Medications for Opioid Use Disorder in the Criminal/Legal System: Knowledge, Beliefs, and Attitudes Among Rural Community-Based Stakeholders

• Author: Brandon del Pozo,Guijin Lee,Catherine Zettner,Sydney Silverstein,Rahni Cason,Grant Victor,Bradley Ray
• DOI: 10.1177/00220426221076800
• Published date: 01 July 2022
• Date: 01 July 2022
• Subject Matter: Articles

Article

Journal of Drug Issues

2022, Vol. 52(3) 389–405

© The Author(s) 2022

Article reuse guidelines:

sagepub.com/journals-permissions

DOI: 10.1177/00220426221076800

journals.sagepub.com/home/jod

Medications for Opioid Use

Disorder in the Criminal/Legal

System: Knowledge, Beliefs,

and Attitudes Among Rural

Community-Based

Stakeholders

Grant Victor

1

, Guijin Lee

1

, Brandon del Pozo

2

, Sydney Silverstein

3

,

Catherine Zettner

1

, Rahni Cason

1

, and Bradley Ray

4

Abstract

The aim of this study was to describe rural community stakeholders’attitudes and perceptions of

providing medication for opioid use disorder (MOUD) to individuals in the criminal/legal system.

Data were utilized from a technical assistance initiative aimed at strengthening community-based

OUD treatment within criminal/legal systems. A mixed-methods approach was applied. Survey

responses were used to compare stakeholders’who had and had not attended an MOUD training,

and semistructured interviews were conducted with a convenience sample of rural criminal/legal

and treatment stakeholders. MOUD training was associated with endorsing the effectiveness of

methadone, oral naltrexone, and injectable naltrexone. Three primary themes emerged from the

stakeholder interviews: 1) acceptance of MOUD uptake; 2) stigma of MOUD and diversion

concerns; and 3) gaps in MOUD treatment. Most interviewees noted that there is a scarcity of

treatment options in their community, and among the existing services, there are considerable

barriers to care.

Keywords

bprenorphine, criminal/legal system, mixed-methods, medication for opioid use disorder

1

School of Social Work, Center for Behavioral Health and Justice, Wayne State University, Michigan, MI, USA

2

Miriam Hospital/Warren Alpert Medical School of Brown University, Department of Health Policy and Management,

Johns Hopkins Bloomberg School of Public Health, Rhode Island, RI, USA

3

Center for Interventions, Treatment, and Addictions Research, Wright State University, Boonshoft School of Medicine,

OH, USA

4

RTI International, Division for Applied Justice Research, 3040 Cornwallis Road, Research Triangle Park, NC 27709

Corresponding Author:

Grant Victor, School of Social Work, Center for Behavioral Health and Justice, Wayne State University, 5201 Cass

Avenue, Suite 226, Detroit 48202, USA.

Email: grantvictor@wayne.edu

Introduction

Rural communities across the United States have been impacted by an ongoing crisis of overdose

deaths—attributed largely to opioid use. From 1999 to 2015, rural counties experienced a 325%

increase in overdose-related mortality which outpaced the rates of overdose-related death in urban

areas (Hedegaard, Warner, & Miniño, 2017). Reasons for these rising rates include an increased

availability of prescription opioids, high rates of unemployment, rapid diffusion of drugs within

kinship networks, inadequate health insurance, and co-occurring mental health concerns (Dew,

Elifson, & Dozier, 2007;Roy, Arruda, Bruneau, & Jutras-Aswad, 2016;Snell-Rood, Staton-

Tindall, & Victor, 2016;Wenger, Lopez, Kral, & Bluthenthal, 2016). There are also distinct

characteristics of opioid-related mortality among rural residents, such as low health literacy related

to opioid overdose symptomology, increased likelihood of injecting in isolation without recourse

to rapid intervention in the event of overdose, and adverse effects related to injection drug use

(Dunn et al., 2016;Wang, Becker, & Fiellin, 2013;Wunsch, Nakamoto, Behonick, & Massello,

2009;Young, Havens, & Leukefeld, 2010).

Many rural areas do not have access to effective evidence-based treatments; specif‌ically,

medications for opioid use disorder (MOUD): methadone, buprenorphine, and naltrexone

(Brown, Goodin, & Talbert, 2018;Browne et al., 2016;Rosenblatt, Andrilla, Catlin, & Larson,

2015). A recent systematic review identif‌ied several “consumer-focused,”and “provider-focused”

barriers to MOUD care in rural areas (Lister, Weaver, Ellis, Himle, & Ledgerwood, 2020). For

instance, consumer-focused barriers (Ellis, Konrad, Thomas, & Morrissey, 2009;Kaufman et al.,

2016) included the dearth of MOUD treatment options available to rural residents with OUD,

while provider-focused studies (Andrilla, Coulthard& Larson, 2017;DeFlavio, Rolin, Nordstrom,

& Louis A Kazal, 2015;Jones, 2018;McCarty, Gustafson, Capoccia, & Cotter, 2004) referenced

barriers related to availability and acceptability of MOUD in rural communities (Lister et al.,

2020). Anticipated stigma, whereby individuals come to expect particular forms of discriminatory

treatment (Turan et al. 2017;VanBrakel et al. 2019), has also been identif‌ied as a barrier associated

with MOUD—particularly agonist therapies—such that reinforcing negative attitudes may be-

come internalized, and negatively impact on individuals’mental health and willingness to utilize

treatment (Crapanzano, Hammarlund, Ahmad, Hunsinger, & Kullar, 2018).

Publicly-enacted forms of stigma against individuals with substance use disorders (e.g., use of

discriminatory/biased language, mistrust of patients; framing as unmotivated patients) has a

detrimental effect on providers’attitudes and motivation to prescribe MOUD (Andrilla et al.,

2017;DeFlavio et al., 2015;Jones, 2018;McCarty et al., 2009;Quest, Merrill, Roll, Saxon, &

Rosenblatt, 2012). A recent qualitative study of community stakeholders (i.e., healt hcare and

treatment providers, law enforcement and judicial off‌icials) in rural Appalachia found widespread

mistrust of MOUD, with stigma against MOUD accepted culturally and incorporate d into local

policies (Richard et al., 2020). From the perspective of individuals that live in rural areas who are

in recovery from OUD, stigma-related barriers to MOUD treatment were pronounced in health

care settings, with pharmacies and pharmacist technicians being the most prominent enactors of

stigma, through use of stigmatizing language and discriminatory treatment in clinical settings

(Burgess et al., 2021). There is also growing evidence that individuals from rural communities

with OUD experience stigma across multiple domains—publicly enacted, anticipated, experi-

enced, and internalized—see Turan et al. (2017) for a conceptual model), which, along with

structural factors (Lister et al., 2020; e.g., lack of access to treatment), generate more expansive

barriers to care for rural people who use drugs. There is also little knowledge whether MOUD

training may help mitigate these negative attitudes (Beachler, Zeller, Heo, Lanzillotta-Rangeley, &

Litwin, 2021).

390 Journal of Drug Issues 52(3)