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Curtis SJ, Colledge-Frisby S, Stewardson AJ, Doyle JS, Higgs P, Maher L, Hickman M, Stoové MA, Dietze PM. Prevalence and incidence of emergency department presentations and hospital separations with injecting-related infections in a longitudinal cohort of people who inject drugs. Epidemiol Infect 2023; 151:e192. [PMID: 37953739 PMCID: PMC10728979 DOI: 10.1017/s0950268823001784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/05/2023] [Accepted: 10/26/2023] [Indexed: 11/14/2023] Open
Abstract
People who inject drugs are at risk of acute bacterial and fungal injecting-related infections. There is evidence that incidence of hospitalizations for injecting-related infections are increasing in several countries, but little is known at an individual level. We aimed to examine injecting-related infections in a linked longitudinal cohort of people who inject drugs in Melbourne, Australia. A retrospective descriptive analysis was conducted to estimate the prevalence and incidence of injecting-related infections using administrative emergency department and hospital separation datasets linked to the SuperMIX cohort, from 2008 to 2018. Over the study period, 33% (95%CI: 31-36%) of participants presented to emergency department with any injecting-related infections and 27% (95%CI: 25-30%) were admitted to hospital. Of 1,044 emergency department presentations and 740 hospital separations, skin and soft tissue infections were most common, 88% and 76%, respectively. From 2008 to 2018, there was a substantial increase in emergency department presentations and hospital separations with any injecting-related infections, 48 to 135 per 1,000 person-years, and 18 to 102 per 1,000 person-years, respectively. The results emphasize that injecting-related infections are increasing, and that new models of care are needed to help prevent and facilitate early detection of superficial infection to avoid potentially life-threatening severe infections.
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Affiliation(s)
- Stephanie J. Curtis
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Samantha Colledge-Frisby
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- National Drug Research Institute, Curtin University, Melbourne, VIC, Australia
| | - Andrew J. Stewardson
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Joseph S. Doyle
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Peter Higgs
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- Department of Public Health, La Trobe University, Bundoora, VIC, Australia
| | - Lisa Maher
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- The Kirby Institute, Faculty of Medicine, UNSW, Wallace Wurth Building, Kensington, NSW, Australia
| | - Matthew Hickman
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Mark A. Stoové
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- The Kirby Institute, Faculty of Medicine, UNSW, Wallace Wurth Building, Kensington, NSW, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Paul M. Dietze
- Disease Elimination Program, Burnet Institute, Melbourne, VIC, Australia
- National Drug Research Institute, Curtin University, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Rammohan I, Jain S, Sun S, Marks C, Milloy MJ, Hayashi K, DeBeck K, González-Zúñiga P, Strathdee S, Werb D. Latent polydrug use patterns and the provision of injection initiation assistance among people who inject drugs in three North American settings. Drug Alcohol Rev 2023; 42:1504-1516. [PMID: 37321850 PMCID: PMC10524861 DOI: 10.1111/dar.13687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/17/2023] [Accepted: 05/05/2023] [Indexed: 06/17/2023]
Abstract
INTRODUCTION We sought to identify latent profiles of polysubstance use patterns among people who inject drugs in three distinct North American settings, and then determine whether profile membership was associated with providing injection initiation assistance to injection-naïve persons. METHODS Cross-sectional data from three linked cohorts in Vancouver, Canada; Tijuana, Mexico; and San Diego, USA were used to conduct separate latent profile analyses based on recent (i.e., past 6 months) injection and non-injection drug use frequency. We then assessed the association between polysubstance use patterns and recent injection initiation assistance provision using logistic regression analyses. RESULTS A 6-class model for Vancouver participants, a 4-class model for Tijuana participants and a 4-class model for San Diego participants were selected based on statistical indices of fit and interpretability. In all settings, at least one profile included high-frequency polysubstance use of crystal methamphetamine and heroin. In Vancouver, several profiles were associated with a greater likelihood of providing recent injection initiation assistance compared to the referent profile (low-frequency use of all drugs) in unadjusted and adjusted analyses, however, the inclusion of latent profile membership in the multivariable model did not significantly improve model fit. DISCUSSION AND CONCLUSIONS We identified commonalities and differences in polysubstance use patterns among people who inject drugs in three settings disproportionately impacted by injection drug use. Our results also suggest that other factors may be of greater priority when tailoring interventions to reduce the incidence of injection initiation. These findings can aid in efforts to identify and support specific higher-risk subpopulations of people who inject drugs.
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Affiliation(s)
- Indhu Rammohan
- Centre on Drug Policy and Evaluation, St. Michael’s Hospital, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, United States
| | - Shelly Sun
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, United States
| | - Charles Marks
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, United States
- School of Community Health Sciences, University of Reno, Reno, United States
| | - M-J Milloy
- British Columbia Centre on Substance Use, Vancouver, Canada
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, Vancouver, Canada
| | - Kora DeBeck
- British Columbia Centre on Substance Use, Vancouver, Canada
| | - Patricia González-Zúñiga
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, United States
| | - Steffanie Strathdee
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, United States
| | - Dan Werb
- Centre on Drug Policy and Evaluation, St. Michael’s Hospital, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, United States
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Gicquelais RE, Astemborski J, Werb D, Kirk GD, Mehta SH, Genberg BL. Context and correlates of providing assistance with someone's first injection in the AIDS linked to the IntraVenous Experience cohort, Baltimore, MD. Drug Alcohol Depend 2023; 250:110909. [PMID: 37517262 PMCID: PMC10529208 DOI: 10.1016/j.drugalcdep.2023.110909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 07/14/2023] [Accepted: 07/15/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND The social processes around initiating injection may be well-suited to intervention, yet there is substantial heterogeneity in the reported experiences of people who inject drugs (PWID) who assist with another individual's first drug injection. We aimed to describe the lifetime prevalence and context of providing initiation assistance among a cohort of PWID. METHODS Participants of the AIDS Linked to the IntraVenous Experience (ALIVE) cohort of PWID in Baltimore, Maryland (n=848) were surveyed during 2019-2020 about assisting with another person's first injection. Associations between factors related to injection risk and history of providing assistance were estimated using logistic regression models adjusted for sociodemographic and behavioral characteristics. RESULTS At baseline, participants were primarily male (66.1%), black (82.9%), aged a median of 42 years, and had been injecting a median of 18 years. Overall, 19% (n=157) of participants reported ever providing assistance for a median of 2 people (Interquartile Range: 1-4). Having hepatitis C infection (adjusted Odds Ratio [95% Confidence Interval]: 2.5 [1.4-4.6]), syringe sharing (2.2 [1.2-3.9]), and injecting ≥3 times per day (2.0 [1.2-3.4]) at study enrollment were associated with a history of assistance. Participants primarily assisted friends (58.0%), acquaintances (29.9%), and partners (21.7%). Common reasons for assisting were the other person's lack of injection knowledge (73.7%) or sharing drugs (44.9%). Additional reasons included to prevent injury. CONCLUSION PWID with a history of assisting with another person's first injection exhibited heightened vulnerability to infections and more frequent substance use. Expanding implementation of interventions with an emphasis on harm reduction is needed.
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Affiliation(s)
- Rachel E Gicquelais
- University of Wisconsin-Madison School of Nursing, 701 Highland AveMadisonWI53705, United States
| | - Jacqueline Astemborski
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe StBaltimoreMD21205, United States
| | - Daniel Werb
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael's HospitalTorontoOntario, Canada; Department of Medicine, University of California San DiegoSan DiegoCA92161, United States
| | - Gregory D Kirk
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe StBaltimoreMD21205, United States; Johns Hopkins University School of Medicine, Division of Infectious DiseasesBaltimoreMD21205, United States
| | - Shruti H Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe StBaltimoreMD21205, United States
| | - Becky L Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe StBaltimoreMD21205, United States.
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Bouck Z, Tricco AC, Rosella LC, Banack HR, Fox MP, Platt RW, Milloy MJ, DeBeck K, Hayashi K, Werb D. First-line opioid agonist treatment as prevention against assisting others in initiating injection drug use: A longitudinal cohort study of people who inject drugs in Vancouver, Canada. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 7:100168. [PMID: 37397436 PMCID: PMC10311194 DOI: 10.1016/j.dadr.2023.100168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/18/2023] [Accepted: 05/19/2023] [Indexed: 07/04/2023]
Abstract
Background Among people who inject drugs, frequent injecting and experiencing withdrawal are associated with facilitating others' first injections. As these factors may reflect an underlying substance use disorder, we investigated whether first-line oral opioid agonist treatment (OAT; methadone or buprenorphine/naloxone) reduces the likelihood that people who inject drugs help others initiate injecting. Methods We used questionnaire data from semi-annual visits between December 2014-May 2018 on 334 people who inject drugs with frequent non-medical opioid use in Vancouver, Canada. We estimated the effect of current first-line OAT on subsequent injection initiation assistance provision (i.e., helped someone initiate injecting in the following six months) using inverse-probability-weighted estimation of repeated measures marginal structural models to reduce confounding and informative censoring by time-fixed and time-varying covariates. Results By follow-up visit, 54-64% of participants reported current first-line OAT whereas 3.4-6.9% provided subsequent injection initiation assistance. Per the primary weighted estimate (n = 1114 person-visits), participants currently on first-line OAT (versus no OAT) were 50% less likely, on average, to subsequently help someone initiate injecting (relative risk [RR]=0.50, 95% CI=0.23-1.11). First-line OAT was associated with reduced risk of subsequent injection initiation assistance provision in participants who, at baseline, injected opioids less than daily (RR=0.15, 95% CI=0.05-0.44) but not in those who injected opioids daily (RR=0.86, 95% CI=0.35-2.11). Conclusions First-line OAT seemingly reduces the short-term likelihood that people who inject drugs facilitate first injections. However, the extent of this potential effect remains uncertain due to imprecise estimation and observed heterogeneity by baseline opioid injecting frequency.
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Affiliation(s)
- Zachary Bouck
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Andrea C. Tricco
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Knowledge Translation Program, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Laura C. Rosella
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | - Hailey R. Banack
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Matthew P. Fox
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States
- Department of Global Health, Boston University School of Public Health, Boston, MA, United States
| | - Robert W. Platt
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montréal, QC, Canada
- Department of Pediatrics, McGill University, Montréal, QC, Canada
| | - M-J Milloy
- British Columbia Centre for Substance Use, Vancouver, BC, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kora DeBeck
- British Columbia Centre for Substance Use, Vancouver, BC, Canada
| | - Kanna Hayashi
- British Columbia Centre for Substance Use, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Dan Werb
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, CA, United States
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Pilarinos A, Bingham B, Kwa Y, Joe R, Grant C, Fast D, Buxton JA, DeBeck K. Interest in using buprenorphine-naloxone among a prospective cohort of street-involved young people in Vancouver, Canada. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 148:209005. [PMID: 36921770 PMCID: PMC10773610 DOI: 10.1016/j.josat.2023.209005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 11/20/2022] [Accepted: 02/15/2023] [Indexed: 03/14/2023]
Abstract
INTRODUCTION Limited research examines buprenorphine-naloxone interest among adolescents and young adults (AYA). This longitudinal study examined factors associated with initial buprenorphine-naloxone interest and the time to a positive change in buprenorphine-naloxone interest or enrollment, in addition to identifying reasons for buprenorphine-naloxone disinterest. METHODS The study derived data from a cohort of street-involved AYA in Vancouver, Canada between December 2014 and June 2018. The analysis was restricted to AYA who reported weekly or daily illicit opioid use in the last six months but had not initiated buprenorphine-naloxone. The study examined factors associated with initial buprenorphine-naloxone interest using multivariable logistic regression, while multivariable Cox regression identified factors associated with the time to a positive change in buprenorphine-naloxone interest or actual enrollment over follow-up among AYA initially disinterested in buprenorphine-naloxone. RESULTS Of 281 participants who reported weekly illicit opioid use but were not on buprenorphine-naloxone, 52 (18.5 %) AYA reported initial buprenorphine-naloxone interest, while 68 (24.2 %) AYA who were initially disinterested in buprenorphine-naloxone reported interest or enrollment over follow-up. In multivariable logistic regression, initial interest was positively associated with older age (Adjusted Odds Ratio [AOR] = 1.09, 95 % Confidence Interval [CI]: 1.03-1.15), but negatively associated with self-reported Indigenous identity (AOR = 0.22, 95 % CI: 0.07-0.68). In multivariable Cox regression, recent detoxification program access (Adjusted Hazard Ratio [AHR] = 0.85, 95 % CI: 0.73-0.98) was positively associated with the time to a positive change in buprenorphine-naloxone interest or enrollment. Common reasons for buprenorphine-naloxone disinterest included not wanting opioid agonist treatments (OAT) (initial n = 67, follow-up n = 105); not wanting to experience precipitated withdrawal (initial n = 42, follow-up n = 54), being satisfied with or preferring other OAT (initial n = 33, follow-up n = 52), not knowing what buprenorphine-naloxone is (initial n = 27, follow-up n = 9), previous negative treatment experiences (initial n = 19, follow-up n = 20), and wanting to continue opioid use (initial n = 13, follow-up n = 9), among others. CONCLUSIONS We documented persistent disinterest in buprenorphine-naloxone among AYA, though participants' reasons for disinterest provide insight into the potential benefits of expanding micro-dosing induction; ensuring treatment is culturally safe; and communicating changes in buprenorphine-naloxone programming to AYA. Nevertheless, a need remains to improve the continuum of harm reduction and treatment supports for AYA.
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Affiliation(s)
- Andreas Pilarinos
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Interdisciplinary Studies Graduate Program, University of British Columbia, 270-2357 Main Mall, Vancouver, BC V6T 1Z4, Canada
| | - Brittany Bingham
- Vancouver Coastal Health, 520 West 6th Avenue, Vancouver, BC V5Z 1A1, Canada; Division of Social Medicine, Department of Medicine, University of British Columbia, 317-2914 Health Sciences Mall, Vancouver, BC V6T1Z3, Canada
| | - Yandi Kwa
- Vancouver Coastal Health, 520 West 6th Avenue, Vancouver, BC V5Z 1A1, Canada
| | - Ronald Joe
- Vancouver Coastal Health, 520 West 6th Avenue, Vancouver, BC V5Z 1A1, Canada
| | - Cameron Grant
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada
| | - Danya Fast
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Division of Social Medicine, Department of Medicine, University of British Columbia, 317-2914 Health Sciences Mall, Vancouver, BC V6T1Z3, Canada
| | - Jane A Buxton
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada
| | - Kora DeBeck
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; School of Public Policy, Simon Fraser University, 515 West Hastings Street, Suite 3271, Vancouver, BC V6B 5K3, Canada.
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Pilarinos A, Kwa Y, Joe R, Dong H, Grant C, Fast D, Buxton JA, DeBeck K. Methadone Maintenance Treatment Discontinuation Among Young People who use Opioids in Vancouver, Canada. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2023; 68:89-100. [PMID: 36377240 PMCID: PMC9923138 DOI: 10.1177/07067437221136468] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Retaining adolescents and young adults (AYA) in medications for opioid use disorder (MOUD), like methadone maintenance treatment (MMT), is critical to reducing toxic drug fatalities. This analysis sought to identify factors associated with MMT discontinuation among AYA. METHOD Data were derived from the At-Risk Youth Study, a prospective cohort study of street-involved AYA in Vancouver, Canada, between December 2005 and June 2018. Multivariable extended Cox regression identified factors associated with time to MMT discontinuation among AYA who recently initiated MMT. In subanalysis, multivariable extended Cox regression analysis identified factors associated with time to "actionable" MMT discontinuation, which could be addressed through policy changes. RESULTS A total of 308 participants reported recent MMT during the study period. Participants were excluded if they reported MMT in the past 6 months at baseline and were retained in MMT (n = 94, 30.5%); were missing MMT status data (n = 43, 14.0%); or completed an MMT taper (n = 11, 3.6%). Of the remaining 160 participants who initiated MMT over the study period, 102 (63.8%) discontinued MMT accounting for 119 unique discontinuation events. In multivariable extended Cox regression, MMT discontinuation was positively associated with recent weekly crystal methamphetamine use (adjusted hazard ratio [AHR] = 1.67, 95% confidence interval [CI]: 1.19 to 2.35), but negatively associated with age of first "hard" drug use (per year older) (AHR = 0.95, 95% CI: 0.90 to 1.00) and female sex (AHR = 0.66, 95% CI: 0.44 to 0.99). In subanalysis, recent weekly crystal methamphetamine use (AHR = 4.61, 95% CI: 1.78 to 11.9) and weekly heroin or fentanyl use (AHR = 3.37, 95% CI: 1.21 to 9.38) were positively associated with "actionable" MMT discontinuation, while older age (AHR = 0.87, 95% CI: 0.76 to 0.99) was negatively associated. CONCLUSIONS Efforts to revise MMT programming; provide access to a range of MOUD, harm reduction, and treatments; and explore coprescribing stimulants to AYA with concurrent stimulant use may improve treatment retention and reduce toxic drug fatalities.
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Affiliation(s)
- Andreas Pilarinos
- 558158British Columbia Centre on Substance Use, Vancouver, Canada.,Interdisciplinary Studies Graduate Program, 8166University of British Columbia, Vancouver, Canada
| | - Yandi Kwa
- Vancouver Coastal Health, Vancouver, Canada
| | - Ronald Joe
- Vancouver Coastal Health, Vancouver, Canada
| | - Huiru Dong
- 558158British Columbia Centre on Substance Use, Vancouver, Canada.,1811Harvard Medical School, Harvard University, Boston, MA, USA.,213912Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA
| | - Cameron Grant
- 558158British Columbia Centre on Substance Use, Vancouver, Canada
| | - Danya Fast
- 558158British Columbia Centre on Substance Use, Vancouver, Canada.,Department of Medicine, 8166University of British Columbia, Vancouver, Canada
| | - Jane Alison Buxton
- School of Population and Public Health, 8166University of British Columbia, Vancouver, Canada
| | - Kora DeBeck
- 558158British Columbia Centre on Substance Use, Vancouver, Canada.,School of Public Policy, 175073Simon Fraser University, Vancouver, Canada
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Meyers-Pantele SA, Mittal ML, Jain S, Sun S, Rammohan I, Fairbairn N, Milloy MJ, DeBeck K, Hayashi K, Werb D. The influence of poly-drug use patterns on the association between opioid agonist treatment engagement and injecting initiation assistance. Subst Abuse Treat Prev Policy 2022; 17:39. [PMID: 35590419 PMCID: PMC9118611 DOI: 10.1186/s13011-022-00470-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Evidence suggests people who inject drugs (PWID) prescribed opioid agonist treatment (OAT) are less likely to provide injection drug use (IDU) initiation assistance. We investigated the association between OAT engagement and providing IDU initiation assistance across poly-drug use practices in Vancouver, Canada. METHODS Preventing Injecting by Modifying Existing Responses (PRIMER) is a prospective study seeking to identify structural interventions that reduce IDU initiation. We employed data from linked cohorts of PWID in Vancouver and extended the findings of a latent profile analysis (LPA). Multivariable logistic regression models were performed separately for the six poly-drug use LPA classes. The outcome was recently assisting others in IDU initiation; the independent variable was recent OAT engagement. RESULTS Among participants (n = 1218), 85 (7.0%) reported recently providing injection initiation assistance. When adjusting for age and sex, OAT engagement among those who reported a combination of high-frequency heroin and methamphetamine IDU and low-to-moderate-frequency prescription opioid IDU and methamphetamine non-injection drug use (NIDU) was associated with lower odds of IDU initiation assistance provision (Adjusted Odds Ratio [AOR]: 0.18, 95% CI: 0.05-0.63, P = 0.008). Significant associations were not detected among other LPA classes. CONCLUSIONS Our findings extend evidence suggesting that OAT may provide a population-level protective effect on the incidence of IDU initiation and suggest that this effect may be specific among PWID who engage in high-frequency methamphetamine and opioid use. Future research should seek to longitudinally investigate potential causal pathways explaining the association between OAT and initiation assistance provision among PWID to develop tailored intervention efforts.
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Affiliation(s)
- Stephanie A Meyers-Pantele
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093-0507, USA
- Department of Psychology, San Diego State University, San Diego, CA, USA
| | - Maria Luisa Mittal
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093-0507, USA
- School of Medicine, Universidad Xochicalco, Tijuana, BC, Mexico
| | - Sonia Jain
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA, USA
| | - Shelly Sun
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA, USA
| | - Indhu Rammohan
- Centre on Drug Policy Evaluation, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Nadia Fairbairn
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - M-J Milloy
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kora DeBeck
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- School of Public Policy, Simon Fraser University, Vancouver, BC, Canada
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada
| | - Dan Werb
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093-0507, USA.
- Centre on Drug Policy Evaluation, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
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Lim J, Farhat I, Douros A, Panagiotoglou D. Relative effectiveness of medications for opioid-related disorders: A systematic review and network meta-analysis of randomized controlled trials. PLoS One 2022; 17:e0266142. [PMID: 35358261 PMCID: PMC8970369 DOI: 10.1371/journal.pone.0266142] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/15/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Several pharmacotherapeutic interventions are available for maintenance treatment for opioid-related disorders. However, previous meta-analyses have been limited to pairwise comparisons of these interventions, and their efficacy relative to all others remains unclear. Our objective was to unify findings from different healthcare practices and generate evidence to strengthen clinical treatment protocols for the most widely prescribed medications for opioid-use disorders. METHODS We searched Medline, EMBASE, PsycINFO, CENTRAL, and ClinicalTrials.gov for all relevant randomized controlled trials (RCT) from database inception to February 12, 2022. Primary outcome was treatment retention, and secondary outcome was opioid use measured by urinalysis. We calculated risk ratios (RR) and 95% credible interval (CrI) using Bayesian network meta-analysis (NMA) for available evidence. We assessed the credibility of the NMA using the Confidence in Network Meta-Analysis tool. RESULTS Seventy-nine RCTs met the inclusion criteria. Due to heterogeneity in measuring opioid use and reporting format between studies, we conducted NMA only for treatment retention. Methadone was the highest ranked intervention (Surface Under the Cumulative Ranking [SUCRA] = 0.901) in the network with control being the lowest (SUCRA = 0.000). Methadone was superior to buprenorphine for treatment retention (RR = 1.22; 95% CrI = 1.06-1.40) and buprenorphine superior to naltrexone (RR = 1.39; 95% CrI = 1.10-1.80). However, due to a limited number of high-quality trials, confidence in the network estimates of other treatment pairs involving naltrexone and slow-release oral morphine (SROM) remains low. CONCLUSION All treatments had higher retention than the non-pharmacotherapeutic control group. However, additional high-quality RCTs are needed to estimate more accurately the extent of efficacy of naltrexone and SROM relative to other medications. For pharmacotherapies with established efficacy profiles, assessment of their long-term comparative effectiveness may be warranted. TRIAL REGISTRATION This systematic review has been registered with PROSPERO (https://www.crd.york.ac.uk/prospero) (identifier CRD42021256212).
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Affiliation(s)
- Jihoon Lim
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
| | - Imen Farhat
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
| | - Antonios Douros
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada
- Institute of Clinical Pharmacology and Toxicology, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Dimitra Panagiotoglou
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
- * E-mail:
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9
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Meyers-Pantele SA, Jain S, Sun X, Marks C, DeBeck K, Hayashi K, Strathdee SA, Werb D. Gender and the first-time provision of injection initiation assistance among people who inject drugs across two distinct North American contexts: Tijuana, Mexico and Vancouver, Canada. Drug Alcohol Rev 2022; 41:686-696. [PMID: 34636100 PMCID: PMC8930605 DOI: 10.1111/dar.13390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 09/03/2021] [Accepted: 09/12/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Injection drug use initiation is commonly facilitated by other people who inject drugs (PWID). We investigated how the gender of PWID influences their risk of providing initiation assistance to others across two distinct geo-cultural settings. METHODS Data were drawn from two prospective cohorts in Tijuana, Mexico and Vancouver, Canada which conducted semi-annual interviews within the PReventing Injecting by Modifying Existing Responses (PRIMER) study. Participants consisted of PWID who had reported never providing injection initiation assistance at baseline. We then conducted site-specific discrete-time survival analyses assessing the relationship between gender and other relevant covariates (e.g. age and past 6-month sex work) on the risk of the first reported instance of providing initiation assistance. RESULTS Of 1988 PWID (Tijuana: n = 596; Vancouver: n = 1392), 256 (43%) and 511 (36.7%) participants were women, and 42 (1.7%) and 78 (1.6%) reported recent injection initiation assistance across a median of three and two follow-up visits, respectively. Women had a lower risk of providing injection initiation assistance for the first time in Tijuana (adjusted hazard ratio = 0.52, 95% confidence interval 0.27-0.99), but not in Vancouver. Gendered pathways, like sex work, were associated with providing initiation assistance for the first time in Vancouver (adjusted hazard ratio = 1.97, 95% confidence interval 1.08-3.61). DISCUSSION AND CONCLUSIONS Women in Tijuana, but not Vancouver, were less likely to provide first-time initiation assistance among PWID. These results can inform gender- and site-specific prevention efforts aimed at reducing transitions into drug injecting across geographic contexts.
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Affiliation(s)
- Stephanie A. Meyers-Pantele
- Department of Psychology, San Diego State University, San Diego, USA,Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, USA
| | - Sonia Jain
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, USA
| | - Xiaoying Sun
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, USA
| | - Charles Marks
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, USA,School of Public Health, University of Nevada, Reno, USA
| | - Kora DeBeck
- British Columbia Centre on Substance Use, Vancouver, Canada
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, Vancouver, Canada
| | - Steffanie A. Strathdee
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, USA
| | - Dan Werb
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, USA,Centre on Drug Policy Evaluation, St. Michael’s Hospital, Toronto, Canada
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10
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Bouck Z, Tricco AC, Rosella LC, Ling V, Gomes T, Tadrous M, Fox MP, Scheim AI, Werb D. Validation of Self-reported Opioid Agonist Treatment Among People Who Inject Drugs Using Prescription Dispensation Records. Epidemiology 2022; 33:287-294. [PMID: 34799473 DOI: 10.1097/ede.0000000000001443] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Studies of people who inject drugs (PWID) commonly use questionnaires to determine whether participants are currently, or have recently been, on opioid agonist treatment for opioid use disorder. However, these previously unvalidated self-reported treatment measures may be susceptible to inaccurate reporting. METHODS We linked baseline questionnaire data from 521 PWID in the Ontario integrated Supervised Injection Services cohort in Toronto (November 2018-March 2020) with record-level health administrative data. We assessed the validity (sensitivity, specificity, positive and negative predictive value [PPV and NPV]) of self-reported recent (in the past 6 months) and current (as of interview) opioid agonist treatment with methadone or buprenorphine-naloxone relative to prescription dispensation records from a provincial narcotics monitoring system, considered the reference standard. RESULTS For self-reported recent opioid agonist treatment, sensitivity was 78% (95% CI = 72, 83), specificity was 90% (95% CI = 86, 94), PPV was 90% (95% CI = 85, 93), and NPV was 79% (95% CI = 74, 84). For self-reported current opioid agonist treatment, sensitivity was 84% (95% CI = 78, 90), specificity was 87% (95% CI = 83, 91), PPV was 74% (95% CI = 67, 81), and NPV was 93% (95% CI = 89, 95). CONCLUSIONS Self-reported opioid agonist treatment measures were fairly accurate among PWID, with some exceptions. Inaccurate recall due to a lengthy lookback window may explain underreporting of recent treatment, whereas social desirability bias may have led to overreporting of current treatment. These validation data could be used in future studies of PWID to adjust for misclassification in similar self-reported treatment measures.
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Affiliation(s)
- Zachary Bouck
- From the Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Andrea C Tricco
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Knowledge Translation Program, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Laura C Rosella
- From the Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
| | | | - Tara Gomes
- ICES, Toronto, ON, Canada
- Ontario Drug Policy Research Network, Toronto, ON, Canada
| | - Mina Tadrous
- Ontario Drug Policy Research Network, Toronto, ON, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Matthew P Fox
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
- Department of Global Health, Boston University School of Public Health, Boston, MA
| | - Ayden I Scheim
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Dornsife School of Public Health, Drexel University, Philadelphia, PA
| | - Dan Werb
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, CA
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11
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Brener L, Caruana T, Broady T, Cama E, Ezard N, Madden A, Treloar C. Addressing injecting related risks among people who inject both opioids and stimulants: Findings from an Australian survey of people who inject drugs. Addict Behav Rep 2022; 15:100398. [PMID: 35005190 PMCID: PMC8717740 DOI: 10.1016/j.abrep.2021.100398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/18/2021] [Accepted: 12/08/2021] [Indexed: 01/04/2023] Open
Abstract
Background Opioids and stimulants are the most commonly injected illicit drugs worldwide and in Australia. While some people who inject drugs (PWID) prefer either opioids or stimulants, others regularly use both opioids and stimulants. Limited available research indicates that those who use opioids and stimulants together, either in combination or alternating between the two, may engage in injection-related practices which potentially place them at greater health risk and could lead to poorer health outcomes. Methods Participants were recruited nationally through member organizations of the Australian Injecting and Illicit Drug Users League (AIVL); these organizations represent PWID in each Australian state and territory. This study compared a sample of PWID (N = 535) who reported past-month injection of opioids only (N = 173), stimulants only (N = 208), or both (N = 154) on a range of health and wellbeing outcomes. PWID completed a survey assessing drugs injected, frequency of injecting, receptive equipment sharing, psychological distress, self-reported hepatitis C (HCV) status, experienced and internalized stigma, drug use salience, and community attachment. Results People who injected both opioids and stimulants reported more frequent injecting, more experiences of stigma, and greater reported HCV diagnosis than people who injected stimulants or opioids alone. They also showed greater attachment to a community of PWID and greater salience of drug use to their identity. Conclusions The findings of increased injecting and broader harms associated with injecting both stimulants and opioids are important for tailoring harm reduction and intervention designs for people who use both opioid and stimulant drugs, including prioritizing peer-based approaches.
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Affiliation(s)
- L. Brener
- Centre for Social Research in Health, University of New South Wales, Sydney,
Australia
- Corresponding author at: Centre for Social Research in Health, University of
New South Wales, Sydney 2052, Australia.
| | - T. Caruana
- Centre for Social Research in Health, University of New South Wales, Sydney,
Australia
| | - T. Broady
- Centre for Social Research in Health, University of New South Wales, Sydney,
Australia
| | - E. Cama
- Centre for Social Research in Health, University of New South Wales, Sydney,
Australia
| | - N. Ezard
- St Vincent’s Hospital Sydney, Alcohol and Drug Service and the National
Centre for Clinical Research in Emerging Drugs Drug and Alcohol Clinical Research and
Improvement Network, National Drug and Alcohol Centre, University of New South Wales,
Sydney, Australia
| | - A. Madden
- Centre for Social Research in Health, University of New South Wales, Sydney,
Australia
| | - C. Treloar
- Centre for Social Research in Health, University of New South Wales, Sydney,
Australia
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12
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Allen ST, Schneider KE, Mazhnaya A, White RH, O’Rourke A, Kral AH, Bluthenthal RN, Kilkenny ME, Sherman SG. Factors Associated with Likelihood of Initiating Others into Injection Drug Use Among People Who Inject Drugs in West Virginia. AIDS Behav 2022; 26:47-56. [PMID: 34076812 PMCID: PMC8170059 DOI: 10.1007/s10461-021-03325-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2021] [Indexed: 02/08/2023]
Abstract
People who inject drugs (PWID) play a critical role in injection-naïve individuals transitioning to injection drug use. We investigated factors associated with future likelihood of initiating injection-naïve individuals using multivariable logistic regression among 418 PWID in rural Appalachia (Cabell County, West Virginia). Less than 10% reported they were likely to initiate someone in the future. Acquiring syringes from a syringe services program was associated with decreased odds of being likely to initiate someone in the future (adjusted odds ratio [aOR] 0.46, 95% CI 0.23, 0.95), while having previously initiated someone into injection drug use was associated with increased odds (aOR 8.65, 95% CI 4.07, 18.41). Among our sample of PWID in Appalachia, a small proportion reported that they would be likely to initiate an injection-naïve individual in the future. Efforts to reduce injection initiation assistance should focus on this subpopulation of PWID who indicate a willingness to engage in this behavior.
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Affiliation(s)
- Sean T. Allen
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway #184, Baltimore, MD 21205 USA
| | - Kristin E. Schneider
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Alyona Mazhnaya
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway #184, Baltimore, MD 21205 USA
| | - Rebecca Hamilton White
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway #184, Baltimore, MD 21205 USA
| | - Allison O’Rourke
- DC Center for AIDS Research, Department of Psychological and Brain Sciences, George Washington University, Washington, DC USA
| | | | - Ricky N. Bluthenthal
- Department of Preventive Medicine, Institute for Health Promotion & Disease Prevention, Keck School of Medicine, University of Southern California, Los Angeles, CA USA
| | | | - Susan G. Sherman
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway #184, Baltimore, MD 21205 USA
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13
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Marks C, Meyers SA, Jain S, Sun X, Hayashi K, Gonzalez-Zuniga P, Strathdee SA, Garfein RS, Milloy MJ, DeBeck K, Cummins K, Werb D. Involvement of people who inject drugs in injection initiation events: a cross-sectional analysis identifying similarities and differences across three North American settings. BMJ Open 2021; 11:e046957. [PMID: 34385244 PMCID: PMC8362731 DOI: 10.1136/bmjopen-2020-046957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES People who inject drugs (PWID) play an integral role in facilitating the entry of others into injection drug use (IDU). We sought to assess factors influencing PWID in providing IDU initiation assistance across three distinct North American settings and to generate pooled measures of risk. DESIGN We employed data from three PWID cohort studies participating in PReventing Injecting by Modifying Existing Responses (PRIMER), for this cross-sectional analysis. SETTING Tijuana, Mexico; San Diego, USA; Vancouver, Canada. PARTICIPANTS A total of 2944 participants were included in this study (Tijuana: n=766, San Diego: n=353, Vancouver: n=1825). MEASUREMENTS The outcome was defined as recently (ie, past 6 months) assisting in an IDU initiation event. Independent variables of interest were identified from previous PRIMER analyses. Site-specific multiple modified Poisson regressions were fit. Pooled relative risks (pRR) were calculated and heterogeneity across sites was assessed via linear random effects models. RESULTS Evidence across all three sites indicated that having a history of providing IDU initiation assistance (pRR: 4.83, 95% CI: 3.49 to 6.66) and recently being stopped by law enforcement (pRR: 1.49, 95% CI: 1.07 to 2.07) were associated with a higher risk of providing assistance with IDU initiation; while recent opioid agonist treatment (OAT) enrolment (pRR: 0.64, 95% CI: 0.43 to 0.96) and no recent IDU (pRR: 0.21, 95% CI: 0.07 to 0.64) were associated with a lower risk. We identified substantial differences across site in the association of age (I2: 52%), recent housing insecurity (I2: 39%) and recent non-injection heroin use (I2: 78%). CONCLUSION We identified common and site-specific factors related to PWID's risk of assisting in IDU initiation events. Individuals reporting a history of assisting IDU initiations, being recently stopped by law enforcement, and recently injecting methamphetamine/speedball were more likely to have recently assisted an IDU initiation. Whereas those who reported not recently engaging in IDU and those recently enrolled in OAT were less likely to have done so. Interventions and harm reduction strategies aimed at reducing the harms of IDU should incorporate context-specific approaches to reduce the initiation of IDU.
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Affiliation(s)
- Charles Marks
- Department of Medicine, University of California San Diego, La Jolla, California, USA
- Interdisciplinary Research on Substance Use Joint Doctoral Program, San Diego State University and University of California San Diego, San Diego, California, USA
- School of Social Work, San Diego State University, San Diego, California, USA
| | - Stephanie A Meyers
- Department of Medicine, University of California San Diego, La Jolla, California, USA
- Interdisciplinary Research on Substance Use Joint Doctoral Program, San Diego State University and University of California San Diego, San Diego, California, USA
- School of Social Work, San Diego State University, San Diego, California, USA
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, California, USA
| | - Xiaoying Sun
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, California, USA
| | - Kanna Hayashi
- Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | | | - Steffanie A Strathdee
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Richard S Garfein
- Family Medicine and Public Health, University of California San Diego, La Jolla, California, USA
| | - M J Milloy
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kora DeBeck
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- School of Public Policy, Simon Fraser University, Vancouver, British Columbia, Canada
| | - Kevin Cummins
- Department of Public Health, CSU Fullerton, Fullerton, California, USA
| | - Dan Werb
- Department of Medicine, University of California San Diego, La Jolla, California, USA
- Centre on Drug Policy Evaluation, Unity Health Toronto, Toronto, Ontario, Canada
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14
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Investigating a bidirectional relationship between overdose and provision of injection initiation assistance among persons who inject drugs in Vancouver, Canada and Tijuana, Mexico. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 95:103398. [PMID: 34390966 DOI: 10.1016/j.drugpo.2021.103398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 07/13/2021] [Accepted: 07/17/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Individuals who initiate injection drug use often receive assistance from an injection-knowledgeable peer. Persons who assist peers in injection initiation events often inject frequently, which heightens overdose risk. As such, overdose and injection initiation events may be correlated. To explore a potential relationship, we assessed temporal associations between experiencing a non-fatal overdose and assisting others in initiating injection drug use among persons who inject drugs in two North American cities - Vancouver, Canada and Tijuana, Mexico. METHODS From 2014 to 2018, this retrospective cohort study included people who inject drugs from Vancouver (n=1332) and Tijuana (n=666) who completed a baseline and six-month follow-up interview. Within each site, we assessed bidirectional temporal associations using two separate multivariable logistic regression models: for model 1, recent provision of injection initiation assistance (at six months) was the outcome and recent overdose (at baseline) was the exposure; for model 2, recent overdose (at six months) was the outcome and recent provision of injection initiation assistance (at baseline) was the exposure. Both models adjusted for potential confounders. RESULTS Vancouver-based participants reporting overdose at baseline had 163% greater odds of reporting provision of injection initiation assistance at follow-up (adjusted Odds Ratio [aOR] 2.63; 95% Confidence Interval [CI] 1.41-4.90); while participants reporting provision of injection initiation assistance at baseline had 89% greater odds of reporting a non-fatal overdose at follow-up (aOR 1.89; 95% CI 1.00-3.57). Among Tijuana-based participants, we did not observe a statistically significant association in either direction. CONCLUSION Findings in Vancouver suggest that injection initiation assistance and overdose are bidirectionally-associated phenomena. The present findings highlight the need for interventions that ensure that persons who provide injection initiation assistance are given overdose prevention support, both for themselves and for those they assist to initiate injection drug use. While our Tijuana-based results did not suggest a bidirectional relationship, preventative approaches should nonetheless be undertaken.
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15
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Antuori A, Montoya V, Piñeyro D, Sumoy L, Joy J, Krajden M, González-Gómez S, Folch C, Casabona J, Matas L, Colom J, Saludes V, Martró E. Characterization of Acute HCV Infection and Transmission Networks in People Who Currently Inject Drugs in Catalonia: Usefulness of Dried Blood Spots. Hepatology 2021; 74:591-606. [PMID: 33609288 DOI: 10.1002/hep.31757] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 01/13/2021] [Accepted: 01/20/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIMS Accurate identification of recent HCV infections is critical for tracing the extent and mechanisms of ongoing transmission. We aimed to validate dried blood spot (DBS) samples for the assessment of Hepatitis C virus (HCV) genetic diversity and to determine epidemiological parameters including incidence, determinants of acute infection, and phylogenetic clustering in people who inject drugs (PWID). APPROACH AND RESULTS HCV nonstructural protein 5B next-generation sequencing was performed from plasma and/or DBS in 220 viremic PWID from the HepCdetect II study. No significant differences were found in consensus sequences or Shannon entropy (SE) intrahost diversity estimate between paired plasma/DBS specimens. SE values were used to identify acute infections with 93.3% sensitivity (95% CI, 0.81-1.06) and 95.0% specificity (95% CI, 0.88-1.02) in a set of well-defined controls. An acute HCV infection (either primary infection or reinfection) was detected in 13.5% of viremic participants and was associated with age ≤30 years (OR, 8.09), injecting less than daily (OR, 4.35), ≤5 years of injected drug use (OR, 3.43), sharing cocaine snorting straws (OR, 2.89), and being unaware of their HCV status (OR, 3.62). Annualized HCV incidence was estimated between 31 and 59/100 person-years. On phylogenetic analysis, 46.8% of viremic cases were part of a transmission pair or cluster; age ≤30 years (OR, 6.16), acute infection (OR, 5.73), and infection with subtype 1a (OR, 4.78) were independently associated with this condition. CONCLUSIONS The results obtained from plasma and DBS characterize PWID with acute infection and those involved in ongoing HCV transmission and allow estimating incidence from cross-sectional data. This information is critical for the design and assessment of targeted harm reduction programs and test-and-treat interventions and to facilitate monitoring of HCV elimination in this key population.
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Affiliation(s)
- Adrián Antuori
- Microbiology DepartmentLaboratori Clínic Metropolitana NordHospital Universitari Germans Trias i PujolInstitut d'Investigació en Ciències de la Salut Germans Trias i PujolBadalonaSpain
- Genetics and Microbiology DepartmentUniversitat Autònoma de BarcelonaBellaterraSpain
| | | | - David Piñeyro
- High Content Genomics & Bioinformatics UnitInstitut d'Investigació en Ciències de la Salut Germans Trias i PujolProgram of Predictive and Personalized Medicine of CancerBadalonaSpain
| | - Lauro Sumoy
- High Content Genomics & Bioinformatics UnitInstitut d'Investigació en Ciències de la Salut Germans Trias i PujolProgram of Predictive and Personalized Medicine of CancerBadalonaSpain
| | - Jeffrey Joy
- BC Centre for Excellence in HIVVancouverBCCanada
- Department of MedicineUniversity of British ColumbiaVancouverBCCanada
| | - Mel Krajden
- Public Health LaboratoryHepatitis-Clinical Prevention Services British Columbia Centre for Disease ControlVancouverBCCanada
| | - Sara González-Gómez
- Microbiology DepartmentLaboratori Clínic Metropolitana NordHospital Universitari Germans Trias i PujolInstitut d'Investigació en Ciències de la Salut Germans Trias i PujolBadalonaSpain
| | - Cinta Folch
- Centre for Epidemiological Studies on Sexually Transmitted Infections and HIV/AIDS of CataloniaPublic Health Agency of CataloniaBadalonaSpain
- Group 27Biomedical Research Networking Centre in Epidemiology and Public HealthInstituto de Salud Carlos IIIMadridSpain
| | - Jordi Casabona
- Centre for Epidemiological Studies on Sexually Transmitted Infections and HIV/AIDS of CataloniaPublic Health Agency of CataloniaBadalonaSpain
- Group 27Biomedical Research Networking Centre in Epidemiology and Public HealthInstituto de Salud Carlos IIIMadridSpain
| | - Lurdes Matas
- Microbiology DepartmentLaboratori Clínic Metropolitana NordHospital Universitari Germans Trias i PujolInstitut d'Investigació en Ciències de la Salut Germans Trias i PujolBadalonaSpain
- Genetics and Microbiology DepartmentUniversitat Autònoma de BarcelonaBellaterraSpain
- Group 27Biomedical Research Networking Centre in Epidemiology and Public HealthInstituto de Salud Carlos IIIMadridSpain
| | - Joan Colom
- Programme for Prevention, Control and Treatment of HIVSTIs and Viral HepatitisPublic Health Agency of CataloniaBarcelonaSpain
| | - Verónica Saludes
- Microbiology DepartmentLaboratori Clínic Metropolitana NordHospital Universitari Germans Trias i PujolInstitut d'Investigació en Ciències de la Salut Germans Trias i PujolBadalonaSpain
- Genetics and Microbiology DepartmentUniversitat Autònoma de BarcelonaBellaterraSpain
- Group 27Biomedical Research Networking Centre in Epidemiology and Public HealthInstituto de Salud Carlos IIIMadridSpain
| | - Elisa Martró
- Microbiology DepartmentLaboratori Clínic Metropolitana NordHospital Universitari Germans Trias i PujolInstitut d'Investigació en Ciències de la Salut Germans Trias i PujolBadalonaSpain
- Genetics and Microbiology DepartmentUniversitat Autònoma de BarcelonaBellaterraSpain
- Group 27Biomedical Research Networking Centre in Epidemiology and Public HealthInstituto de Salud Carlos IIIMadridSpain
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16
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Sa M, C R, Ml M, Lr S, J TM, S J, X S, Rs G, Sa S, K D, K H, R M, Mj M, M O, A G, D W, Ai S. Examining the gender composition of drug injecting initiation events: A mixed methods investigation of three North American contexts. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 90:103056. [PMID: 33310638 PMCID: PMC8046711 DOI: 10.1016/j.drugpo.2020.103056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 11/03/2020] [Accepted: 11/19/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Gender influences the health and social risks faced by individuals initiating drug injecting. Using mixed methods across three settings in North America, we investigated the gender composition of injection initiation events and the gendered risk environments in which they occurred. METHODS The PReventing Injecting by Modifying Existing Responses (PRIMER) study pooled data from three prospective community-recruited cohorts of people who inject drugs (PWID) in San Diego, USA, Vancouver, Canada, and Tijuana, Mexico. A qualitative subsample provided narrative data on their experiences of, and the contexts for, injection initiation events. Guided by Rhodes' risk environment framework, we examined the gender composition of initiation events stratified by city, and analyzed qualitative data using abductive thematic analyses. RESULTS Among 2,622 PWID (Tijuana: n = 531; San Diego: n = 352; Vancouver: n = 1,739), 112 (4.3%) reported providing initiation assistance to injection-naïve individuals in the previous six months. The proportion of gender concordant (e.g., male-male) initiation pairs varied, (χ2 = 10.32, p <0.001) with greater than expected concordance among pairs in Tijuana compared with those in Vancouver or San Diego. Sixty-one interviews provided context for the discrepancy across sites by highlighting the gendered injection initiation risk environments of prison/jail detention in Tijuana, intimate partnerships in San Diego, and overdose risk in Vancouver. CONCLUSIONS These results highlight how gender influences injection initiation events within spatial, social, and economic risk environments, and how this influence varies across settings. These findings can inform interventions to reduce the risk of injection initiation and related harms.
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Affiliation(s)
- Meyers Sa
- School of Social Work, College of Health and Human Services, San Diego State University, 5500 Campanile Drive, San Diego, CA 92182, United States; Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, United States
| | - Rafful C
- Facultad de Psicología, Universidad Nacional Autónoma de México, University City, Coyoacán, 04510, Mexico City, Mexico
| | - Mittal Ml
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, United States; Facultad de Medicina, Universidad Xochicalco, Rampa Yumalinda 4850, Colonia Chapultepec Alamar C.P. 22540, Tijuana, Baja California, Mexico
| | - Smith Lr
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, United States
| | - Tirado-Muñoz J
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, United States
| | - Jain S
- Department of Family Medicine and Public Health, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, United States
| | - Sun X
- Department of Family Medicine and Public Health, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, United States
| | - Garfein Rs
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, United States
| | - Strathdee Sa
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, United States
| | - DeBeck K
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9 Canada; School of Public Policy, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6 Canada
| | - Hayashi K
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9 Canada; Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, V5A 1S6 Canada
| | - McNeil R
- School of Medicine, Yale, 333 Cedar Street, New Haven, CT, 06510, United States
| | - Milloy Mj
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9 Canada; Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC, V5Z 1M9 Canada
| | - Olding M
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9 Canada
| | - Guise A
- Addison House, Guy's Hospital, King's College London, Strand, London WC2R 2LS, United Kingdom
| | - Werb D
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, United States; Centre on Drug Policy Evaluation, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8 Canada
| | - Scheim Ai
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, United States; Centre on Drug Policy Evaluation, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8 Canada; Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, 3215 Market Street, Philadelphia, PA 19104, United States.
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Meyers SA, Rafful C, Jain S, Sun X, Skaathun B, Guise A, Gonzalez-Zuñiga P, Strathdee SA, Werb D, Mittal ML. The role of drug treatment and recovery services: an opportunity to address injection initiation assistance in Tijuana, Mexico. Subst Abuse Treat Prev Policy 2020; 15:78. [PMID: 33046125 PMCID: PMC7552370 DOI: 10.1186/s13011-020-00322-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the U.S. and Canada, people who inject drugs' (PWID) enrollment in medication-assisted treatment (MAT) has been associated with a reduced likelihood that they will assist others in injection initiation events. We aimed to qualitatively explore PWID's experiences with MAT and other drug treatment and related recovery services in Tijuana Mexico, a resource-limited setting disproportionately impacted by injection drug use. METHODS PReventing Injecting by Modifying Existing Responses (PRIMER) seeks to assess socio-structural factors associated with PWID provision of injection initiation assistance. This analysis drew on qualitative data from Proyecto El Cuete (ECIV), a Tijuana-based PRIMER-linked cohort study. In-depth qualitative interviews were conducted with a subset of study participants to further explore experiences with MAT and other drug treatment services. Qualitative thematic analyses examined experiences with these services, including MAT enrollment, and related experiences with injection initiation assistance provision. RESULTS At PRIMER baseline, 607(81.1%) out of 748 participants reported recent daily IDU, 41(5.5%) reported recent injection initiation assistance, 92(12.3%) reported any recent drug treatment or recovery service access, and 21(2.8%) reported recent MAT enrollment (i.e., methadone). Qualitative analysis (n = 21; female = 8) revealed that, overall, abstinence-based recovery services did not meet participants' recovery goals, with substance use-related social connections in these contexts potentially shaping injection initiation assistance. Themes also highlighted individual-level (i.e., ambivalence and MAT-related stigma) and structural-level (i.e., cost and availability) barriers to MAT enrollment. CONCLUSION Tijuana's abstinence-based drug treatment and recovery services were viewed as unable to meet participants' recovery-related goals, which could be limiting the potential benefits of these services. Drug treatment and recovery services, including MAT, need to be modified to improve accessibility and benefits, like preventing transitions into drug injecting, for PWID.
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Affiliation(s)
- Stephanie A Meyers
- School of Social Work, College of Health and Human Services, San Diego State University, 5500 Campanile Drive, San Diego, CA, 92182, USA
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, MC 0507, La Jolla, CA, 92093-0507, USA
| | - Claudia Rafful
- Facultad de Psicología, Universidad Nacional Autónoma de México, University City, Coyoacán, 04510, Mexico City, Mexico
- Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Sonia Jain
- Department of Family Medicine and Public Health, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA
| | - Xiaoying Sun
- Department of Family Medicine and Public Health, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92093, USA
| | - Britt Skaathun
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, MC 0507, La Jolla, CA, 92093-0507, USA
| | - Andrew Guise
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, MC 0507, La Jolla, CA, 92093-0507, USA
- Addison House, Guy's Hospital, King's College London, Strand, London, WC2R 2LS, UK
| | - Patricia Gonzalez-Zuñiga
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, MC 0507, La Jolla, CA, 92093-0507, USA
| | - Steffanie A Strathdee
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, MC 0507, La Jolla, CA, 92093-0507, USA
| | - Dan Werb
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, MC 0507, La Jolla, CA, 92093-0507, USA
- Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Maria Luisa Mittal
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, MC 0507, La Jolla, CA, 92093-0507, USA.
- Facultad de Medicina, Universidad Xochicalco, Rampa Yumalinda 4850, Colonia Chapultepec Alamar C.P, 22540, Tijuana, Baja California, Mexico.
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Gicquelais RE, Werb D, Marks C, Ziegler C, Mehta SH, Genberg BL, Scheim AI. Prevalence and Correlates of Providing and Receiving Assistance With the Transition to Injection Drug Use. Epidemiol Rev 2020; 42:4-18. [PMID: 33024995 DOI: 10.1093/epirev/mxaa008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 09/22/2020] [Accepted: 10/01/2020] [Indexed: 01/13/2023] Open
Abstract
Preventing the transition to injection drug use is an important public health goal, as people who inject drugs (PWID) are at high risk for overdose and acquisition of infectious disease. Initiation into drug injection is primarily a social process, often involving PWID assistance. A better understanding of the epidemiology of this phenomenon would inform interventions to prevent injection initiation and to enhance safety when assistance is provided. We conducted a systematic review of the literature to 1) characterize the prevalence of receiving (among injection-naive persons) and providing (among PWID) help or guidance with the first drug injection and 2) identify correlates associated with these behaviors. Correlates were organized as substance use behaviors, health outcomes (e.g., human immunodeficiency virus infection), or factors describing an individual's social, economic, policy, or physical environment, defined by means of Rhodes' risk environments framework. After screening of 1,164 abstracts, 57 studies were included. The prevalence of receiving assistance with injection initiation (help or guidance at the first injection) ranged 74% to 100% (n = 13 estimates). The prevalence of ever providing assistance with injection initiation varied widely (range, 13%-69%; n = 13 estimates). Injecting norms, sex/gender, and other correlates classified within Rhodes' social risk environment were commonly associated with providing and receiving assistance. Nearly all PWID receive guidance about injecting for the first time, whereas fewer PWID report providing assistance. Substantial clinical and statistical heterogeneity between studies precluded meta-analysis, and thus local-level estimates may be necessary to guide the implementation of future psychosocial and sociostructural interventions. Further, estimates of providing assistance may be downwardly biased because of social desirability factors.
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Bloom BE, Jain S, Sun X, Garfein RS, Strathdee SA, Milloy MJ, Hayashi K, DeBeck K, Bluthenthal R, Werb D, Rafful C. Self-perception of assisting with future injection drug initiation: The influence of relationships in the process of drug injecting initiation. Drug Alcohol Rev 2020; 40:109-117. [PMID: 32840027 DOI: 10.1111/dar.13145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 07/01/2020] [Accepted: 07/12/2020] [Indexed: 12/13/2022]
Abstract
INTRODUCTION AND AIMS People who inject drugs (PWID) play critical roles in assisting others into injection drug use (IDU) initiation. Understanding perceptions of PWID's risk of initiating others is needed to inform interventions for prevention. The objective was to examine factors associated with self-perception of assisting with future IDU initiation events. The primary variables of interest are the relationships of PWID with the person(s) they assisted and their reasons for previously providing initiation assistance. DESIGN AND METHODS Data from Preventing Injecting by Modifying Existing Responses, a multi-site prospective community-recruited cohort study, were analysed. Analyses were restricted to PWID who reported ever providing IDU initiation assistance. Site-specific (Vancouver, Canada [n = 746]; San Diego, USA [n = 95] and Tijuana, Mexico [n = 92]) multivariable logistic regression analyses were performed to determine factors associated with self-perception of assisting with future IDU initiation. RESULTS Having provided IDU initiation assistance to a family member or intimate partner decreased the odds of self-perception of assisting with future IDU initiation in Vancouver (AOR = 0.4; 95% CI 0.2-0.8); however, previous IDU initiation assistance to an 'other' increased the odds of self-perception of assisting with future IDU in Tijuana (AOR = 12.0; 95% CI 2.1-70.3). Daily IDU (Vancouver: AOR = 3.7; 95% CI 2.1-6.4) and less than daily IDU (San Diego: AOR = 5.9; 95% CI 1.3-27.1) (Vancouver: AOR = 2.6; 95% CI 1.4-2.9) were associated with increased self-perception of assisting with future IDU compared to current non-injectors. DISCUSSION AND CONCLUSIONS Relationship to past initiates and IDU frequency might increase PWID's self-perception of assisting with future IDU. Interventions focused on social support and reducing IDU frequency may decrease occurrences of IDU initiation assistance.
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Affiliation(s)
- Brittnie E Bloom
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, San Diego, USA.,Graduate School of Public Health, San Diego State University, San Diego, USA
| | - Sonia Jain
- Department of Family Medicine and Public Health, Biostatistics Research Center, University of California, San Diego, San Diego, USA
| | - Xiaoying Sun
- Department of Family Medicine and Public Health, Biostatistics Research Center, University of California, San Diego, San Diego, USA
| | - Richard S Garfein
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, San Diego, USA
| | - Steffanie A Strathdee
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, San Diego, USA
| | - M-J Milloy
- British Columbia Centre on Substance Use, Vancouver, Canada.,Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Kanna Hayashi
- Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Kora DeBeck
- Department of Medicine, University of British Columbia, Vancouver, Canada.,Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada
| | - Ricky Bluthenthal
- Department of Preventive Medicine, Keck School of Medicine of University of Southern California, Los Angeles, USA
| | - Dan Werb
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, San Diego, USA.,Centre on Drug Policy Evaluation, St. Michael's Hospital, Toronto, Canada
| | - Claudia Rafful
- Centre on Drug Policy Evaluation, St. Michael's Hospital, Toronto, Canada.,Universidad Nacional Autónoma de México, Mexico City, Mexico.,Center on Global Mental Health Research, National Institute of Psychiatry, Mexico City, Mexico
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Tyree GA, Mosery N, Closson EF, Mabude Z, du Toit C, Bangsberg DR, Safren SA, Mayer KH, Smit JA, Mimiaga MJ, Grelotti DJ. Trajectories of initiation for the heroin-based drug whoonga - qualitative evidence from South Africa. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 82:102799. [PMID: 32535541 PMCID: PMC7493467 DOI: 10.1016/j.drugpo.2020.102799] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 03/04/2020] [Accepted: 05/12/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Whoonga is a smoked heroin-based street drug that first emerged in South Africa a decade ago. While previous scientific reports suggest that use is growing and youth are particularly vulnerable, trajectories of initiation are not well characterized. METHODS In 2015, 30 men undergoing residential addiction treatment for this smoked heroin drug in KwaZulu-Natal, South Africa participated in semi-structured interviews about their experiences using the drug. Interview data were coded using qualitative content analysis. RESULTS Participant trajectories to initiating smoked heroin were "vertical" in the context of marijuana use or "horizontal" in the context of other hard drug use. Participants reporting vertical trajectories began smoking heroin as youth at school or in other settings where people were smoking marijuana. Several participants with horizontal trajectories started smoking heroin to address symptoms of other drug or alcohol addiction. Social influences on initiation emerged as an overarching theme. Members of participants' social networks who were smoking or distributing heroin figured prominently in initiation narratives. Surprisingly, references to injection drug use were absent from initiation narratives. Participants reported people who smoke heroin differ from those who inject heroin by race. CONCLUSION Consistent with theories implicating social and structural influences on substance use initiation, people who started smoking heroin had social contacts who smoked heroin and frequented places where substance use was common. Smoked heroin initiation for several participants with horizontal trajectories may have been averted if they accessed evidence-based treatments for stimulant or alcohol use disorders. With increasing reports of heroin use across Africa, a coordinated approach to address this growing epidemic is needed. However, because smoked heroin and injection heroin use occur in distinct risk environments, interventions tailored to people who use smoked heroin will be needed to prevent smoked heroin use, prevent transition to injection use, and mitigate other social harms.
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Affiliation(s)
- Griffin A Tyree
- University of California, San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA 92093, United States
| | - Nzwakie Mosery
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaegology, Faculty of Health Sciences, University of the Witwatersrand, 40 Dr AB Xuma Street, Suite 1108-9, Commercial City, Durban, KwaZulu-Natal 4001, South Africa
| | - Elizabeth F Closson
- The Fenway Institute, Fenway Health, 1340 Boylston Street, Boston, MA 02215, United States
| | - Zonke Mabude
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaegology, Faculty of Health Sciences, University of the Witwatersrand, 40 Dr AB Xuma Street, Suite 1108-9, Commercial City, Durban, KwaZulu-Natal 4001, South Africa
| | - Carol du Toit
- SANCA Durban Alcohol & Drug Centres, 185 Vause Road, Durban, KwaZulu-Natal 4001, South Africa
| | - David R Bangsberg
- OHSU-PSU School of Public Health, 506 SW Mill Street, Portland, OR 97201, United States
| | - Steven A Safren
- The Fenway Institute, Fenway Health, 1340 Boylston Street, Boston, MA 02215, United States; University of Miami, 1320 S Dixie Highway, Coral Gables, FL 33146, United States
| | - Kenneth H Mayer
- The Fenway Institute, Fenway Health, 1340 Boylston Street, Boston, MA 02215, United States; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, United States
| | - Jennifer A Smit
- MatCH Research Unit (MRU), Department of Obstetrics and Gynaegology, Faculty of Health Sciences, University of the Witwatersrand, 40 Dr AB Xuma Street, Suite 1108-9, Commercial City, Durban, KwaZulu-Natal 4001, South Africa
| | - Matthew J Mimiaga
- The Fenway Institute, Fenway Health, 1340 Boylston Street, Boston, MA 02215, United States; Brown University, School of Public Health, 121 S Main Street, Providence, RI 02903, United States; Alpert Medical School, 222 Richmond Street, Providence, RI 02903, United States
| | - David J Grelotti
- University of California, San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA 92093, United States; HIV Neurobehavioral Research Program, University of California, San Diego, 220 Dickinson Street, San Diego, CA 92103, United States.
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Meyers SA, Smith LR, Werb D. Preventing transitions into injection drug use: A call for gender-responsive upstream prevention. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 83:102836. [PMID: 32679459 DOI: 10.1016/j.drugpo.2020.102836] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/17/2020] [Accepted: 06/19/2020] [Indexed: 01/30/2023]
Abstract
In 2017, there were large increases (260-500%) in overdose deaths among women in the United States across age groups (30-64 years and 55-64 years). In addition, U.S. women who inject drugs (WWID) are at increased risk for substance use-related disease transmission, bacterial infections, as well as sexual and physical violence compared to men who inject drugs. Relatedly, women face unique access barriers to substance use-related services, such as stigma and low coverage of gender-specific drug use-related services. Despite these heightened risks experienced by WWID, interventions specifically tailored to preventing women from transitioning into injection drug use have not been developed to date. As such, we advocate for the development of gender-responsive programs to prevent injection drug use initiation. This is critical to ensuring a comprehensive approach to preventing injection drug use initiation among those populations at highest risk of injection-related morbidity and mortality.
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Affiliation(s)
- Stephanie A Meyers
- School of Social Work, College of Health and Human Services, San Diego State University, 5500 Campanile Drive, San Diego, CA, 92182, USA; Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Laramie R Smith
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Dan Werb
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA; Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1T8, Canada.
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Bouck Z, Jain S, Sun X, Milloy MJ, Werb D, Hayashi K. Recent incarceration and risk of first-time injection initiation assistance: A prospective cohort study of persons who inject drugs. Drug Alcohol Depend 2020; 212:107983. [PMID: 32380374 PMCID: PMC7293943 DOI: 10.1016/j.drugalcdep.2020.107983] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 03/23/2020] [Accepted: 03/24/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Given the prevalence and harms of incarceration among persons who inject drugs (PWID) and their role in injection drug use initiation, we aimed to investigate whether recent incarceration influences the likelihood PWID assist others in their first-ever injection. METHODS Prospective cohort study of PWID in Vancouver, Canada who had their PReventing Injecting by Modifying Existing Responses (PRIMER) baseline visit between December 2014 and May 2017, reported never providing injection initiation assistance previously, and had ≥1 follow-up visit. The primary outcome, provision of injection initiation assistance, was defined via self-report as helping anybody inject for the first time in the past six months. The primary exposure was recent incarceration, i.e., self-report of being jailed, imprisoned or detained in the past six months. Participants were assessed biannually until November 2017, drop-out, or their first report of the primary outcome. RESULTS 1,199 PWID (62.1% male; mean (SD) age, 44.4 (12.3) years) were included in our study. Across 4,171 follow-up visits, 67 participants (5.6%) reported providing injection initiation assistance. The proportion of participants reporting recent incarceration varied between 2.4% to 5.1% per follow-up visit. Based on a multivariable discrete-time proportional hazards regression analysis, recent incarceration was associated with an increased risk of providing injection initiation assistance during the same six-month period (adjusted hazard ratio, 2.64; 95% CI, 1.19 to 5.86). CONCLUSIONS The observed association between recent incarceration and risk of providing injection initiation assistance suggests that incarceration could be contributing to the expansion of injection drug use practices within vulnerable populations over time.
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Affiliation(s)
- Zachary Bouck
- Centre for Drug Policy and Evaluation, Unity Health Toronto, 209 Victoria St, Toronto, ON M5B 1T8, Canada; Dalla Lana School of Public Health, University of Toronto, 55 College St Room 500, Toronto, ON M5T 3M7, Canada
| | - Sonia Jain
- Biostatistics Research Center, Department of Family Medicine and Public Health, University of California San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA
| | - Xiaoying Sun
- Biostatistics Research Center, Department of Family Medicine and Public Health, University of California San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA
| | - M-J Milloy
- British Columbia Centre on Substance Use, 1045 Howe St Suite 400, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada
| | - Dan Werb
- Centre for Drug Policy and Evaluation, Unity Health Toronto, 209 Victoria St, Toronto, ON M5B 1T8, Canada; Division of Global Public Health, University of California San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA.
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, 1045 Howe St Suite 400, Vancouver, BC V6Z 2A9, Canada; Faculty of Health Sciences, Simon Fraser University, 8888 University Dr, Burnaby, BC V5A 1S6, Canada
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Morozova O, Crawford FW, Cohen T, Paltiel AD, Altice FL. Cost-effectiveness of expanding the capacity of opioid agonist treatment in Ukraine: dynamic modeling analysis. Addiction 2020; 115:437-450. [PMID: 31478285 PMCID: PMC7015766 DOI: 10.1111/add.14797] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 06/24/2019] [Accepted: 08/23/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Although opioid agonist treatment (OAT) for opioid use disorder (OUD) is cost-effective in settings where the HIV epidemic is concentrated among people who inject drugs, OAT coverage in Ukraine remains far below internationally recommended targets. Scale-up is limited by both OAT availability and demand. This study aimed to evaluate the cost-effectiveness of a range of plausible OAT scale-up strategies in Ukraine incorporating the potential impact of treatment spillover and the real-world demand for addiction treatment. DESIGN, SETTING AND PARTICIPANTS Ten-year horizon (2016-25) modeling study of opioid addiction epidemic and treatment that accommodated potential peer effects in opioid use initiation and supply-induced treatment demand in three Ukrainian cities: Kyiv, Mykolaiv and Lviv, comprising a simulated population of people at risk of and with OUD. MEASUREMENTS Incremental cost per quality-adjusted life-year gained in the simulated population. FINDINGS An estimated 12.2-, 2.4- and 13.4-fold OAT capacity increase over 2016 baseline capacity in Kyiv, Mykolaiv and Lviv, respectively, would be cost-effective at a willingness-to-pay of one per-capita gross domestic product (GDP) per quality-adjusted life-year gained. This result is robust to parametric and structural uncertainty. Even under the most ambitious capacity increase, OAT coverage (i.e. the proportion of people with OUD receiving OAT) over a 10-year modeling horizon would be 20, 11 and 17% in Kyiv, Mykolaiv and Lviv, respectively, owing to limited demand. CONCLUSIONS It is estimated that a substantial increase in opioid agonist treatment (OAT) capacity in three Ukrainian cities would be cost-effective for a wide range of willingness-to-pay thresholds. Even a very ambitious capacity increase, however, is unlikely to reach internationally recommended coverage levels. Further increases in coverage may be limited by demand and would require addressing existing structural barriers to OAT access.
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Affiliation(s)
- Olga Morozova
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Forrest W Crawford
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Department of Ecology and Evolutionary Biology, Yale University, New Haven, CT, USA
- Department of Statistics and Data Science, Yale University, New Haven, CT, USA
- Yale School of Management, New Haven, CT, USA
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - A David Paltiel
- Yale School of Management, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | - Frederick L Altice
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
- University of Malaya, Kuala Lumpur, Malaysia
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Marks C, Borquez A, Jain S, Sun X, Strathdee SA, Garfein RS, Milloy MJ, DeBeck K, Cepeda JA, Werb D, Martin NK. Opioid agonist treatment scale-up and the initiation of injection drug use: A dynamic modeling analysis. PLoS Med 2019; 16:e1002973. [PMID: 31770373 PMCID: PMC6879119 DOI: 10.1371/journal.pmed.1002973] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 10/18/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Injection drug use (IDU) is associated with multiple health harms. The vast majority of IDU initiation events (in which injection-naïve persons first adopt IDU) are assisted by a person who injects drugs (PWID), and as such, IDU could be considered as a dynamic behavioral transmission process. Data suggest that opioid agonist treatment (OAT) enrollment is associated with a reduced likelihood of assisting with IDU initiation. We assessed the association between recent OAT enrollment and assisting IDU initiation across several North American settings and used dynamic modeling to project the potential population-level impact of OAT scale-up within the PWID population on IDU initiation. METHODS AND FINDINGS We employed data from a prospective multicohort study of PWID in 3 settings (Vancouver, Canada [n = 1,737]; San Diego, United States [n = 346]; and Tijuana, Mexico [n = 532]) from 2014 to 2017. Site-specific modified Poisson regression models were constructed to assess the association between recent (past 6 month) OAT enrollment and history of ever having assisted an IDU initiation with recently assisting IDU initiation. Findings were then pooled using linear mixed-effects techniques. A dynamic transmission model of IDU among the general population was developed, stratified by known factors associated with assisting IDU initiation and relevant drug use behaviors. The model was parameterized to a generic North American setting (approximately 1% PWID) and used to estimate the impact of increasing OAT coverage among PWID from baseline (approximately 21%) to 40%, 50%, and 60% on annual IDU initiation incidence and corresponding PWID population size across a decade. From Vancouver, San Diego, and Tijuana, respectively, 4.5%, 5.2%, and 4.3% of participants reported recently assisting an IDU initiation, and 49.4%, 19.7%, and 2.1% reported recent enrollment in OAT. Recent OAT enrollment was significantly associated with a 45% lower likelihood of providing recent IDU initiation assistance among PWID (relative risk [RR] 0.55 [95% CI 0.36-0.84], p = 0.006) compared to those not recently on OAT. Our dynamic model predicts a baseline mean of 1,067 (2.5%-97.5% interval [95% I 490-2,082]) annual IDU initiations per 1,000,000 individuals, of which 886 (95% I 406-1,750) are assisted by PWID. Based on our observed statistical associations, our dynamic model predicts that increasing OAT coverage from approximately 21% to 40%, 50%, or 60% among PWID could reduce annual IDU initiations by 11.5% (95% I 2.4-21.7), 17.3% (95% I 5.6-29.4), and 22.8% (95% I 8.1-36.8) and reduce the PWID population size by 5.4% (95% I 0.1-12.0), 8.2% (95% I 2.2-16.9), and 10.9% (95% I 3.2-21.8) relative to baseline, respectively, in a decade. Less impact occurs when the protective effect of OAT is diminished, when a greater proportion of IDU initiations are unassisted by PWID, and when average IDU career length is longer. The study's main limitations are uncertainty in the causal pathway between OAT enrollment and assisting with IDU initiation and the use of a simplified model of IDU initiation. CONCLUSIONS In addition to its known benefits on preventing HIV, hepatitis C virus (HCV), and overdose among PWID, our modeling suggests that OAT scale-up may also reduce the number of IDU initiations and PWID population size.
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Affiliation(s)
- Charles Marks
- SDSU-UCSD Joint Doctoral Program in Interdisciplinary Research on Substance Use, San Diego, California, United States of America
- The School of Social Work, San Diego State University, San Diego, California, United States of America
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, United States of America
| | - Annick Borquez
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, United States of America
| | - Sonia Jain
- Biostatistics Research Center, Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California, United States of America
| | - Xiaoying Sun
- Biostatistics Research Center, Department of Family Medicine and Public Health, University of California San Diego, La Jolla, California, United States of America
| | - Steffanie A. Strathdee
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, United States of America
| | - Richard S. Garfein
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, United States of America
| | - M-J Milloy
- British Columbia Centre on Substance Use, Vancouver, Canada
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Kora DeBeck
- British Columbia Centre on Substance Use, Vancouver, Canada
- School of Public Policy, Simon Fraser University, Vancouver, Canada
| | - Javier A. Cepeda
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, United States of America
| | - Dan Werb
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, United States of America
| | - Natasha K. Martin
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, United States of America
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
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Mittal ML, Guise A, Rafful C, Gonzalez-Zuñiga P, Davidson P, Vashishtha D, Strathdee SA, Werb D. "Another Person Was Going to Do It": The Provision of Injection Drug Use Initiation Assistance in a High-Risk U.S.-Mexico Border Region. Subst Use Misuse 2019; 54:2338-2350. [PMID: 31389282 PMCID: PMC6883155 DOI: 10.1080/10826084.2019.1648514] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background: Persons who inject drugs (PWID) play a key role in assisting others' initiation into injection drug use (IDU). We aimed to explore the pathways and socio-structural contexts for this phenomenon in Tijuana, Mexico, a border setting marked by a large PWID population with limited access to health and social services. Methods: Preventing Injecting by Modifying Existing Responses (PRIMER) is a multi-cohort study assessing socio-structural factors associated with PWID assisting others into initiating IDU. Semi-structured qualitative interviews in Tijuana included participants ≥18 years old, who reported IDU within the month prior to cohort enrollment and ever initiating others into IDU. Purposive sampling ensured a range of drug use experiences and behaviors related to injection initiation assistance. Thematic analysis was used to develop recurring and significant data categories. Results: Twenty-one participants were interviewed (8 women, 13 men). Broadly, participants considered public injection to increase curiosity about IDU. Many considered transitioning into IDU as inevitable. Emergent themes included providing assistance to mitigate overdose risk and to protect initiates from being taken advantage of by others. Participants described reluctance in engaging in this process. For some, access to resources (e.g., shared drugs or a monetary fee) was a motivator to initiate others. Conclusion: In Tijuana, public injection and a lack of harm reduction services are perceived to fuel the incidence of IDU initiation and to incentivize PWID to assist in injection initiation. IDU prevention efforts should address structural factors driving PWID participation in IDU initiation while including PWID in their development and implementation.
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Affiliation(s)
- Maria L Mittal
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA, USA.,Facultad de Medicina, Universidad Xochicalco, Tijuana, Mexico
| | - Andrew Guise
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA, USA.,Division of Health and Social Care Research, King's College, London, UK
| | - Claudia Rafful
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA, USA.,Centre on Drug Policy Evaluation, St. Michael's Hospital, Toronto, ON, Canada
| | - Patricia Gonzalez-Zuñiga
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Peter Davidson
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Devesh Vashishtha
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Steffanie A Strathdee
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Dan Werb
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, CA, USA.,Centre on Drug Policy Evaluation, St. Michael's Hospital, Toronto, ON, Canada
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