Kentucky Communities and Researchers Engaging to Halt the Opioid Epidemic (CARE2HOPE)

National Institute on Drug Abuse (NIDA), Appalachian Regional Commission, Substance Abuse and Mental Health Services Administration (SAMHSA), Centers for Disease Control and Prevention, Emory University

This study will test the effects of an intervention to reduce substance use and related harms among people leaving rural jails or otherwise involved in the criminal justice system. This study will compare people in a health linkage intervention with people who will get overdose (OD) education. Everyone will take part in the baseline and follow-up surveys and receive OD education. Participants will be assigned to one of the two groups by chance based on when they are enrolled to the study and if their county is randomly assigned to an intervention or a comparison condition. By doing this study, the investigators hope to learn if providing linkage to health services along with HIV, hepatitis C virus (HCV), and overdose education to people leaving rural jails or otherwise involved in the criminal justice system will reduce substance use and related harms.

The overarching objective of this study is to determine the effectiveness of an evidence-based community response project using a community randomized trial. Specifically, the investigators will test the effect of an intervention to reduce substance use and related harms among people re- entering the community from rural jails or otherwise recently involved in the criminal justice system (out on bond, under warrant for arrest, arrested, on pre-trial supervision, probation or parole, court-involved, or under home incarceration with digital monitoring). This study will compare people in a health navigation intervention with a comparison group of people who will get overdose education. Everyone will take part in follow-up surveys for up to 6 months after release. The intervention is a health navigation intervention designed to reduce substance use disorder (SUD) and increase engagement in the SUD care cascade; reduce vulnerability to HIV, sexually transmitted infections (STIs), and HCV and increase engagement in the HIV, STI, and HCV care cascades; and reduce vulnerability to overdose deaths among adults who use drugs and are leaving local jails or otherwise involved in the criminal justice system. The intervention is based on enhancements to START, a CDC-recognized, evidence-based, individual-level intervention designed to reduce HIV/STI/HCV risk. START core components: (1) Hold pre- and post-release program sessions with clients transitioning back to the community from a correctional setting; (2) Use a client-focused incremental risk reduction approach; (3) Use assessment & documentation tools to provide structure; (4) Hire program staff that are familiar with HIV/STIs/HCV prevention and with the specific needs of people being released; (5) Staff /client relationships must be maintained post-release; (6) Conduct enrollment and schedule two pre-release program sessions within 60 days of a client's release that: a. give HIV/STI/HCV information; b. review client's HIV/STI/HCV risk; c. identify transitional needs; d. develop a personalized risk reduction and transitional plan; e. make facilitated referrals; 7) Schedule four post-release sessions to review and update the risk reduction/ transitional plan(s) and provide facilitated referrals; (8) Provide condoms at each post-release session; (9) Actively maintain contact with clients. The investigators will modify START a priori as follows: 1) Though originally designed for young men, START has been successfully applied to women leaving correctional settings. The investigators will implement START with all genders; 2) START originally targeted incarcerated people preparing to leave correction facilities. The investigators will continue to target individuals who are incarcerated but also expand the target population to people who are involved in other parts of the criminal justice system (e.g., those out on bond, under warrant for arrest, arrested, court-involved; those on probation, parole or pre-trial supervision; and individuals under home incarceration with digital monitoring [an ankle monitoring program]). Individuals who are not incarcerated will be recruited in the communities. 3) All intervention sessions will be conducted in the community setting (post-release for those recruited in jails). 4) START's post-release sessions primarily occurred in homes and community venues, such as restaurants. Staff who will deliver START will be stationed primarily within the local department of health (DOH); 5) To enhance START's impact on drug use and HIV/HCV-related harms (e.g., drug injection frequency), the investigators will integrate the NIDA Standard HIV intervention into START, including rapid HIV and HCV antibody testing and counseling. In addition, START interventionists will distribute harm reduction supplies at the first intervention session with people who inject drugs (PWID). The NIDA Standard has been demonstrated to reduce drug use frequency, high-risk injection practices, and sexual risk; 6) START was not designed to reduce overdoses. The investigators will integrate an interactive training with animated scenarios and narration on preventing, recognizing, and responding effectively to an opioid OD. Participants in the intervention group will receive naloxone (not all participants will get naloxone), at their first intervention session. Interventionists will encompass OD in risk reduction motivational interviewing. 7) To accommodate participants who are not able to visit the study office in-person, data collection and intervention sessions will be conducted remotely via phone or videoconferencing. CARE2HOPE covers the following counties: Rowan, Bath, Morgan, Menifee, Elliott, Lee, Owsley, Wolfe, Perry, Letcher, Leslie, Knott. Research staff will recruit participants from a) jails, b) Probation, Parole and Pre-Trial Services c) digital jails (i.e. home incarceration with digital monitoring programs); d) peer referral; e) existing participants in CARE2HOPE and other University of Kentucky studies, including PROUD-R2 (Peer-Based Retention of People Who Use Drugs in Rural Research) and SNAP (Social Networks among Appalachian People), who have consented to be contacted to learn about future studies; f) harm reduction and social service programs serving people who use drugs; and g) community-based organizations serving the 12 CARE2HOPE counties. Recruitment in jails will involve jails either located in CARE2HOPE counties or counties that have contracts with them to incarcerate their residents. The intervention sessions and data collection will be delivered by research staff called "Rural Health Navigators" or "REHNs". Participants are assigned to one of the two groups by chance based on when they are enrolled to the study and when their county is randomly chosen to start the project. Counties were originally randomized using a stepped wedge design. The counties were then randomized in November 2020, accounting for a new study design. The investigators randomized 12 study counties to two groups. In Months 1-6 six counties randomly assigned to Group 1 will recruit participants to the intervention, while in the remaining six counties (Group 2) the participants will be enrolled into a control condition. The investigators anticipate an average enrollment of 40 participants per county per arm, with a total final sample size for the trial of 960 (n=480intervention, n=480comparison). After a county has met its target enrollment in both conditions, the intervention and comparison activities will no longer be offered in that county.

Substance Use, HIV Infections, HCV Infection, Sexually Transmitted Infections (Not HIV or Hepatitis), Overdose, Drug, Opioid Use

Community randomized trial. Six counties will be randomized to start 6 months of enrollment into an intervention condition. Six other communities will be assigned to 6 months of a comparison condition. All participants in both the intervention and comparison conditions will be followed for 6 months for data collection.

Research staff will: 1) meet with participants in a community setting, by phone, or video call to ask them questions about drug use and related behaviors, access to needed health and social services, and personal goals; provide overdose education and help develop a plan for reducing risks and accessing services; conduct saliva drug testing, offer HIV and hepatitis C testing and counseling, naloxone, and harm reduction supplies, and connect participants with needed services; 2) follow up with participants once a month for three months to help participants overcome challenges; and 3) six months after enrollment to the study, contact participants to conduct saliva drug testing. Participants will complete surveys at baseline, 3 months, and 6 months. The baseline will be conducted in jail for incarcerated participants preparing for re-entry, or in a community setting for those recruited in the community. The 3 and 6-month surveys will be conducted in a community setting.

The investigators will initiate the comparison group in Group 2 counties six months before the intervention begins. Research staff will conduct an overdose intervention with the comparison cohort. This will occur pre-release if individual is recruited in jail. The comparison group participants will watch a video on preventing, recognizing, and responding effectively to an opioid OD, accompanied by information about Kentucky's Good Samaritan Law and Naloxone Access Law. Research staff will answer questions after the video. Individuals will receive a Community Resource Guide at this visit. As in the intervention group, the comparison group participants will complete surveys at the baseline (in jail if recruited in jail, in a community setting if recruited in the community), and at 3 months and 6 months after the baseline. Surveys will be identical to those delivered to the intervention cohort.

Research staff will: 1) help participants set goals and reduce their health risks by helping them to reflect on personal drug use, sexual relationships, and their consequences in the context of personal values and goals; 2) help link participants to services that they need and want; 3) offer participants the option of HIV and hepatitis C testing, provide the test result, and provide post-test counseling; and 4) provided participants nasal spray naloxone (Narcan) to carry with them in case they encounter someone who has an opioid overdose or in case they have an opioid overdose and a friend can use the naloxone to respond.

Participants will complete a 10-minute overdose education training video on preventing, recognizing, and responding effectively to an opioid OD.

Item:Self-reported frequency of substance use to get high in past 30 days (continuous variable) Source: Rural opioid initiative (ROI Harmonized UG3 Survey) Harmonized UG3 Survey

Item: Self-reported recent (past 30 days) frequency of using a syringe that had been previously used by someone else (continuous; number and proportion) Source: ROI Harmonized UG3 Survey

Item: Self-reported recent (past 30 days) frequency of condomless anal or vaginal sex (continuous; number and proportion) Source: ROI Harmonized UG3 Survey

Item: Self-reported recent (past 30 days) frequency of using a syringe that had been previously used by someone else (continuous; number and proportion) Source: ROI Harmonized UG3 Survey

Item: Self-reported recent (past 30 days) frequency of shared cookers, cotton, spoon, or water (continuous; number and proportion) Source: ROI Harmonized UG3 Survey

Item:Self-reported recent (past 90 days) number of times overdosed (ordinal, continuous) Source: Modified from ROI Harmonized UG3 Survey

Item:Self-reported recent (past 30 days) frequency of using a syringe that had been previously used by someone else (continuous; number and proportion) Source: ROI Harmonized UG3 Survey

Item: Self-reported recent (past 30 days) frequency of injection (ordinal, continuous) Source: ROI Harmonized UG3 Survey

Item:Self-reported recent (past 90 days) number of days carrying naloxone (continuous) Source: Modified from ROI Harmonized UG3 Survey

Item: Self-reported recent (past 90 days) engagement in evidence-based responses (i.e., called 911, gave naloxone, stayed until an ambulance or police arrived, transported person to the hospital) to a witnessed overdose by self or other bystanders (nominal) Source: CDC NHBS Supplemental overdose items

Change in number of days on medication for opioid use disorder (MOUD) among participants for whom MOUD is indicated

Item:Self-reported recent (past 90 days) frequency of being on MOUD (continuous) Source: Modified from ROI Harmonized UG3 Survey

Item:Self-reported recent (past 90 days) access to follow-up HCV RNA testing (nominal); Source: ROI Harmonized UG3 Survey

Item: Self-reported recent (past 90 days) frequency of receiving treatment among those who test RNA positive (binary) Source: Modified from ROI Harmonized UG3 Survey

Change in proportion of syringes obtained from syringe service program among participants who inject drugs

Item: Self-reported proportion of recent (past 90 days) injections that involved a new, sterile syringe obtained from a syringe service program (continuous, proportion) Source: ROI Harmonized UG3 Survey

Inclusion Criteria: Be aged 18 or older; and A resident of one of the 12 CARE2HOPE counties randomized to intervention or control data collection; and Have used opioids to get high in the past 30 days or have injected any drug to get high during that same period (if incarcerated at home under digital monitoring program or on probation or parole: have used opioids to get high or injected any drug to get high in 30 days before the date of incarceration or start of the probation or parole term); and Have been recently involved in the criminal justice system defined as being incarcerated in jail or prison, out on bond, under warrant for arrest, arrested, under pre-trial supervision, on probation or parole, court-involved, or individuals who are incarcerated at home under an electronic monitoring program (i.e., digital jail) in the past 30 days. OR Be a resident of or anticipate being released to one of the 12 CARE2HOPE counties randomized to intervention or control data collection; and Have used opioids to get high in the 30 days before they were incarcerated, or have injected any drug to get high during that period; and Be aged 18 or older; and Be incarcerated in a local jail and expected to be released in <21 days OR Be a participant in the CARE2HOPE longitudinal survey who consented to be contacted for future research; and Be a resident of or anticipate being released to one of the 12 CARE2HOPE counties randomized to intervention or control data collection; and Have used opioids to get high in the 30 days before they were incarcerated, or have injected any drug to get high during that period; and Be aged 18 or older; and Be incarcerated in a local jail and expected to be released in <21 days Exclusion criteria: Previously enrolled in the START-C2H study (i.e., cannot enroll more than once) Not speaking English fluently Residence in or move to a county not randomized to intervention or control data collection within 21 days of release Transfer to prison Being charged with a violent crime (e.g., homicide, murder, rape and sexual assault, robbery, and assault) Having been incarcerated for one year or more

Data from the University of Kentucky are required to be submitted to the University of Washington as part of the NIH-funded Rural Opioid Initiative (ROI) data harmonization project. The University of Washington Data Harmonization Coordinating Center will be harmonizing data across 8 ROI studies in order to create new, harmonized datasets to be used for analyses across the consortium. The University of Washington and other ROI grantees will perform data analyses on these data for peer-reviewed publication. The harmonized datasets will be provided to other ROI grantees as required for analysis and will be considered under the umbrella of mandated DCC activities. No third parties outside of the ROI will be given access to this harmonized data. Harmonized datasets will be built to specific project concept proposals, and all project proposals must be reviewed and approved by the ROI consortium's Publications Working Group before distribution of the customized dataset.