1. Michele Staton-Tindall, Ph.D., M.S.W. University of Kentucky College of Social Work Center on Drug & Alcohol Research Presented to the University of Kentucky Symposium on Drug Abuse, Obesity, and Diabetes in Appalachia November 17, 2015

2.  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

3.  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.

4.  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 studies 1.  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. 1 Havens, Walker, & Leukefeld, 2007

5.  Funded by NIDA in July 2012

7.  Screening – NIDA Modified ASSIST (N=688) Total ScoreLow RiskMod riskHigh Risk Rx Opioid26.5 (sd=14.3)14.8%22.8%62.4% Sedatives/Sleep Pills19.7 (sd=14.9)26.5%32.0%41.6% Methamphetamine14.9 (sd=15.7)44.0%23.4%32.6% Marijuana11.8 (sd=11.7)36.1%48.1%15.8% Street Opioid10.0 (sd=14.7)62.4%16.3%21.4% Cocaine8.9 (sd=12.2)55.1%31.1%13.8% Rx Stimulant6.6 (sd=11.0)65.3%24.7%10.0%

8.  Random selection  Screening  Baseline interviews (N=400)  HIV/HCV testing  Brief intervention  Education (NIDA Standard)  Education + Brief Motivational Interviewing for HIV Risk

9. Lindsey 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.

10. Randomly selected for screening N=900 Screened Eligible N=425 No drug use (n= 6) No risky sex (n= 11) Refusal (n= 105) Baseline completed N =400 Time frame (n=192) Randomization Intervention Group n = 199 Intervention Group n = 199 Comparison Group n = 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)

11.  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 WaveFollow-up Percentage 3 month88% 6 month84% 12 month86%

13. Percent/Mean (SD) SD, Range Age32.88.2, 18-61 Race - %white99.0% Average days spent incarcerated70.287.7, 3-800 Ever had a driver’s license75.8% Current marital status – married32.0% Have any children87.2% Highest grade of education completed11.12.3, 0-19 Working full or part time in past 6 months22.8% Had money problems in 6 months before jail71.3%

15. Ever UsedUsed in Past Year Opiates97.8%89.2% Alcohol96.8%57.5% Marijuana95.8%76.3% Stimulants88.5%51.5% Downers86.8%80.9% Methamphetamine74.3%73.2% Heroin46.8%61.5%

16. 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)

17. Ever InjectedPast 6 MonthsPast 30 Days Any Drug75.5%78.2%50.6% Prescription Pain Relievers88.4%68.5%39.9% Prescription Stimulants23.8%39.4%6.3% Prescription Benzodiazepines31.9%55.2%10.8% Methamphetamine66.2%70.0%29.4% Cocaine53.0%39.6%12.3% Heroin38.9%48.7%9.3%

18. Percent reporting lifetime history of… Major or Untreated Dental Problems34.8% Convulsions, Migraines, or Nervous System Problems34.3% Allergies34.0% Heart, Blood or Circulatory Problems23.3% Asthma, Shortness of Breath, or Other Respiratory Problems19.5% Female Problems17.5% Bone, Muscle, or Foot Problems15.0% Stomach or Digestive System Problems12.5% Tumors, Cancer, or Unusual Lumps Under Skin11.3% Vitamin Deficiencies, Fluid Buildup, Anemia10.3% Diabetes, Thyroid Problems9.3% Physical Injuries or Unhealed Wounds8.0% Any Other Major Medical Problems6.3% Sexual or Fertility Problems4.5% Skin Problems1.8%

19. Percent endorsing symptoms (GAIN) in past year consistent with… Major Depressive Disorder68.5% Posttraumatic Stress Disorder67.4% Generalized Anxiety Disorder45.3%

20. 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 partners4.5% Last main partner injected drugs58.1% Last male casual partner injected drugs48.3% Used drugs/alcohol before sex with main partner83.2% Used drugs/alcohol before sex with male casual partner89.4%

21. Ever been told by a doctor/health care provider that you were HIV positive? 0% Tested positive for HIV in the study0% Ever been told by a doctor/health care provider that you were HCV positive? 26.3% Tested positive for HCV in the study59.0%

23. 46.6%

24. 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.

26. Routine physical exam17.4% Routine eye exam16.1% Routine dental exam28.8% Pap Smear or women's health exam25.6% Mammogram12.3%

27. Lifetime… Ever been in substance treatment49.8% Ever sought mental health treatment55.5%

28. *** p<.000

29. Bp OR (CI 95) Age0.05.017 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)

30.  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.

31. Contact information: Michele Staton-Tindall, Ph.D. UK College of Social Work UK Center on Drug & Alcohol Research 659 Patterson Office Tower Lexington, KY 40508 Email: mstindall@uky.edumstindall@uky.edu Phone: 859-257-2483