A comparison of syringe disposal practices among injection drug users in a city with versus a city without needle and syringe programs

Were Needles Everywhere?: Differing Views on Syringe Waste and Disposal Associated With Needs-Based Syringe Services Programs Among Community Partners and Persons Who Inject Drugs

BACKGROUND

Community concerns surrounding syringe waste are a common barrier to syringe services program (SSP) implementation. In Kanawha County, West Virginia, community opposition to SSPs resulted in the closure of needs-based SSPs prior to and during an HIV outbreak among persons who inject drugs (PWID). This qualitative analysis examines views of PWID and community partners on syringe waste and disposal associated with needs-based SSPs.

METHODS

Qualitative interviews with 26 PWID and 45 community partners (medical and social service providers, law enforcement personnel, policymakers, and religious leaders) were conducted. Interviews were recorded, transcribed, and coded. Code summaries described participants' views on syringe waste and disposal and needs-based SSPs.

RESULTS

Community partners and PWID who favored needs-based SSPs reported that needs-based SSPs had not affected or reduced syringe waste. Conversely, community partners who favored one-to-one exchange models and/or barcoded syringes described needs-based SSPs increasing syringe waste. Community partners often cited pervasive community beliefs that SSPs increased syringe waste, risk of needlesticks, drug use, and crime. Community partners were unsure how to address syringe waste concerns and emphasized that contradictory views on syringe waste posed barriers to discussing and implementing SSPs.

CONCLUSIONS

Participants' views on whether syringe waste was associated with needs-based SSPs often aligned with their support or opposition for needs-based SSPs. These differing views resulted in challenges finding common ground to discuss SSP operations amid an HIV outbreak among PWID. SSPs might consider addressing syringe waste concerns by expanding syringe disposal efforts and implementing community engagement and stigma reduction activities.

Use of Syringe Service Programs in Rural vs Urban Maine: A Harm-Reduction Study

Introduction

Syringe service programs (SSPs) reduce HIV and viral hepatitis transmission, as well as the prevalence of improperly disposed needles and needle stick injuries among first responders. Infections associated with injection drug use are rising in rural areas, including Maine, leading to concerns that SSP services are difficult to access for rural residents.

Methods

A cross-sectional survey of 101 participants hospitalized with infections associated with injection drug use at 4 hospitals in Maine was collected over a 15-month period. Descriptive analyses were performed. Statistical analyses were completed using Fisher's exact tests, Pearson's chi-squared tests, and Student's t tests.

Results

Of 101 participants, 66 (65%) lived in urban areas, and 35 (35%) lived rurally. Participants living in rural areas reported less SSP use in the past 3 months (76% urban vs 43% rural). Rural participants also had a higher prevalence of injecting buprenorphine than urban participants (6% urban vs 12% rural). Rural participants were also more likely to obtain needles from pharmacies than urban participants (40% urban vs 71% rural).

Discussion

SSP programs are underrepresented and accessed less in rural areas of Maine. Rural populations of people who inject drugs have unique health characteristics and syringe-use practices.

Conclusions

These findings highlight the need to develop rural SSP programs that address the unique needs of rural populations.

Strategies for addressing needle debris: A scoping review of needle debris and discarded drug paraphernalia associated with substance use

BACKGROUND AND AIMS

Needle debris and discarded drug paraphernalia can pose risks to people who use drugs (PWUD) and other members of the community. The research question guiding our scoping review was, "What is the scope of literature around discussions of and interventions for needle debris associated with drug use in a community setting"?

METHODS

The review was guided by the Joanna Briggs Institute methodology. Reporting was in accordance with the PRISMA scoping review extension. Searches in August of 2022 on Medline, CINAHL, PsycINFO, EMBASE, and Social Services Abstracts were completed. Quantitative and qualitative study designs were included. Grey literature was excluded. Extracted data included disposal initiatives and factors influencing disposal practices.

RESULTS

The databases combined search total was 3074. A total of 1115 duplicates were removed. Inclusion and exclusion criteria resulted in 72 studies full-text studies reviewed. Nineteen articles met all requirements. Studies from multiple continents resulted in similar themes. Two main themes were identified: needle disposal challenges for PWUD and disposal initiatives. Disposal challenges related to legal barriers and law enforcement influence, the varying definitions of 'safe disposal' and perspectives of PWUD. Disposal initiatives stemmed from community-based initiatives, pharmacy contributions and the perceptions and attitudes of community members.

CONCLUSIONS

Needle debris is a complex phenomenon highly impacted by the threat of persecution from law enforcement. PWUD need various disposal methods in proximity to their injecting location to avoid fear of prosecution from residual substances on the syringes.

People with lived and living experience of methamphetamine use and admission to hospital: what harm reduction do they suggest needs to be addressed?

INTRODUCTION

People who use substances may access hospital services for treatment of infections and injuries, substance use disorder, mental health issues and other reasons. Our aim was to identify the experiences, issues and recommendations of people who use methamphetamine and have accessed hospital services.

METHODS

Of the 114 people with lived and living experience of methamphetamine use recruited for a mixed-methods study conducted in southwestern Ontario, Canada, 104 completed the qualitative component. Interviews were conducted from October 2020 to April 2021. Participants were asked open-ended questions and the responses were analyzed using an ethnographic thematic approach.

RESULTS

Negative patient-staff interactions included stigma and a lack of understanding of addiction and methamphetamine use, leading to distrust, avoidance of hospital care and reduced help-seeking and health care engagement. The consequences can be infections, unsafe needle use, discharge against medical advice and withdrawal. Almost all participants were in favour of in-hospital harm reduction strategies including safe consumption services, provision of sterile equipment and sharps containers, and withdrawal support. Clinical implications include education to reduce knowledge gaps about methamphetamine use and addiction and address stigma, which could facilitate the introduction of harm reduction strategies.

CONCLUSION

Although the strategies identified by participants could promote a safer care environment, improving therapeutic relationships through education of health care providers and hospital staff is an essential first step. The addition of in-hospital harm reduction strategies requires attention as the approach remains uncommon in hospitals in Canada.

Syringe Services Programs to Reduce Intravenous Disease Transmission in Substance Use Disorders

Syringe services programs (SSPs) are evidence-based programs. SSPs are integral in preventing bloodborne diseases while increasing access to care and reducing drug overdose deaths. SSPs are often the only source of health care for people who use drugs. Several states in the United States support and offer community-based SPPs; however, US prisons do not offer such programs to those incarcerated. Nurses are bridging the gap in support of SSPs and are being backed by organizations such as the American Nurses Association and the Association of Nurses in AIDS Care.

Improved syringe disposal practices associated with unsanctioned safe consumption site use: A cohort study of people who inject drugs in the United States

BACKGROUND

Community opposition to safe consumption sites often centers around improper syringe disposal. People are concerned these sites might attract people who inject drugs to the neighborhood, which might in turn lead to more used syringes left in public settings.

METHODS

We evaluated an unsanctioned safe consumption site in an undisclosed United States city in 2018-2020 to assess whether use of the site was associated with improper syringe disposal practices. We recruited people who inject drugs (N=494) using targeted sampling methods, and interviewed participants at baseline, 6 months, and 12 months. We employed a quasi-experimental design involving inverse probability of treatment weighting using propensity scores. We used generalized estimating equations and Poisson models to calculate relative risk and incidence rate ratios of improper syringe disposal.

RESULTS

The risk of any improper syringe disposal was comparable among people who used and did not use the unsanctioned safe consumption site in prior 30 days (relative risk 1.03; 95% confidence interval=0.53, 1.17). The rate of improperly disposed syringes per number of injections in prior 30 days was significantly lower among people who had used the unsanctioned safe consumption site during the same period (incident rate ratio 0.42; 95% confidence interval=0.18, 0.88).

CONCLUSION

When people used this unsanctioned safe consumption site, they disposed of significantly fewer syringes in public places, including streets, sidewalks, parks, or parking lots, than people not using the site. This study helps allay concerns that implementing safe consumption sites in the US would lead to increases in improperly disposed syringes.

Examining the spatial risk environment tied to the opioid crisis through a unique public health, EMS, and academic research collaborative: Lowell, Massachusetts, 2008–2018

Between 2015 and 2018, Lowell Massachusetts experienced outbreaks in opioid overdoses, HIV, and hepatitis C virus infections (HCV) among people who inject drugs. Through an innovative collaboration between emergency medical services (EMS), public health, and academic partners, we assessed the geographic distribution of opioid-related risks to inform intervention efforts. We analyzed data from three unique data sources for publicly discarded syringes, opioid-related incidents (ORIs), and fatal opioid overdoses in Lowell between 2008 and 2018. We assessed the risk environment over time using a geographic information system to identify and characterize hotspots and noted parallel trends within the syringe discard and ORI data. We identified two notable increases in ORIs per day: the first occurring between 2008 and 2010 (from 0.3 to 0.5), and the second between 2011 and 2014 (from 0.9 to 1.3), following the introduction of fentanyl within local drug markets. We also identified seasonal patterns in the syringe discard, ORI, and overdose data. Through our spatial analyses, we identified significant clusters of discarded syringes, ORIs, and fatal overdoses (p < 0.05), and neighborhoods where high densities of these outcomes overlapped. We found that areas with the highest densities shifted over time, expanding beyond the epicenter of the Downtown neighborhood. Data sharing and analyses among EMS, public health, and academic partners can foster better assessments of local risk environments. Our work, along with new public health efforts in Lowell, led to a city-funded position to improve pick-up and proper disposal of publicly discarded syringes, and better targeted harm reduction services.

Syringe services programs in the Bluegrass: Evidence of population health benefits using Kentucky Medicaid data

PURPOSE

To evaluate whether Kentucky counties that established a new syringe services program realized a significant decline in the incidence rate of a set of infectious disease diagnoses commonly transmitted via injection drug use.

METHODS

Longitudinal count models of within-county rates of newly diagnosed infections among populations at risk were estimated using Medicaid claims/encounters data. Generalized estimating equation models were used to report incident rate ratios of 6 diagnoses: (1) HIV; (2) hepatitis C; (3) hepatitis B; (4) osteomyelitis; (5) endocarditis; and (6) skin/soft tissue infection. To investigate whether a delay in effect was present, separate models were fit to estimate the effects of establishing a syringe services program: at its opening date, and again at 1, 3, and 6 months postopening date.

FINDINGS

Taken together, the aggregated within-county incidence rate of these 6 diagnoses was significantly lower following the implementation of a syringe services program (P < .05). Our models estimated that counties which opted to open a syringe services program realized an approximate month-over-month decline in new diagnoses of 0.5% among the population at risk.

CONCLUSIONS

These results lend further support to previous conclusions made in the public health literature regarding the efficacy of syringe services programs. Specifically, declines in incidence rates were observable beginning at 1 month post syringe services program opening. These results are particularly notable due to the typical setting in which these syringe services programs operated-rural communities of fewer than 40,000 residents.

Between Emergency Department Visits: The Role of Harm Reduction Programs in Mitigating the Harms Associated With Injection Drug Use

Injection drug use is a major public health problem in the United States. Cocaine, heroin, and methamphetamine are the most commonly injected illicit drugs, whereas opioids are responsible for the majority of overdose fatalities. Although recent emergency department (ED) efforts have focused on expanding capacity for buprenorphine induction for opioid use disorder treatment, the injection of illicit drugs carries specific health risks that require acknowledgment and management, particularly for patients who decline substance use treatment. Harm reduction is a public health approach that aims to reduce the harms associated with a health risk behavior, short of eliminating the behavior itself. Harm-reduction strategies fundamental to emergency medicine include naloxone distribution for opioid overdose. This clinical Review Article examines the specific health complications of injection drug use and reviews the evidence base for 2 interventions effective in reducing morbidity and mortality related to drug injection, irrespective of the specific drug used, that are less well known and infrequently leveraged by emergency medicine clinicians: syringe service programs and supervised injection facilities. In accordance with the recommendations of health authorities such as the Centers for Disease Control and Prevention, emergency clinicians can promote the use of harm-reduction programs in the community to reduce viral transmission and other risks of injection drug use by providing patients with information about and referrals to these programs after injection drug use-related ED visits.

The University of Miami Infectious Disease Elimination Act Syringe Services Program: A Blueprint for Student Advocacy, Education, and Innovation

After the closure of pill mills and implementation of Florida's Prescription Drug Monitoring Program in 2010, high demand for opioids was met with counterfeit pills, heroin, and fentanyl. In response, medical students at the University of Miami Miller School of Medicine embarked on a journey to bring syringe services programs (SSPs) to Florida through an innovative grassroots approach. Working with the Florida Medical Association, students learned patient advocacy, legislation writing, and negotiation within a complex political climate. Advocacy over 4 legislative sessions (2013-2016) included committee testimony and legislative visit days, resulting in the authorization of a 5-year SSP pilot. The University of Miami's Infectious Disease Elimination Act (IDEA) SSP opened on December 1, 2016. Students identified an urgent need for expanded health care for program participants and founded a weekly free clinic at the SSP. Students who rotate through the clinic learn medicine and harm reduction through the lens of social justice, with exposure to people who use drugs, sex workers, individuals experiencing homelessness, and other vulnerable populations. The earliest success of the IDEA SSP was the distribution of over 2,000 boxes of nasal naloxone, which the authors believe positively contributed to a decrease in the number of opioid-related deaths in Miami-Dade County for the first time since 2013. The second was the early identification of a cluster of acute human immunodeficiency virus infections among program participants. Inspired by these successes, students from across the state joined University of Miami students and met with legislators in their home districts, wrote op-eds, participated in media interviews, and traveled to the State Capitol to advocate for decisive action to mitigate the opioid crisis. The 2019 legislature passed legislation authorizing SSPs statewide. In states late to adopt SSPs, medical schools have a unique opportunity to address the opioid crisis using this evidence-based approach.

Prevalence and Correlates of Syringe Disposal Box Use in a Philadelphia Neighborhood with High Levels of Public Drug Injection

Background: Philadelphia (Pennsylvania, USA) is facing an unprecedented public health crisis due to fentanyl use. To combat drug-related litter, the Philadelphia Department of Public Health installed 7 public syringe disposal boxes (SDB) in Kensington, the neighborhood most impacted by the opioid crisis and home to a syringe exchange. Methods: We used street- and business-intercepts to recruit residents (N=358) and business owners/staff (N=78) who completed a brief survey with two binary items measuring observing and using SDB. Multivariable logistic regression was used to assess factors independently associated with SDB observance and use. Results: 78% (340/436) observed SDB and 34.1% (116/340) had ever used SDB among those who had seen them. Unstably housed persons had 4.3 times greater odds of observing SDB (Adjusted odds ratio [aOR= 4.29; 95% confidence interval [CI]: 1.56, 11.82) and had 2.5 times greater odds of using SDB (aOR = 2.51; 95% CI: 1.33, 4.74) as did people who use opioids (aOR = 2.61; 95% CI: 1.45, 4.72). Among individuals reporting opioid use who also saw SDB (n=123), those who were unstably housed were more likely to use SDB than those with stable housing (67.8% vs 45.3%, p=.012). Conclusion: These results suggest Kensington residents, especially those who are unstably housed, use SDB once they see them in the neighborhood.

Syringe services programs and real-world research: An overview for pharmacists

OBJECTIVE

To review key arguments supporting and criticizing syringe services programs (SSPs).

DATA SOURCES

Peer-reviewed literature and publicly available documents.

SUMMARY

Pharmacy organizations-including the American Pharmacists Association and the American Society of Health-System Pharmacists-have stated that pharmacists should support programs that supply sterile injection materials to persons who use injection drugs. SSPs may include needle exchanges or other programs that meet these aims. Pharmacists should know that observational public health research demonstrates that SSPs can lower the transmission of blood-borne illnesses, improve linkage to care for substance use disorders, reduce health care expenditures, and reduce drug overdoses. Concerns about SSPs and increases in syringe litter or crime have not been borne out by research. Despite these findings and the positions of professional organizations, contemporary research suggests that pharmacists may be reluctant to support SSPs and other programs that would increase supply of sterile injection supplies to their communities.

CONCLUSION

The review of evidence in this commentary should help pharmacists better understand the evidence in favor of SSPs, the potential criticisms of SSPs, and the reasons that their profession is moving to support these programs.

HIV Injection Risk Behaviors among HIV-Negative People Who Inject Drugs Experiencing Homelessness, 23 U.S. Cities

Despite recent declines in numbers of people who inject drugs (PWID) diagnosed with HIV, clusters of HIV among PWID are ongoing, especially among PWID experiencing homelessness. Using data from the National HIV Behavioral Surveillance in 2018, we evaluated the association between homelessness and injection risk and prevention behaviors among HIV-negative PWID who were recruited by respondent-driven sampling in 23 U.S. cities. Interviewers assessed sociodemographic characteristics, history of overdose, and behavioral risk and prevention factors for HIV. Adjusted prevalence ratios (aPR) and 95% CI were obtained using Poisson regression models. Of 10,614 HIV-negative PWID participants, 7275 (68.5%) reported experiencing homelessness. Homeless PWID were more likely than those who were not to be younger age, white, unemployed, without health insurance, in poverty, experiencing psychological distress, and incarcerated in the past 12 months. PWID experiencing homelessness were significantly more likely to report injection risk behaviors [share syringes/equipment (aPR = 1.26; 95% CI = 1.20-1.33), non-fatal opioid overdose (aPR = 1.64; 95% CI = 1.49-1.79)] and prevention behaviors [testing for HIV in past 12 months (aPR = 1.18; 95% CI = 1.12-1.24) and using syringe services programs (aPR = 1.09; 95% CI = 1.03-1.16)] than PWID not experiencing homelessness. Homelessness among PWID is associated with injection risk behaviors and non-fatal overdose.

Rapid Identification and Investigation of an HIV Risk Network Among People Who Inject Drugs -Miami, FL, 2018

Prevention of HIV outbreaks among people who inject drugs remains a challenge to ending the HIV epidemic in the United States. The first legal syringe services program (SSP) in Florida implemented routine screening in 2018 leading to the identification of ten anonymous HIV seroconversions. The SSP collaborated with the Department of Health to conduct an epidemiologic investigation. All seven acute HIV seroconversions were linked to care (86% within 30 days) and achieved viral suppression (mean 70 days). Six of the seven individuals are epidemiologically and/or socially linked to at least two other seroconversions. Analysis of the HIV genotypes revealed that two individuals are connected molecularly at 0.5% genetic distance. We identified a risk network with complex transmission dynamics that could not be explained by epidemiological methods or molecular analyses alone. Providing wrap-around services through the SSP, including routine screening, intensive linkage and patient navigation, could be an effective model for achieving viral suppression for people who inject drugs.

Syringe disposal among people who inject drugs before and after the implementation of a syringe services program

INTRODUCTION

Due to the increase in people who use opioids in the US, there has been a steady increase in injection drug use. Without access to safe syringe disposal locations, people who inject drugs (PWID) have few options other than improper disposal, including in public places. In 2016, Florida's first legal Syringe Services Program (SSP) was established in Miami. This study aims to compare syringe disposal practices among PWID before and after the implementation of an SSP.

METHODS

Visual inspection walkthroughs of randomly selected census blocks in the neighborhoods in the top quartile of narcotics-related arrests were conducted to assess improperly discarded syringes. Syringe location was geocoded in ArcGIS. Adult PWID pre-SSP (n = 448) and post-SSP (n = 482) implementation were recruited for a survey using respondent-driven sampling in Miami. A Poisson regression model was used to determine the adjusted relative risk (aRR) of improper syringe disposal pre- and post-SSP.

RESULTS

A total of 191 syringes/1000 blocks were found post-implementation versus 371/1000 blocks pre-implementation, representing a 49% decrease after SSP implementation. In the surveys, 70% reported any improper syringe disposal post-SSP implementation versus 97% pre-SSP implementation. PWID in the post-implementation survey had 39% lower adjusted relative risk (aRR = 0.613; 95% CI = 0.546, 0.689) of improper syringe disposal as compared to pre-implementation.

CONCLUSIONS

There was a significant decrease in the number of improperly discarded syringes in public in Miami after the implementation of an SSP. Providing PWID with proper disposal venues such as an SSP could decrease public disposal in other communities.

Baseline differences in characteristics and risk behaviors among people who inject drugs by syringe exchange program modality: an analysis of the Miami IDEA syringe exchange

Background

In March of 2016, Florida passed the Infection Disease Elimination Act (IDEA), legalizing the formation of the first syringe exchange program in Florida, which opened in December of 2016 at a fixed site in Overtown, Miami. Since that time, the exchange expanded in April of 2017 to include a mobile van unit that provides the same services at different locations throughout Miami-Dade County.

Methods

Trained interviewers conducted face-to-face interviews from all first-time participants at the IDEA Exchange, both at the fixed site and the mobile van unit.

Results

Among 718 first-time enrollees, 74.8% were male, 52.1% were non-Hispanic White, 85.9% completed high school, 59.8% were unemployed, 42.1% were homeless, 54.2% reported an annual income of less than $15,000, and the mean age was 38 years. Participants at the fixed site and mobile van unit reported differences in socioeconomic status, injection drug-related behaviors, and pre-existing hepatitis C virus (HCV) infection status.

Conclusions

Taken together, these results suggest that the mobile unit is capturing a subset of PWID in Miami that the fixed site is not, and vice-versa. As the opioid crisis extends into all demographics, such multimodal efforts to target various populations of PWID should be kept in mind, especially when unveiling future syringe exchanges in Florida and other late-adopting states.

Factors associated with obtaining sterile syringes from pharmacies among persons who inject drugs in 20 US cities

BACKGROUND

Increased access to sterile syringes has been shown to reduce HIV risk among people who inject drugs (PWID). Where syringe services programs (SSPs) are limited, pharmacies are an important sterile syringe source. We assessed factors associated with using pharmacies as the primary source of syringes among PWID from 20 US cities.

METHODS

PWID ages ≥18 years were recruited for the 2015 National HIV Behavioral Surveillance using respondent-driven sampling. Using generalized estimating equation (GEE) models, we assessed demographic characteristics independently associated with participant-reported primary syringe source: pharmacies vs. SSPs. We calculated associations between primary syringe source and various behavioural outcomes, adjusted for participant characteristics.

RESULTS

PWID who were <30 years old, female, white, and less frequent injectors were more likely have used pharmacies as their primary syringe source. Accessing syringes primarily from pharmacies, as compared to SSPs, was associated with receptive syringe sharing and unsafe syringe disposal; using sterile syringes, recent HIV testing and participation in an HIV behavioural intervention were negatively associated with primary pharmacy use.

CONCLUSIONS

Pharmacies can play an important role in comprehensive HIV prevention among PWID. Linkage to HIV interventions and syringe disposal services at pharmacies could strengthen prevention efforts for PWID who cannot access or choose not to utilize SSPs.

Building the Case for Localized Approaches to HIV: Structural Conditions and Health System Capacity to Address the HIV/AIDS Epidemic in Six US Cities

Since the discovery of the secondary preventive benefits of antiretroviral therapy, national and international governing bodies have called for countries to reach 90% diagnosis, ART engagement and viral suppression among people living with HIV/AIDS. The US HIV epidemic is dispersed primarily across large urban centers, each with different underlying epidemiological and structural features. We selected six US cities, including Atlanta, Baltimore, Los Angeles, Miami, New York, and Seattle, with the objective of demonstrating the breadth of epidemiological and structural differences affecting the HIV/AIDS response across the US. We synthesized current and publicly-available surveillance, legal statutes, entitlement and discretionary funding, and service location data for each city. The vast differences we observed in each domain reinforce disparities in access to HIV treatment and prevention, and necessitate targeted, localized strategies to optimize the limited resources available for each city's HIV/AIDS response.

Changes in public order after the opening of an overdose monitoring facility for people who inject drugs

BACKGROUND

In the face of an increasingly fatal opioid crisis, Boston Health Care for the Homeless Program (BHCHP) opened the Supportive Place for Observation and Treatment (SPOT), a unique low-threshold harm reduction program for monitoring people who have injected drugs and are at imminent risk of overdose. This study examines the impact of the opening of the SPOT program on measures of injection drug-related public order in the neighborhood surrounding the facility.

METHODS

Data was collected at 10 weeks prior and 12 weeks post SPOT implementation on: number of over-sedated individuals in public, publicly discarded syringes, publicly discarded injection-related litter, and instances of active injection drug use or exchange of drugs. Changes were evaluated using Poisson log-linear regression models. Potential confounders such as weather and police presence were measured and controlled for.

RESULTS

The average number of over-sedated individuals observed in public significantly decreased by 28% (4.3 [95% Confidence Interval (CI) 2.7-6.9] v 3.1 [CI 1.4-6.8]) after SPOT opened. The opening of SPOT did not have a significant effect on the other measures of public order. The daily average number of publicly discarded syringes (28.5 [CI 24.5-33.1] v 28.4 [CI 22.0-36.5]), pieces of publicly discarded injection-related litter (376.3 [CI 358.6-394.8] v 375.0 [CI 345.8-406.6]), and observed instances of active use or exchange of drugs (0.2 [CI 0.1-0.9] v 0.1 [CI 0.0-0.1]) were not statistically significantly different after the opening of SPOT.

CONCLUSIONS

The opening of SPOT was associated with a significant decrease in observed over-sedated individuals. Other measures of injection-drug related public order did not improve or worsen with the opening of SPOT, however, they have been shown to improve with the implementation of a supervised injection facility.

Students as effective harm reductionists and needle exchange organizers

BACKGROUND

Needle exchange programs are safe, highly effective programs for promoting health among people who inject drugs. However, they remain poorly funded, and often illegal, in many places worldwide due to fear and stigma surrounding drug use. Continued advocacy, education, and implementation of new needle exchanges are thus essential to improve public health and reduce structural inequality.

COMMENTARY

We argue that students, and especially professional and graduate students, have the potential to play an important role in advancing harm reduction. Students benefit from the respect given to the professions they are training to enter, which gives them leverage to navigate the political hurdles often faced by needle exchange organizers, especially in areas that presently lack services. In addition, due to their relative simplicity, needle exchanges do not require much of the licensing, clinical knowledge, and infrastructure associated with more traditional student programs, such as student-run free medical clinics. Students are capable of learning harm reduction cultural approaches and techniques if they remain humble, open-minded, and seek the help of the harm reduction community. Consequently, students can generate tremendous benefits to their community without performing beyond their appropriate clinical limitations. Students benefit from organizing needle exchanges by gaining applied experience in advocacy, organization-building, and political finesse. Working in a needle exchange significantly helps erode stigma against multiple marginalized populations. Students in health-related professions additionally learn clinically-relevant knowledge that is often lacking from their formal training, such as an understanding of structural violence and inequality, root causes of substance use, client-centered approaches to health services, and interacting with clients as peers, rather than through the standard hierarchical medical interaction.

CONCLUSION

We therefore encourage students to learn about and consider organizing needle exchanges during their training. Our experience is that students can be successful in developing sustainable programs which benefit their clients, the broader harm reduction movement, and themselves alike.

A Cost Analysis of Hospitalizations for Infections Related to Injection Drug Use at a County Safety-Net Hospital in Miami, Florida

Background

Infections related to injection drug use are common. Harm reduction strategies such as syringe exchange programs and skin care clinics aim to prevent these infections in injection drug users (IDUs). Syringe exchange programs are currently prohibited by law in Florida. The goal of this study was to estimate the mortality and cost of injection drug use-related bacterial infections over a 12-month period to the county safety-net hospital in Miami, Florida. Additionally, the prevalence of HIV and hepatitis C virus among this cohort of hospitalized IDUs was estimated.

Methods and Findings

IDUs discharged from Jackson Memorial Hospital were identified using the International Classification of Diseases, Ninth Revision, codes for illicit drug abuse and endocarditis, bacteremia or sepsis, osteomyelitis and skin and soft tissue infections (SSTIs). 349 IDUs were identified for chart abstraction and 92% were either uninsured or had publicly funded insurance. SSTIs, the most common infection, were reported in 64% of IDUs. HIV seroprevalence was 17%. Seventeen patients (4.9%) died during their hospitalization. The total cost for treatment for injection drug use-related infections to Jackson Memorial Hospital over the 12-month period was $11.4 million.

Conclusions

Injection drug use-related bacterial infections represent a significant morbidity for IDUs in Miami-Dade County and a substantial financial cost to the county hospital. Strategies aimed at reducing risk of infections associated with injection drug use could decrease morbidity and the cost associated with these common, yet preventable infections.