DRUG USE AND HEALTH AMONG WOMEN IN APPALACHIA

Michele Staton-Tindall, Ph.D., M.S.W.

University of KentuckyCollege of Social Work

Center on Drug & Alcohol Research

Presented to the University of Kentucky Symposium on Drug Abuse, Obesity, and Diabetes in AppalachiaNovember 17, 2015

Acknowledgement This presentation is supported by the National

Institute on Drug Abuse (R01-DA033866).

Recognize the cooperation and partnership with the Kentucky Department of Corrections and jail administrators and staff in the Laurel County Detention Center, Leslie County Detention Center, and Kentucky River Regional Jail.

Recognize project Co-Investigators: Matt Webster, Carrie Oser, Jennifer Havens, and Carl Leukefeld

Presentation objectives Describe UK study in Appalachia targeting

screening and brief intervention for substance use and high risk sexual behavior among rural women.

Profile drug use and related health risks of 400 rural Appalachian women.

Discuss clinical implications for identifying and targeting services for at-risk and hard-to-reach substance users in rural areas.

Background Drug abuse, especially prescription opiates, is rampant

in certain rural areas of the country, particularly the Appalachian region.

In recent years, the injection prevalence rate is higher among KY samples of opiate users from Appalachia (44.3%) than reported in other national studies1.

The rise of injection drug use in Appalachia creates an impending and significant public health concern.

One group that may be particularly vulnerable to the negative consequences of injection drug use including HIV and HCV is women who engage in high-risk drug use and risky sexual activities.

1Havens, Walker, & Leukefeld, 2007

Project overview Funded by NIDA in July 2012

Recruitment sites – Random selection

Methods Screening – NIDA Modified ASSIST (N=688) Total Score Low Risk Mod risk High Risk

Rx Opioid 26.5 (sd=14.3) 14.8% 22.8% 62.4%

Sedatives/Sleep Pills 19.7 (sd=14.9) 26.5% 32.0% 41.6%

Methamphetamine 14.9 (sd=15.7) 44.0% 23.4% 32.6%

Marijuana 11.8 (sd=11.7) 36.1% 48.1% 15.8%

Street Opioid 10.0 (sd=14.7) 62.4% 16.3% 21.4%

Cocaine 8.9 (sd=12.2) 55.1% 31.1% 13.8%

Rx Stimulant 6.6 (sd=11.0) 65.3% 24.7% 10.0%

Methods Random selection

Screening

Baseline interviews (N=400)

HIV/HCV testing

Brief intervention Education (NIDA Standard) Education + Brief Motivational Interviewing for HIV Risk

Intervention typical caseLindsey is a 26 year old white female from Perry County, KY. She is currently in the Leslie County Jail for possession of a forged instrument, escape, and contraband. She began experimenting with drugs at the age of 15 (marijuana and alcohol), however, she was a talented basketball player and this limited her use to parties on weekends. Lindsey experimented with prescription pain pills and became a heavy user during the last semester of her senior year in high school, after basketball season was over. She reports she has been in and out of jail since she graduated at the age of 18. Her drug of choice is Oxycodone (previously OxyContin, currently Roxicodone 30’s). She reports she has been using drugs via IV for 6 or 7 years.

Lindsey has a supportive mother and father, who has attempted to help her get sober on numerous occasions. They have paid to send her to rehab five times. Lindsey says she didn’t take the rehab serious and her parents have given up on her ever changing. Lindsey’s 28 year old sister was also a drug addict, but has maintained sobriety for two years. She now has a job and is doing well. Lindsey appears jealous of her sister and seems annoyed that she is sober.

Randomly selected for screening

N=900

Screened EligibleN=425

No drug use (n= 6)

No risky sex (n= 11)

Refusal (n= 105)

Baseline completedN =400

Time frame (n=192)

Randomization

Intervention Groupn = 199

Comparison Groupn = 201

Released early (n=150)

Not from area (n=11)

Not screened(n=255)

Screened Ineligible(n=220)

Released (n=23)Refusal (n=2)

Baseline not completed (n=25)

Final Study CONSORT

Follow-up Follow-ups are currently being conducted at 3, 6,

and 12 months post-release to examine changes in injection drug use practices, other drug use, sex risk behavior, and service utilization.

Current follow-up rates

Wave Follow-up Percentage

3 month 88%

6 month 84%

12 month 86%

Participant Profile

Demographics (N=400)

Percent/Mean (SD) SD, Range

Age 32.8 8.2, 18-61

Race - %white 99.0%

Average days spent incarcerated 70.2 87.7, 3-800

Ever had a driver’s license 75.8%

Current marital status – married 32.0%

Have any children 87.2%

Highest grade of education completed 11.1 2.3, 0-19

Working full or part time in past 6 months 22.8%

Had money problems in 6 months before jail 71.3%

Drug use and health risk

Drug and alcohol use

Ever Used Used in Past Year

Opiates 97.8% 89.2%

Alcohol 96.8% 57.5%

Marijuana 95.8% 76.3%

Stimulants 88.5% 51.5%

Downers 86.8% 80.9%

Methamphetamine 74.3% 73.2%

Heroin 46.8% 61.5%

Drug and alcohol use (cont)

Average number of days using multiple substances in one day in the past 6 months

132.3(sd=70.3, range 0-180)

Average number of days in the past 6 months being “high” on drugs

135.8(sd=70.1, range 0-180)

Average number of days in the past 6 months being “drunk” for most of the day

11.0(sd=37.3, range 0-180)

Injection drug use (IDU)

Ever Injected Past 6 Months Past 30 Days

Any Drug 75.5% 78.2% 50.6%

• Prescription Pain Relievers 88.4% 68.5% 39.9%

• Prescription Stimulants 23.8% 39.4% 6.3%

• Prescription Benzodiazepines 31.9% 55.2% 10.8%

• Methamphetamine 66.2% 70.0% 29.4%

• Cocaine 53.0% 39.6% 12.3%

• Heroin 38.9% 48.7% 9.3%

HealthPercent reporting lifetime history of…

Major or Untreated Dental Problems 34.8%Convulsions, Migraines, or Nervous System Problems 34.3%Allergies 34.0%Heart, Blood or Circulatory Problems 23.3%Asthma, Shortness of Breath, or Other Respiratory Problems 19.5%Female Problems 17.5%Bone, Muscle, or Foot Problems 15.0%Stomach or Digestive System Problems 12.5%Tumors, Cancer, or Unusual Lumps Under Skin 11.3%Vitamin Deficiencies, Fluid Buildup, Anemia 10.3%Diabetes, Thyroid Problems 9.3%Physical Injuries or Unhealed Wounds 8.0%Any Other Major Medical Problems 6.3%Sexual or Fertility Problems 4.5%Skin Problems 1.8%

Mental health

Percent endorsing symptoms (GAIN) in past year consistent with…

Major Depressive Disorder 68.5%

Posttraumatic Stress Disorder 67.4%

Generalized Anxiety Disorder 45.3%

Sexual health risk behavior

Age first time had sex 14.8(sd=2.05; range 6—22)

Average number of lifetime male sexual partners 33.0(sd=49.77; range 2—500)

Average number of lifetime female sexual partners 3.5(sd=9.85; range 0—500)

Ever had sex in exchange for $, drugs, etc. 43.5%

Always uses condom/protection with main partners 4.5%

Last main partner injected drugs 58.1%

Last male casual partner injected drugs 48.3%

Used drugs/alcohol before sex with main partner 83.2%

Used drugs/alcohol before sex with male casual partner 89.4%

HIV/HCV

Ever been told by a doctor/health care provider that you were HIV positive?

0%

• Tested positive for HIV in the study 0%

Ever been told by a doctor/health care provider that you were HCV positive?

26.3%

• Tested positive for HCV in the study 59.0%

46.6%

Focus Groups: HCV

Drug use impacts health, particularly increasing the risk for HCV…

Oh yeah, Hepatitis is just like a plague around here. 9 times out of 10 around here you’ll have it around here.

It’s not a big thing [laughter], “oh hey, I got Hep”. I don’t mean that in a negative way toward the area around here, it’s just that the IV drug use is so heavy around here. When you have such common IV drug use, hepatitis just comes with it.

Clinical implications

Past year health service use

Routine physical exam 17.4%

Routine eye exam 16.1%

Routine dental exam 28.8%

Pap Smear or women's health exam 25.6%

Mammogram 12.3%

Behavioral health service use

Lifetime…

Ever been in substance treatment 49.8%

Ever sought mental health treatment 55.5%

Insurance coverage at 3 month follow-up***

Study Enrollment0%

10%20%30%40%50%60%70%80%90%

36.5%

79.3%

Before ACA (n=137) After ACA (n=82)***p<.000

Access to health care at 3 month follow-up

B p OR(CI 95)

Age 0.05 .017 1.06(1.01-1.10)

Income during 6 months prior to incarceration -.07 .018 0.94

(0.89-0.99)

Had money problems during 6 months before incarceration 1.03 .008 2.81

(1.31-6.03)

Insured for at least 1 month during 3 month follow-up period 1.60 .000 4.94

(2.49-10.64)

# of days bothered by health problems during 3 month follow-up 0.13 .014 1.14

(1.03-1.26)

Conclusions and Implications Rates of drug use, particularly prescription opioid use, are

alarmingly high in this area of Appalachia.

Injection is the preferred route of administration, which is coupled with increased public health risks including HCV and HIV.

Risky drug use is associated with a number of mental health and health consequences, including HCV.

Jails provide an important venue to identify, assess, and intervene with high-risk rural women substance users who may not access services.

Questions?

Contact information:

Michele Staton-Tindall, Ph.D.UK College of Social Work

UK Center on Drug & Alcohol Research659 Patterson Office Tower

Lexington, KY 40508

Email: mstindall@uky.eduPhone: 859-257-2483