(51) Elevating Patient Voices: Substance Use Care, Recovery Support, & Overdose Prevention

Background & Introduction: Harm reduction and public health messaging encourages people who use drugs (PWUD) to not use alone to reduce risk, yet people who suffer fatal overdoses are often found alone (1). Factors influencing solitary drug use include the availability of drugs, personal safety, stigma and shame, privacy concerns, and lack of engagement with harm reduction services (2,3,4). Home outreach, prevention hotlines, and supervised consumptions sites have been conceived as mitigating measures (5). Cook County Health’s Substance Use Disorder (SUD) program provides medications for opioid use disorder plus embedded recovery support services within the safety net healthcare system to over 500 patients each month. Patients’ patterns of drug use and their preferences, beliefs, and attitudes toward various SUD treatment and overdose prevention options within the Cook County Health (CCH) SUD program are not well understood.

Methods: This cross-sectional, observational study performed secondary analysis of patient surveys and corresponding demographic and clinical data of 77 adult patients being actively treated for SUD within CCH’s outpatient health centers or emergency department. Recovery coaches administered the survey during routine clinical care (November 2023 - January 2024) using REDcap. The survey contained 87 patient-reported items. Items of interest for this study included patient-reported solitary drug use, patient-reported substance use behaviors, patient-reported preferences for substance use treatment, and overdose prevention strategies. By linking survey data to the electronic medical record, we collected participant demographics, medical utilization data, and patient-reported social functioning measures. The social functioning measures were collected using a validated 4-item short form from the Patient-Reported Outcomes Measurement Information System (PROMIS). Fisher's exact tests of independence were used to explore associations between different demographic factors and attitudes towards different SUD treatment and overdose prevention tools. We used stepwise logistic regression modeling to determine which patient factors were most able to predict solitary substance use. In the model, variables except for PROMIS scores were dichotomized and then removed for p>0.2. Statistical analyses were conducted in STATA. Free text answers were analyzed for thematic groupings. This study is approved by CCH’s Institutional Review Board.

Results: Of the 77 patients surveyed, 77.9% identified as male; 41.6% identified as non-Hispanic white, 37.7% as non-Hispanic Black, and 14.3% as Hispanic/Latinx. Patients’ mean age was 45.4 years (range 23 - 68 years), and the majority (63.6%) were involved in the criminal legal system as defined by prior registration in Cook County Jail. See table for additional demographic data. Over three-quarters (76.6%, n=59) of patients sometimes or usually use drugs alone. This did not differ significantly when stratified by race, gender, relationship status, history of overdose in the past 2 years, involvement in the criminal legal system, or whether or not the patient had a primary care provider. The most commonly cited reasons for using drugs alone were the lack of ability or desire to share drugs (n=11), preferring to be alone while using (n=10), using alone out of habit (n=8), and shame or stigma (n=6). Sixty-one percent (n=47) of patients usually kept naloxone available when using drugs. This did not differ when stratified by the presence or absence of solitary drug use. Almost three-quarters (74.6%, n=44) of patients who use drugs alone said they would use at least one of the following existing overdose prevention tools: Never Use Alone hotline, fentanyl/benzodiazepine/xylazine test strips, or a community drug testing center. Almost half (45.5%, n=35) of all patients would use an overdose prevention site if it were available locally. Patients who reported better social functioning had lower odds of using drugs alone, with a 12% decreased odds of solitary use for every 1 point increase in PROMIS score.

Conclusion & Discussion: Most patients in the sample reported using drugs alone. While efforts to expand access to naloxone are critical to an overall overdose prevention strategy, it is of limited use for individuals who use alone. It is critical to offer a variety of overdose prevention tools from which patients may choose. The vast majority of surveyed patients who use alone indicated interest in other evidence-based overdose prevention strategies. The CCH SUD program is engaging in a quality improvement effort to train patients and team members on additional overdose prevention tools. Overdose prevention centers are not available locally, but these data suggest this could be a utilized tool to serve our patient population. Our findings are limited by the small sample size, and results may be less translatable to populations that differ significantly from our study cohort or to locations outside of urban safety net health care systems. More research is warranted to determine how to best support patients’ social functioning, and how this may reduce solitary drug use.

References: 1. Bardwell, G., Kerr, T., & McNeil, R. (2019). The Opioid Overdose Epidemic and the Urgent Need for Effective Public Health Interventions That Address Men Who Use Drugs Alone. American journal of men's health, 13(3), 1557988319859113. https://doi.org/10.1177/1557988319859113

2. Rosen, J. G., Glick, J. L., Zhang, L., Cooper, L., Olatunde, P. F., Pelaez, D., Rouhani, S., Sue, K. L., & Park, J. N. (2023). Safety in solitude? Competing risks and drivers of solitary drug use among women who inject drugs and implications for overdose detection. Addiction (Abingdon, England), 118(5), 847–854. https://doi.org/10.1111/add.16103

3. Gicquelais, R. E., Genberg, B. L., Maksut, J. L., Bohnert, A. S. B., & Fernandez, A. C. (2022). Prevalence and correlates of using opioids alone among individuals in a residential treatment program in Michigan: implications for overdose mortality prevention. Harm reduction journal, 19(1), 135. https://doi.org/10.1186/s12954-022-00723-4

4. Fernando, S., Hawkins, J., Kniseley, M., Sikora, M., Robson, J., Snyder, D., Battle, C., & Salmon, A. (2022). The Overdose Crisis and Using Alone: Perspectives of People Who Use Drugs in Rural and Semi-Urban Areas of British Columbia. Substance use & misuse, 57(12), 1864–1872. https://doi.org/10.1080/10826084.2022.2120361

5. Fleming, T., Boyd, J., Chayama, K.L. et al. Using alone at home: What’s missing in housing-based responses to the overdose crisis?. Harm Reduct J 21, 24 (2024). https://doi.org/10.1186/s12954-024-00933-y