Stigma at every turn: Health services experiences among people who inject drugs

Prevalence and severity of abscesses and cellulitis, and their associations with other health outcomes, in a community-based study of people who inject drugs in London, UK

BACKGROUND

Skin and soft tissue infections (SSTI) are a common but preventable cause of morbidity and mortality among people who inject drugs (PWID). They can be severe, and hospitalisations of PWID with SSTI are rising. The most common SSTI presentations are abscesses and cellulitis.

METHODS

We used data from Care & Prevent, a cross-sectional community survey of PWID in London. We reported the lifetime prevalence of SSTI, severity of infections, key risk factors, and associated sequelae. Pictorial questions were used to assess SSTI severity.

RESULTS

We recruited 455 PWID. SSTI lifetime prevalence was high: 64% reported an abscess and/or cellulitis. Over one-third (37%) reported a severe infection, 137 (47%) reported hospitalisation. SSTIrisk factors were: aged 35+ years, injecting once or more times a day, subcutaneous or intra-muscular injections, and making four or more attempts to achieve an injection. Those who reported having other health conditions were at higher odds of having an abscess or cellulitis, with risk tending to increase with number of reported conditions. Half (46%) employed self-care for their worst SSTI, and 43% waited for ten or more days before seeking medical care or not seeking medical care at all.

CONCLUSIONS

Abscess and cellulitis are very common among PWID in London. We corroborate findings indicating SSTIs are associated with risks, e.g. venous access problems, as well as other co-morbid conditions: septicaemia, endocarditis, DVT, and kidney disease. These co-morbidities may impact SSTIs severity and outcomes. Delayed healthcare seeking potentially exacerbates infection severity, which in turn increases poorer health outcomes and complications.

Providing reproductive health services for women who inject drugs: a pilot program

Background

Needle syringe programs (NSPs), a proven harm reduction strategy for people who inject drugs, frequently offer limited healthcare services for their clients. Women who inject drugs face multiple barriers to accessing reproductive health care in traditional settings: personal histories of trauma, judgmental treatment from providers, and competing demands on their time. Our aim was to implement patient-centered reproductive healthcare services at a Seattle NSP.

Methods

We interviewed clients and staff of an NSP in Seattle and staff of other community-based organizations serving women who inject drugs, then used the Consolidated Framework for Implementation Research to code transcripts deductively. Based on our qualitative work, we implemented reproductive health care at the NSP program 1 day per week. We evaluated the implementation by surveying staff and clients and auditing charts over a 9-month period.

Results

Clients and staff (N = 15 for clients, N = 13 for staff) noted a high unmet need for trauma-informed, accessible reproductive health care. We successfully implemented reproductive health care services including short- and long-acting contraception, sexually transmitted disease testing, and cervical cancer screening. Survey data was limited but demonstrated client satisfaction with services.

Conclusions

Integrating reproductive health care into an NSP’s clinical services is feasible and can be a source of low-barrier preventive care for women unable to seek gynecologic care elsewhere.

Normalised pain and severe health care delay among people who inject drugs in London: Adapting cultural safety principles to promote care

In the United Kingdom, increases in premature mortality among the intersecting populations of people made homeless and people who inject drugs map onto the implementation and solidification of fiscal austerity policies over the past decade, rather than drug market fluctuations and trends as in North America. In this context, it is crucial to explore how poverty, multi-morbidity and care delay interplay in exacerbating vulnerability to mortality among an aging population of people who use illicit drugs. The mixed methods Care & Prevent study generated survey data with 455 PWID and in-depth qualitative interviews with a subsample (n = 36). Participants were recruited though drug treatment services and homeless hostels in London from October 2017-June 2019. This paper focuses on qualitative findings, analysed thematically and contextualised in relation to the broader survey sample. Survey participants report an extensive history of rough sleeping (78%); injecting-related bacterial infections (65%) and related hospitalisation (30%). Qualitative accounts emphasise engagement with the medical system as a 'last resort', with admission to hospital in a critical or a "near death" condition common. For many severe physical pain and debility were normalised, incorporated into the day to day. In a context of everyday violence and marginalisation, avoidance of medical care can have a protective impetus. Translation of cultural safety principles to care for people who inject drugs in hospital settings offers transformative potential to reduce serious health harms among this population.

Challenges posed by COVID-19 to people who inject drugs and lessons from other outbreaks

INTRODUCTION

In light of the COVID-19 pandemic, considerable effort is going into identifying and protecting those at risk. Criminalization, stigmatization and the psychological, physical, behavioural and economic consequences of substance use make people who inject drugs (PWID) extremely vulnerable to many infectious diseases. While relationships between drug use and blood-borne and sexually transmitted infections are well studied, less attention has been paid to other infectious disease outbreaks among PWID.

DISCUSSION

COVID-19 is likely to disproportionally affect PWID due to a high prevalence of comorbidities that make the disease more severe, unsanitary and overcrowded living conditions, stigmatization, common incarceration, homelessness and difficulties in adhering to quarantine, social distancing or self-isolation mandates. The COVID-19 pandemic also jeopardizes essential for PWID services, such as needle exchange or substitution therapy programmes, which can be affected both in a short- and a long-term perspective. Importantly, there is substantial evidence of other infectious disease outbreaks in PWID that were associated with factors that enable COVID-19 transmission, such as poor hygiene, overcrowded living conditions and communal ways of using drugs.

CONCLUSIONS

The COVID-19 crisis might increase risks of homelessnes, overdoses and unsafe injecting and sexual practices for PWID. In order to address existing inequalities, consultations with PWID advocacy groups are vital when designing inclusive health response to the COVID-19 pandemic.

Addiction stigma and the production of impediments to take-home naloxone uptake

Opioid overdose deaths are a major health issue in Australia and around the world. Programmes to provide opioid consumers with 'take-home' naloxone to reverse overdose exist internationally, but uptake by mainstream health services and consumers remains inconsistent. Researchers have identified a range of important educational, training and logistical impediments to take-home naloxone uptake and distribution, yet they have focused less on the social dynamics that can enhance or limit access, such as stigma. In this article, we also explore impediments to uptake, drawing on qualitative interview data gathered for an Australian research project on take-home naloxone. Mobilising a performative approach to stigma, we argue that overdose and prevention are shaped by the social dynamics of stigma and, as such, responsibility for dealing with overdose, as with take-home naloxone, should also be considered social (i.e. shared among peers, the public, communities and governments). Our interview data illuminate the various ways in which addiction stigma limits the possibilities and capacities of take-home naloxone and overdose prevention. First, we focus on how stigma may impede professional information provision about take-home naloxone by limiting the extent to which it is presented as a matter of interest for all opioid consumers, not just those who consume opioids illicitly. Second, we explore how stigma may limit the scale-up and expansion of programmes and access points. From here, we focus on how stigma co-constitutes the politics of overdose and prevention, rendering take-home naloxone ill-suited to many social settings of overdose. In closing, we point out that stigma is not just a post hoc impediment to access to and use of take-home naloxone but is central to opioid overdose production itself, and to effective prevention. While take-home naloxone is an excellent life-saving initiative, uncritically valorising it may divert attention from broader goals, such as the de-stigmatisation of drug consumption through decriminalisation, and other ambitious attempts to reduce overdose.

"It's not just injecting drugs": Supervised consumption sites and the social determinants of health

BACKGROUND

People who inject drugs are highly vulnerable to social determinants of health (SDOH) inequities, such as homelessness, food insecurity, lack of social support, and poor access to healthcare. Supervised consumption sites (SCSs) have been developed to reduce harms associated with injection drug use but their social impacts remain largely unknown. This study explored service users' experiences with SCSs and how their service use affected their SDOH.

METHODS

A qualitative descriptive study design was used. Participants were recruited from an SCS in Ottawa, Canada. Data were collected using in-depth interviews (n = 21). Data analysis involved two cycles of coding that were visibly presented in an analytic matrix. Member checking of the findings was then completed using two focus groups (n = 7).

RESULTS

Five themes were identified with regard to how SCSs impacted the SDOH: (1) social connectedness and community, (2) emotional support and stress reduction, (3) safety and security, (4) current shelter statuses and search for housing, and (5) health service access and use. The perceived effects of SCSs in these domains were mostly positive, though the importance of being vigilant and cautious when using the services was also expressed by participants.

CONCLUSIONS

SCSs represent a potential downstream intervention to addressing some of the SDOH inequities experienced by people who inject drugs. In particular, the findings indicate that SCSs can be a bridge to rebuilding service users' connections with the healthcare system and an important service in efforts to prevent unsheltered homelessness.

Experiences of Clients in Three Types of Methadone Maintenance Therapy in an Atlantic Canadian City: A Qualitative Study

BACKGROUND

Methadone maintenance therapy remains the most common form of substitution therapy for opioid use disorder in Canada. Effectiveness of methadone maintenance therapy has been established, but recently newer treatment delivery models have emerged. Differences across these treatment models have not been examined.

PURPOSE

This descriptive qualitative study used semi-structured interviews to assess client experiences in three methadone maintenance therapy treatment delivery models: (a) comprehensive programs, (b) low-threshold/high-tolerance programs, and (c) fee-for-service programs.

METHODS

A total of 32 participants were recruited from methadone maintenance therapy clinics in an Atlantic Canadian city and grouped into three models of care (n_a = 9, n_b = 11, n_c = 12). Content analysis was performed on interview data to assess the frequency of relevant themes in the data.

RESULTS

Participants from all groups stressed the importance of supportive staff and having access to some form of counselling. However, low-threshold/high-tolerance and fee-for-service clients voiced a need for more formal counselling and programming at their clinics. Methadone was reported as the most helpful aspect of the methadone maintenance therapy programs; however, participants also expressed negative views about the substance.

CONCLUSIONS

These findings have important implications for the development and implementation of methadone maintenance therapy, specifically pertaining to further integration of addiction and mental health services.

Supporting individuals using medications for opioid use disorder in recovery residences: challenges and opportunities for addressing the opioid epidemic

Full and partial opioid agonists and opioid antagonist medications play an important role in containing the opioid epidemic. However, these medications have not been used to their full extent. Recovery support services, such as recovery residences (RRs), also play a key role. RRs may increase an individual's recovery capital, facilitate social support for abstinence, and foster a sense of community among residents. These processes may be critical for individuals with opioid use disorder (OUD). In combination these two recovery pathways have the potential to enhance one another and improve outcomes among residents with OUD. Barriers to doing so have resulted in a limited supply of residences that can support residents using opioid agonist and antagonist medications. This perspective describes key interpersonal and structural barriers to medication use among individuals with an OUD seeking support from a recovery residence and discusses measures for reducing these barriers. These measures include workforce development to address stigma and attitudinal barriers and enhancing residence capability to ensure resident safety and reduce potential diversion. The perspective also highlights the need for additional research to facilitate the identification of best practices to improve outcomes among residents treated with medications living in recovery residences.

The role of prison-based interventions for hepatitis C virus (HCV) micro-elimination among people who inject drugs in Montréal, Canada

BACKGROUND

In Canada, hepatitis C virus (HCV) transmission primarily occurs among people who inject drugs (PWID) and people with experience in the prison system bare a disproportionate disease burden. These overlapping groups of individuals have been identified as priority populations for HCV micro-elimination in Canada, which is currently not on track to achieve its elimination targets. Considering the missed opportunities to intervene in provincial prisons, this study aims to estimate the population-level impact of prison-based interventions and post-release risk reduction strategies on HCV transmission among PWID in Montréal, a Canadian city with high HCV burden.

METHODS

A dynamic HCV transmission model among PWID was developed and calibrated to community and prison bio-behavioural surveys in Montréal. Then, the relative impact of prison-based testing and treatment or post-release linkage to care (both 90% testing and 75% treatment coverage), alone or in combination with strategies that reduce the heightened post-release transmission risk by 50%, was estimated from 2018 to 2030, and compared to counterfactual scenarios.

RESULTS

Prison-based test-and-treat strategies could lead to the greatest declines in incidence (48%; 95%CrI: 38-57%) over 2018-2030 and prevent the most new first chronic infections (22%; 95%CrI: 16-28%) among people never exposed to HCV. Prison testing and post-release linkage to care lead to a slightly lower decrease in incidence and prevented fraction of new chronic infections. Combining test-and-treat with risk reduction measures could further its epidemiological impact, preventing 35% (95%CrI: 29-40%) of new first chronic infections. When implemented concomitantly with community-based treatment scale-up, prison-based interventions had synergistic effects, averting a higher fraction of new first chronic infections.

CONCLUSION

Offering HCV testing and treatment in provincial prisons, where incarcerations are frequent and sentences short, could change the course of the HCV epidemic in Montréal. Prison-based interventions with potential integration of post-release risk reduction measures should be considered as an integral part of HCV micro-elimination strategies in this setting.

"Now hospital leaders are paying attention": A qualitative study of internal and external factors influencing addiction consult services

BACKGROUND

Hospitalizations related to opioid use disorder (OUD) are increasing, necessitating an increase in the delivery of opioid agonist therapy (OAT) among hospitalized adults. The addiction consult service (ACS) is a promising organizational intervention to address this growing clinical need. Little is known about the barriers and facilitators of ACS development and operations.

METHODS

We completed 17 semi-structured telephone interviews with board-certified or board-eligible addiction physicians across 16 U.S. acute care hospitals. Interviews explored contextual facilitators and barriers for ACS development and operations. We transcribed, coded, analyzed interviews, and derived final themes using a directed content analysis.

RESULTS

We identified six themes that promoted or inhibited ACS development and operations: 1) stigma and discrimination; 2) internal (e.g., hospital administrators) and external stakeholders (e.g., State Medicaid programs); 3) addiction-informed institutions with addiction-related resources; 4) access to community-based treatment programs (e.g., local opioid treatment programs); 5) restrictive and misinterpreted OAT policies; and 6) service financing. The first theme, stigma and discrimination, is presented as a stand-alone-theme but permeates the five other themes as a broader meta-theme.

CONCLUSIONS

As OUD-related hospitalizations increase, and the opioid-related overdose crisis continues, understanding the constraints related to the development and operations of ACSs are important preliminary steps for improving the care of patients hospitalized with OUD. Clinical champions, hospital leaders, and hospital societies could act, through practice and policy initiatives, to support ACS development and increase the delivery of evidence-based services (e.g., OAT) to patients hospitalized with OUD.

HIV and drug related stigma and risk-taking behaviors among people who inject drugs: a systematic review and meta-analysis

The impact of HIV-related stigma on people living with HIV has been well documented, but there have been few studies examining how drug-related stigma impacts risk-taking in the lives of people who inject drugs (PWID). This meta-analysis aimed to determine HIV and drug-related stigma and the association it has with risk-taking behaviors among PWID. We searched PubMed, Science Direct, Web of Science, and Cochrane electronic databases independently in March 2019. After reviewing for any study duplicates the full-text of selected articles were assessed for eligibility using Population, Intervention, Comparator, Outcomes (PICO) criteria. We used fixed and random-effects meta-analysis models to estimate the pooled prevalence, pooled odds ratio (OR) and 95% confidence intervals. After a detailed assessment, a total of 14 studies containing 13,689 participants met the eligibility criteria. Among the potential risk factors: employment status, depression and sharing injecting paraphernalia had a significant relationship with HIV and drug stigma among PWIDs respectively (OR = 0.78, 95%CI = 0.62-0.98), (OR = 1.84, 95%CI = 1.45-2.33) and (OR = 2.20, 95%CI = 1.84-1.63). Illicit drug use related stigma was found to be associated with several concurrent effects. The impact of stigma should be considered in the development of drug use prevention strategies. Perceived stigma is correlated with numerous negative consequences in other populations including people living with HIV/AIDS. These data suggest this could also be generalized to people who inject drugs because it seems that individuals with internalized stigma experience drug dependence, reduced comfort in seeking help from services and higher rates of depression.

Integrating naloxone education into an undergraduate nursing course: Developing partnerships with a local department of health

BACKGROUND

Substance misuse continues to be a significant concern in the United States, with over 700,000 lives lost from a drug overdose between 1999 and 2017. However, nursing curricula have failed to keep pace with the epidemic.

METHODS

The current study used a pre-post study design and involved a convenience sample of undergraduate nursing students (n = 37) enrolled in a community health nursing course. Students completed an 11-item online survey examining naloxone stigma, naloxone self-efficacy, and naloxone knowledge. A paired sample t test was conducted to evaluate the impact of the in-person training and education event.

RESULTS

There was a statistically significant increase in post-intervention naloxone knowledge scores from the pre-survey (M = 3.57, SD = 0.959) to the post-survey (M = 4.70, SD = 0.520). Stigma toward naloxone demonstrated a statistically significant increase in the post-intervention stigma survey (M = 9.00, SD = 1.312) compared with the pre-intervention stigma survey (M = 7.78, SD = 2.228). Naloxone self-efficacy also demonstrated a statistically significant increase in the post-intervention naloxone efficacy survey (M = 10.08, SD = 1.064) compared with the pre-intervention naloxone efficacy scores (M = 7.38, SD = 2.22).

CONCLUSIONS

The students' scores demonstrated a significant increase in naloxone knowledge, self-efficacy, and stigma. Future research is needed to explore the impact of integrating naloxone education in the undergraduate nursing curriculum.

Factors Associated with Gabapentin Misuse among People Who Inject Drugs in Appalachian Kentucky

Gabapentin is misused to potentiate the euphoric effects of opioids, self-treat physical pain, and moderate opioid withdrawal symptoms. Because examinations of gabapentin misuse among people who inject drugs (PWID) are scant, the aim of this study is to identify factors associated with gabapentin misuse among this population. Methods: Data are drawn from a study examining the uptake of syringe service programs (SSPs) in Appalachian Kentucky. The sample includes 324 PWID who were age 18 and over and reported past month drug injection. Logistic regression models were constructed to examine recent (past 90 days) gabapentin misuse. Results: Participants are female (50.0%); Hispanic (2.2%), Black (1.5%), white (90.7%), and other race/ethnicity (4.6%). Mean age is 37. Participants reporting gabapentin misuse had higher odds of reporting (mis)use of marijuana, cocaine, methamphetamine, prescription opioids, benzodiazepines, prescription stimulants, fentanyl, and buprenorphine (p < .042); severe substance use disorder (p < .000); and recent physical pain (p < .003). In multivariable models, findings related to misuse of prescription opioids and buprenorphine; severe substance use disorder; and recent physical pain or discomfort, remained significant (p < .042). Conclusions: This is one of the first studies to examine gabapentin misuse among PWID. It is possible that individuals reporting recent gabapentin misuse are attempting to self-treat physical pain when healthcare is limited. Gabapentin may also be misused to achieve desired central nervous system effects and to potentiate opioid highs. Syringe service programs can educate PWID about the potential dangers of polydrug use involving gabapentin and to connect PWID with needed healthcare services.

Over the counter naloxone needed to save lives in the United States

The United States continues to face a public health emergency of opioid-related harm, the effects of which could be dramatically reduced through increased access to the opioid antagonist naloxone. Unfortunately, naloxone is too often unavailable when and where it is most needed, partly due to its continued status as a prescription medication. Although states and the federal Food and Drug Administration (FDA) have acted to increase access to naloxone, these changes are insufficient to address this unprecedented crisis. In this Commentary, we argue that FDA can and should immediately reclassify naloxone from prescription-only to over-the-counter status, a change that could save hundreds if not thousands of lives in the United States every year.

Syringe access and health harms: Characterizing "landscapes of antagonism" in California's Central Valley

BACKGROUND

Sterile syringe access reduces injection-related health harms, yet access in the U.S. remains grossly inadequate. In California, syringe services programs (SSPs) are authorized mainly at the local level, and many communities remain underserved. State law also allows, but does not require, non-prescription syringe sales at pharmacies, but participation is low. We draw on the theoretical concept of "landscapes of antagonism" to examine how discordance between state and local decision-making contributes to uneven syringe access and health harms in California's Central Valley, where injection rates are high.

METHODS

Our study took place in Fresno and Kern counties. We draw on participant observation and qualitative interviews with individuals who inject drugs and key informants to examine issues around syringe access.

RESULTS

Overall, 8 key informants represented harm reduction, medical, and faith-based organizations. Among 46 people who inject drugs, mean age was 39 (range: 20-65), 37% were female, and 37% self-identified as Latino. About half of individuals at each site had ever successfully purchased from pharmacies, but limited locations and perceived judgement from pharmacy staff posed common barriers. There was no SSP in Kern County due to political opposition; Fresno's SSP has been run by volunteers for more than 20 years despite opposition, and recently gained authorization. Reflecting this disparity, all but two individuals in Fresno accessed syringes from the SSP, whereas only one person in Kern had ever been to an SSP. To fill gaps in access in both sites, individuals obtained syringes that were often already used from diabetics, friends, and people on the street, sharing and reusing syringes at dangerously high rates.

CONCLUSION

Landscapes of antagonism create syringe access inequities that threaten to exacerbate disease transmission and other health harms. Our study raises questions about accountability for the health of people who use drugs and suggests a need for political action.

Long term surgical outcomes for infective endocarditis in people who inject drugs: a systematic review and meta-analysis

Background

In recent years, the number of infective endocarditis (IE) cases associated with injection drug use has increased. Clinical guidelines suggest deferring surgery for IE in people who inject drugs (PWID) due to a concern for worse outcomes in comparison to non-injectors (non-PWID). We performed a systematic review and meta-analysis of long-term outcomes in PWID who underwent cardiac surgery and compared these outcomes to non-PWID.

Methods

We systematically searched for studies reported between 1965 and 2018. We used an algorithm to estimate individual patient data (eIPD) from Kaplan-Meier (KM) curves and combined it with published individual patient data (IPD) to analyze long-term outcomes after cardiac surgery for IE in PWID. Our primary outcome was survival. Secondary outcomes were reoperation and mortality at 30-days, one-, five-, and 10-years. Random effects Cox regression was used for estimating survival.

Results

We included 27 studies in the systematic review and 19 provided data (KM or IPD) for the meta-analysis. PWID were younger and more likely to have S. aureus than non-PWID. Survival at 30-days, one-, five-, and 10-years was 94.3, 81.0, 62.1, and 56.6% in PWID, respectively; and 96.4, 85.0, 70.3, and 63.4% in non-PWID. PWID had 47% greater hazard of death (HR 1.47, 95% CI, 1.05–2.05) and more than twice the hazard of reoperation (HR 2.37, 95% CI, 1.25–4.50) than non-PWID.

Conclusion

PWID had shorter survival that non-PWID. Implementing evidence-based interventions and testing new modalities are urgently needed to improve outcomes in PWID after cardiac surgery.

A scoping review of post opioid-overdose interventions

INTRODUCTION

Nonfatal opioid overdose is a significant risk factor for subsequent fatal overdose. The time after a nonfatal overdose may provide a critical engagement opportunity to both reduce subsequent overdose risk and link individuals to treatment. Post-overdose interventions have emerged in affected communities throughout the United States (US). The objective of this scoping review is to identify US-based post-overdose intervention models (1) described in peer-reviewed literature and (2) implemented in public health and community settings.

METHODS

Using the adapted PRISMA Checklist for Scoping Reviews, we searched PubMed, PsychInfo, Academic OneFile, and federal and state databases for peer-reviewed and gray literature descriptions of post-overdose programs. We developed search strings with a reference librarian. We included studies or programs with at least the following information available: name of program, description of key components, intervention team, and intervention timing.

RESULTS

We identified a total of 27 programs, 3 from the peer-reviewed literature and 24 from the gray literature. 9 programs operated out of the ED, while 18 programs provided post-overdose support in other ways: through home or overdose location visits, mobile means, or as law enforcement diversion. Commonly, they include partnerships among public safety and community service providers.

CONCLUSIONS

Programs are emerging throughout the US to care for individuals after a nonfatal opioid overdose. There is variability in the timing, components, and follow-up in these programs and little is known about their effectiveness. Future work should focus on evaluation and testing of post-overdose programs so that best practices for care can be implemented.

Stigma as a fundamental hindrance to the United States opioid overdose crisis response

Alexander Tsai and co-authors discuss the role of stigma in responses to the US opioid crisis.

"You're kind of at war with yourself as a nurse": Perspectives of inpatient nurses on treating people who present with a comorbid opioid use disorder

BACKGROUND

In the midst of an opioid epidemic, health care workers are encountering an increasing number of patients who have opioid use disorder in addition to complex social, behavioral and medical issues. Of all the clinicians in the hospital, nurses spend the most time with hospitalized patients who have opioid use disorder, yet there has been little research exploring their experiences in caring for this population. The objective of this study was to assess the attitudes, perceptions, and training needs of nurses in the inpatient setting when caring for patients who have opioid use disorder.

METHODS

One-on-one in-depth interviews were conducted with nurses working at a large academic medical center in Boston, MA, using a semi-structured interview guide. Nurses were recruited via email notifications and subsequent snowball sampling. Interviews were recorded, transcribed and analyzed using a grounded theory approach.

RESULTS

Data from in-depth interviews with 22 nurses were grouped into six themes: (1) stigma, (2) assessing & treating pain, (3) feelings of burn out, (4) communication between providers, (5) safety & security, and (6) opportunities for change. These themes were organized within four ecological levels of the Socio-Ecological Model: I) societal context, II) hospital environment, III) interpersonal interactions, and IV) individual factors. Nurses were cognizant of the struggles that patients who have opioid use disorder confront during hospitalization such as pain, withdrawal and stigma, and elaborated on how these challenges translate to professional and emotional strain among nurses. Nurses offered recommendations by which the hospital could streamline care for this population, including expanded role support for nurses and more structured policies regarding care for patients who present with a comorbid opioid use disorder.

CONCLUSION

Our results highlight the need for the development of programs targeting both organizational culture and the inpatient nurse quality of life to ultimately enhance quality of care for patients who present with opioid use disorder.

HIV Pre-exposure Prophylaxis for People Who Inject Drugs: The Context of Co-occurring Injection- and Sexual-Related HIV Risk in the U.S. Northeast

Background: People who inject drugs (PWID) are at increased risk for HIV infection through sharing contaminated needles and injection equipment, and engaging in condomless sex. Objectives: To qualitatively examine the overlapping nature of these behaviors among PWID in the US Northeast. Methods: We recruited HIV-uninfected PWID and key informants through community-based organizations. Qualitative interviews explored sexual partnerships as they related to sharing contaminated needles and injection equipment, engaging in condomless sex, and associated indications for PrEP among PWID. Results: Among 33 PWID, 66% engaged in condomless vaginal or anal sex in the past 3 months, and 27% had three or more sexual partners in this same time period. Over half engaged in any past month distributive or receptive syringe sharing (64%). We identified three contexts through which overlapping sexual and injection-related HIV risks emerged, including (1) multiple concurrent sexual partnerships; (2) using and injecting drugs with sexual partners (including increase injecting of crystal methamphetamine); and (3) exchanging sex for money or drugs (including among male PWID). Condom use was inconsistent across these contexts. Limited interactions with healthcare providers often resulted in sexual risks being overlooked in light of competing health concerns. Conclusions: Sexual risk for HIV acquisition is complex and multi-faceted among PWID yet may be overlooked by prevention and healthcare providers. Comprehensive HIV prevention efforts must acknowledge the distinct contexts in which overlapping injection and sexual risk behaviors occur. Increased sexual health screening and risk reduction services including PrEP for PWID may help curtail transmission in this population.

A missing perspective: injectable pre-exposure prophylaxis for people who inject drugs

The efficacy of pre-exposure prophylaxis (PrEP) for HIV prevention has been established among people who inject drugs (PWID). HIV uninfected, at risk PWID, could likely benefit from long-acting injectable formulations of PrEP ("LAI-PrEP"); however, its acceptability in this population has not been previously documented. Thirty-three HIV-uninfected PWID in the U.S. Northeast completed an in-depth interview regarding perceived acceptability of LAI-PrEP. Coded data were synthesized using deductive thematic analysis. The majority of PWID interviewed believed LAI-PrEP would be acceptable. Participants perceived that receiving injections every two months would reduce barriers to daily oral PrEP adherence, including forgetting while "high" and safeguarding pills when homeless. A few participants expressed concerns regarding LAI-PrEP, including medical mistrust, a concern that injections could alter their "high" or be "triggering" for PWID. LAI-PrEP has the potential to reduce HIV among PWID; however, their perspectives are largely absent from research examining its efficacy, representing a missed opportunity.

I could take the judgment if you could just provide the service: non-prescription syringe purchase experience at Arizona pharmacies, 2018

Background

Community pharmacies are important for health access by rural populations and those who do not have optimum access to the health system, because they provide myriad health services and are found in most communities. This includes the sale of non-prescription syringes, a practice that is legal in the USA in all but two states. However, people who inject drugs (PWID) face significant barriers accessing sterile syringes, particularly in states without laws allowing syringe services programming. To our knowledge, no recent studies of pharmacy-based syringe purchase experience have been conducted in communities that are both rural and urban, and none in the Southwestern US. This study seeks to understand the experience of retail pharmacy syringe purchase in Arizona by PWID.

Methods

An interview study was conducted between August and December 2018 with 37 people living in 3 rural and 2 urban Arizona counties who identified as current or former users of injection drugs. Coding was both a priori and emergent, focusing on syringe access through pharmacies, pharmacy experiences generally, experiences of stigma, and recommendations for harm reduction services delivered by pharmacies.

Results

All participants reported being refused syringe purchase at pharmacies. Six themes emerged about syringe purchase: (1) experience of stigma and judgment by pharmacy staff, (2) feelings of internalized stigma, (3) inconsistent sales outcomes at the same pharmacy or pharmacy chain, (4) pharmacies as last resort for syringes, (5) fear of arrest for syringe possession, and (6) health risks resulting from syringe refusal.

Conclusions

Non-prescription syringe sales in community pharmacies are a missed opportunity to improve the health of PWID by reducing syringe sharing and reuse. Yet, current pharmacy syringe sales refusal and stigmatization by staff suggest that pharmacy-level interventions will be necessary to impact pharmacy practice. Lack of access to sterile syringes reinforces health risk behaviors among PWID. Retail syringe sales at pharmacies remain an important, yet barrier-laden, element of a comprehensive public health response to reduce HIV and hepatitis C among PWID. Future studies should test multilevel evidence-based interventions to decrease staff discrimination and stigma and increase syringe sales.

Lessons learned from the opioid crisis across the pillars of the Canadian drugs and substances strategy

Background

Canada is facing an urgent challenge to reduce the harms associated with opioids: from January 2016 to December of 2018, more than 11,500 individuals lost their lives due to opioid related harms. This review examines responses to the opioid crisis thus far, the lessons learned from these initiatives and the knowledge gaps that still need to be addressed across the four pillar model adopted by the CDSS.

Methods

A search of peer-reviewed literature was conducted in PubMed and PsycNet, and grey literature was retrieved from reputable substance use and health organizations to determine responses to the opioid crisis and related outcomes between 2013 and 2019. Findings related to actions, outcomes and unintended consequences across the categories of prevention, treatment, harm reduction, enforcement and the evidence base were included and synthesized into a narrative review on lessons learned.

Results

The opioid crisis is a result of multiple, complex interrelated factors. Many physicians may not feel competent to appropriately treat pain and/or addiction. Pushes for opioid deprescribing have resulted in some individuals using illicit opioids as treatment. A range of effective and accessible pharmacological and psychological treatments are still required. When regulations are barriers, unsanctioned actions, such as overdose prevention sites, may be enacted by individuals to respond to urgent public health needs. A nimble response with evolving enforcement perspectives can aid individuals experiencing harms from opioid use.

Conclusions

There is no one size fits all response to this crisis, and consideration should be given to the unique needs of different communities and populations, as well as the broader impact of harms on families, communities, and society. A situation so multifaceted requires both immediate and long-term strategies implemented concurrently in order to address the differing and on-going needs of Canadians experiencing opioid harms. The expertise of individuals and families affected by the opioid crisis must be included in consultations and decisions related to different strategies, to ensure responses are not stigmatizing, that they will be effective and acceptable and that unintended consequences are quickly recognized and mitigated.

Factors Associated with Awareness of Pre-exposure Prophylaxis for HIV Among Persons Who Inject Drugs in Philadelphia: National HIV Behavioral Surveillance, 2015

Persons who inject drugs (PWID) continue to experience disproportionate HIV burden. Though studies demonstrate PWID find pre-exposure prophylaxis (PrEP) acceptable, awareness and uptake remains low. Data from the 2015 PWID cycle of the National HIV Behavioral Surveillance (n = 612) in Philadelphia, Pennsylvania (USA) were analyzed to evaluate how socio-demographics and behavioral factors impact PrEP awareness. Only 12.4% of PWID surveyed were PrEP-aware and 2.6% reported receiving a prescription. Factors associated with PrEP awareness included having at least some college education (aOR 2.13, 95% CI 1.03, 4.43), sharing paraphernalia (aOR 2.37, 95% CI 1.23, 4.56), obtaining syringes/needles primarily from a syringe exchange program (aOR 2.28, 95% CI 1.35, 3.87), STI testing (aOR 1.71, 95% CI 1.01, 2.89) and drug treatment (aOR 2.81, 95% CI 1.62, 4.87). Accessing prevention and health services increased the odds of being PrEP-aware; however, awareness was low overall. Additional promotion efforts are warranted.

Attitudes towards people living with HIV and people who inject drugs: A mixed method study of stigmas within harm reduction programs in Kazakhstan

BACKGROUND

High levels of stigma towards people who inject drugs (PWID) and people living with HIV (PLWH) exist in Kazakhstan, yet little is known about the role of stigma in harm reduction service settings. In this paper, we use a mixed method design to explore and describe the actionable drivers and facilitators of stigma among harm reduction service providers. Additionally, we describe the manifestations of stigma among PWID who are living with HIV (PWID/LWH), and the impact that stigma has on harm reduction and healthcare service utilization.

METHODS

Eight focus groups with 57 PWID/LWH were convened between March 2016 and July 2016 to describe manifestations of stigma from the perspective of syringe exchange program (SEP) clients. Additionally, we surveyed 80 nurses, social workers, outreach workers, and providers of HIV care at SEPs between January 2017 and July 2017 to assess stigmatizing attitudes among staff within the SEP environment. Joint displays were used to integrate quantitative and qualitative data.

RESULTS

The actionable drivers of stigma identified in this study include negative opinions and moral judgements towards PWID/LWH. Facilitators identified included stigmatization as a social norm within the service provision environment, a lack of awareness of anti-discrimination policies, and lack of enforcement of anti-discrimination policies. Qualitative findings highlight manifestations of stigma in which PWID/LWH experienced denial of services, perceived negative attitudes, and avoidance from service provision staff. PWID/LWH also described segregation in healthcare settings, the use of unnecessary precautions by providers, and unauthorized disclosure of HIV status.

CONCLUSIONS

This paper highlights the urgent need to address stigma in the harm reduction and HIV service settings in Kazakhstan. These findings have implications for informing an actionable model for stigma reduction for providers who deliver services to PWID/LWH in Kazakhstan. Drivers, facilitators, and manifestations of stigma are multifaceted and addressing them will require a multilevel approach.

Substance Use Stigma and Antiretroviral Therapy Adherence Among a Drug-Using Population Living with HIV

Among people living with HIV (PLWH), HIV-related stigma predicts nonadherence to antiretroviral therapy (ART); however, the role of stigma associated with drug use is largely unknown. We examined the association between substance use (SU) stigma and optimal ART adherence in a sample of 172 self-reported HIV-infected drug users. Participants completed surveys on SU, stigma, and ART adherence. The three substance classes with the greatest number of participants exhibiting moderate/high-risk scores were for cocaine/crack cocaine (66.28%), cannabis (64.53%), and hazardous alcohol consumption (65.70%). Multivariable logistic regression was conducted to investigate associations between levels of SU stigma and optimal ART adherence, adjusting for sociodemographic characteristics, severity of illicit drug use (alcohol, smoking and substance involvement screening test) and alcohol use severity (Alcohol Use Disorders Identification Test-C), HIV-related stigma, and social support. The odds of optimal adherence among participants experiencing moderate [Adjusted Odds Ratio (AOR) = 0.36, p = 0.039] and very high (AOR = 0.25, p = 0.010) levels of anticipated SU stigma were significantly lower than participants experiencing low levels of anticipated SU stigma. No other stigma subscales were significant predictors of ART adherence. Interventions aiming to improve ART adherence among drug-using PLWH need to address anticipated SU stigma.

Strategies used by people who inject drugs to avoid stigma in healthcare settings

BACKGROUND

People who inject drugs (PWID) have limited engagement in healthcare services and report frequent experiences of stigma and mistreatment when accessing services. This paper explores the impact of stigma against injection drug use on healthcare utilization among PWID in the U.S. Northeast.

METHODS

We recruited PWID through community-based organizations (CBOs; e.g., syringe service programs). Participants completed brief surveys and semi-structured interviews lasting approximately 45 min exploring HIV risk behaviors and prevention needs. Thematic analysis examined the emergent topic of stigma experiences in relation to healthcare utilization.

RESULTS

Among 33 PWID (55% male; age range 24-62 years; 67% White; 24% Latino), most used heroin (94%) and injected at least daily (60%). Experiences of dehumanization in healthcare settings were common, with many participants perceiving that they had been treated unfairly or discriminated against due to their injection drug use. As participants anticipated this type of stigma from healthcare providers, they developed strategies to avoid it, including delaying presenting for healthcare, not disclosing drug use, downplaying pain, and seeking care elsewhere. In contrast to large institutional healthcare settings, participants described non-stigmatizing environments within CBOs, where they experienced greater acceptance, mutual respect, and stronger connections with staff.

CONCLUSIONS

Stigma against injection drug use carries important implications for PWID health. Increased provider training on addiction as a medical disorder could improve PWID healthcare experiences, and integrating health services into organizations frequented by PWID could increase utilization of health services by this population.

Conceptualising access in the direct-acting antiviral era: An integrated framework to inform research and practice in HCV care for people who inject drugs

As direct-acting antiviral (DAA) therapy costs fall and eligibility criteria are relaxed, people who inject drugs (PWID) will increasingly become eligible for HCV treatment. Yet eligibility does not necessarily equate to access. Amidst efforts to expand treatment uptake in this population, we seek to synthesise and clarify the conceptual underpinnings of access to health care for PWID, with a view to informing research and practice. Integrating dominant frameworks of health service utilisation, care seeking processes, and ecological perspectives on health promotion, we present a comprehensive theoretical framework to understand, investigate and intervene upon barriers and facilitators to HCV care for PWID. Built upon the concept of Candidacy, the framework describes access to care as a continually negotiated product of the alignment between individuals, health professionals, and health systems. Individuals must identify themselves as candidates for services and then work to stake this claim; health professionals serve as gatekeepers, adjudicating asserted candidacies within the context of localised operating conditions; and repeated interactions build experiential knowledge and patient-practitioner relationships, influencing identification and assertion of candidacy over time. These processes occur within a complex social ecology of interdependent individual, service, system, and policy factors, on which other established theories provide guidance. There is a pressing need for a deliberate and nuanced theory of health care access to complement efforts to document the HCV 'cascade of care' among PWID. We offer this framework as an organising device for observational research, intervention, and implementation science to expand access to HCV care in this vulnerable population. Using practical examples from the HCV literature, we demonstrate its utility for specifying research questions and intervention targets across multiple levels of influence; describing and testing plausible effect mechanisms; and identifying potential threats to validity or barriers to research translation.

Self-Rated Physical Health and Unmet Healthcare Needs among Swedish Patients in Opioid Substitution Treatment

Background

Individuals with opioid dependence are at increased risk of deteriorating health due to the lifestyle connected to heroin use. Barriers surrounding the healthcare system seem to hinder patients to seek help through conventional healthcare, even after entering opioid substitution treatment (OST), resulting in a high level of unmet healthcare needs. However, this field is still unexplored, with only a few studies focusing on general health within this population. The first step, in order to provide suitable and accessible primary healthcare, is to assess the extent of physical symptoms and unmet healthcare needs within the OST population, which, to this point, has been sparsely studied.

Aim

To assess OST patients' self-rated physical health and healthcare seeking behaviour.

Methods

Two-hundred and eighteen patients from four different OST sites answered a questionnaire regarding physical health and healthcare seeking.

Results

Patients in OST have a high degree of physical symptoms and a high degree of unmet healthcare needs. Sixty-six percent reported suffering from musculoskeletal pain. Fifty-six percent reported gastrointestinal symptoms. Genital problems and airway symptoms were reported by 47%, respectively, and dental problems were reported by 69% of the respondents. General unmet healthcare needs were reported by 82%. Musculoskeletal pain was positively correlated with having an unstable housing situation (AOR 4.26 [95% CI 1.73-10.48]), negatively correlated with male sex (AOR 0.45 [95% CI 0.22-0.91]), and positively correlated with age (AOR 1.04 [95% CI 1.01-1.07]). No statistically significant correlates of respiratory, gastrointestinal, genital, or dental symptoms were found.

Conclusion

Patients in OST carry a heavy burden of physical symptoms and unmet healthcare needs, potentially due to societal barriers. Patients' frequent visits to the OST clinics offer a unique opportunity to build a base for easily accessible on-site primary healthcare.

Limited Knowledge and Mixed Interest in Pre-Exposure Prophylaxis for HIV Prevention Among People Who Inject Drugs

People who inject drugs (PWID) experience sexual and injection-related HIV risks, but uptake of pre-exposure prophylaxis (PrEP) for HIV prevention among PWID has been low. Improving PrEP uptake in this population will require understanding of PrEP knowledge and interest. In 2017, we conducted in-depth, semistructured interviews with HIV-uninfected PWID and key informants (PrEP and harm reduction providers) in the US Northeast. Thematic analysis of coded data explored PrEP knowledge and the factors that influence PrEP interest. Among PWID (n = 33), median age was 36 years, 55% were male, 67% were white, and 24% identified as Hispanic/Latino. Accurate PrEP knowledge among PWID was low, which key informants (n = 12) attributed to PrEP marketing focused on other risk populations, as well as healthcare providers' lack of time and unwillingness to discuss PrEP with PWID. There was a discrepancy between self-reported HIV risk behaviors, which were common, and HIV risk perceptions, which varied and strongly influenced PrEP interest. Most PWID and key informants thought that PrEP would be most beneficial for those who shared syringes, used discarded syringes, engaged in transactional sex, or were homeless. Improving uptake of PrEP for HIV prevention among high-risk PWID will require education to increase PrEP knowledge and addressing factors that negatively influence PrEP interest such as perceptions regarding low HIV risk and the process for obtaining PrEP. This may require specialized PrEP marketing and outreach efforts and improved capacity of healthcare providers to effectively assess HIV risk (and perceptions) and communicate the benefits of PrEP to at-risk PWID.