and, demonstrating the benefits of joined working – ‘Maximising Impact’. References Dreyfus& Dreyfus Model discussed by Benner P. From novice to expert: Excellence and power in clinical nursing practice 1984. Addison Wesley. Pendleton D, Schofield T, Tate P, Havelock P. The consultation: An approach to learning and teaching1982. Oxford: Oxford University Press: 68–72.

Background North America is experiencing a rising trend of opioid overdose exacerbated primarily in recent years through adulteration of the heroin supply with fentanyl and its analogues. The east coast of the United States has been particularly hard hit by the epidemic. In three east coast states of Maryland, Massachusetts and Rhode Island, fentanyl has been detected in over half of all overdoses with available toxicology screens. To determine the acceptability of drug checking involving fentanyl test strips (FTS) or other technologies among those at high risk for overdose, we assessed correlates of intention to utilize such services and logistical preferences among people who use drugs (PWUD). Methods Through FORECAST (the Fentanyl Overdose REduction Checking Analysis STudy), street-based PWUD (N = 334) were recruited in Baltimore, Maryland, Boston, Massachusetts, and Providence, Rhode Island. Questionnaires 7were administered from June to October 2017 and ascertained drug use, overdose history, fentanyl knowledge, and drug checking intent and logistical preferences. Pearson’s χ2 and logistic regression determined factors associated with drug checking intent. Results Overall, 84% were concerned about fentanyl, 63% had ever overdosed, and 42% had ever witnessed a fatal overdose. Ninety percent felt drug checking would help them prevent an overdose, the majority of those interested would utilize drug checking at least daily (54%). Factors independently associated with intent to use drug checking included: older age (aOR: 1.5, 95% CI: 1.3–1.8); homelessness (aOR: 0.6, 95% CI: 0.5–0.7); being non-white (aOR: 2.0, 95% CI: 1.0–4.0); witnessing ≥1 fatal overdose (aOR: 1.6, 95% CI:1.1–2.3); and suspected recent fentanyl exposure (aOR: 1.8, 95% CI: 1.1–3.1). Conclusions The majority of PWUD endorsed drug checking for overdose prevention, with intent amplified by having witnessed a fatal overdose and recent fentanyl exposure. Drug checking should be part of a comprehensive approach to address the risks associated with the proliferation of fentanyl.

Aim To describe the process of developing a replacement clinical skills assessment tool.1-3 Objectives To describe: Initial development and the teams involved Trial and audit outcomes, the process of change from the existing tool to a new one Policy driven, policy believed to be corporate and not clinical Partnership working, to develop the tool for multi–agency use across a geographical area Application for intellectual property rights. Summary of work undertaken After initial development, completed whilst undertaking an MSc in Health Professional Education, roll out commenced in January 2017 giving a 6 month crossover with the existing tool, allowing time for those who had commenced an assessment programme using the previous tool to complete. A data collection tool was developed in order to measure the effectiveness of the new assessment tool. Impact on practice Existing assessors required a 1 hour update, new assessors attended a 2½ hr training session. There were over 400 assessors previously. Now there are 166 new assessors. Results from the first audit are favourable, using the RAG rating system, all areas within the audit are good and one reached outstanding, on average the score was 88%, prompting some changes and a revised data collection tool being developed. Next steps along with the partnership working and imminent roll out across a geographical area, the original Trust is looking at Learning Environment Managers auditing their assessments and recording on the electronic staff record (ESR). References . Dreyfus & Dreyfus Model discussed by Benner in Novice to Expert Excellence and Power in Clinical Nursing Practice, 1984. . Pendleton D, Schofield T, Tate P, Havelock P. The consultation: An approach to learning and teaching 1982;2017:68–72. Oxford: Oxford University Press. . Jaye P, Thomas L, Reedy G. ‘The Diamond’: A structure for simulation debrief. The Clinical Teacher2015:12:171–175.

Individuals on probation and parole are disproportionately at high risk for HIV infection and experience significant barriers to accessing health care. This study was a two-group randomized controlled trial conducted at a community corrections office and was designed to link HIV positive probationers/parolees to HIV treatment in the community. HIV positive participants were assigned to one of the two treatment conditions: (1) Project Bridge (PB), an intensive case-management intervention; or (2) treatment as usual (TAU), involving standard referral to treatment. We hypothesized that PB would be more effective than TAU in terms of initiating individuals in community HIV treatment. We found no difference in rates of, or time to, treatment initiation when comparing the PB to TAU (all ns > 0.05). Additionally, there was no statistically significant difference between HIV medication regiment initiation by treatment condition (p > 0.05). Despite limitations, we found that probationers and parolees were willing to be screened and linked to treatment.

Objective Rhode Island Medicaid offers high emergency department utilizers the opportunity to take part in the Chronic Pain Program, an integrated treatment approach that includes free complementary therapies (massage, chiropractic, and acupuncture). The aim of the current analysis was to understand beliefs about the Rhode Island Chronic Pain Program from the perspective of the patient receiving services, the provider delivering services, and the administrator implementing the program. Design A qualitative interview-based study. Subjects Patients (N = 24), providers (N = 13), and administrators (N = 11) who were already involved, or were eligible to be involved, in the Chronic Pain Program. Methods Semistructured interviews were conducted to elicit information about experiences with the program. Transcriptions of audio recordings were analyzed according to principles of deductive thematic analysis. Results Patient interviews revealed five themes: 1) relationship between stress and pain, 2) trusting patient-provider relationships, 3) increased quality of life, 4) temporary pain relief, and 5) anxiety and discomfort associated with acupuncture. Provider interviews revealed three themes: 1) a way to reach the disenfranchised, 2) not enough visits with patients, and 3) opportunity to build relationships with patients. Administrator interviews revealed two themes: 1) a means to offer a range of support services to complicated patients and 2) unanswered questions over whether the program adequately serves patients with the greatest needs. Conclusions Key stakeholders in this new initiative agree that the Rhode Island Chronic Pain Program shows promise and that the holistic approach may be a good match for this hard-to-reach population.

Objectives: The first 2 weeks following release from prison are associated with extraordinary risk of fatal drug overdose. However, bystanders can reverse opioid overdoses using rescue breathing and naloxone, an overdose antidote. We reviewed overdose prevention and naloxone administration training videos for incarceration-specific and behaviour change theory–specific content and then developed a video that addressed these gaps. Design: Systematic review of educational videos and community-based participatory video development process. Setting: Community-based organisations, correctional health programmes. Method: Video development proceeded as a community-informed, iterative process of creating and testing the acceptability of a new DVD among end-user populations, community and correctional staff. Data collection and video development advisory process included three focus groups with opioid users and formerly incarcerated individuals, two consultations with national expert groups and overdose prevention programme staff and ongoing informal presentations to correctional staff and leadership. Results: Of nine eligible and reviewed videos, three contained theory-based learning components, and only one also contained peer-based content; none directly addressed post-incarceration overdose prevention. The created 19-minute film, Staying Alive on the Outside, uses interviews, conversation and model training sessions by peers, who candidly discuss the challenges of re-entry from prison, opioid addiction and relapse and misconceptions about opioid tolerance and overdose. Viewers learn strategies to avoid overdose while using opioids and what to do in an overdose. Peer ‘learners’ and peer ‘trainers’ model the dissemination of education and naloxone administration. Conclusion: The DVD is currently used in several prisons and jails; a multi-site evaluation of programme effectiveness is discussed.

Background Overdose is a leading cause of death for former prisoners, exacting its greatest toll during the first 2 weeks post release. Protective effects have been observed with training individuals at high risk of overdose and prescribing them naloxone, an opioid antagonist that reverses the effects of the opioid-induced respiratory depression that causes death. Cases The authors report 2 people with opiate use histories who self-administered intranasal naloxone to treat their own heroin overdoses following release from prison. Patient A is a 34-year-old male, who reported having experienced an overdose on heroin the day after he was released from incarceration. Patient B is a 29-year-old female, who reported an overdose on her first injection of heroin, 17 days post release from incarceration. Both patients self-administered the medication but were assisted at some point during the injury by a witness whom they had personally instructed in how to prepare and administer the medication. Neither patient experienced withdrawal symptoms following exposure to naloxone. Discussion Self-administration of naloxone should not be a goal of overdose death prevention training. A safer, more reliable approach is to prescribe naloxone to at-risk patients and train and also equip members of their household and social or drug-using networks in overdose prevention and response.

In the wake of the Francis Report and its 290 recommendations, the role and training of the healthcare assistant (HCA) have once again come under the spotlight. Francis asks for HCAs to be regulated and national standards for their education and training to be agreed ( Francis, 2013 ). The HCA Crisis Avoidance and Resource Management (CARMA) course has run at the Montagu Clinical Simulation Centre (MCSC), South Yorkshire for 5 years now. This article evaluates the impact that this course, which uses simulation-based education as a teaching methodology, has had on the attitudes of HCAs and on their role in clinical practice. Simulation is an ideal educational method for addressing nontechnical skills, such as communicating with patients and members of the multidisciplinary team ( Gaba, 2004 ). Allowing participants to prepare for emergency situations, simulation-based education gives individuals and teams the opportunity to practise within a safe environment, making behaviours more or less permanent ( Beaubien and Baker, 2004 ).

A case of heroin overdose reversed through the intravenous (IV) administration of a crushed sublingual tablet of buprenorphine/naloxone (Suboxone®) by a lay responder is described. Although the sublingual administration of buprenorphine/naloxone to reverse an overdose has been reported elsewhere, this is the first report of IV administration. Healthcare professionals should be aware that injection drug users may respond to an opioid overdose by injecting buprenorphine/naloxone and should consequently counsel all opioid-using patients on the proper response to an overdose. Physicians should also consider prescribing naloxone to at-risk patients. The work of community-based naloxone distribution programs should be expanded.

Individuals who use heroin and illicit opioids are at high risk for infection with human immunodeficiency virus (HIV) and other blood-borne pathogens, as well as incarceration. The purpose of the randomized trial reported here is to compare outcomes between participants who initiated methadone maintenance treatment (MMT) prior to release from incarceration, with those who were referred to treatment at the time of release. Participants who initiated MMT prior to release were significantly more likely to enter treatment postrelease ( P < .001) and for participants who did enter treatment, those who received MMT prerelease did so within fewer days ( P = .03). They also reported less heroin use ( P = .008), other opiate use ( P = .09), and injection drug use ( P = .06) at 6 months. Initiating MMT in the weeks prior to release from incarceration is a feasible and effective way to improve MMT access postrelease and to decrease relapse to opioid use.

Death from opiate overdose is a tremendous source of mortality, with a heightened risk in the weeks following incarceration. The goal of this study is to assess overdose experience and response among long-term opiate users involved in the criminal justice system. One hundred thirty-seven subjects from a project linking opiate-dependent individuals being released from prison with methadone maintenance programs were asked 73 questions regarding overdose. Most had experienced and witnessed multiple overdoses; 911 was often not called. The majority of personal overdoses occurred within 1 month of having been institutionalized. Nearly all participants expressed an interest in being trained in overdose prevention with Naloxone. The risk of death from overdose is greatly increased in the weeks following release from prison. A pre-release program of overdose prevention education, including Naloxone prescription, for inmates with a history of opiate addiction would likely prevent many overdose deaths.

Summary Background Methadone is an effective treatment for opioid dependence. When people who are receiving methadone maintenance treatment for opioid dependence are incarcerated in prison or jail, most US correctional facilities discontinue their methadone treatment, either gradually, or more often, abruptly. This discontinuation can cause uncomfortable symptoms of withdrawal and renders prisoners susceptible to relapse and overdose on release. We aimed to study the effect of forced withdrawal from methadone upon incarceration on individuals' risk behaviours and engagement with post-release treatment programmes. Methods In this randomised, open-label trial, we randomly assigned (1:1) inmates of the Rhode Island Department of Corrections (RI, USA) who were enrolled in a methadone maintenance-treatment programme in the community at the time of arrest and wanted to remain on methadone treatment during incarceration and on release, to either continuation of their methadone treatment or to usual care—forced tapered withdrawal from methadone. Participants could be included in the study only if their incarceration would be more than 1 week but less than 6 months. We did the random assignments with a computer-generated random permutation, and urn randomisation procedures to stratify participants by sex and race. Participants in the continued-methadone group were maintained on their methadone dose at the time of their incarceration (with dose adjustments as clinically indicated). Patients in the forced-withdrawal group followed the institution's standard withdrawal protocol of receiving methadone for 1 week at the dose at the time of their incarceration, then a tapered withdrawal regimen (for those on a starting dose >100 mg, the dose was reduced by 5 mg per day to 100 mg, then reduced by 3 mg per day to 0 mg; for those on a starting dose >100 mg, the dose was reduced by 3 mg per day to 0 mg). The main outcomes were engagement with a methadone maintenance-treatment clinic after release from incarceration and time to engagement with methadone maintenance treatment, by intention-to-treat and as-treated analyses, which we established in a follow-up interview with the participants at 1 month after their release from incarceration. Our study paid for 10 weeks of methadone treatment after release if participants needed financial help. This trial is registered with ClinicalTrials.gov, number NCT01874964. Findings Between June 14, 2011, and April 3, 2013, we randomly assigned 283 prisoners to our study, 142 to continued methadone treatment, and 141 to forced withdrawal from methadone. Of these, 60 were excluded because they did not fit the eligibility criteria, leaving 114 in the continued-methadone group and 109 in the forced-withdrawal group (usual care). Participants assigned to continued methadone were more than twice as likely than forced-withdrawal participants to return to a community methadone clinic within 1 month of release (106 [96%] of 110 in the continued-methadone group compared with 68 [78%] of 87 in the forced-withdrawal group; adjusted hazard ratio [HR] 2·04, 95% CI 1·48–2·80). We noted no differences in serious adverse events between groups. For the continued-methadone and forced-withdrawal groups, the number of deaths were one and zero, non-fatal overdoses were one and two, admissions to hospital were one and four; and emergency-room visits were 11 and 16, respectively. Interpretation Although our study had several limitations—eg, it only included participants incarcerated for fewer than 6 months, we showed that forced withdrawal from methadone on incarceration reduced the likelihood of prisoners re-engaging in methadone maintenance after their release. Continuation of methadone maintenance during incarceration could contribute to greater treatment engagement after release, which could in turn reduce the risk of death from overdose and risk behaviours. Funding National Institute on Drug Abuse and the Lifespan/Tufts/Brown Center for AIDS Research from the National Institutes of Health.

Injection drug users (IDUs) are at increased risk for HIV, viral hepatitis, and tuberculosis, and making up more than a quarter of the incarcerated population in the United States. Methadone maintenance treatment of opiate addiction is highly effective at reducing drug use, drug-related criminal activity, and risk of HIV transmission. Recently released inmates are at particularly high risk for overdose and disease transmission. Linkage to methadone treatment immediately upon release from incarceration is a promising opportunity to combat disease transmission, facilitate reentry into the community, and reduce recidivism.

Approximately 7 million people in the United States are in jail, in prison, or on probation or parole, many as a result of drug-related offenses. Individuals who use opiates account for a significant minority of this population. Methadone maintenance treatment (MMT) of opiate addiction is highly effective in reducing drug use, drugrelated criminal activity, and risk of human immunodeficiency virus transmission. Recently released inmates are at particularly high risk for overdose and disease transmission. Project MOD (Managing Opioid Dependency) provides services to eliminate logistical and financial barriers to MMT entry immediately on release from incarceration. Such programs provide a promising opportunity to facilitate reentry into the community, combat disease transmission, and reduce recidivism.

Injection drug users (IDUs) are at increased risk for many health problems, including acquisition of human immunodeficiency virus (HIV) and hepatitis B and C. These risks are compounded by barriers in obtaining legal, sterile syringes and in accessing necessary medical care. In 1999, we established the first-ever syringe prescription program in Providence, Rhode Island, to provide legal access to sterile syringes, reduce HIV risk behaviors, and encourage entry into medical care. Physicians provided free medical care, counseling, disease testing, vaccination, community referrals, and prescriptions for sterile syringes for patients who were not ready to stop injecting. We recruited 327 actively injecting people. Enrolled participants had limited stable contact with the health care system at baseline; 45% were homeless, 59% were uninsured, and 63% did not have a primary care physician. Many reported high-risk injection behaviors such as sharing syringes (43% in the last 30 days), reusing syringes (median of eight times), and obtaining syringes from unreliable sources (80%). This program demonstrates the feasibility, acceptability, and unique features of syringe prescription for IDUs. The fact that drug use is acknowledged allows an open and frank discussion of risk behaviors and other issues often not disclosed to physicians. The syringe prescription program in Providence represents a promising and innovative approach to disease prevention and treatment for IDUs.

Efforts to prevent the spread of HIV and hepatitis among injection drug users (IDUs) by improving access to sterile syringes can raise questions about syringe disposal. This study sought to evaluate the acceptability and utility of the Voyager, a newly approved, hand-held syringe disposal device for active injection drug users (IDUs). We offered the Voyager to active IDUs (n = 97), and interviewed them upon receiving the device and one month later. Almost all (90%) accepted the device. At follow-up, 78% had used the Voyager and 44% reported using it all the time; 65% reported they would like to continue using the Voyager and 77% rated the device “somewhat better” or “much better” than other methods of syringe disposal. Many IDUs care about safe syringe disposal and are willing and able to use a convenient disposal device such as the Voyager. Communities concerned about needlestick injuries and re-use of contaminated syringes should explore increasing the availability of such a device for IDUs as part of an overall approach to prevent improperly discarded syringes.

In order to assess attitudes and practices of physicians regarding prescribing syringes to injection drug users (IDUs) to prevent disease transmission, a survey was conducted at the 2000 ASAM Conference. Of 497 physicians, 104 responded, representing 30 states and 3 countries. Seventy-eight percent provided care for IDUs. Only 2% had prescribed syringes to IDUs for safer injection of illegal drugs. Nineteen percent had prescribed syringes to diabetic patients whom they believed would use the syringes for injecting illegal drugs. Overall, 61% of physicians (74% of internists, 37% of psychiatrists) (p = 0.04) would consider prescribing syringes to IDUs. Prescribing syringes to IDUs can be part of a comprehensive approach to preventing spread of HIV and other infections, decreasing complications of syringe reuse, and bringing IDUs into medical and substance abuse treatment. The majority of physicians surveyed expressed interest in prescribing syringes. Psychiatrists may be less willing to do so.

The challenge of addressing the epidemic of opioid overdose in Rhode Island, and nationwide, is only possible through collaborative efforts among a wide breadth of stakeholders. This article describes the range of efforts by numerous partners that have come together to facilitate community, and treatment-related approaches to address opioid-involved overdose and substance use disorder. Strategies to address this crisis have largely focused on increasing access both to the opioid overdose antidote naloxone and to high quality and timely treatment and recovery services. [Full text available at http://rimed.org/rimedicaljournal-2014-10.asp, free with no login].

This article describes the assessment of physicians' attitudes and practices regarding prescribing syringes to injection drug users (IDUs). A brief, anonymous, self-administered questionnaire was sent to all Infectious Disease and Addiction Medicine specialists in Rhode Island. Of 49 eligible physicians, 39 responded (response rate 80%). Most (95%) indicated that there is a legitimate medical reason for IDUs to obtain sterile syringes. Many (71%) agreed that they would prescribe syringes to prevent disease in IDUs if it were clearly legal to do so. We can conclude that physician syringe prescription to IDUs may be an acceptable supplement to existing HIV prevention strategies.

A significant number of people are currently misusing and abusing anabolic steroids. Hepatitis B, C, and HIV have all been documented to occur among anabolic steroid injectors (ASIs), most likely from the sharing of injection equipment. A survey was administered to 42 needle exchange programs (NEPs) from 17 states in the US to determine ASI participation. Sixty percent of the NEPs surveyed reported having at least some ASIs as participants, however, only 512 ASIs were identified among the 36,000 total monthly participants (1.4%). With the expanding number of NEPs in the US, it is possible to reach a higher proportion of ASIs with clean syringes and education, thus offering the means to prevent the spread of infection in this population.

Maintaining study cohorts is a key element of longitudinal research. Participant attrition introduces the possibility of bias and limits the generalizability of a study's findings, but with appropriate planning it is possible to sustain contact with even the most transient participants. This paper reviews the essential elements of tracking and follow-up of marginalized populations, which are (1) collection of contact information, (2) thorough organization of tracking efforts, (3) attention to staff training and support, (4) use of phone and mail follow-up, (5) use of incentives, (6) establishing rapport with participants, (7) assurance of confidentiality, (8) use of agency tracking, (9) use of field tracking, and (10) attention to safety concerns. Diligent application of these tracking strategies allows researchers to achieve follow-up rates of 75 percent to 97 percent with vulnerable populations such as homeless, mentally ill adults, injection drug users, and runaway youth.

Many probationers and parolees do not receive HIV testing despite being at increased risk for obtaining and transmitting HIV. A two-group randomized controlled trial was conducted between April, 2011 and May, 2012 at probation/parole offices in Baltimore, Maryland and Providence/Pawtucket, Rhode Island. Male and female probationers/parolees were interviewed (n = 1,263) and then offered HIV testing based on random assignment to one of two conditions: (1) On-site rapid HIV testing conducted at the probation/parole office; or (2) Referral for rapid HIV testing off site at a community HIV testing clinic. Outcomes were: (1) undergoing HIV testing; and (2) receipt of HIV testing results. Participants were significantly more likely to be tested on-site at a probation/parole office versus off-site at a HIV testing clinic (p < 0.001). There was no difference between the two groups in terms of receiving HIV testing results. Findings indicate that probationers/parolees are willing to be tested on-site and, independent of testing location, are equally willing to receive their results. Implications for expanding rapid HIV testing to more criminal justice related locations and populations are discussed.